Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US GUIDED NEEDLE PLACEMENT

Facility

$215.00

Service Code	HCPCS 76942
Hospital Charge Code	4850119
Hospital Revenue Code	402
Min. Negotiated Rate	$139.75
Max. Negotiated Rate	$139.75
Rate for Payer: Cash Price	$161.25
Rate for Payer: Galaxy Health Commercial	$139.75

US GUIDED NEEDLE PLACEMENT

Facility

$215.00

Service Code	HCPCS 76942
Hospital Charge Code	4000371
Hospital Revenue Code	402
Min. Negotiated Rate	$139.75
Max. Negotiated Rate	$139.75
Rate for Payer: Cash Price	$161.25
Rate for Payer: Galaxy Health Commercial	$139.75

US GUIDED NEEDLE PLACEMENT

Facility

$215.00

Service Code	HCPCS 76942
Hospital Charge Code	4609651
Hospital Revenue Code	402
Min. Negotiated Rate	$55.55
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$150.50
Rate for Payer: Aetna of NY Medicare	$98.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$161.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$161.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$79.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$107.50
Rate for Payer: Cash Price	$161.25
Rate for Payer: Cash Price	$161.25
Rate for Payer: CDPHP Commercial	$173.08
Rate for Payer: CDPHP Medicare	$79.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$150.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$172.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$172.00
Rate for Payer: EmblemHealth Medicaid	$172.00
Rate for Payer: EmblemHealth Medicare	$73.10
Rate for Payer: EmblemHealth Select Care	$139.75
Rate for Payer: Fidelis Medicare	$81.94
Rate for Payer: Galaxy Health Commercial	$139.75
Rate for Payer: Hamaspik Choice Medicare	$79.55
Rate for Payer: Humana Medicare	$79.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$150.50
Rate for Payer: Local 1199SEIU Medicare	$98.90
Rate for Payer: MVP Health Care of NY Commercial	$161.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$121.04
Rate for Payer: MVP Health Care of NY Medicare	$83.53
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$55.55
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$79.55
Rate for Payer: WellCare Medicare	$118.25

US GUIDE INTRAOP

Facility

$560.00

Service Code	HCPCS 76998
Hospital Charge Code	4200090
Hospital Revenue Code	402
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$364.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Galaxy Health Commercial	$364.00

US GUIDE INTRAOP

Facility

$560.00

Service Code	HCPCS 76998
Hospital Charge Code	4200090
Hospital Revenue Code	402
Min. Negotiated Rate	$45.95
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$392.00
Rate for Payer: Aetna of NY Medicare	$257.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$420.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$420.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$207.20
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$280.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: CDPHP Commercial	$450.80
Rate for Payer: CDPHP Medicare	$207.20
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$392.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$448.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$448.00
Rate for Payer: EmblemHealth Medicaid	$448.00
Rate for Payer: EmblemHealth Medicare	$190.40
Rate for Payer: EmblemHealth Select Care	$364.00
Rate for Payer: Fidelis Medicare	$213.42
Rate for Payer: Galaxy Health Commercial	$364.00
Rate for Payer: Hamaspik Choice Medicare	$207.20
Rate for Payer: Humana Medicare	$207.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$392.00
Rate for Payer: Local 1199SEIU Medicare	$257.60
Rate for Payer: MVP Health Care of NY Commercial	$420.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$315.28
Rate for Payer: MVP Health Care of NY Medicare	$217.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$45.95
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$207.20
Rate for Payer: WellCare Medicare	$308.00

US GUIDE VASCULAR ACCESS

Facility

$147.00

Service Code	HCPCS 76937
Hospital Charge Code	4201044
Hospital Revenue Code	402
Min. Negotiated Rate	$95.55
Max. Negotiated Rate	$95.55
Rate for Payer: Cash Price	$110.25
Rate for Payer: Galaxy Health Commercial	$95.55

US GUIDE VASCULAR ACCESS

Facility

$147.00

Service Code	HCPCS 76937
Hospital Charge Code	4201044
Hospital Revenue Code	402
Min. Negotiated Rate	$49.98
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$102.90
Rate for Payer: Aetna of NY Medicare	$67.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$110.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$110.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$54.39
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$73.50
Rate for Payer: Cash Price	$110.25
Rate for Payer: Cash Price	$110.25
Rate for Payer: CDPHP Commercial	$118.34
Rate for Payer: CDPHP Medicare	$54.39
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$102.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$117.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$117.60
Rate for Payer: EmblemHealth Medicaid	$117.60
Rate for Payer: EmblemHealth Medicare	$49.98
Rate for Payer: EmblemHealth Select Care	$95.55
Rate for Payer: Fidelis Medicare	$56.02
Rate for Payer: Galaxy Health Commercial	$95.55
Rate for Payer: Hamaspik Choice Medicare	$54.39
Rate for Payer: Humana Medicare	$54.39
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$102.90
Rate for Payer: Local 1199SEIU Medicare	$67.62
Rate for Payer: MVP Health Care of NY Commercial	$110.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$82.76
Rate for Payer: MVP Health Care of NY Medicare	$57.11
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$475.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$55.55
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$54.39
Rate for Payer: WellCare Medicare	$80.85

US HYSTEROSALPINGOGRAM

Facility

$701.00

Service Code	HCPCS 74740
Hospital Charge Code	4150197
Hospital Revenue Code	320
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 HYSTEROSALPINGOGRAM

Facility

$701.00

Service Code	HCPCS 74740
Hospital Charge Code	4150197
Hospital Revenue Code	320
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$420.60
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	$420.60
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	$390.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$25.25
Rate for Payer: United Healthcare Commercial	$390.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$315.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	4200071
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$315.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	4200071
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$315.00

Service Code	HCPCS 76882 LT,TC
Hospital Charge Code	4201063
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$315.00

Service Code	HCPCS 76882 LT,TC
Hospital Charge Code	4201063
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$315.00

Service Code	HCPCS 76882 RT,TC
Hospital Charge Code	4201062
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$315.00

Service Code	HCPCS 76882 RT,TC
Hospital Charge Code	4201062
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 NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$315.00

Service Code	HCPCS 76883
Hospital Charge Code	4201091
Hospital Revenue Code	402
Min. Negotiated Rate	$13.00
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 CHIP/Family Health Plus/Medicaid	$13.00
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$315.00

Service Code	HCPCS 76883
Hospital Charge Code	4201091
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 OF GALLBLADDER

Facility

$315.00

Service Code	HCPCS 76705
Hospital Charge Code	4200025
Hospital Revenue Code	402
Min. Negotiated Rate	$40.40
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 CHIP/Family Health Plus/Medicaid	$40.40
Rate for Payer: United Healthcare Commercial	$475.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

US OF GALLBLADDER

Facility

$315.00

Service Code	HCPCS 76705
Hospital Charge Code	4200025
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 PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U

Facility

$461.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	4200015
Hospital Revenue Code	402
Min. Negotiated Rate	$299.65
Max. Negotiated Rate	$299.65
Rate for Payer: Cash Price	$345.75
Rate for Payer: Galaxy Health Commercial	$299.65

US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U

Facility

$461.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	4200015
Hospital Revenue Code	402
Min. Negotiated Rate	$156.74
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$322.70
Rate for Payer: Aetna of NY Medicare	$212.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$345.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$345.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$170.57
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$230.50
Rate for Payer: Cash Price	$345.75
Rate for Payer: Cash Price	$345.75
Rate for Payer: CDPHP Commercial	$371.10
Rate for Payer: CDPHP Medicare	$170.57
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$322.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$368.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$368.80
Rate for Payer: EmblemHealth Medicaid	$368.80
Rate for Payer: EmblemHealth Medicare	$156.74
Rate for Payer: EmblemHealth Select Care	$299.65
Rate for Payer: Fidelis Medicare	$175.69
Rate for Payer: Galaxy Health Commercial	$299.65
Rate for Payer: Hamaspik Choice Medicare	$170.57
Rate for Payer: Humana Medicare	$170.57
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$322.70
Rate for Payer: Local 1199SEIU Medicare	$212.06
Rate for Payer: MVP Health Care of NY Commercial	$345.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$259.54
Rate for Payer: MVP Health Care of NY Medicare	$179.10
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	$170.57
Rate for Payer: WellCare Medicare	$253.55

US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Facility

$494.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	4200034
Hospital Revenue Code	402
Min. Negotiated Rate	$321.10
Max. Negotiated Rate	$321.10
Rate for Payer: Cash Price	$370.50
Rate for Payer: Galaxy Health Commercial	$321.10

US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Facility

$494.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	4200034
Hospital Revenue Code	402
Min. Negotiated Rate	$167.96
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna of NY Commercial	$345.80
Rate for Payer: Aetna of NY Medicare	$227.24
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$370.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$370.50
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$182.78
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$247.00
Rate for Payer: Cash Price	$370.50
Rate for Payer: Cash Price	$370.50
Rate for Payer: CDPHP Commercial	$397.67
Rate for Payer: CDPHP Medicare	$182.78
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$345.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$395.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$395.20
Rate for Payer: EmblemHealth Medicaid	$395.20
Rate for Payer: EmblemHealth Medicare	$167.96
Rate for Payer: EmblemHealth Select Care	$321.10
Rate for Payer: Fidelis Medicare	$188.26
Rate for Payer: Galaxy Health Commercial	$321.10
Rate for Payer: Hamaspik Choice Medicare	$182.78
Rate for Payer: Humana Medicare	$182.78
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$345.80
Rate for Payer: Local 1199SEIU Medicare	$227.24
Rate for Payer: MVP Health Care of NY Commercial	$370.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$278.12
Rate for Payer: MVP Health Care of NY Medicare	$191.92
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	$182.78
Rate for Payer: WellCare Medicare	$271.70

US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$621.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	4200086
Hospital Revenue Code	402
Min. Negotiated Rate	$211.14
Max. Negotiated Rate	$499.90
Rate for Payer: Aetna of NY Commercial	$434.70
Rate for Payer: Aetna of NY Medicare	$285.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$465.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$465.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$229.77
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$310.50
Rate for Payer: Cash Price	$465.75
Rate for Payer: Cash Price	$465.75
Rate for Payer: CDPHP Commercial	$499.90
Rate for Payer: CDPHP Medicare	$229.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$434.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$496.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$496.80
Rate for Payer: EmblemHealth Medicaid	$496.80
Rate for Payer: EmblemHealth Medicare	$211.14
Rate for Payer: EmblemHealth Select Care	$403.65
Rate for Payer: Fidelis Medicare	$236.66
Rate for Payer: Galaxy Health Commercial	$403.65
Rate for Payer: Hamaspik Choice Medicare	$229.77
Rate for Payer: Humana Medicare	$229.77
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$434.70
Rate for Payer: Local 1199SEIU Medicare	$285.66
Rate for Payer: MVP Health Care of NY Commercial	$465.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$349.62
Rate for Payer: MVP Health Care of NY Medicare	$241.26
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	$229.77
Rate for Payer: WellCare Medicare	$341.55

US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$621.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	4200086
Hospital Revenue Code	402
Min. Negotiated Rate	$403.65
Max. Negotiated Rate	$403.65
Rate for Payer: Cash Price	$465.75
Rate for Payer: Galaxy Health Commercial	$403.65

Know your out-of-pocket cost for care.

All Charges