Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$1,900.00

Service Code	CPT 64640
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

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64634
Hospital Revenue Code	490
Min. Negotiated Rate	$66.24
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	$66.24
Rate for Payer: United Healthcare Commercial	$1,828.00

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT

Facility

$2,097.00

Service Code	CPT 64633
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

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,900.00

Service Code	CPT 64636
Hospital Revenue Code	490
Min. Negotiated Rate	$57.92
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	$57.92
Rate for Payer: United Healthcare Commercial	$1,828.00

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

Facility

$2,097.00

Service Code	CPT 64635
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

DETROL LA 2 MG

Facility

$38.11

Service Code	NDC 51079019701
Hospital Charge Code	4409010
Hospital Revenue Code	250
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$24.77
Rate for Payer: Cash Price	$28.58
Rate for Payer: Galaxy Health Commercial	$24.77
Rate for Payer: WellCare Medicare	$20.96

DETROL LA 2 MG

Facility

$38.11

Service Code	NDC 51079019701
Hospital Charge Code	4409010
Hospital Revenue Code	250
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$30.49
Rate for Payer: Aetna of NY Commercial	$26.68
Rate for Payer: Aetna of NY Medicare	$17.53
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$15.24
Rate for Payer: Cash Price	$28.58
Rate for Payer: CDPHP Medicare	$14.10
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$30.49
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$30.49
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$30.49
Rate for Payer: EmblemHealth Medicaid	$30.49
Rate for Payer: EmblemHealth Medicare	$12.96
Rate for Payer: EmblemHealth Select Care	$27.44
Rate for Payer: Fidelis Medicare	$15.24
Rate for Payer: Galaxy Health Commercial	$24.77
Rate for Payer: Hamaspik Choice Medicare	$15.24
Rate for Payer: Humana Medicare	$15.24
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$26.68
Rate for Payer: Local 1199SEIU Medicare	$17.53
Rate for Payer: MVP Health Care of NY Commercial	$28.58
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$21.46
Rate for Payer: MVP Health Care of NY Medicare	$16.01
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.72
Rate for Payer: United Healthcare Medicare	$15.24
Rate for Payer: WellCare Medicare	$20.96

DEVICE 5MM ENDO PEANUT LAPAR

Facility

$291.49

Hospital Charge Code	4471176
Hospital Revenue Code	270
Min. Negotiated Rate	$189.47
Max. Negotiated Rate	$189.47
Rate for Payer: Cash Price	$218.62
Rate for Payer: Galaxy Health Commercial	$189.47

DEVICE 5MM ENDO PEANUT LAPAR

Facility

$291.49

Hospital Charge Code	4471176
Hospital Revenue Code	270
Min. Negotiated Rate	$43.72
Max. Negotiated Rate	$233.19
Rate for Payer: Aetna of NY Commercial	$204.04
Rate for Payer: Aetna of NY Medicare	$134.09
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.60
Rate for Payer: Cash Price	$218.62
Rate for Payer: CDPHP Medicare	$107.85
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$233.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$233.19
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$233.19
Rate for Payer: EmblemHealth Medicaid	$233.19
Rate for Payer: EmblemHealth Medicare	$99.11
Rate for Payer: EmblemHealth Select Care	$209.87
Rate for Payer: Fidelis Medicare	$116.60
Rate for Payer: Galaxy Health Commercial	$189.47
Rate for Payer: Hamaspik Choice Medicare	$116.60
Rate for Payer: Humana Medicare	$116.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.04
Rate for Payer: Local 1199SEIU Medicare	$134.09
Rate for Payer: MVP Health Care of NY Commercial	$218.62
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$164.11
Rate for Payer: MVP Health Care of NY Medicare	$122.43
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$43.72
Rate for Payer: United Healthcare Medicare	$116.60
Rate for Payer: WellCare Medicare	$160.32

DEXAMETHASONE 0.75MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 54818025
Hospital Charge Code	4400216
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

DEXAMETHASONE 0.75MG TABS 10X10EA

Facility

$6.18

Service Code	NDC 54818025
Hospital Charge Code	4400216
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

dexAMETHasone 4 MG TABLET 4 mg, 100 eaches

Facility

$6.00

Service Code	HCPCS J8540
Hospital Charge Code	4401463
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of NY Commercial	$3.30
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.03
Rate for Payer: EmblemHealth Select Care	$0.03
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.30
Rate for Payer: WellCare Medicare	$3.30

dexAMETHasone 4 MG TABLET 4 mg, 100 eaches

Facility

$6.00

Service Code	HCPCS J8540
Hospital Charge Code	4401463
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.03
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$0.03
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.17
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Commercial	$0.17
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$0.36

Service Code	HCPCS J1100
Hospital Charge Code	4400219
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of NY Commercial	$0.20
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.27
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Galaxy Health Commercial	$0.23
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$0.20
Rate for Payer: WellCare Medicare	$0.20

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$0.36

Service Code	HCPCS J1100
Hospital Charge Code	4400219
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of NY Medicare	$0.17
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$0.14
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.27
Rate for Payer: CDPHP Medicare	$0.13
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$0.29
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$0.29
Rate for Payer: EmblemHealth Medicaid	$0.29
Rate for Payer: EmblemHealth Medicare	$0.12
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Fidelis Medicare	$0.14
Rate for Payer: Galaxy Health Commercial	$0.23
Rate for Payer: Hamaspik Choice Medicare	$0.14
Rate for Payer: Humana Medicare	$0.14
Rate for Payer: Local 1199SEIU Medicare	$0.17
Rate for Payer: MVP Health Care of NY Commercial	$0.27
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$0.20
Rate for Payer: MVP Health Care of NY Medicare	$0.15
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.20
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.05
Rate for Payer: United Healthcare Commercial	$0.20
Rate for Payer: United Healthcare Medicare	$0.14
Rate for Payer: WellCare Medicare	$0.20

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$6.00

Service Code	HCPCS J1100
Hospital Charge Code	4400217
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of NY Commercial	$3.30
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.30
Rate for Payer: WellCare Medicare	$3.30

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$6.00

Service Code	HCPCS J1100
Hospital Charge Code	4400220
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of NY Commercial	$3.30
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$3.30
Rate for Payer: WellCare Medicare	$3.30

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$6.00

Service Code	HCPCS J1100
Hospital Charge Code	4400217
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.20
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Commercial	$0.20
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

DEXAMETHASONE SODIUM PHOSPHATE, 1 MG

Facility

$6.00

Service Code	HCPCS J1100
Hospital Charge Code	4400220
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of NY Medicare	$2.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$2.40
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: CDPHP Medicare	$2.22
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$0.11
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$4.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$4.80
Rate for Payer: EmblemHealth Medicaid	$4.80
Rate for Payer: EmblemHealth Medicare	$2.04
Rate for Payer: EmblemHealth Select Care	$0.11
Rate for Payer: Fidelis Medicare	$2.40
Rate for Payer: Galaxy Health Commercial	$3.90
Rate for Payer: Hamaspik Choice Medicare	$2.40
Rate for Payer: Humana Medicare	$2.40
Rate for Payer: Local 1199SEIU Medicare	$2.76
Rate for Payer: MVP Health Care of NY Commercial	$4.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$3.38
Rate for Payer: MVP Health Care of NY Medicare	$2.52
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$0.20
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$0.90
Rate for Payer: United Healthcare Commercial	$0.20
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: WellCare Medicare	$3.30

DEXA-VERTEBRAL FRACTURE ASSES

Facility

$267.00

Service Code	HCPCS 77086
Hospital Charge Code	4150313
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

DEXA-VERTEBRAL FRACTURE ASSES

Facility

$267.00

Service Code	HCPCS 77086
Hospital Charge Code	4150313
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

DEXA-VERTEBRAL FRACTURE ASSESSMENT

Facility

$25.00

Service Code	HCPCS 77086 26
Hospital Charge Code	5150313
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

DEXA-VERTEBRAL FRACTURE ASSESSMENT

Facility

$25.00

Service Code	HCPCS 77086 26
Hospital Charge Code	5150313
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

DEXTROSE 0.4 GEL 3X37.5GM

Facility

$12.10

Service Code	NDC 574007015
Hospital Charge Code	4400334
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$9.68
Rate for Payer: Aetna of NY Commercial	$8.47
Rate for Payer: Aetna of NY Medicare	$5.57
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.84
Rate for Payer: Cash Price	$9.07
Rate for Payer: CDPHP Medicare	$4.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$9.68
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.68
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.68
Rate for Payer: EmblemHealth Medicaid	$9.68
Rate for Payer: EmblemHealth Medicare	$4.11
Rate for Payer: EmblemHealth Select Care	$8.71
Rate for Payer: Fidelis Medicare	$4.84
Rate for Payer: Galaxy Health Commercial	$7.87
Rate for Payer: Hamaspik Choice Medicare	$4.84
Rate for Payer: Humana Medicare	$4.84
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$8.47
Rate for Payer: Local 1199SEIU Medicare	$5.57
Rate for Payer: MVP Health Care of NY Commercial	$9.07
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.81
Rate for Payer: MVP Health Care of NY Medicare	$5.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.81
Rate for Payer: United Healthcare Medicare	$4.84
Rate for Payer: WellCare Medicare	$6.66

DEXTROSE 0.4 GEL 3X37.5GM

Facility

$12.10

Service Code	NDC 574007015
Hospital Charge Code	4400334
Hospital Revenue Code	250
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$9.07
Rate for Payer: Galaxy Health Commercial	$7.87
Rate for Payer: WellCare Medicare	$6.66

Know your out-of-pocket cost for care.

All Charges