Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

MILD KIT

Facility

$9,072.24

Service Code	HCPCS C1889
Hospital Charge Code	4473019
Hospital Revenue Code	272
Min. Negotiated Rate	$5,896.96
Max. Negotiated Rate	$5,896.96
Rate for Payer: Cash Price	$6,804.18
Rate for Payer: Galaxy Health Commercial	$5,896.96

MILD KIT

Facility

$9,072.24

Service Code	HCPCS C1889
Hospital Charge Code	4473019
Hospital Revenue Code	272
Min. Negotiated Rate	$1,360.84
Max. Negotiated Rate	$7,257.79
Rate for Payer: Aetna of NY Commercial	$6,350.57
Rate for Payer: Aetna of NY Medicare	$4,173.23
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,628.90
Rate for Payer: Cash Price	$6,804.18
Rate for Payer: CDPHP Medicare	$3,356.73
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7,257.79
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,257.79
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,257.79
Rate for Payer: EmblemHealth Medicaid	$7,257.79
Rate for Payer: EmblemHealth Medicare	$3,084.56
Rate for Payer: EmblemHealth Select Care	$6,532.01
Rate for Payer: Fidelis Medicare	$3,628.90
Rate for Payer: Galaxy Health Commercial	$5,896.96
Rate for Payer: Hamaspik Choice Medicare	$3,628.90
Rate for Payer: Humana Medicare	$3,628.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$6,350.57
Rate for Payer: Local 1199SEIU Medicare	$4,173.23
Rate for Payer: MVP Health Care of NY Commercial	$6,804.18
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5,107.67
Rate for Payer: MVP Health Care of NY Medicare	$3,810.34
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,360.84
Rate for Payer: United Healthcare Medicare	$3,628.90
Rate for Payer: WellCare Medicare	$4,989.73

MILRINONE LACT 50 MG/50 ML VL 5 mg, 50 mL

Facility

$66.00

Service Code	HCPCS J2260
Hospital Charge Code	4401380
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$42.90
Rate for Payer: Aetna of NY Commercial	$36.30
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.18
Rate for Payer: EmblemHealth Select Care	$1.18
Rate for Payer: Galaxy Health Commercial	$42.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$36.30
Rate for Payer: WellCare Medicare	$36.30

MILRINONE LACT 50 MG/50 ML VL 5 mg, 50 mL

Facility

$66.00

Service Code	HCPCS J2260
Hospital Charge Code	4401380
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$52.80
Rate for Payer: Aetna of NY Medicare	$30.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$26.40
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: CDPHP Medicare	$24.42
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$52.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$52.80
Rate for Payer: EmblemHealth Medicaid	$52.80
Rate for Payer: EmblemHealth Medicare	$22.44
Rate for Payer: EmblemHealth Select Care	$1.18
Rate for Payer: Fidelis Medicare	$26.40
Rate for Payer: Galaxy Health Commercial	$42.90
Rate for Payer: Hamaspik Choice Medicare	$26.40
Rate for Payer: Humana Medicare	$26.40
Rate for Payer: Local 1199SEIU Medicare	$30.36
Rate for Payer: MVP Health Care of NY Commercial	$49.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$37.16
Rate for Payer: MVP Health Care of NY Medicare	$27.72
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$3.09
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.90
Rate for Payer: United Healthcare Commercial	$3.09
Rate for Payer: United Healthcare Medicare	$26.40
Rate for Payer: WellCare Medicare	$36.30

MILRINONE LACT, 5 MG

Facility

$69.01

Service Code	HCPCS J2260
Hospital Charge Code	4402268
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$44.86
Rate for Payer: Aetna of NY Commercial	$37.96
Rate for Payer: Cash Price	$51.76
Rate for Payer: Cash Price	$51.76
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.18
Rate for Payer: EmblemHealth Select Care	$1.18
Rate for Payer: Galaxy Health Commercial	$44.86
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$37.96
Rate for Payer: WellCare Medicare	$37.96

MILRINONE LACT, 5 MG

Facility

$69.01

Service Code	HCPCS J2260
Hospital Charge Code	4402268
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$55.21
Rate for Payer: Aetna of NY Medicare	$31.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$27.60
Rate for Payer: Cash Price	$51.76
Rate for Payer: Cash Price	$51.76
Rate for Payer: CDPHP Medicare	$25.53
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1.18
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$55.21
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$55.21
Rate for Payer: EmblemHealth Medicaid	$55.21
Rate for Payer: EmblemHealth Medicare	$23.46
Rate for Payer: EmblemHealth Select Care	$1.18
Rate for Payer: Fidelis Medicare	$27.60
Rate for Payer: Galaxy Health Commercial	$44.86
Rate for Payer: Hamaspik Choice Medicare	$27.60
Rate for Payer: Humana Medicare	$27.60
Rate for Payer: Local 1199SEIU Medicare	$31.74
Rate for Payer: MVP Health Care of NY Commercial	$51.76
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$38.85
Rate for Payer: MVP Health Care of NY Medicare	$28.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$3.09
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.35
Rate for Payer: United Healthcare Commercial	$3.09
Rate for Payer: United Healthcare Medicare	$27.60
Rate for Payer: WellCare Medicare	$37.96

MILRINONE THERAPY, ALL SUPPLIES/EQUIPMENT

Facility

$263.68

Hospital Charge Code	1050105
Hospital Revenue Code	250
Min. Negotiated Rate	$145.02
Max. Negotiated Rate	$171.39
Rate for Payer: Cash Price	$197.76
Rate for Payer: Galaxy Health Commercial	$171.39
Rate for Payer: WellCare Medicare	$145.02

MILRINONE THERAPY, ALL SUPPLIES/EQUIPMENT

Facility

$263.68

Hospital Charge Code	1050105
Hospital Revenue Code	250
Min. Negotiated Rate	$39.55
Max. Negotiated Rate	$210.94
Rate for Payer: Aetna of NY Commercial	$184.58
Rate for Payer: Aetna of NY Medicare	$121.29
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$105.47
Rate for Payer: Cash Price	$197.76
Rate for Payer: CDPHP Medicare	$97.56
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$210.94
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$210.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$210.94
Rate for Payer: EmblemHealth Medicaid	$210.94
Rate for Payer: EmblemHealth Medicare	$89.65
Rate for Payer: EmblemHealth Select Care	$189.85
Rate for Payer: Fidelis Medicare	$105.47
Rate for Payer: Galaxy Health Commercial	$171.39
Rate for Payer: Hamaspik Choice Medicare	$105.47
Rate for Payer: Humana Medicare	$105.47
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$184.58
Rate for Payer: Local 1199SEIU Medicare	$121.29
Rate for Payer: MVP Health Care of NY Commercial	$197.76
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$148.45
Rate for Payer: MVP Health Care of NY Medicare	$110.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$39.55
Rate for Payer: United Healthcare Medicare	$105.47
Rate for Payer: WellCare Medicare	$145.02

MIRTAZAPINE 15 MG TAB

Facility

$10.56

Service Code	NDC 68084011911
Hospital Charge Code	4409046
Hospital Revenue Code	250
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$8.45
Rate for Payer: Aetna of NY Commercial	$7.39
Rate for Payer: Aetna of NY Medicare	$4.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.22
Rate for Payer: Cash Price	$7.92
Rate for Payer: CDPHP Medicare	$3.91
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.45
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.45
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.45
Rate for Payer: EmblemHealth Medicaid	$8.45
Rate for Payer: EmblemHealth Medicare	$3.59
Rate for Payer: EmblemHealth Select Care	$7.60
Rate for Payer: Fidelis Medicare	$4.22
Rate for Payer: Galaxy Health Commercial	$6.86
Rate for Payer: Hamaspik Choice Medicare	$4.22
Rate for Payer: Humana Medicare	$4.22
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.39
Rate for Payer: Local 1199SEIU Medicare	$4.86
Rate for Payer: MVP Health Care of NY Commercial	$7.92
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$5.95
Rate for Payer: MVP Health Care of NY Medicare	$4.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.58
Rate for Payer: United Healthcare Medicare	$4.22
Rate for Payer: WellCare Medicare	$5.81

MIRTAZAPINE 15 MG TAB

Facility

$10.56

Service Code	NDC 68084011911
Hospital Charge Code	4409046
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$6.86
Rate for Payer: Cash Price	$7.92
Rate for Payer: Galaxy Health Commercial	$6.86
Rate for Payer: WellCare Medicare	$5.81

MISCELLANEOUS INSTRUMENTS

Facility

$323.42

Hospital Charge Code	4472236
Hospital Revenue Code	272
Min. Negotiated Rate	$210.22
Max. Negotiated Rate	$210.22
Rate for Payer: Cash Price	$242.56
Rate for Payer: Galaxy Health Commercial	$210.22

MISCELLANEOUS INSTRUMENTS

Facility

$323.42

Hospital Charge Code	4472236
Hospital Revenue Code	272
Min. Negotiated Rate	$48.51
Max. Negotiated Rate	$258.74
Rate for Payer: Aetna of NY Commercial	$226.39
Rate for Payer: Aetna of NY Medicare	$148.77
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$129.37
Rate for Payer: Cash Price	$242.56
Rate for Payer: CDPHP Medicare	$119.67
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$258.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$258.74
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$258.74
Rate for Payer: EmblemHealth Medicaid	$258.74
Rate for Payer: EmblemHealth Medicare	$109.96
Rate for Payer: EmblemHealth Select Care	$232.86
Rate for Payer: Fidelis Medicare	$129.37
Rate for Payer: Galaxy Health Commercial	$210.22
Rate for Payer: Hamaspik Choice Medicare	$129.37
Rate for Payer: Humana Medicare	$129.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$226.39
Rate for Payer: Local 1199SEIU Medicare	$148.77
Rate for Payer: MVP Health Care of NY Commercial	$242.56
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$182.09
Rate for Payer: MVP Health Care of NY Medicare	$135.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.51
Rate for Payer: United Healthcare Medicare	$129.37
Rate for Payer: WellCare Medicare	$177.88

MISC PHARMACY

Facility

$6.18

Service Code	NDC 51079008320
Hospital Charge Code	4409153
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$4.64
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: WellCare Medicare	$3.40

MISC PHARMACY

Facility

$6.18

Service Code	NDC 51079008320
Hospital Charge Code	4409153
Hospital Revenue Code	250
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna of NY Commercial	$4.33
Rate for Payer: Aetna of NY Medicare	$2.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.47
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Medicare	$2.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.94
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.94
Rate for Payer: EmblemHealth Medicaid	$4.94
Rate for Payer: EmblemHealth Medicare	$2.10
Rate for Payer: EmblemHealth Select Care	$4.45
Rate for Payer: Fidelis Medicare	$2.47
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.47
Rate for Payer: Humana Medicare	$2.47
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.33
Rate for Payer: Local 1199SEIU Medicare	$2.84
Rate for Payer: MVP Health Care of NY Commercial	$4.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

MISOPROSTOL 100 MCG TABLET

Facility

$6.18

Service Code	NDC 68084004001
Hospital Charge Code	4400837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna of NY Commercial	$4.33
Rate for Payer: Aetna of NY Medicare	$2.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.47
Rate for Payer: Cash Price	$4.64
Rate for Payer: CDPHP Medicare	$2.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.94
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.94
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.94
Rate for Payer: EmblemHealth Medicaid	$4.94
Rate for Payer: EmblemHealth Medicare	$2.10
Rate for Payer: EmblemHealth Select Care	$4.45
Rate for Payer: Fidelis Medicare	$2.47
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: Hamaspik Choice Medicare	$2.47
Rate for Payer: Humana Medicare	$2.47
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$4.33
Rate for Payer: Local 1199SEIU Medicare	$2.84
Rate for Payer: MVP Health Care of NY Commercial	$4.63
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.48
Rate for Payer: MVP Health Care of NY Medicare	$2.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.93
Rate for Payer: United Healthcare Medicare	$2.47
Rate for Payer: WellCare Medicare	$3.40

MISOPROSTOL 100 MCG TABLET

Facility

$6.18

Service Code	NDC 68084004001
Hospital Charge Code	4400837
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4.02
Rate for Payer: Cash Price	$4.64
Rate for Payer: Galaxy Health Commercial	$4.02
Rate for Payer: WellCare Medicare	$3.40

M-M-R II

Facility

$268.80

Service Code	NDC 6468100
Hospital Charge Code	4408943
Hospital Revenue Code	250
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$215.04
Rate for Payer: Aetna of NY Commercial	$188.16
Rate for Payer: Aetna of NY Medicare	$123.65
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$107.52
Rate for Payer: Cash Price	$201.60
Rate for Payer: CDPHP Medicare	$99.46
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$215.04
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$215.04
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$215.04
Rate for Payer: EmblemHealth Medicaid	$215.04
Rate for Payer: EmblemHealth Medicare	$91.39
Rate for Payer: EmblemHealth Select Care	$193.54
Rate for Payer: Fidelis Medicare	$107.52
Rate for Payer: Galaxy Health Commercial	$174.72
Rate for Payer: Hamaspik Choice Medicare	$107.52
Rate for Payer: Humana Medicare	$107.52
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$188.16
Rate for Payer: Local 1199SEIU Medicare	$123.65
Rate for Payer: MVP Health Care of NY Commercial	$201.60
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$151.33
Rate for Payer: MVP Health Care of NY Medicare	$112.90
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.32
Rate for Payer: United Healthcare Medicare	$107.52
Rate for Payer: WellCare Medicare	$147.84

M-M-R II

Facility

$268.80

Service Code	NDC 6468100
Hospital Charge Code	4408943
Hospital Revenue Code	250
Min. Negotiated Rate	$147.84
Max. Negotiated Rate	$174.72
Rate for Payer: Cash Price	$201.60
Rate for Payer: Galaxy Health Commercial	$174.72
Rate for Payer: WellCare Medicare	$147.84

MODAFINIL 100 MG TABLET 100 mg, 30 eaches

Facility

$80.00

Service Code	NDC 65862060130
Hospital Charge Code	4401928
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna of NY Commercial	$56.00
Rate for Payer: Aetna of NY Medicare	$36.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$32.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: CDPHP Medicare	$29.60
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$64.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$64.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$64.00
Rate for Payer: EmblemHealth Medicaid	$64.00
Rate for Payer: EmblemHealth Medicare	$27.20
Rate for Payer: EmblemHealth Select Care	$57.60
Rate for Payer: Fidelis Medicare	$32.00
Rate for Payer: Galaxy Health Commercial	$52.00
Rate for Payer: Hamaspik Choice Medicare	$32.00
Rate for Payer: Humana Medicare	$32.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$56.00
Rate for Payer: Local 1199SEIU Medicare	$36.80
Rate for Payer: MVP Health Care of NY Commercial	$60.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$45.04
Rate for Payer: MVP Health Care of NY Medicare	$33.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.00
Rate for Payer: United Healthcare Medicare	$32.00
Rate for Payer: WellCare Medicare	$44.00

MODAFINIL 100 MG TABLET 100 mg, 30 eaches

Facility

$80.00

Service Code	NDC 65862060130
Hospital Charge Code	4401928
Hospital Revenue Code	250
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Galaxy Health Commercial	$52.00
Rate for Payer: WellCare Medicare	$44.00

MODERNA COVID VACCINE 25 MCG/0.25 ML 6 MO - 11Y

Facility

$0.01

Service Code	HCPCS 91321
Hospital Charge Code	4403004
Hospital Revenue Code	636
Max. Negotiated Rate	$147.06
Rate for Payer: Aetna of NY Commercial	$0.01
Rate for Payer: Aetna of NY Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: CDPHP Medicare	$0.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$147.06
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.01
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.01
Rate for Payer: EmblemHealth Medicaid	$0.01
Rate for Payer: EmblemHealth Medicare	$0.00
Rate for Payer: EmblemHealth Select Care	$147.06
Rate for Payer: Fidelis Medicare	$0.00
Rate for Payer: Galaxy Health Commercial	$0.01
Rate for Payer: Hamaspik Choice Medicare	$0.00
Rate for Payer: Humana Medicare	$0.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.01
Rate for Payer: Local 1199SEIU Medicare	$0.00
Rate for Payer: MVP Health Care of NY Commercial	$0.01
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.01
Rate for Payer: MVP Health Care of NY Medicare	$0.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.00
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: WellCare Medicare	$0.01

MODERNA COVID VACCINE 25 MCG/0.25 ML 6 MO - 11Y

Facility

$0.01

Service Code	HCPCS 91321
Hospital Charge Code	4403004
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$147.06
Rate for Payer: Aetna of NY Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$147.06
Rate for Payer: EmblemHealth Select Care	$147.06
Rate for Payer: Galaxy Health Commercial	$0.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.01
Rate for Payer: WellCare Medicare	$0.01

MODERNA COVID VACCINE 50 MCG/0.5 ML 12 Y OLDER

Facility

$0.01

Service Code	HCPCS 91322
Hospital Charge Code	4403005
Hospital Revenue Code	636
Max. Negotiated Rate	$161.65
Rate for Payer: Aetna of NY Commercial	$0.01
Rate for Payer: Aetna of NY Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: CDPHP Medicare	$0.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$161.65
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.01
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.01
Rate for Payer: EmblemHealth Medicaid	$0.01
Rate for Payer: EmblemHealth Medicare	$0.00
Rate for Payer: EmblemHealth Select Care	$161.65
Rate for Payer: Fidelis Medicare	$0.00
Rate for Payer: Galaxy Health Commercial	$0.01
Rate for Payer: Hamaspik Choice Medicare	$0.00
Rate for Payer: Humana Medicare	$0.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.01
Rate for Payer: Local 1199SEIU Medicare	$0.00
Rate for Payer: MVP Health Care of NY Commercial	$0.01
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.01
Rate for Payer: MVP Health Care of NY Medicare	$0.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.00
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: WellCare Medicare	$0.01

MODERNA COVID VACCINE 50 MCG/0.5 ML 12 Y OLDER

Facility

$0.01

Service Code	HCPCS 91322
Hospital Charge Code	4403005
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$161.65
Rate for Payer: Aetna of NY Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$161.65
Rate for Payer: EmblemHealth Select Care	$161.65
Rate for Payer: Galaxy Health Commercial	$0.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.01
Rate for Payer: WellCare Medicare	$0.01

MOD SEDATION OTHER PHYS/QHP EA

Facility

$224.00

Service Code	HCPCS 99157
Hospital Charge Code	4601194
Hospital Revenue Code	450
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$145.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Galaxy Health Commercial	$145.60

Know your out-of-pocket cost for care.

All Charges