Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

TESTICULAR SCAN W/ FLOW

Facility

$105.00

Service Code	HCPCS 78761 26
Hospital Charge Code	5210036
Hospital Revenue Code	960
Min. Negotiated Rate	$68.25
Max. Negotiated Rate	$68.25
Rate for Payer: Cash Price	$78.75
Rate for Payer: Galaxy Health Commercial	$68.25

TESTICULAR SCAN W/ FLOW

Facility

$105.00

Service Code	HCPCS 78761 26
Hospital Charge Code	5210036
Hospital Revenue Code	960
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna of NY Commercial	$73.50
Rate for Payer: Aetna of NY Medicare	$48.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: CDPHP Medicare	$38.85
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$84.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$84.00
Rate for Payer: EmblemHealth Medicaid	$84.00
Rate for Payer: EmblemHealth Medicare	$35.70
Rate for Payer: Fidelis Medicare	$42.00
Rate for Payer: Galaxy Health Commercial	$68.25
Rate for Payer: Hamaspik Choice Medicare	$42.00
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$73.50
Rate for Payer: Local 1199SEIU Medicare	$48.30
Rate for Payer: MVP Health Care of NY Commercial	$78.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$59.12
Rate for Payer: MVP Health Care of NY Medicare	$44.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.75
Rate for Payer: United Healthcare Medicare	$42.00
Rate for Payer: WellCare Medicare	$57.75

TESTICULAR SCAN W/ FLOW

Facility

$1,225.00

Service Code	HCPCS 78761
Hospital Charge Code	4210036
Hospital Revenue Code	341
Min. Negotiated Rate	$796.25
Max. Negotiated Rate	$796.25
Rate for Payer: Cash Price	$918.75
Rate for Payer: Galaxy Health Commercial	$796.25

TESTICULAR SCAN W/ FLOW

Facility

$1,225.00

Service Code	HCPCS 78761
Hospital Charge Code	4210036
Hospital Revenue Code	341
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$1,545.00
Rate for Payer: Aetna of NY Commercial	$857.50
Rate for Payer: Aetna of NY Medicare	$563.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$490.00
Rate for Payer: Cash Price	$918.75
Rate for Payer: Cash Price	$918.75
Rate for Payer: CDPHP Medicare	$453.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$857.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$980.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$980.00
Rate for Payer: EmblemHealth Medicaid	$980.00
Rate for Payer: EmblemHealth Medicare	$416.50
Rate for Payer: EmblemHealth Select Care	$796.25
Rate for Payer: Fidelis Medicare	$490.00
Rate for Payer: Galaxy Health Commercial	$796.25
Rate for Payer: Hamaspik Choice Medicare	$490.00
Rate for Payer: Humana Medicare	$490.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$857.50
Rate for Payer: Local 1199SEIU Medicare	$563.50
Rate for Payer: MVP Health Care of NY Commercial	$918.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$689.67
Rate for Payer: MVP Health Care of NY Medicare	$514.50
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,545.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$183.75
Rate for Payer: United Healthcare Commercial	$1,545.00
Rate for Payer: United Healthcare Medicare	$490.00
Rate for Payer: WellCare Medicare	$673.75

TETRACAINE 0.5% 4 ML OPHTHALMIC DROPS

Facility

$32.00

Service Code	NDC 65074114
Hospital Charge Code	4409239
Hospital Revenue Code	250
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Galaxy Health Commercial	$20.80
Rate for Payer: WellCare Medicare	$17.60

TETRACAINE 0.5% 4 ML OPHTHALMIC DROPS

Facility

$32.00

Service Code	NDC 65074114
Hospital Charge Code	4409239
Hospital Revenue Code	250
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$25.60
Rate for Payer: Aetna of NY Commercial	$22.40
Rate for Payer: Aetna of NY Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: CDPHP Medicare	$11.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$25.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$25.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$25.60
Rate for Payer: EmblemHealth Medicaid	$25.60
Rate for Payer: EmblemHealth Medicare	$10.88
Rate for Payer: EmblemHealth Select Care	$23.04
Rate for Payer: Fidelis Medicare	$12.80
Rate for Payer: Galaxy Health Commercial	$20.80
Rate for Payer: Hamaspik Choice Medicare	$12.80
Rate for Payer: Humana Medicare	$12.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$22.40
Rate for Payer: Local 1199SEIU Medicare	$14.72
Rate for Payer: MVP Health Care of NY Commercial	$24.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.02
Rate for Payer: MVP Health Care of NY Medicare	$13.44
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.80
Rate for Payer: United Healthcare Medicare	$12.80
Rate for Payer: WellCare Medicare	$17.60

TETRACAINE HCL 0.005 DROP 2 ML

Facility

$33.99

Service Code	NDC 65074112
Hospital Charge Code	4400749
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$27.19
Rate for Payer: Aetna of NY Commercial	$23.79
Rate for Payer: Aetna of NY Medicare	$15.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$13.60
Rate for Payer: Cash Price	$25.49
Rate for Payer: CDPHP Medicare	$12.58
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$27.19
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$27.19
Rate for Payer: EmblemHealth Medicaid	$27.19
Rate for Payer: EmblemHealth Medicare	$11.56
Rate for Payer: EmblemHealth Select Care	$24.47
Rate for Payer: Fidelis Medicare	$13.60
Rate for Payer: Galaxy Health Commercial	$22.09
Rate for Payer: Hamaspik Choice Medicare	$13.60
Rate for Payer: Humana Medicare	$13.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$23.79
Rate for Payer: Local 1199SEIU Medicare	$15.64
Rate for Payer: MVP Health Care of NY Commercial	$25.49
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.14
Rate for Payer: MVP Health Care of NY Medicare	$14.28
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.10
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: WellCare Medicare	$18.69

TETRACAINE HCL 0.005 DROP 2 ML

Facility

$33.99

Service Code	NDC 65074112
Hospital Charge Code	4400749
Hospital Revenue Code	250
Min. Negotiated Rate	$18.69
Max. Negotiated Rate	$22.09
Rate for Payer: Cash Price	$25.49
Rate for Payer: Galaxy Health Commercial	$22.09
Rate for Payer: WellCare Medicare	$18.69

TETRACYC HCL/BIS SC/METRONID 125-140-125

Facility

$17.51

Hospital Charge Code	4400670
Hospital Revenue Code	250
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$14.01
Rate for Payer: Aetna of NY Commercial	$12.26
Rate for Payer: Aetna of NY Medicare	$8.05
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.00
Rate for Payer: Cash Price	$13.13
Rate for Payer: CDPHP Medicare	$6.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.01
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.01
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.01
Rate for Payer: EmblemHealth Medicaid	$14.01
Rate for Payer: EmblemHealth Medicare	$5.95
Rate for Payer: EmblemHealth Select Care	$12.61
Rate for Payer: Fidelis Medicare	$7.00
Rate for Payer: Galaxy Health Commercial	$11.38
Rate for Payer: Hamaspik Choice Medicare	$7.00
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.26
Rate for Payer: Local 1199SEIU Medicare	$8.05
Rate for Payer: MVP Health Care of NY Commercial	$13.13
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.86
Rate for Payer: MVP Health Care of NY Medicare	$7.35
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.63
Rate for Payer: United Healthcare Medicare	$7.00
Rate for Payer: WellCare Medicare	$9.63

TETRACYC HCL/BIS SC/METRONID 125-140-125

Facility

$17.51

Hospital Charge Code	4400670
Hospital Revenue Code	250
Min. Negotiated Rate	$9.63
Max. Negotiated Rate	$11.38
Rate for Payer: Cash Price	$13.13
Rate for Payer: Galaxy Health Commercial	$11.38
Rate for Payer: WellCare Medicare	$9.63

THEOPHYLLINE

Facility

$42.00

Service Code	HCPCS 80198
Hospital Charge Code	4300767
Hospital Revenue Code	300
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$33.60
Rate for Payer: Aetna of NY Commercial	$27.30
Rate for Payer: Aetna of NY Medicare	$19.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$16.80
Rate for Payer: Cash Price	$31.50
Rate for Payer: CDPHP Medicare	$15.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$25.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$33.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$33.60
Rate for Payer: EmblemHealth Medicaid	$33.60
Rate for Payer: EmblemHealth Medicare	$14.28
Rate for Payer: EmblemHealth Select Care	$25.20
Rate for Payer: Fidelis Medicare	$16.80
Rate for Payer: Galaxy Health Commercial	$27.30
Rate for Payer: Hamaspik Choice Medicare	$16.80
Rate for Payer: Humana Medicare	$16.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$27.30
Rate for Payer: Local 1199SEIU Medicare	$19.32
Rate for Payer: MVP Health Care of NY Commercial	$31.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$23.65
Rate for Payer: MVP Health Care of NY Medicare	$17.64
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$31.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.30
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Medicare	$16.80
Rate for Payer: WellCare Medicare	$23.10

THEOPHYLLINE

Facility

$42.00

Service Code	HCPCS 80198
Hospital Charge Code	4300767
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$27.30
Rate for Payer: Cash Price	$31.50
Rate for Payer: Galaxy Health Commercial	$27.30

THEOPHYLLINE ER 300 MG TAB 300 mg, 100 eaches

Facility

$13.00

Service Code	NDC 62332002531
Hospital Charge Code	4401318
Hospital Revenue Code	250
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$8.45
Rate for Payer: Cash Price	$9.75
Rate for Payer: Galaxy Health Commercial	$8.45
Rate for Payer: WellCare Medicare	$7.15

THEOPHYLLINE ER 300 MG TAB 300 mg, 100 eaches

Facility

$13.00

Service Code	NDC 62332002531
Hospital Charge Code	4401318
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$10.40
Rate for Payer: Aetna of NY Commercial	$9.10
Rate for Payer: Aetna of NY Medicare	$5.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.20
Rate for Payer: Cash Price	$9.75
Rate for Payer: CDPHP Medicare	$4.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$10.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$10.40
Rate for Payer: EmblemHealth Medicaid	$10.40
Rate for Payer: EmblemHealth Medicare	$4.42
Rate for Payer: EmblemHealth Select Care	$9.36
Rate for Payer: Fidelis Medicare	$5.20
Rate for Payer: Galaxy Health Commercial	$8.45
Rate for Payer: Hamaspik Choice Medicare	$5.20
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$9.10
Rate for Payer: Local 1199SEIU Medicare	$5.98
Rate for Payer: MVP Health Care of NY Commercial	$9.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$7.32
Rate for Payer: MVP Health Care of NY Medicare	$5.46
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.95
Rate for Payer: United Healthcare Medicare	$5.20
Rate for Payer: WellCare Medicare	$7.15

THEOPHYLLINE ER 400 MG TABLET 400 mg, 100 eaches

Facility

$5.00

Service Code	NDC 42858070101
Hospital Charge Code	4401555
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$3.75
Rate for Payer: Galaxy Health Commercial	$3.25
Rate for Payer: WellCare Medicare	$2.75

THEOPHYLLINE ER 400 MG TABLET 400 mg, 100 eaches

Facility

$5.00

Service Code	NDC 42858070101
Hospital Charge Code	4401555
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna of NY Commercial	$3.50
Rate for Payer: Aetna of NY Medicare	$2.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.00
Rate for Payer: Cash Price	$3.75
Rate for Payer: CDPHP Medicare	$1.85
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.00
Rate for Payer: EmblemHealth Medicaid	$4.00
Rate for Payer: EmblemHealth Medicare	$1.70
Rate for Payer: EmblemHealth Select Care	$3.60
Rate for Payer: Fidelis Medicare	$2.00
Rate for Payer: Galaxy Health Commercial	$3.25
Rate for Payer: Hamaspik Choice Medicare	$2.00
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.50
Rate for Payer: Local 1199SEIU Medicare	$2.30
Rate for Payer: MVP Health Care of NY Commercial	$3.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2.81
Rate for Payer: MVP Health Care of NY Medicare	$2.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.75
Rate for Payer: United Healthcare Medicare	$2.00
Rate for Payer: WellCare Medicare	$2.75

THERACATH EPIDURAL CATHETER EC-05000

Facility

$103.00

Hospital Charge Code	4479083
Hospital Revenue Code	270
Min. Negotiated Rate	$15.45
Max. Negotiated Rate	$82.40
Rate for Payer: Aetna of NY Commercial	$72.10
Rate for Payer: Aetna of NY Medicare	$47.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$41.20
Rate for Payer: Cash Price	$77.25
Rate for Payer: CDPHP Medicare	$38.11
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$82.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$82.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$82.40
Rate for Payer: EmblemHealth Medicaid	$82.40
Rate for Payer: EmblemHealth Medicare	$35.02
Rate for Payer: EmblemHealth Select Care	$74.16
Rate for Payer: Fidelis Medicare	$41.20
Rate for Payer: Galaxy Health Commercial	$66.95
Rate for Payer: Hamaspik Choice Medicare	$41.20
Rate for Payer: Humana Medicare	$41.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$72.10
Rate for Payer: Local 1199SEIU Medicare	$47.38
Rate for Payer: MVP Health Care of NY Commercial	$77.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$57.99
Rate for Payer: MVP Health Care of NY Medicare	$43.26
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.45
Rate for Payer: United Healthcare Medicare	$41.20
Rate for Payer: WellCare Medicare	$56.65

THERACATH EPIDURAL CATHETER EC-05000

Facility

$103.00

Hospital Charge Code	4479083
Hospital Revenue Code	270
Min. Negotiated Rate	$66.95
Max. Negotiated Rate	$66.95
Rate for Payer: Cash Price	$77.25
Rate for Payer: Galaxy Health Commercial	$66.95

THERA-COOL INTRODUCER THI-17-75-5.5

Facility

$210.12

Hospital Charge Code	4479244
Hospital Revenue Code	270
Min. Negotiated Rate	$31.52
Max. Negotiated Rate	$168.10
Rate for Payer: Aetna of NY Commercial	$147.08
Rate for Payer: Aetna of NY Medicare	$96.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$84.05
Rate for Payer: Cash Price	$157.59
Rate for Payer: CDPHP Medicare	$77.74
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$168.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$168.10
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$168.10
Rate for Payer: EmblemHealth Medicaid	$168.10
Rate for Payer: EmblemHealth Medicare	$71.44
Rate for Payer: EmblemHealth Select Care	$151.29
Rate for Payer: Fidelis Medicare	$84.05
Rate for Payer: Galaxy Health Commercial	$136.58
Rate for Payer: Hamaspik Choice Medicare	$84.05
Rate for Payer: Humana Medicare	$84.05
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$147.08
Rate for Payer: Local 1199SEIU Medicare	$96.66
Rate for Payer: MVP Health Care of NY Commercial	$157.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$118.30
Rate for Payer: MVP Health Care of NY Medicare	$88.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$31.52
Rate for Payer: United Healthcare Medicare	$84.05
Rate for Payer: WellCare Medicare	$115.57

THERA-COOL INTRODUCER THI-17-75-5.5

Facility

$210.12

Hospital Charge Code	4479244
Hospital Revenue Code	270
Min. Negotiated Rate	$136.58
Max. Negotiated Rate	$136.58
Rate for Payer: Cash Price	$157.59
Rate for Payer: Galaxy Health Commercial	$136.58

THERACOOL KIT-8451775 KIMBERLY CLARK

Facility

$3,131.20

Hospital Charge Code	4479224
Hospital Revenue Code	270
Min. Negotiated Rate	$469.68
Max. Negotiated Rate	$2,504.96
Rate for Payer: Aetna of NY Commercial	$2,191.84
Rate for Payer: Aetna of NY Medicare	$1,440.35
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,252.48
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: CDPHP Medicare	$1,158.54
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,504.96
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,504.96
Rate for Payer: EmblemHealth Medicaid	$2,504.96
Rate for Payer: EmblemHealth Medicare	$1,064.61
Rate for Payer: EmblemHealth Select Care	$2,254.46
Rate for Payer: Fidelis Medicare	$1,252.48
Rate for Payer: Galaxy Health Commercial	$2,035.28
Rate for Payer: Hamaspik Choice Medicare	$1,252.48
Rate for Payer: Humana Medicare	$1,252.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$2,191.84
Rate for Payer: Local 1199SEIU Medicare	$1,440.35
Rate for Payer: MVP Health Care of NY Commercial	$2,348.40
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,762.87
Rate for Payer: MVP Health Care of NY Medicare	$1,315.10
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$469.68
Rate for Payer: United Healthcare Medicare	$1,252.48
Rate for Payer: WellCare Medicare	$1,722.16

THERACOOL KIT-8451775 KIMBERLY CLARK

Facility

$3,131.20

Hospital Charge Code	4479224
Hospital Revenue Code	270
Min. Negotiated Rate	$2,035.28
Max. Negotiated Rate	$2,035.28
Rate for Payer: Cash Price	$2,348.40
Rate for Payer: Galaxy Health Commercial	$2,035.28

THERACOOL PROBE KIT, SINGLE-USE

Facility

$1,053.69

Hospital Charge Code	4479202
Hospital Revenue Code	272
Min. Negotiated Rate	$158.05
Max. Negotiated Rate	$842.95
Rate for Payer: Aetna of NY Commercial	$737.58
Rate for Payer: Aetna of NY Medicare	$484.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$421.48
Rate for Payer: Cash Price	$790.27
Rate for Payer: CDPHP Medicare	$389.87
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$842.95
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$842.95
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$842.95
Rate for Payer: EmblemHealth Medicaid	$842.95
Rate for Payer: EmblemHealth Medicare	$358.25
Rate for Payer: EmblemHealth Select Care	$758.66
Rate for Payer: Fidelis Medicare	$421.48
Rate for Payer: Galaxy Health Commercial	$684.90
Rate for Payer: Hamaspik Choice Medicare	$421.48
Rate for Payer: Humana Medicare	$421.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$737.58
Rate for Payer: Local 1199SEIU Medicare	$484.70
Rate for Payer: MVP Health Care of NY Commercial	$790.27
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$593.23
Rate for Payer: MVP Health Care of NY Medicare	$442.55
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$158.05
Rate for Payer: United Healthcare Medicare	$421.48
Rate for Payer: WellCare Medicare	$579.53

THERACOOL PROBE KIT, SINGLE-USE

Facility

$1,053.69

Hospital Charge Code	4479202
Hospital Revenue Code	272
Min. Negotiated Rate	$684.90
Max. Negotiated Rate	$684.90
Rate for Payer: Cash Price	$790.27
Rate for Payer: Galaxy Health Commercial	$684.90

THERAPEUTIC ACTIVITY 15 MIN

Facility

$136.00

Service Code	HCPCS 97530 GN
Hospital Charge Code	4670074
Hospital Revenue Code	440
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

Know your out-of-pocket cost for care.

All Charges