Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE

Facility

$6,407.00

Service Code	HCPCS 54700
Hospital Charge Code	4002055
Hospital Revenue Code	490
Min. Negotiated Rate	$4,164.55
Max. Negotiated Rate	$4,164.55
Rate for Payer: Cash Price	$4,805.25
Rate for Payer: Galaxy Health Commercial	$4,164.55

I&D HEMATOMA/FLUID

Facility

$5,062.00

Service Code	HCPCS 10140
Hospital Charge Code	4856684
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

I&D HEMATOMA/FLUID

Facility

$5,062.00

Service Code	HCPCS 10140
Hospital Charge Code	4856684
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

I & D HEMATOMA SEROMA FLUID

Facility

$5,062.00

Service Code	HCPCS 10140
Hospital Charge Code	4600103
Hospital Revenue Code	450
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

I & D HEMATOMA SEROMA FLUID

Facility

$5,062.00

Service Code	HCPCS 10140
Hospital Charge Code	4600103
Hospital Revenue Code	450
Min. Negotiated Rate	$759.30
Max. Negotiated Rate	$4,049.60
Rate for Payer: Aetna of NY Commercial	$1,000.00
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: Cash Price	$3,796.50
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	$1,206.00
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	$1,085.00
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	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$2,328.52
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	$2,126.04
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$759.30
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$2,024.80
Rate for Payer: WellCare Medicare	$2,784.10

I&D LEG/ANKLE DEEP ABSC/HEMATOMA

Facility

$8,903.00

Service Code	HCPCS 27603
Hospital Charge Code	4602152
Hospital Revenue Code	450
Min. Negotiated Rate	$5,786.95
Max. Negotiated Rate	$5,786.95
Rate for Payer: Cash Price	$6,677.25
Rate for Payer: Galaxy Health Commercial	$5,786.95

I&D LEG/ANKLE DEEP ABSC/HEMATOMA

Facility

$8,903.00

Service Code	HCPCS 27603
Hospital Charge Code	4602152
Hospital Revenue Code	450
Min. Negotiated Rate	$925.00
Max. Negotiated Rate	$7,122.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$4,095.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$3,561.20
Rate for Payer: Cash Price	$6,677.25
Rate for Payer: Cash Price	$6,677.25
Rate for Payer: Cash Price	$6,677.25
Rate for Payer: CDPHP Medicare	$3,294.11
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$7,122.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$7,122.40
Rate for Payer: EmblemHealth Medicaid	$7,122.40
Rate for Payer: EmblemHealth Medicare	$3,027.02
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$3,561.20
Rate for Payer: Galaxy Health Commercial	$5,786.95
Rate for Payer: Hamaspik Choice Medicare	$3,561.20
Rate for Payer: Humana Medicare	$3,561.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$4,095.38
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	$3,739.26
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,335.45
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$3,561.20
Rate for Payer: WellCare Medicare	$4,896.65

I&D OF PILONIDAL CYST; SIMPLE

Facility

$2,170.00

Service Code	HCPCS 10080
Hospital Charge Code	4850301
Hospital Revenue Code	761
Min. Negotiated Rate	$1,410.50
Max. Negotiated Rate	$1,410.50
Rate for Payer: Cash Price	$1,627.50
Rate for Payer: Galaxy Health Commercial	$1,410.50

I&D OF PILONIDAL CYST; SIMPLE

Facility

$2,170.00

Service Code	HCPCS 10080
Hospital Charge Code	4850301
Hospital Revenue Code	761
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,736.00
Rate for Payer: Aetna of NY Commercial	$1,519.00
Rate for Payer: Aetna of NY Medicare	$998.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$868.00
Rate for Payer: Cash Price	$1,627.50
Rate for Payer: CDPHP Medicare	$802.90
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,736.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,736.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,736.00
Rate for Payer: EmblemHealth Medicaid	$1,736.00
Rate for Payer: EmblemHealth Medicare	$737.80
Rate for Payer: EmblemHealth Select Care	$1,562.40
Rate for Payer: Fidelis Medicare	$868.00
Rate for Payer: Galaxy Health Commercial	$1,410.50
Rate for Payer: Hamaspik Choice Medicare	$868.00
Rate for Payer: Humana Medicare	$868.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,519.00
Rate for Payer: Local 1199SEIU Medicare	$998.20
Rate for Payer: MVP Health Care of NY Commercial	$1,627.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,221.71
Rate for Payer: MVP Health Care of NY Medicare	$911.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$325.50
Rate for Payer: United Healthcare Medicare	$868.00
Rate for Payer: WellCare Medicare	$1,193.50

I&D TRAY ER

Facility

$37.08

Hospital Charge Code	4609641
Hospital Revenue Code	270
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of NY Commercial	$25.96
Rate for Payer: Aetna of NY Medicare	$17.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.83
Rate for Payer: Cash Price	$27.81
Rate for Payer: CDPHP Medicare	$13.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$29.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$29.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$29.66
Rate for Payer: EmblemHealth Medicaid	$29.66
Rate for Payer: EmblemHealth Medicare	$12.61
Rate for Payer: EmblemHealth Select Care	$26.70
Rate for Payer: Fidelis Medicare	$14.83
Rate for Payer: Galaxy Health Commercial	$24.10
Rate for Payer: Hamaspik Choice Medicare	$14.83
Rate for Payer: Humana Medicare	$14.83
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$25.96
Rate for Payer: Local 1199SEIU Medicare	$17.06
Rate for Payer: MVP Health Care of NY Commercial	$27.81
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.88
Rate for Payer: MVP Health Care of NY Medicare	$15.57
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.56
Rate for Payer: United Healthcare Medicare	$14.83
Rate for Payer: WellCare Medicare	$20.39

I&D TRAY ER

Facility

$37.08

Hospital Charge Code	4609641
Hospital Revenue Code	270
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$24.10
Rate for Payer: Cash Price	$27.81
Rate for Payer: Galaxy Health Commercial	$24.10

IGA QUANT CSF

Facility

$28.00

Service Code	HCPCS 82784
Hospital Charge Code	4300462
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$18.20
Rate for Payer: Cash Price	$21.00
Rate for Payer: Galaxy Health Commercial	$18.20

IGA QUANT CSF

Facility

$28.00

Service Code	HCPCS 82784
Hospital Charge Code	4300462
Hospital Revenue Code	301
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of NY Commercial	$18.20
Rate for Payer: Aetna of NY Medicare	$12.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$11.20
Rate for Payer: Cash Price	$21.00
Rate for Payer: CDPHP Medicare	$10.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$16.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$22.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.40
Rate for Payer: EmblemHealth Medicaid	$22.40
Rate for Payer: EmblemHealth Medicare	$9.52
Rate for Payer: EmblemHealth Select Care	$16.80
Rate for Payer: Fidelis Medicare	$11.20
Rate for Payer: Galaxy Health Commercial	$18.20
Rate for Payer: Hamaspik Choice Medicare	$11.20
Rate for Payer: Humana Medicare	$11.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.20
Rate for Payer: Local 1199SEIU Medicare	$12.88
Rate for Payer: MVP Health Care of NY Commercial	$21.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.76
Rate for Payer: MVP Health Care of NY Medicare	$11.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$21.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.20
Rate for Payer: United Healthcare Commercial	$21.00
Rate for Payer: United Healthcare Medicare	$11.20
Rate for Payer: WellCare Medicare	$15.40

IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE

Facility

$2,170.00

Service Code	HCPCS 10030
Hospital Charge Code	4201075
Hospital Revenue Code	402
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$1,736.00
Rate for Payer: Aetna of NY Commercial	$1,519.00
Rate for Payer: Aetna of NY Medicare	$998.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$868.00
Rate for Payer: Cash Price	$1,627.50
Rate for Payer: Cash Price	$1,627.50
Rate for Payer: CDPHP Medicare	$802.90
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,519.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$1,736.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$1,736.00
Rate for Payer: EmblemHealth Medicaid	$1,736.00
Rate for Payer: EmblemHealth Medicare	$737.80
Rate for Payer: EmblemHealth Select Care	$1,410.50
Rate for Payer: Fidelis Medicare	$868.00
Rate for Payer: Galaxy Health Commercial	$1,410.50
Rate for Payer: Hamaspik Choice Medicare	$868.00
Rate for Payer: Humana Medicare	$868.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,519.00
Rate for Payer: Local 1199SEIU Medicare	$998.20
Rate for Payer: MVP Health Care of NY Commercial	$1,627.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,221.71
Rate for Payer: MVP Health Care of NY Medicare	$911.40
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$325.50
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$868.00
Rate for Payer: WellCare Medicare	$1,193.50

IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE

Facility

$2,170.00

Service Code	HCPCS 10030
Hospital Charge Code	4201075
Hospital Revenue Code	402
Min. Negotiated Rate	$1,410.50
Max. Negotiated Rate	$1,410.50
Rate for Payer: Cash Price	$1,627.50
Rate for Payer: Galaxy Health Commercial	$1,410.50

IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINGE

Facility

$417.00

Service Code	HCPCS 10030 26
Hospital Charge Code	5201075
Hospital Revenue Code	960
Min. Negotiated Rate	$271.05
Max. Negotiated Rate	$271.05
Rate for Payer: Cash Price	$312.75
Rate for Payer: Galaxy Health Commercial	$271.05

IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINGE

Facility

$417.00

Service Code	HCPCS 10030 26
Hospital Charge Code	5201075
Hospital Revenue Code	960
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$333.60
Rate for Payer: Aetna of NY Commercial	$291.90
Rate for Payer: Aetna of NY Medicare	$191.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$166.80
Rate for Payer: Cash Price	$312.75
Rate for Payer: CDPHP Medicare	$154.29
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$333.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$333.60
Rate for Payer: EmblemHealth Medicaid	$333.60
Rate for Payer: EmblemHealth Medicare	$141.78
Rate for Payer: Fidelis Medicare	$166.80
Rate for Payer: Galaxy Health Commercial	$271.05
Rate for Payer: Hamaspik Choice Medicare	$166.80
Rate for Payer: Humana Medicare	$166.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$291.90
Rate for Payer: Local 1199SEIU Medicare	$191.82
Rate for Payer: MVP Health Care of NY Commercial	$312.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$234.77
Rate for Payer: MVP Health Care of NY Medicare	$175.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$62.55
Rate for Payer: United Healthcare Medicare	$166.80
Rate for Payer: WellCare Medicare	$229.35

IMHISTOCHEM/CYTCHM 1ST ANTIBODY STAIN PROCEDURE

Facility

$522.00

Service Code	HCPCS 88342 TC
Hospital Charge Code	4008342
Hospital Revenue Code	310
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$339.30
Rate for Payer: Cash Price	$391.50
Rate for Payer: Galaxy Health Commercial	$339.30

IMHISTOCHEM/CYTCHM 1ST ANTIBODY STAIN PROCEDURE

Facility

$522.00

Service Code	HCPCS 88342 TC
Hospital Charge Code	4008342
Hospital Revenue Code	310
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of NY Commercial	$339.30
Rate for Payer: Aetna of NY Medicare	$240.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$208.80
Rate for Payer: Cash Price	$391.50
Rate for Payer: CDPHP Medicare	$193.14
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$313.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$417.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$417.60
Rate for Payer: EmblemHealth Medicaid	$417.60
Rate for Payer: EmblemHealth Medicare	$177.48
Rate for Payer: EmblemHealth Select Care	$313.20
Rate for Payer: Fidelis Medicare	$208.80
Rate for Payer: Galaxy Health Commercial	$339.30
Rate for Payer: Hamaspik Choice Medicare	$208.80
Rate for Payer: Humana Medicare	$208.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$339.30
Rate for Payer: Local 1199SEIU Medicare	$240.12
Rate for Payer: MVP Health Care of NY Commercial	$391.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$293.89
Rate for Payer: MVP Health Care of NY Medicare	$219.24
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$391.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$78.30
Rate for Payer: United Healthcare Commercial	$391.50
Rate for Payer: United Healthcare Medicare	$208.80
Rate for Payer: WellCare Medicare	$287.10

IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE

Facility

$337.00

Service Code	HCPCS 88341 TC
Hospital Charge Code	4008341
Hospital Revenue Code	310
Min. Negotiated Rate	$50.55
Max. Negotiated Rate	$269.60
Rate for Payer: Aetna of NY Commercial	$219.05
Rate for Payer: Aetna of NY Medicare	$155.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$134.80
Rate for Payer: Cash Price	$252.75
Rate for Payer: CDPHP Medicare	$124.69
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$202.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$269.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$269.60
Rate for Payer: EmblemHealth Medicaid	$269.60
Rate for Payer: EmblemHealth Medicare	$114.58
Rate for Payer: EmblemHealth Select Care	$202.20
Rate for Payer: Fidelis Medicare	$134.80
Rate for Payer: Galaxy Health Commercial	$219.05
Rate for Payer: Hamaspik Choice Medicare	$134.80
Rate for Payer: Humana Medicare	$134.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$219.05
Rate for Payer: Local 1199SEIU Medicare	$155.02
Rate for Payer: MVP Health Care of NY Commercial	$252.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$189.73
Rate for Payer: MVP Health Care of NY Medicare	$141.54
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$252.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$50.55
Rate for Payer: United Healthcare Commercial	$252.75
Rate for Payer: United Healthcare Medicare	$134.80
Rate for Payer: WellCare Medicare	$185.35

IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE

Facility

$337.00

Service Code	HCPCS 88341 TC
Hospital Charge Code	4008341
Hospital Revenue Code	310
Min. Negotiated Rate	$219.05
Max. Negotiated Rate	$219.05
Rate for Payer: Cash Price	$252.75
Rate for Payer: Galaxy Health Commercial	$219.05

IMMUNIZATION ADMIN 1 VACCINE

Facility

$221.00

Service Code	HCPCS 90471
Hospital Charge Code	4604611
Hospital Revenue Code	771
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$143.65
Rate for Payer: Cash Price	$165.75
Rate for Payer: Galaxy Health Commercial	$143.65

IMMUNIZATION ADMIN 1 VACCINE

Facility

$221.00

Service Code	HCPCS 90471
Hospital Charge Code	4604611
Hospital Revenue Code	771
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna of NY Commercial	$154.70
Rate for Payer: Aetna of NY Medicare	$101.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$88.40
Rate for Payer: Cash Price	$165.75
Rate for Payer: CDPHP Medicare	$81.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$176.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$176.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$176.80
Rate for Payer: EmblemHealth Medicaid	$176.80
Rate for Payer: EmblemHealth Medicare	$75.14
Rate for Payer: EmblemHealth Select Care	$159.12
Rate for Payer: Fidelis Medicare	$88.40
Rate for Payer: Galaxy Health Commercial	$143.65
Rate for Payer: Hamaspik Choice Medicare	$88.40
Rate for Payer: Humana Medicare	$88.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$154.70
Rate for Payer: Local 1199SEIU Medicare	$101.66
Rate for Payer: MVP Health Care of NY Commercial	$165.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$124.42
Rate for Payer: MVP Health Care of NY Medicare	$92.82
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$33.15
Rate for Payer: United Healthcare Medicare	$88.40
Rate for Payer: WellCare Medicare	$121.55

IMMUNOASSAY NONANTIBODY

Facility

$45.00

Service Code	HCPCS 83516
Hospital Charge Code	4302004
Hospital Revenue Code	300
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of NY Commercial	$29.25
Rate for Payer: Aetna of NY Medicare	$20.70
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$18.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: CDPHP Medicare	$16.65
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$27.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$36.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$36.00
Rate for Payer: EmblemHealth Medicaid	$36.00
Rate for Payer: EmblemHealth Medicare	$15.30
Rate for Payer: EmblemHealth Select Care	$27.00
Rate for Payer: Fidelis Medicare	$18.00
Rate for Payer: Galaxy Health Commercial	$29.25
Rate for Payer: Hamaspik Choice Medicare	$18.00
Rate for Payer: Humana Medicare	$18.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$29.25
Rate for Payer: Local 1199SEIU Medicare	$20.70
Rate for Payer: MVP Health Care of NY Commercial	$33.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$25.34
Rate for Payer: MVP Health Care of NY Medicare	$18.90
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$33.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$6.75
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$18.00
Rate for Payer: WellCare Medicare	$24.75

IMMUNOASSAY NONANTIBODY

Facility

$45.00

Service Code	HCPCS 83516
Hospital Charge Code	4302004
Hospital Revenue Code	300
Min. Negotiated Rate	$29.25
Max. Negotiated Rate	$29.25
Rate for Payer: Cash Price	$33.75
Rate for Payer: Galaxy Health Commercial	$29.25

Know your out-of-pocket cost for care.

All Charges