Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

PEDIATRIC CAPNOLINE (CANNULA)

Facility

$43.26

Hospital Charge Code	4479200
Hospital Revenue Code	270
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$28.12
Rate for Payer: Cash Price	$32.44
Rate for Payer: Galaxy Health Commercial	$28.12

PEDIATRIC DRAPE

Facility

$24.72

Hospital Charge Code	4479161
Hospital Revenue Code	270
Min. Negotiated Rate	$16.07
Max. Negotiated Rate	$16.07
Rate for Payer: Cash Price	$18.54
Rate for Payer: Galaxy Health Commercial	$16.07

PEDIATRIC DRAPE

Facility

$24.72

Hospital Charge Code	4479161
Hospital Revenue Code	270
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$19.78
Rate for Payer: Aetna of NY Commercial	$17.30
Rate for Payer: Aetna of NY Medicare	$11.37
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.89
Rate for Payer: Cash Price	$18.54
Rate for Payer: CDPHP Medicare	$9.15
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$19.78
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$19.78
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$19.78
Rate for Payer: EmblemHealth Medicaid	$19.78
Rate for Payer: EmblemHealth Medicare	$8.40
Rate for Payer: EmblemHealth Select Care	$17.80
Rate for Payer: Fidelis Medicare	$9.89
Rate for Payer: Galaxy Health Commercial	$16.07
Rate for Payer: Hamaspik Choice Medicare	$9.89
Rate for Payer: Humana Medicare	$9.89
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$17.30
Rate for Payer: Local 1199SEIU Medicare	$11.37
Rate for Payer: MVP Health Care of NY Commercial	$18.54
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.92
Rate for Payer: MVP Health Care of NY Medicare	$10.38
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.71
Rate for Payer: United Healthcare Medicare	$9.89
Rate for Payer: WellCare Medicare	$13.60

PEDIATRIC ELECTROLYTE SOLN ORAL

Facility

$13.13

Service Code	NDC 37205022208
Hospital Charge Code	4408977
Hospital Revenue Code	250
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna of NY Commercial	$9.19
Rate for Payer: Aetna of NY Medicare	$6.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.25
Rate for Payer: Cash Price	$9.85
Rate for Payer: CDPHP Medicare	$4.86
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.50
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$10.50
Rate for Payer: EmblemHealth Medicaid	$10.50
Rate for Payer: EmblemHealth Medicare	$4.46
Rate for Payer: EmblemHealth Select Care	$9.45
Rate for Payer: Fidelis Medicare	$5.25
Rate for Payer: Galaxy Health Commercial	$8.53
Rate for Payer: Hamaspik Choice Medicare	$5.25
Rate for Payer: Humana Medicare	$5.25
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.19
Rate for Payer: Local 1199SEIU Medicare	$6.04
Rate for Payer: MVP Health Care of NY Commercial	$9.85
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.39
Rate for Payer: MVP Health Care of NY Medicare	$5.51
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.97
Rate for Payer: United Healthcare Medicare	$5.25
Rate for Payer: WellCare Medicare	$7.22

PEDIATRIC ELECTROLYTE SOLN ORAL

Facility

$13.13

Service Code	NDC 37205022208
Hospital Charge Code	4408977
Hospital Revenue Code	250
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$8.53
Rate for Payer: Cash Price	$9.85
Rate for Payer: Galaxy Health Commercial	$8.53
Rate for Payer: WellCare Medicare	$7.22

PEDIATRIC PACER PAD

Facility

$65.92

Hospital Charge Code	4479116
Hospital Revenue Code	270
Min. Negotiated Rate	$42.85
Max. Negotiated Rate	$42.85
Rate for Payer: Cash Price	$49.44
Rate for Payer: Galaxy Health Commercial	$42.85

PEDIATRIC PACER PAD

Facility

$65.92

Hospital Charge Code	4479116
Hospital Revenue Code	270
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$52.74
Rate for Payer: Aetna of NY Commercial	$46.14
Rate for Payer: Aetna of NY Medicare	$30.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$26.37
Rate for Payer: Cash Price	$49.44
Rate for Payer: CDPHP Medicare	$24.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$52.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$52.74
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$52.74
Rate for Payer: EmblemHealth Medicaid	$52.74
Rate for Payer: EmblemHealth Medicare	$22.41
Rate for Payer: EmblemHealth Select Care	$47.46
Rate for Payer: Fidelis Medicare	$26.37
Rate for Payer: Galaxy Health Commercial	$42.85
Rate for Payer: Hamaspik Choice Medicare	$26.37
Rate for Payer: Humana Medicare	$26.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$46.14
Rate for Payer: Local 1199SEIU Medicare	$30.32
Rate for Payer: MVP Health Care of NY Commercial	$49.44
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$37.11
Rate for Payer: MVP Health Care of NY Medicare	$27.69
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.89
Rate for Payer: United Healthcare Medicare	$26.37
Rate for Payer: WellCare Medicare	$36.26

PEDIATRIC PULSE OX

Facility

$73.13

Hospital Charge Code	4479199
Hospital Revenue Code	270
Min. Negotiated Rate	$47.53
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$54.85
Rate for Payer: Galaxy Health Commercial	$47.53

PEDIATRIC PULSE OX

Facility

$73.13

Hospital Charge Code	4479199
Hospital Revenue Code	270
Min. Negotiated Rate	$10.97
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of NY Commercial	$51.19
Rate for Payer: Aetna of NY Medicare	$33.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$29.25
Rate for Payer: Cash Price	$54.85
Rate for Payer: CDPHP Medicare	$27.06
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$58.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$58.50
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$58.50
Rate for Payer: EmblemHealth Medicaid	$58.50
Rate for Payer: EmblemHealth Medicare	$24.86
Rate for Payer: EmblemHealth Select Care	$52.65
Rate for Payer: Fidelis Medicare	$29.25
Rate for Payer: Galaxy Health Commercial	$47.53
Rate for Payer: Hamaspik Choice Medicare	$29.25
Rate for Payer: Humana Medicare	$29.25
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$51.19
Rate for Payer: Local 1199SEIU Medicare	$33.64
Rate for Payer: MVP Health Care of NY Commercial	$54.85
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$41.17
Rate for Payer: MVP Health Care of NY Medicare	$30.71
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.97
Rate for Payer: United Healthcare Medicare	$29.25
Rate for Payer: WellCare Medicare	$40.22

PELVIS MRA W CONTR

Facility

$2,847.00

Service Code	HCPCS C8918
Hospital Charge Code	4230070
Hospital Revenue Code	618
Min. Negotiated Rate	$1,850.55
Max. Negotiated Rate	$1,850.55
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Galaxy Health Commercial	$1,850.55

PELVIS MRA W CONTR

Facility

$2,847.00

Service Code	HCPCS C8918
Hospital Charge Code	4230070
Hospital Revenue Code	618
Min. Negotiated Rate	$427.05
Max. Negotiated Rate	$2,328.00
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,309.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,138.80
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: CDPHP Medicare	$1,053.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,992.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,277.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,277.60
Rate for Payer: EmblemHealth Medicaid	$2,277.60
Rate for Payer: EmblemHealth Medicare	$967.98
Rate for Payer: EmblemHealth Select Care	$1,850.55
Rate for Payer: Fidelis Medicare	$1,138.80
Rate for Payer: Galaxy Health Commercial	$1,850.55
Rate for Payer: Hamaspik Choice Medicare	$1,138.80
Rate for Payer: Humana Medicare	$1,138.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,309.62
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,195.74
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$427.05
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,138.80
Rate for Payer: WellCare Medicare	$1,565.85

PELVIS MRA WO CONTR

Facility

$1,915.00

Service Code	HCPCS C8919
Hospital Charge Code	4230120
Hospital Revenue Code	619
Min. Negotiated Rate	$1,244.75
Max. Negotiated Rate	$1,244.75
Rate for Payer: Cash Price	$1,436.25
Rate for Payer: Galaxy Health Commercial	$1,244.75

PELVIS MRA WO CONTR

Facility

$1,915.00

Service Code	HCPCS C8919
Hospital Charge Code	4230120
Hospital Revenue Code	619
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$2,328.00
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$880.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$766.00
Rate for Payer: Cash Price	$1,436.25
Rate for Payer: Cash Price	$1,436.25
Rate for Payer: Cash Price	$1,436.25
Rate for Payer: CDPHP Medicare	$708.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,340.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,532.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,532.00
Rate for Payer: EmblemHealth Medicaid	$1,532.00
Rate for Payer: EmblemHealth Medicare	$651.10
Rate for Payer: EmblemHealth Select Care	$1,244.75
Rate for Payer: Fidelis Medicare	$766.00
Rate for Payer: Galaxy Health Commercial	$1,244.75
Rate for Payer: Hamaspik Choice Medicare	$766.00
Rate for Payer: Humana Medicare	$766.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$880.90
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$804.30
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$287.25
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$766.00
Rate for Payer: WellCare Medicare	$1,053.25

PELVIS MRA W & WO CONTR

Facility

$2,847.00

Service Code	HCPCS C8920
Hospital Charge Code	4230071
Hospital Revenue Code	618
Min. Negotiated Rate	$427.05
Max. Negotiated Rate	$2,328.00
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,309.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,138.80
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: CDPHP Medicare	$1,053.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,992.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,277.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,277.60
Rate for Payer: EmblemHealth Medicaid	$2,277.60
Rate for Payer: EmblemHealth Medicare	$967.98
Rate for Payer: EmblemHealth Select Care	$1,850.55
Rate for Payer: Fidelis Medicare	$1,138.80
Rate for Payer: Galaxy Health Commercial	$1,850.55
Rate for Payer: Hamaspik Choice Medicare	$1,138.80
Rate for Payer: Humana Medicare	$1,138.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,309.62
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,195.74
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$427.05
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,138.80
Rate for Payer: WellCare Medicare	$1,565.85

PELVIS MRA W & WO CONTR

Facility

$2,847.00

Service Code	HCPCS C8920
Hospital Charge Code	4230071
Hospital Revenue Code	618
Min. Negotiated Rate	$1,850.55
Max. Negotiated Rate	$1,850.55
Rate for Payer: Cash Price	$2,135.25
Rate for Payer: Galaxy Health Commercial	$1,850.55

PENICILLIN V POTASSIUM 250MG/5ML POSR 10

Facility

$6.18

Service Code	NDC 93412773
Hospital Charge Code	4400615
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

PENICILLIN V POTASSIUM 250MG/5ML POSR 10

Facility

$6.18

Service Code	NDC 93412773
Hospital Charge Code	4400615
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

PENICILLIN V POTASSIUM 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 781165501
Hospital Charge Code	4400616
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

PENICILLIN V POTASSIUM 500MG TABS 100 EA

Facility

$6.18

Service Code	NDC 781165501
Hospital Charge Code	4400616
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

PERCUTANEOUS DECOMPRESSION DEVICE KIT #M

Facility

$8,383.17

Hospital Charge Code	4478231
Hospital Revenue Code	270
Min. Negotiated Rate	$1,257.48
Max. Negotiated Rate	$6,706.54
Rate for Payer: Aetna of NY Commercial	$5,868.22
Rate for Payer: Aetna of NY Medicare	$3,856.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,353.27
Rate for Payer: Cash Price	$6,287.38
Rate for Payer: CDPHP Medicare	$3,101.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6,706.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$6,706.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$6,706.54
Rate for Payer: EmblemHealth Medicaid	$6,706.54
Rate for Payer: EmblemHealth Medicare	$2,850.28
Rate for Payer: EmblemHealth Select Care	$6,035.88
Rate for Payer: Fidelis Medicare	$3,353.27
Rate for Payer: Galaxy Health Commercial	$5,449.06
Rate for Payer: Hamaspik Choice Medicare	$3,353.27
Rate for Payer: Humana Medicare	$3,353.27
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$5,868.22
Rate for Payer: Local 1199SEIU Medicare	$3,856.26
Rate for Payer: MVP Health Care of NY Commercial	$6,287.38
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$4,719.72
Rate for Payer: MVP Health Care of NY Medicare	$3,520.93
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,257.48
Rate for Payer: United Healthcare Medicare	$3,353.27
Rate for Payer: WellCare Medicare	$4,610.74

PERCUTANEOUS DECOMPRESSION DEVICE KIT #M

Facility

$8,383.17

Hospital Charge Code	4478231
Hospital Revenue Code	270
Min. Negotiated Rate	$5,449.06
Max. Negotiated Rate	$5,449.06
Rate for Payer: Cash Price	$6,287.38
Rate for Payer: Galaxy Health Commercial	$5,449.06

PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL

Facility

$6,758.03

Service Code	CPT 63650
Hospital Revenue Code	490
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$6,758.03
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$3,771.92
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$3,143.27
Rate for Payer: EmblemHealth Medicaid	$3,143.27
Rate for Payer: Galaxy Health Workers Comp	$3,080.40
Rate for Payer: Hamaspik Choice Medicaid	$3,143.27
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$3,300.43
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$6,758.03
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$6,758.03
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,373.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6,516.28
Rate for Payer: United Healthcare Commercial	$2,373.00
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$3,300.43

PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY

Facility

$1,900.00

Service Code	CPT 62264
Hospital Revenue Code	490
Min. Negotiated Rate	$868.45
Max. Negotiated Rate	$1,900.00
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,828.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$868.45
Rate for Payer: United Healthcare Commercial	$1,828.00

PERFIX PLUG LARGE, 1.6"

Facility

$1,469.81

Hospital Charge Code	4471028
Hospital Revenue Code	278
Min. Negotiated Rate	$661.41
Max. Negotiated Rate	$1,028.87
Rate for Payer: Aetna of NY Commercial	$1,028.87
Rate for Payer: Cash Price	$1,102.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$734.90
Rate for Payer: EmblemHealth Select Care	$734.90
Rate for Payer: Galaxy Health Commercial	$955.38
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,028.87
Rate for Payer: Multiplan Commercial	$661.41
Rate for Payer: MVP Health Care of NY Commercial	$955.38
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$955.38
Rate for Payer: WellCare Medicare	$808.40

PERFIX PLUG LARGE, 1.6"

Facility

$1,469.81

Hospital Charge Code	4471028
Hospital Revenue Code	278
Min. Negotiated Rate	$220.47
Max. Negotiated Rate	$1,175.85
Rate for Payer: Aetna of NY Commercial	$1,028.87
Rate for Payer: Aetna of NY Medicare	$676.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$587.92
Rate for Payer: Cash Price	$1,102.36
Rate for Payer: CDPHP Medicare	$543.83
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$734.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,175.85
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,175.85
Rate for Payer: EmblemHealth Medicaid	$1,175.85
Rate for Payer: EmblemHealth Medicare	$499.74
Rate for Payer: EmblemHealth Select Care	$734.90
Rate for Payer: Fidelis Medicare	$587.92
Rate for Payer: Galaxy Health Commercial	$955.38
Rate for Payer: Hamaspik Choice Medicare	$587.92
Rate for Payer: Humana Medicare	$587.92
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,028.87
Rate for Payer: Local 1199SEIU Medicare	$676.11
Rate for Payer: MVP Health Care of NY Commercial	$955.38
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$955.38
Rate for Payer: MVP Health Care of NY Medicare	$617.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$220.47
Rate for Payer: United Healthcare Medicare	$587.92
Rate for Payer: WellCare Medicare	$808.40

Know your out-of-pocket cost for care.

All Charges