Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION

Facility

$600.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	4200012
Hospital Revenue Code	402
Min. Negotiated Rate	$390.00
Max. Negotiated Rate	$390.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Galaxy Health Commercial	$390.00

US ABDOMINAL REAL TIME W/IMAGE LIMITED

Facility

$600.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	4200198
Hospital Revenue Code	402
Min. Negotiated Rate	$390.00
Max. Negotiated Rate	$390.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Galaxy Health Commercial	$390.00

US ABDOMINAL REAL TIME W/IMAGE LIMITED

Facility

$600.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	4200198
Hospital Revenue Code	402
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$483.00
Rate for Payer: Aetna of NY Commercial	$420.00
Rate for Payer: Aetna of NY Medicare	$276.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$450.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$450.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$222.00
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$300.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: CDPHP Commercial	$483.00
Rate for Payer: CDPHP Medicare	$222.00
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$420.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$480.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$480.00
Rate for Payer: EmblemHealth Medicaid	$480.00
Rate for Payer: EmblemHealth Medicare	$204.00
Rate for Payer: EmblemHealth Select Care	$390.00
Rate for Payer: Fidelis Medicare	$228.66
Rate for Payer: Galaxy Health Commercial	$390.00
Rate for Payer: Hamaspik Choice Medicare	$222.00
Rate for Payer: Humana Medicare	$222.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$420.00
Rate for Payer: Local 1199SEIU Medicare	$276.00
Rate for Payer: MVP Health Care of NY Commercial	$450.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$337.80
Rate for Payer: MVP Health Care of NY Medicare	$233.10
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$222.00
Rate for Payer: WellCare Medicare	$330.00

US ARTERY EXTREMITY LOWER BILATERAL

Facility

$701.00

Service Code	HCPCS 93925 50
Hospital Charge Code	4201035
Hospital Revenue Code	921
Min. Negotiated Rate	$455.65
Max. Negotiated Rate	$455.65
Rate for Payer: Cash Price	$525.75
Rate for Payer: Galaxy Health Commercial	$455.65

US ARTERY EXTREMITY LOWER BILATERAL

Facility

$701.00

Service Code	HCPCS 93925 50
Hospital Charge Code	4201035
Hospital Revenue Code	921
Min. Negotiated Rate	$238.34
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$455.65
Rate for Payer: Aetna of NY Medicare	$322.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$259.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$350.50
Rate for Payer: Cash Price	$525.75
Rate for Payer: Cash Price	$525.75
Rate for Payer: CDPHP Commercial	$564.30
Rate for Payer: CDPHP Medicare	$259.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$490.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$560.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$560.80
Rate for Payer: EmblemHealth Medicaid	$560.80
Rate for Payer: EmblemHealth Medicare	$238.34
Rate for Payer: EmblemHealth Select Care	$455.65
Rate for Payer: Fidelis Medicare	$267.15
Rate for Payer: Galaxy Health Commercial	$455.65
Rate for Payer: Hamaspik Choice Medicare	$259.37
Rate for Payer: Humana Medicare	$259.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.65
Rate for Payer: Local 1199SEIU Medicare	$322.46
Rate for Payer: MVP Health Care of NY Commercial	$525.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$394.66
Rate for Payer: MVP Health Care of NY Medicare	$272.34
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

US ARTERY EXTREMITY LOWER LEFT

Facility

$315.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	4201037
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

US ARTERY EXTREMITY LOWER LEFT

Facility

$315.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	4201037
Hospital Revenue Code	921
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US ARTERY EXTREMITY UPPER BILAT

Facility

$701.00

Service Code	HCPCS 93930 50
Hospital Charge Code	4201038
Hospital Revenue Code	921
Min. Negotiated Rate	$238.34
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$455.65
Rate for Payer: Aetna of NY Medicare	$322.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$259.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$350.50
Rate for Payer: Cash Price	$525.75
Rate for Payer: Cash Price	$525.75
Rate for Payer: CDPHP Commercial	$564.30
Rate for Payer: CDPHP Medicare	$259.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$490.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$560.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$560.80
Rate for Payer: EmblemHealth Medicaid	$560.80
Rate for Payer: EmblemHealth Medicare	$238.34
Rate for Payer: EmblemHealth Select Care	$455.65
Rate for Payer: Fidelis Medicare	$267.15
Rate for Payer: Galaxy Health Commercial	$455.65
Rate for Payer: Hamaspik Choice Medicare	$259.37
Rate for Payer: Humana Medicare	$259.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.65
Rate for Payer: Local 1199SEIU Medicare	$322.46
Rate for Payer: MVP Health Care of NY Commercial	$525.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$394.66
Rate for Payer: MVP Health Care of NY Medicare	$272.34
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

US ARTERY EXTREMITY UPPER BILAT

Facility

$701.00

Service Code	HCPCS 93930 50
Hospital Charge Code	4201038
Hospital Revenue Code	921
Min. Negotiated Rate	$455.65
Max. Negotiated Rate	$455.65
Rate for Payer: Cash Price	$525.75
Rate for Payer: Galaxy Health Commercial	$455.65

US BREAST UNI REAL TIME WITH IMAGE COMPLETE

Facility

$315.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	4201048
Hospital Revenue Code	402
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$220.50
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$220.50
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US BREAST UNI REAL TIME WITH IMAGE COMPLETE

Facility

$315.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	4201048
Hospital Revenue Code	402
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$315.00

Service Code	HCPCS 76641 50,TC
Hospital Charge Code	4201058
Hospital Revenue Code	402
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$315.00

Service Code	HCPCS 76641 50,TC
Hospital Charge Code	4201058
Hospital Revenue Code	402
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$220.50
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$220.50
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, LEFT

Facility

$315.00

Service Code	HCPCS 76641 LT,TC
Hospital Charge Code	4201056
Hospital Revenue Code	402
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, LEFT

Facility

$315.00

Service Code	HCPCS 76641 LT,TC
Hospital Charge Code	4201056
Hospital Revenue Code	402
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$220.50
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$220.50
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, RIGHT

Facility

$315.00

Service Code	HCPCS 76641 RT,TC
Hospital Charge Code	4201057
Hospital Revenue Code	402
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$220.50
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$220.50
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, RIGHT

Facility

$315.00

Service Code	HCPCS 76641 RT,TC
Hospital Charge Code	4201057
Hospital Revenue Code	402
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

US BREAST UNI REAL TIME WITH IMAGE LIMITED

Facility

$260.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	4200006
Hospital Revenue Code	402
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$182.00
Rate for Payer: Aetna of NY Medicare	$119.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$96.20
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$130.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: CDPHP Commercial	$209.30
Rate for Payer: CDPHP Medicare	$96.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$182.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$208.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$208.00
Rate for Payer: EmblemHealth Medicaid	$208.00
Rate for Payer: EmblemHealth Medicare	$88.40
Rate for Payer: EmblemHealth Select Care	$169.00
Rate for Payer: Fidelis Medicare	$99.09
Rate for Payer: Galaxy Health Commercial	$169.00
Rate for Payer: Hamaspik Choice Medicare	$96.20
Rate for Payer: Humana Medicare	$96.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$182.00
Rate for Payer: Local 1199SEIU Medicare	$119.60
Rate for Payer: MVP Health Care of NY Commercial	$195.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$146.38
Rate for Payer: MVP Health Care of NY Medicare	$101.01
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$96.20
Rate for Payer: WellCare Medicare	$143.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED

Facility

$260.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	4200006
Hospital Revenue Code	402
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Galaxy Health Commercial	$169.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, BILATERAL

Facility

$260.00

Service Code	HCPCS 76642 50,TC
Hospital Charge Code	4201061
Hospital Revenue Code	402
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Galaxy Health Commercial	$169.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, BILATERAL

Facility

$260.00

Service Code	HCPCS 76642 50,TC
Hospital Charge Code	4201061
Hospital Revenue Code	402
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$182.00
Rate for Payer: Aetna of NY Medicare	$119.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$96.20
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$130.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: CDPHP Commercial	$209.30
Rate for Payer: CDPHP Medicare	$96.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$182.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$208.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$208.00
Rate for Payer: EmblemHealth Medicaid	$208.00
Rate for Payer: EmblemHealth Medicare	$88.40
Rate for Payer: EmblemHealth Select Care	$169.00
Rate for Payer: Fidelis Medicare	$99.09
Rate for Payer: Galaxy Health Commercial	$169.00
Rate for Payer: Hamaspik Choice Medicare	$96.20
Rate for Payer: Humana Medicare	$96.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$182.00
Rate for Payer: Local 1199SEIU Medicare	$119.60
Rate for Payer: MVP Health Care of NY Commercial	$195.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$146.38
Rate for Payer: MVP Health Care of NY Medicare	$101.01
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$96.20
Rate for Payer: WellCare Medicare	$143.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, LEFT

Facility

$260.00

Service Code	HCPCS 76642 LT,TC
Hospital Charge Code	4201059
Hospital Revenue Code	402
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$182.00
Rate for Payer: Aetna of NY Medicare	$119.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$96.20
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$130.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: CDPHP Commercial	$209.30
Rate for Payer: CDPHP Medicare	$96.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$182.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$208.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$208.00
Rate for Payer: EmblemHealth Medicaid	$208.00
Rate for Payer: EmblemHealth Medicare	$88.40
Rate for Payer: EmblemHealth Select Care	$169.00
Rate for Payer: Fidelis Medicare	$99.09
Rate for Payer: Galaxy Health Commercial	$169.00
Rate for Payer: Hamaspik Choice Medicare	$96.20
Rate for Payer: Humana Medicare	$96.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$182.00
Rate for Payer: Local 1199SEIU Medicare	$119.60
Rate for Payer: MVP Health Care of NY Commercial	$195.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$146.38
Rate for Payer: MVP Health Care of NY Medicare	$101.01
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$96.20
Rate for Payer: WellCare Medicare	$143.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, LEFT

Facility

$260.00

Service Code	HCPCS 76642 LT,TC
Hospital Charge Code	4201059
Hospital Revenue Code	402
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Galaxy Health Commercial	$169.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, RIGHT

Facility

$260.00

Service Code	HCPCS 76642 RT,TC
Hospital Charge Code	4201060
Hospital Revenue Code	402
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Galaxy Health Commercial	$169.00

US BREAST UNI REAL TIME WITH IMAGE LIMITED, RIGHT

Facility

$260.00

Service Code	HCPCS 76642 RT,TC
Hospital Charge Code	4201060
Hospital Revenue Code	402
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$182.00
Rate for Payer: Aetna of NY Medicare	$119.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$195.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$96.20
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$130.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: CDPHP Commercial	$209.30
Rate for Payer: CDPHP Medicare	$96.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$182.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$208.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$208.00
Rate for Payer: EmblemHealth Medicaid	$208.00
Rate for Payer: EmblemHealth Medicare	$88.40
Rate for Payer: EmblemHealth Select Care	$169.00
Rate for Payer: Fidelis Medicare	$99.09
Rate for Payer: Galaxy Health Commercial	$169.00
Rate for Payer: Hamaspik Choice Medicare	$96.20
Rate for Payer: Humana Medicare	$96.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$182.00
Rate for Payer: Local 1199SEIU Medicare	$119.60
Rate for Payer: MVP Health Care of NY Commercial	$195.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$146.38
Rate for Payer: MVP Health Care of NY Medicare	$101.01
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$96.20
Rate for Payer: WellCare Medicare	$143.00

Know your out-of-pocket cost for care.

All Charges