Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DEB MUSC/FASCIA 20 SQ CM/<

Facility

$2,265.00

Service Code	HCPCS 11043
Hospital Charge Code	4850259
Hospital Revenue Code	761
Min. Negotiated Rate	$339.75
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna of NY Commercial	$1,585.50
Rate for Payer: Aetna of NY Medicare	$1,041.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$906.00
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: CDPHP Medicare	$838.05
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,812.00
Rate for Payer: EmblemHealth Medicaid	$1,812.00
Rate for Payer: EmblemHealth Medicare	$770.10
Rate for Payer: EmblemHealth Select Care	$1,630.80
Rate for Payer: Fidelis Medicare	$906.00
Rate for Payer: Galaxy Health Commercial	$1,472.25
Rate for Payer: Hamaspik Choice Medicare	$906.00
Rate for Payer: Humana Medicare	$906.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,585.50
Rate for Payer: Local 1199SEIU Medicare	$1,041.90
Rate for Payer: MVP Health Care of NY Commercial	$1,698.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,275.19
Rate for Payer: MVP Health Care of NY Medicare	$951.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$339.75
Rate for Payer: United Healthcare Medicare	$906.00
Rate for Payer: WellCare Medicare	$1,245.75

DEB MUSC/FASCIA 20 SQ CM/<

Facility

$2,265.00

Service Code	HCPCS 11043
Hospital Charge Code	4850259
Hospital Revenue Code	761
Min. Negotiated Rate	$1,472.25
Max. Negotiated Rate	$1,472.25
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: Galaxy Health Commercial	$1,472.25

DEB MUSC/FASCIA 20 SQ CM/<

Facility

$2,265.00

Service Code	HCPCS 11043
Hospital Charge Code	4856685
Hospital Revenue Code	761
Min. Negotiated Rate	$1,472.25
Max. Negotiated Rate	$1,472.25
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: Galaxy Health Commercial	$1,472.25

DEB MUSC/FASCIA 20 SQ CM/<

Facility

$2,265.00

Service Code	HCPCS 11043
Hospital Charge Code	4856685
Hospital Revenue Code	761
Min. Negotiated Rate	$339.75
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna of NY Commercial	$1,585.50
Rate for Payer: Aetna of NY Medicare	$1,041.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$906.00
Rate for Payer: Cash Price	$1,698.75
Rate for Payer: CDPHP Medicare	$838.05
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,812.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,812.00
Rate for Payer: EmblemHealth Medicaid	$1,812.00
Rate for Payer: EmblemHealth Medicare	$770.10
Rate for Payer: EmblemHealth Select Care	$1,630.80
Rate for Payer: Fidelis Medicare	$906.00
Rate for Payer: Galaxy Health Commercial	$1,472.25
Rate for Payer: Hamaspik Choice Medicare	$906.00
Rate for Payer: Humana Medicare	$906.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,585.50
Rate for Payer: Local 1199SEIU Medicare	$1,041.90
Rate for Payer: MVP Health Care of NY Commercial	$1,698.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,275.19
Rate for Payer: MVP Health Care of NY Medicare	$951.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$339.75
Rate for Payer: United Healthcare Medicare	$906.00
Rate for Payer: WellCare Medicare	$1,245.75

DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/<

Facility

$5,062.00

Service Code	HCPCS 11044
Hospital Charge Code	4856686
Hospital Revenue Code	761
Min. Negotiated Rate	$759.30
Max. Negotiated Rate	$4,049.60
Rate for Payer: Aetna of NY Commercial	$3,543.40
Rate for Payer: Aetna of NY Medicare	$2,328.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2,024.80
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: CDPHP Medicare	$1,872.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$4,049.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4,049.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4,049.60
Rate for Payer: EmblemHealth Medicaid	$4,049.60
Rate for Payer: EmblemHealth Medicare	$1,721.08
Rate for Payer: EmblemHealth Select Care	$3,644.64
Rate for Payer: Fidelis Medicare	$2,024.80
Rate for Payer: Galaxy Health Commercial	$3,290.30
Rate for Payer: Hamaspik Choice Medicare	$2,024.80
Rate for Payer: Humana Medicare	$2,024.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3,543.40
Rate for Payer: Local 1199SEIU Medicare	$2,328.52
Rate for Payer: MVP Health Care of NY Commercial	$3,796.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$2,849.91
Rate for Payer: MVP Health Care of NY Medicare	$2,126.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$759.30
Rate for Payer: United Healthcare Medicare	$2,024.80
Rate for Payer: WellCare Medicare	$2,784.10

DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/<

Facility

$5,062.00

Service Code	HCPCS 11044
Hospital Charge Code	4856686
Hospital Revenue Code	761
Min. Negotiated Rate	$3,290.30
Max. Negotiated Rate	$3,290.30
Rate for Payer: Cash Price	$3,796.50
Rate for Payer: Galaxy Health Commercial	$3,290.30

DEBRIDEMENT OF NAIL

Facility

$181.00

Service Code	HCPCS 11720
Hospital Charge Code	4609569
Hospital Revenue Code	450
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$1,234.00
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: Cash Price	$135.75
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

DEBRIDEMENT OF NAIL

Facility

$181.00

Service Code	HCPCS 11720
Hospital Charge Code	4609569
Hospital Revenue Code	450
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

DEBRIDE NAIL 1-5

Facility

$181.00

Service Code	HCPCS 11720
Hospital Charge Code	4855443
Hospital Revenue Code	761
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$144.80
Rate for Payer: Aetna of NY Commercial	$126.70
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$144.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$130.32
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$126.70
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$135.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$101.90
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

DEBRIDE NAIL 1-5

Facility

$181.00

Service Code	HCPCS 11720
Hospital Charge Code	4855443
Hospital Revenue Code	761
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

DEBRIDE NAIL 6 OR MORE

Facility

$181.00

Service Code	HCPCS 11721
Hospital Charge Code	4855442
Hospital Revenue Code	761
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$117.65
Rate for Payer: Cash Price	$135.75
Rate for Payer: Galaxy Health Commercial	$117.65

DEBRIDE NAIL 6 OR MORE

Facility

$181.00

Service Code	HCPCS 11721
Hospital Charge Code	4855442
Hospital Revenue Code	761
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$144.80
Rate for Payer: Aetna of NY Commercial	$126.70
Rate for Payer: Aetna of NY Medicare	$83.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$72.40
Rate for Payer: Cash Price	$135.75
Rate for Payer: CDPHP Medicare	$66.97
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$144.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$144.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$144.80
Rate for Payer: EmblemHealth Medicaid	$144.80
Rate for Payer: EmblemHealth Medicare	$61.54
Rate for Payer: EmblemHealth Select Care	$130.32
Rate for Payer: Fidelis Medicare	$72.40
Rate for Payer: Galaxy Health Commercial	$117.65
Rate for Payer: Hamaspik Choice Medicare	$72.40
Rate for Payer: Humana Medicare	$72.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$126.70
Rate for Payer: Local 1199SEIU Medicare	$83.26
Rate for Payer: MVP Health Care of NY Commercial	$135.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$101.90
Rate for Payer: MVP Health Care of NY Medicare	$76.02
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$27.15
Rate for Payer: United Healthcare Medicare	$72.40
Rate for Payer: WellCare Medicare	$99.55

DEB SUBQ TISSUE 20 SQ CM/<

Facility

$1,246.00

Service Code	HCPCS 11042
Hospital Charge Code	4856548
Hospital Revenue Code	761
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$996.80
Rate for Payer: Aetna of NY Commercial	$872.20
Rate for Payer: Aetna of NY Medicare	$573.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$498.40
Rate for Payer: Cash Price	$934.50
Rate for Payer: CDPHP Medicare	$461.02
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$996.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$996.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$996.80
Rate for Payer: EmblemHealth Medicaid	$996.80
Rate for Payer: EmblemHealth Medicare	$423.64
Rate for Payer: EmblemHealth Select Care	$897.12
Rate for Payer: Fidelis Medicare	$498.40
Rate for Payer: Galaxy Health Commercial	$809.90
Rate for Payer: Hamaspik Choice Medicare	$498.40
Rate for Payer: Humana Medicare	$498.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$872.20
Rate for Payer: Local 1199SEIU Medicare	$573.16
Rate for Payer: MVP Health Care of NY Commercial	$934.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$701.50
Rate for Payer: MVP Health Care of NY Medicare	$523.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$186.90
Rate for Payer: United Healthcare Medicare	$498.40
Rate for Payer: WellCare Medicare	$685.30

DEB SUBQ TISSUE 20 SQ CM/<

Facility

$1,246.00

Service Code	HCPCS 11042
Hospital Charge Code	4856548
Hospital Revenue Code	761
Min. Negotiated Rate	$809.90
Max. Negotiated Rate	$809.90
Rate for Payer: Cash Price	$934.50
Rate for Payer: Galaxy Health Commercial	$809.90

DECALCIFICATION PROCEDURE

Facility

$64.00

Service Code	HCPCS 88311 TC
Hospital Charge Code	4008311
Hospital Revenue Code	312
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$51.20
Rate for Payer: Aetna of NY Commercial	$41.60
Rate for Payer: Aetna of NY Medicare	$29.44
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$25.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: CDPHP Medicare	$23.68
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$38.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$51.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$51.20
Rate for Payer: EmblemHealth Medicaid	$51.20
Rate for Payer: EmblemHealth Medicare	$21.76
Rate for Payer: EmblemHealth Select Care	$38.40
Rate for Payer: Fidelis Medicare	$25.60
Rate for Payer: Galaxy Health Commercial	$41.60
Rate for Payer: Hamaspik Choice Medicare	$25.60
Rate for Payer: Humana Medicare	$25.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$41.60
Rate for Payer: Local 1199SEIU Medicare	$29.44
Rate for Payer: MVP Health Care of NY Commercial	$48.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$36.03
Rate for Payer: MVP Health Care of NY Medicare	$26.88
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$48.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.60
Rate for Payer: United Healthcare Commercial	$48.00
Rate for Payer: United Healthcare Medicare	$25.60
Rate for Payer: WellCare Medicare	$35.20

DECALCIFICATION PROCEDURE

Facility

$64.00

Service Code	HCPCS 88311 TC
Hospital Charge Code	4008311
Hospital Revenue Code	312
Min. Negotiated Rate	$41.60
Max. Negotiated Rate	$41.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Galaxy Health Commercial	$41.60

DELIVERY OF PLACENTA

Facility

$9,922.00

Service Code	HCPCS 59414
Hospital Charge Code	4602215
Hospital Revenue Code	450
Min. Negotiated Rate	$925.00
Max. Negotiated Rate	$7,937.60
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$4,564.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,968.80
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: CDPHP Medicare	$3,671.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,937.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,937.60
Rate for Payer: EmblemHealth Medicaid	$7,937.60
Rate for Payer: EmblemHealth Medicare	$3,373.48
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$3,968.80
Rate for Payer: Galaxy Health Commercial	$6,449.30
Rate for Payer: Hamaspik Choice Medicare	$3,968.80
Rate for Payer: Humana Medicare	$3,968.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$4,564.12
Rate for Payer: MVP Health Care of NY Commercial	$1,234.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$925.00
Rate for Payer: MVP Health Care of NY Medicare	$4,167.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,488.30
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$3,968.80
Rate for Payer: WellCare Medicare	$5,457.10

DELIVERY OF PLACENTA

Facility

$9,922.00

Service Code	HCPCS 59414
Hospital Charge Code	4602215
Hospital Revenue Code	450
Min. Negotiated Rate	$6,449.30
Max. Negotiated Rate	$6,449.30
Rate for Payer: Cash Price	$7,441.50
Rate for Payer: Galaxy Health Commercial	$6,449.30

DELZICOL 400 MG CAPSULE

Facility

$11.07

Service Code	NDC 23585318
Hospital Charge Code	4409133
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

DELZICOL 400 MG CAPSULE

Facility

$11.07

Service Code	NDC 23585318
Hospital Charge Code	4409133
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

DEPAKOTE LEVEL/VALPORIC ACID (VALPORATE)

Facility

$52.00

Service Code	HCPCS 80164
Hospital Charge Code	4300820
Hospital Revenue Code	300
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$41.60
Rate for Payer: Aetna of NY Commercial	$33.80
Rate for Payer: Aetna of NY Medicare	$23.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$20.80
Rate for Payer: Cash Price	$39.00
Rate for Payer: CDPHP Medicare	$19.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$31.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$41.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$41.60
Rate for Payer: EmblemHealth Medicaid	$41.60
Rate for Payer: EmblemHealth Medicare	$17.68
Rate for Payer: EmblemHealth Select Care	$31.20
Rate for Payer: Fidelis Medicare	$20.80
Rate for Payer: Galaxy Health Commercial	$33.80
Rate for Payer: Hamaspik Choice Medicare	$20.80
Rate for Payer: Humana Medicare	$20.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$33.80
Rate for Payer: Local 1199SEIU Medicare	$23.92
Rate for Payer: MVP Health Care of NY Commercial	$39.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$29.28
Rate for Payer: MVP Health Care of NY Medicare	$21.84
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$39.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$7.80
Rate for Payer: United Healthcare Commercial	$39.00
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: WellCare Medicare	$28.60

DEPAKOTE LEVEL/VALPORIC ACID (VALPORATE)

Facility

$52.00

Service Code	HCPCS 80164
Hospital Charge Code	4300820
Hospital Revenue Code	300
Min. Negotiated Rate	$33.80
Max. Negotiated Rate	$33.80
Rate for Payer: Cash Price	$39.00
Rate for Payer: Galaxy Health Commercial	$33.80

DESTRUCT B9 LESION 1-14

Facility

$615.00

Service Code	HCPCS 17110
Hospital Charge Code	4856727
Hospital Revenue Code	761
Min. Negotiated Rate	$92.25
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna of NY Commercial	$430.50
Rate for Payer: Aetna of NY Medicare	$282.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$246.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: CDPHP Medicare	$227.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$492.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$492.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$492.00
Rate for Payer: EmblemHealth Medicaid	$492.00
Rate for Payer: EmblemHealth Medicare	$209.10
Rate for Payer: EmblemHealth Select Care	$442.80
Rate for Payer: Fidelis Medicare	$246.00
Rate for Payer: Galaxy Health Commercial	$399.75
Rate for Payer: Hamaspik Choice Medicare	$246.00
Rate for Payer: Humana Medicare	$246.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.50
Rate for Payer: Local 1199SEIU Medicare	$282.90
Rate for Payer: MVP Health Care of NY Commercial	$461.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$346.25
Rate for Payer: MVP Health Care of NY Medicare	$258.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$92.25
Rate for Payer: United Healthcare Medicare	$246.00
Rate for Payer: WellCare Medicare	$338.25

DESTRUCT B9 LESION 1-14

Facility

$615.00

Service Code	HCPCS 17110
Hospital Charge Code	4856727
Hospital Revenue Code	761
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$399.75
Rate for Payer: Cash Price	$461.25
Rate for Payer: Galaxy Health Commercial	$399.75

DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$2,097.00

Service Code	CPT 64624
Hospital Revenue Code	490
Min. Negotiated Rate	$1,839.63
Max. Negotiated Rate	$2,097.00
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	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,839.63
Rate for Payer: United Healthcare Commercial	$2,097.00

Know your out-of-pocket cost for care.

All Charges