Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

X-RAY JOINT SURVEY SINGLE VIEW 2+ JOINTS, RIGHT

Facility

$320.00

Service Code	HCPCS 77077 RT
Hospital Charge Code	4150524
Hospital Revenue Code	320
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Galaxy Health Commercial	$208.00

X-RAY JOINT SURVEY, SINGLE VIEW, 2+ JOINTS, RIGHT

Facility

$51.00

Service Code	HCPCS 77077 26,RT
Hospital Charge Code	5150524
Hospital Revenue Code	960
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$33.15
Rate for Payer: Cash Price	$38.25
Rate for Payer: Galaxy Health Commercial	$33.15

X-RAY JOINT SURVEY, SINGLE VIEW, 2+ JOINTS, RIGHT

Facility

$51.00

Service Code	HCPCS 77077 26,RT
Hospital Charge Code	5150524
Hospital Revenue Code	960
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$40.80
Rate for Payer: Aetna of NY Commercial	$35.70
Rate for Payer: Aetna of NY Medicare	$23.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.40
Rate for Payer: Cash Price	$38.25
Rate for Payer: CDPHP Medicare	$18.87
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$40.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$40.80
Rate for Payer: EmblemHealth Medicaid	$40.80
Rate for Payer: EmblemHealth Medicare	$17.34
Rate for Payer: Fidelis Medicare	$20.40
Rate for Payer: Galaxy Health Commercial	$33.15
Rate for Payer: Hamaspik Choice Medicare	$20.40
Rate for Payer: Humana Medicare	$20.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.70
Rate for Payer: Local 1199SEIU Medicare	$23.46
Rate for Payer: MVP Health Care of NY Commercial	$38.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$28.71
Rate for Payer: MVP Health Care of NY Medicare	$21.42
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.65
Rate for Payer: United Healthcare Medicare	$20.40
Rate for Payer: WellCare Medicare	$28.05

X-RAY OF LOWER SPINE DISK

Facility

$5,985.00

Service Code	HCPCS 72295
Hospital Charge Code	4150346
Hospital Revenue Code	320
Min. Negotiated Rate	$3,890.25
Max. Negotiated Rate	$3,890.25
Rate for Payer: Cash Price	$4,488.75
Rate for Payer: Galaxy Health Commercial	$3,890.25

X-RAY OF LOWER SPINE DISK

Facility

$123.00

Service Code	HCPCS 72295 26
Hospital Charge Code	5150346
Hospital Revenue Code	960
Min. Negotiated Rate	$79.95
Max. Negotiated Rate	$79.95
Rate for Payer: Cash Price	$92.25
Rate for Payer: Galaxy Health Commercial	$79.95

X-RAY OF LOWER SPINE DISK

Facility

$5,985.00

Service Code	HCPCS 72295
Hospital Charge Code	4150346
Hospital Revenue Code	320
Min. Negotiated Rate	$402.00
Max. Negotiated Rate	$4,788.00
Rate for Payer: Aetna of NY Commercial	$3,591.00
Rate for Payer: Aetna of NY Medicare	$2,753.10
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,394.00
Rate for Payer: Cash Price	$4,488.75
Rate for Payer: Cash Price	$4,488.75
Rate for Payer: CDPHP Medicare	$2,214.45
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,189.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4,788.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4,788.00
Rate for Payer: EmblemHealth Medicaid	$4,788.00
Rate for Payer: EmblemHealth Medicare	$2,034.90
Rate for Payer: EmblemHealth Select Care	$3,890.25
Rate for Payer: Fidelis Medicare	$2,394.00
Rate for Payer: Galaxy Health Commercial	$3,890.25
Rate for Payer: Hamaspik Choice Medicare	$2,394.00
Rate for Payer: Humana Medicare	$2,394.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,591.00
Rate for Payer: Local 1199SEIU Medicare	$2,753.10
Rate for Payer: MVP Health Care of NY Commercial	$4,488.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3,369.55
Rate for Payer: MVP Health Care of NY Medicare	$2,513.70
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$897.75
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$2,394.00
Rate for Payer: WellCare Medicare	$3,291.75

X-RAY OF LOWER SPINE DISK

Facility

$123.00

Service Code	HCPCS 72295 26
Hospital Charge Code	5150346
Hospital Revenue Code	960
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$98.40
Rate for Payer: Aetna of NY Commercial	$86.10
Rate for Payer: Aetna of NY Medicare	$56.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$49.20
Rate for Payer: Cash Price	$92.25
Rate for Payer: CDPHP Medicare	$45.51
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$98.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$98.40
Rate for Payer: EmblemHealth Medicaid	$98.40
Rate for Payer: EmblemHealth Medicare	$41.82
Rate for Payer: Fidelis Medicare	$49.20
Rate for Payer: Galaxy Health Commercial	$79.95
Rate for Payer: Hamaspik Choice Medicare	$49.20
Rate for Payer: Humana Medicare	$49.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$86.10
Rate for Payer: Local 1199SEIU Medicare	$56.58
Rate for Payer: MVP Health Care of NY Commercial	$92.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$69.25
Rate for Payer: MVP Health Care of NY Medicare	$51.66
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.45
Rate for Payer: United Healthcare Medicare	$49.20
Rate for Payer: WellCare Medicare	$67.65

X-RAY SALIVARY GLAND CALCULUS

Facility

$267.00

Service Code	HCPCS 70380 TC
Hospital Charge Code	4150511
Hospital Revenue Code	320
Min. Negotiated Rate	$173.55
Max. Negotiated Rate	$173.55
Rate for Payer: Cash Price	$200.25
Rate for Payer: Galaxy Health Commercial	$173.55

X-RAY SALIVARY GLAND CALCULUS

Facility

$267.00

Service Code	HCPCS 70380 TC
Hospital Charge Code	4150511
Hospital Revenue Code	320
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$160.20
Rate for Payer: Aetna of NY Medicare	$122.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.80
Rate for Payer: Cash Price	$200.25
Rate for Payer: Cash Price	$200.25
Rate for Payer: CDPHP Medicare	$98.79
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$186.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$213.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$213.60
Rate for Payer: EmblemHealth Medicaid	$213.60
Rate for Payer: EmblemHealth Medicare	$90.78
Rate for Payer: EmblemHealth Select Care	$173.55
Rate for Payer: Fidelis Medicare	$106.80
Rate for Payer: Galaxy Health Commercial	$173.55
Rate for Payer: Hamaspik Choice Medicare	$106.80
Rate for Payer: Humana Medicare	$106.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$160.20
Rate for Payer: Local 1199SEIU Medicare	$122.82
Rate for Payer: MVP Health Care of NY Commercial	$200.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$150.32
Rate for Payer: MVP Health Care of NY Medicare	$112.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

X-RAY SALIVARY GLAND CALCULUS

Facility

$25.00

Service Code	HCPCS 70380 26
Hospital Charge Code	5150511
Hospital Revenue Code	960
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$16.25
Rate for Payer: Cash Price	$18.75
Rate for Payer: Galaxy Health Commercial	$16.25

X-RAY SALIVARY GLAND CALCULUS

Facility

$25.00

Service Code	HCPCS 70380 26
Hospital Charge Code	5150511
Hospital Revenue Code	960
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of NY Commercial	$17.50
Rate for Payer: Aetna of NY Medicare	$11.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.00
Rate for Payer: Cash Price	$18.75
Rate for Payer: CDPHP Medicare	$9.25
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$20.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$20.00
Rate for Payer: EmblemHealth Medicaid	$20.00
Rate for Payer: EmblemHealth Medicare	$8.50
Rate for Payer: Fidelis Medicare	$10.00
Rate for Payer: Galaxy Health Commercial	$16.25
Rate for Payer: Hamaspik Choice Medicare	$10.00
Rate for Payer: Humana Medicare	$10.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$17.50
Rate for Payer: Local 1199SEIU Medicare	$11.50
Rate for Payer: MVP Health Care of NY Commercial	$18.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$14.07
Rate for Payer: MVP Health Care of NY Medicare	$10.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.75
Rate for Payer: United Healthcare Medicare	$10.00
Rate for Payer: WellCare Medicare	$13.75

XS LEFT COMFORTFORM WRIST

Facility

$43.26

Hospital Charge Code	4471569
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$34.61
Rate for Payer: Aetna of NY Commercial	$30.28
Rate for Payer: Aetna of NY Medicare	$19.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$17.30
Rate for Payer: Cash Price	$32.44
Rate for Payer: CDPHP Medicare	$16.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$34.61
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$34.61
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$34.61
Rate for Payer: EmblemHealth Medicaid	$34.61
Rate for Payer: EmblemHealth Medicare	$14.71
Rate for Payer: EmblemHealth Select Care	$31.15
Rate for Payer: Fidelis Medicare	$17.30
Rate for Payer: Galaxy Health Commercial	$28.12
Rate for Payer: Hamaspik Choice Medicare	$17.30
Rate for Payer: Humana Medicare	$17.30
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$30.28
Rate for Payer: Local 1199SEIU Medicare	$19.90
Rate for Payer: MVP Health Care of NY Commercial	$32.45
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$24.36
Rate for Payer: MVP Health Care of NY Medicare	$18.17
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.49
Rate for Payer: United Healthcare Medicare	$17.30
Rate for Payer: WellCare Medicare	$23.79

XS LEFT COMFORTFORM WRIST

Facility

$43.26

Hospital Charge Code	4471569
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

XS RIGHT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471564
Hospital Revenue Code	270
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$18.08
Rate for Payer: Cash Price	$20.86
Rate for Payer: Galaxy Health Commercial	$18.08

XS RIGHT COMFORTFORM WRIST

Facility

$27.81

Hospital Charge Code	4471564
Hospital Revenue Code	270
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$22.25
Rate for Payer: Aetna of NY Commercial	$19.47
Rate for Payer: Aetna of NY Medicare	$12.79
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.12
Rate for Payer: Cash Price	$20.86
Rate for Payer: CDPHP Medicare	$10.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$22.25
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$22.25
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.25
Rate for Payer: EmblemHealth Medicaid	$22.25
Rate for Payer: EmblemHealth Medicare	$9.46
Rate for Payer: EmblemHealth Select Care	$20.02
Rate for Payer: Fidelis Medicare	$11.12
Rate for Payer: Galaxy Health Commercial	$18.08
Rate for Payer: Hamaspik Choice Medicare	$11.12
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$19.47
Rate for Payer: Local 1199SEIU Medicare	$12.79
Rate for Payer: MVP Health Care of NY Commercial	$20.86
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.66
Rate for Payer: MVP Health Care of NY Medicare	$11.68
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.17
Rate for Payer: United Healthcare Medicare	$11.12
Rate for Payer: WellCare Medicare	$15.30

XS SPECIALTY ARM SLING

Facility

$14.42

Hospital Charge Code	4471555
Hospital Revenue Code	270
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$9.37
Rate for Payer: Cash Price	$10.82
Rate for Payer: Galaxy Health Commercial	$9.37

XS SPECIALTY ARM SLING

Facility

$14.42

Hospital Charge Code	4471555
Hospital Revenue Code	270
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$11.54
Rate for Payer: Aetna of NY Commercial	$10.09
Rate for Payer: Aetna of NY Medicare	$6.63
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$5.77
Rate for Payer: Cash Price	$10.82
Rate for Payer: CDPHP Medicare	$5.34
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.54
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$11.54
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$11.54
Rate for Payer: EmblemHealth Medicaid	$11.54
Rate for Payer: EmblemHealth Medicare	$4.90
Rate for Payer: EmblemHealth Select Care	$10.38
Rate for Payer: Fidelis Medicare	$5.77
Rate for Payer: Galaxy Health Commercial	$9.37
Rate for Payer: Hamaspik Choice Medicare	$5.77
Rate for Payer: Humana Medicare	$5.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.09
Rate for Payer: Local 1199SEIU Medicare	$6.63
Rate for Payer: MVP Health Care of NY Commercial	$10.81
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.12
Rate for Payer: MVP Health Care of NY Medicare	$6.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.16
Rate for Payer: United Healthcare Medicare	$5.77
Rate for Payer: WellCare Medicare	$7.93

XXL GOWN

Facility

$15.45

Hospital Charge Code	4479185
Hospital Revenue Code	270
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$10.04
Rate for Payer: Cash Price	$11.59
Rate for Payer: Galaxy Health Commercial	$10.04

XXL GOWN

Facility

$15.45

Hospital Charge Code	4479185
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$12.36
Rate for Payer: Aetna of NY Commercial	$10.81
Rate for Payer: Aetna of NY Medicare	$7.11
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.18
Rate for Payer: Cash Price	$11.59
Rate for Payer: CDPHP Medicare	$5.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$12.36
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$12.36
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$12.36
Rate for Payer: EmblemHealth Medicaid	$12.36
Rate for Payer: EmblemHealth Medicare	$5.25
Rate for Payer: EmblemHealth Select Care	$11.12
Rate for Payer: Fidelis Medicare	$6.18
Rate for Payer: Galaxy Health Commercial	$10.04
Rate for Payer: Hamaspik Choice Medicare	$6.18
Rate for Payer: Humana Medicare	$6.18
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$10.81
Rate for Payer: Local 1199SEIU Medicare	$7.11
Rate for Payer: MVP Health Care of NY Commercial	$11.59
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$8.70
Rate for Payer: MVP Health Care of NY Medicare	$6.49
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.32
Rate for Payer: United Healthcare Medicare	$6.18
Rate for Payer: WellCare Medicare	$8.50

XXL UNIVER KNEE WRAP CLOSED P

Facility

$52.53

Hospital Charge Code	4471545
Hospital Revenue Code	270
Min. Negotiated Rate	$34.14
Max. Negotiated Rate	$34.14
Rate for Payer: Cash Price	$39.40
Rate for Payer: Galaxy Health Commercial	$34.14

XXL UNIVER KNEE WRAP CLOSED P

Facility

$52.53

Hospital Charge Code	4471545
Hospital Revenue Code	270
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$42.02
Rate for Payer: Aetna of NY Commercial	$36.77
Rate for Payer: Aetna of NY Medicare	$24.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.01
Rate for Payer: Cash Price	$39.40
Rate for Payer: CDPHP Medicare	$19.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$42.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$42.02
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$42.02
Rate for Payer: EmblemHealth Medicaid	$42.02
Rate for Payer: EmblemHealth Medicare	$17.86
Rate for Payer: EmblemHealth Select Care	$37.82
Rate for Payer: Fidelis Medicare	$21.01
Rate for Payer: Galaxy Health Commercial	$34.14
Rate for Payer: Hamaspik Choice Medicare	$21.01
Rate for Payer: Humana Medicare	$21.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$36.77
Rate for Payer: Local 1199SEIU Medicare	$24.16
Rate for Payer: MVP Health Care of NY Commercial	$39.40
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.57
Rate for Payer: MVP Health Care of NY Medicare	$22.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.88
Rate for Payer: United Healthcare Medicare	$21.01
Rate for Payer: WellCare Medicare	$28.89

XYLOCAINE 2% 10ML INJ

Facility

$11.07

Service Code	NDC 63323048617
Hospital Charge Code	4409205
Hospital Revenue Code	250
Min. Negotiated Rate	$6.09
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$8.30
Rate for Payer: Galaxy Health Commercial	$7.20
Rate for Payer: WellCare Medicare	$6.09

XYLOCAINE 2% 10ML INJ

Facility

$11.07

Service Code	NDC 63323048617
Hospital Charge Code	4409205
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$8.86
Rate for Payer: Aetna of NY Commercial	$7.75
Rate for Payer: Aetna of NY Medicare	$5.09
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.43
Rate for Payer: Cash Price	$8.30
Rate for Payer: CDPHP Medicare	$4.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8.86
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.86
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.86
Rate for Payer: EmblemHealth Medicaid	$8.86
Rate for Payer: EmblemHealth Medicare	$3.76
Rate for Payer: EmblemHealth Select Care	$7.97
Rate for Payer: Fidelis Medicare	$4.43
Rate for Payer: Galaxy Health Commercial	$7.20
Rate for Payer: Hamaspik Choice Medicare	$4.43
Rate for Payer: Humana Medicare	$4.43
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.75
Rate for Payer: Local 1199SEIU Medicare	$5.09
Rate for Payer: MVP Health Care of NY Commercial	$8.30
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.23
Rate for Payer: MVP Health Care of NY Medicare	$4.65
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.66
Rate for Payer: United Healthcare Medicare	$4.43
Rate for Payer: WellCare Medicare	$6.09

XYLOCAINE MPF .01 INJ 5ML

Facility

$35.15

Service Code	NDC 63323049257
Hospital Charge Code	4409193
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$28.12
Rate for Payer: Aetna of NY Commercial	$24.61
Rate for Payer: Aetna of NY Medicare	$16.17
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.06
Rate for Payer: Cash Price	$26.36
Rate for Payer: CDPHP Medicare	$13.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$28.12
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$28.12
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$28.12
Rate for Payer: EmblemHealth Medicaid	$28.12
Rate for Payer: EmblemHealth Medicare	$11.95
Rate for Payer: EmblemHealth Select Care	$25.31
Rate for Payer: Fidelis Medicare	$14.06
Rate for Payer: Galaxy Health Commercial	$22.85
Rate for Payer: Hamaspik Choice Medicare	$14.06
Rate for Payer: Humana Medicare	$14.06
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.61
Rate for Payer: Local 1199SEIU Medicare	$16.17
Rate for Payer: MVP Health Care of NY Commercial	$26.36
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$19.79
Rate for Payer: MVP Health Care of NY Medicare	$14.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.27
Rate for Payer: United Healthcare Medicare	$14.06
Rate for Payer: WellCare Medicare	$19.33

XYLOCAINE MPF .01 INJ 5ML

Facility

$35.15

Service Code	NDC 63323049257
Hospital Charge Code	4409193
Hospital Revenue Code	250
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$22.85
Rate for Payer: Cash Price	$26.36
Rate for Payer: Galaxy Health Commercial	$22.85
Rate for Payer: WellCare Medicare	$19.33

Know your out-of-pocket cost for care.

All Charges