Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

UNIVERSAL STRYKER SAW BLADE

Facility

$147.29

Hospital Charge Code	4471625
Hospital Revenue Code	272
Min. Negotiated Rate	$95.74
Max. Negotiated Rate	$95.74
Rate for Payer: Cash Price	$110.47
Rate for Payer: Galaxy Health Commercial	$95.74

UNLISTED PROCEDURE ABD PERITONEUM

Facility

$2,813.00

Service Code	HCPCS 49999
Hospital Charge Code	4602231
Hospital Revenue Code	450
Min. Negotiated Rate	$421.95
Max. Negotiated Rate	$2,250.40
Rate for Payer: Aetna of NY Commercial	$1,000.00
Rate for Payer: Aetna of NY Medicare	$1,293.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,125.20
Rate for Payer: Cash Price	$2,109.75
Rate for Payer: Cash Price	$2,109.75
Rate for Payer: Cash Price	$2,109.75
Rate for Payer: CDPHP Medicare	$1,040.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,206.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,250.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,250.40
Rate for Payer: EmblemHealth Medicaid	$2,250.40
Rate for Payer: EmblemHealth Medicare	$956.42
Rate for Payer: EmblemHealth Select Care	$1,085.00
Rate for Payer: Fidelis Medicare	$1,125.20
Rate for Payer: Galaxy Health Commercial	$1,828.45
Rate for Payer: Hamaspik Choice Medicare	$1,125.20
Rate for Payer: Humana Medicare	$1,125.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,000.00
Rate for Payer: Local 1199SEIU Medicare	$1,293.98
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	$1,181.46
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$1,009.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$421.95
Rate for Payer: United Healthcare Commercial	$1,009.00
Rate for Payer: United Healthcare Medicare	$1,125.20
Rate for Payer: WellCare Medicare	$1,547.15

UNLISTED PROCEDURE ABD PERITONEUM

Facility

$2,813.00

Service Code	HCPCS 49999
Hospital Charge Code	4602231
Hospital Revenue Code	450
Min. Negotiated Rate	$1,828.45
Max. Negotiated Rate	$1,828.45
Rate for Payer: Cash Price	$2,109.75
Rate for Payer: Galaxy Health Commercial	$1,828.45

UNLISTED PROCEDURE CASTING OR STRAPPING

Facility

$498.00

Service Code	HCPCS 29799
Hospital Charge Code	4856725
Hospital Revenue Code	761
Min. Negotiated Rate	$323.70
Max. Negotiated Rate	$323.70
Rate for Payer: Cash Price	$373.50
Rate for Payer: Galaxy Health Commercial	$323.70

UNLISTED PROCEDURE CASTING OR STRAPPING

Facility

$498.00

Service Code	HCPCS 29799
Hospital Charge Code	4856725
Hospital Revenue Code	761
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$398.40
Rate for Payer: Aetna of NY Commercial	$348.60
Rate for Payer: Aetna of NY Medicare	$229.08
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$199.20
Rate for Payer: Cash Price	$373.50
Rate for Payer: CDPHP Medicare	$184.26
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$398.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$398.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$398.40
Rate for Payer: EmblemHealth Medicaid	$398.40
Rate for Payer: EmblemHealth Medicare	$169.32
Rate for Payer: EmblemHealth Select Care	$358.56
Rate for Payer: Fidelis Medicare	$199.20
Rate for Payer: Galaxy Health Commercial	$323.70
Rate for Payer: Hamaspik Choice Medicare	$199.20
Rate for Payer: Humana Medicare	$199.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$348.60
Rate for Payer: Local 1199SEIU Medicare	$229.08
Rate for Payer: MVP Health Care of NY Commercial	$373.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$280.37
Rate for Payer: MVP Health Care of NY Medicare	$209.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$74.70
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: WellCare Medicare	$273.90

UNLISTED PROCEDURE FEMUR/KNEE

Facility

$756.00

Service Code	HCPCS 27599
Hospital Charge Code	4853042
Hospital Revenue Code	761
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$491.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: Galaxy Health Commercial	$491.40

UNLISTED PROCEDURE FEMUR/KNEE

Facility

$756.00

Service Code	HCPCS 27599
Hospital Charge Code	4853042
Hospital Revenue Code	761
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$604.80
Rate for Payer: Aetna of NY Commercial	$529.20
Rate for Payer: Aetna of NY Medicare	$347.76
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$302.40
Rate for Payer: Cash Price	$567.00
Rate for Payer: CDPHP Medicare	$279.72
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$604.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$604.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$604.80
Rate for Payer: EmblemHealth Medicaid	$604.80
Rate for Payer: EmblemHealth Medicare	$257.04
Rate for Payer: EmblemHealth Select Care	$544.32
Rate for Payer: Fidelis Medicare	$302.40
Rate for Payer: Galaxy Health Commercial	$491.40
Rate for Payer: Hamaspik Choice Medicare	$302.40
Rate for Payer: Humana Medicare	$302.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$529.20
Rate for Payer: Local 1199SEIU Medicare	$347.76
Rate for Payer: MVP Health Care of NY Commercial	$567.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$425.63
Rate for Payer: MVP Health Care of NY Medicare	$317.52
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$113.40
Rate for Payer: United Healthcare Medicare	$302.40
Rate for Payer: WellCare Medicare	$415.80

UNLISTED PROCEDURE, FOOT OR TOES

Facility

$1,900.00

Service Code	CPT 28899
Hospital Revenue Code	490
Min. Negotiated Rate	$224.69
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	$224.69
Rate for Payer: United Healthcare Commercial	$1,828.00

UNLISTED PROCEDURE, NERVOUS SYSTEM

Facility

$1,900.00

Service Code	CPT 64999
Hospital Revenue Code	490
Min. Negotiated Rate	$282.20
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	$282.20
Rate for Payer: United Healthcare Commercial	$1,828.00

UNLISTED REHAB MODALITY

Facility

$123.60

Service Code	HCPCS 97039 GO
Hospital Charge Code	4690268
Hospital Revenue Code	430
Min. Negotiated Rate	$80.34
Max. Negotiated Rate	$80.34
Rate for Payer: Cash Price	$92.70
Rate for Payer: Galaxy Health Commercial	$80.34

UNLISTED REHAB MODALITY

Facility

$123.60

Service Code	HCPCS 97039 GO
Hospital Charge Code	4690268
Hospital Revenue Code	430
Min. Negotiated Rate	$18.54
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna of NY Commercial	$115.00
Rate for Payer: Aetna of NY Medicare	$56.86
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$49.44
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cash Price	$92.70
Rate for Payer: CDPHP Medicare	$45.73
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$98.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$26.90
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$22.42
Rate for Payer: EmblemHealth Medicaid	$22.42
Rate for Payer: EmblemHealth Medicare	$42.02
Rate for Payer: EmblemHealth Select Care	$88.99
Rate for Payer: Fidelis Medicare	$49.44
Rate for Payer: Galaxy Health Commercial	$80.34
Rate for Payer: Galaxy Health Workers Comp	$21.97
Rate for Payer: Hamaspik Choice Medicaid	$22.42
Rate for Payer: Hamaspik Choice Medicare	$49.44
Rate for Payer: Humana Medicare	$49.44
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$115.00
Rate for Payer: Local 1199SEIU Medicare	$56.86
Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid	$23.54
Rate for Payer: MVP Health Care of NY Commercial	$187.00
Rate for Payer: MVP Health Care of NY Essential Plan 1&2	$48.20
Rate for Payer: MVP Health Care of NY Essential Plan 3&4	$48.20
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.00
Rate for Payer: MVP Health Care of NY Medicare	$51.91
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.54
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$49.44
Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid	$23.54
Rate for Payer: WellCare Medicare	$67.98

UNNA BOOT STRAPPING

Facility

$498.00

Service Code	HCPCS 29580
Hospital Charge Code	4855440
Hospital Revenue Code	761
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$398.40
Rate for Payer: Aetna of NY Commercial	$348.60
Rate for Payer: Aetna of NY Medicare	$229.08
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$199.20
Rate for Payer: Cash Price	$373.50
Rate for Payer: CDPHP Medicare	$184.26
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$398.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$398.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$398.40
Rate for Payer: EmblemHealth Medicaid	$398.40
Rate for Payer: EmblemHealth Medicare	$169.32
Rate for Payer: EmblemHealth Select Care	$358.56
Rate for Payer: Fidelis Medicare	$199.20
Rate for Payer: Galaxy Health Commercial	$323.70
Rate for Payer: Hamaspik Choice Medicare	$199.20
Rate for Payer: Humana Medicare	$199.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$348.60
Rate for Payer: Local 1199SEIU Medicare	$229.08
Rate for Payer: MVP Health Care of NY Commercial	$373.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$280.37
Rate for Payer: MVP Health Care of NY Medicare	$209.16
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$74.70
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: WellCare Medicare	$273.90

UNNA BOOT STRAPPING

Facility

$498.00

Service Code	HCPCS 29580 GP
Hospital Charge Code	4650284
Hospital Revenue Code	420
Min. Negotiated Rate	$323.70
Max. Negotiated Rate	$323.70
Rate for Payer: Cash Price	$373.50
Rate for Payer: Galaxy Health Commercial	$323.70

UNNA BOOT STRAPPING

Facility

$498.00

Service Code	HCPCS 29580 GP
Hospital Charge Code	4650284
Hospital Revenue Code	420
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$398.40
Rate for Payer: Aetna of NY Commercial	$115.00
Rate for Payer: Aetna of NY Medicare	$229.08
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$199.20
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cash Price	$373.50
Rate for Payer: CDPHP Medicare	$184.26
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$398.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$398.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$398.40
Rate for Payer: EmblemHealth Medicaid	$398.40
Rate for Payer: EmblemHealth Medicare	$169.32
Rate for Payer: EmblemHealth Select Care	$358.56
Rate for Payer: Fidelis Medicare	$199.20
Rate for Payer: Galaxy Health Commercial	$323.70
Rate for Payer: Hamaspik Choice Medicare	$199.20
Rate for Payer: Humana Medicare	$199.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$115.00
Rate for Payer: Local 1199SEIU Medicare	$229.08
Rate for Payer: MVP Health Care of NY Commercial	$187.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.00
Rate for Payer: MVP Health Care of NY Medicare	$209.16
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$161.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$74.70
Rate for Payer: United Healthcare Commercial	$161.00
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: WellCare Medicare	$273.90

UNNA BOOT STRAPPING

Facility

$498.00

Service Code	HCPCS 29580
Hospital Charge Code	4855440
Hospital Revenue Code	761
Min. Negotiated Rate	$323.70
Max. Negotiated Rate	$323.70
Rate for Payer: Cash Price	$373.50
Rate for Payer: Galaxy Health Commercial	$323.70

UNNA BOOT WITH CALAMINE 4"

Facility

$19.57

Hospital Charge Code	4471478
Hospital Revenue Code	270
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$12.72
Rate for Payer: Cash Price	$14.68
Rate for Payer: Galaxy Health Commercial	$12.72

UNNA BOOT WITH CALAMINE 4"

Facility

$19.57

Hospital Charge Code	4471478
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna of NY Commercial	$13.70
Rate for Payer: Aetna of NY Medicare	$9.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.83
Rate for Payer: Cash Price	$14.68
Rate for Payer: CDPHP Medicare	$7.24
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$15.66
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.66
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.66
Rate for Payer: EmblemHealth Medicaid	$15.66
Rate for Payer: EmblemHealth Medicare	$6.65
Rate for Payer: EmblemHealth Select Care	$14.09
Rate for Payer: Fidelis Medicare	$7.83
Rate for Payer: Galaxy Health Commercial	$12.72
Rate for Payer: Hamaspik Choice Medicare	$7.83
Rate for Payer: Humana Medicare	$7.83
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$13.70
Rate for Payer: Local 1199SEIU Medicare	$9.00
Rate for Payer: MVP Health Care of NY Commercial	$14.68
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$11.02
Rate for Payer: MVP Health Care of NY Medicare	$8.22
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.94
Rate for Payer: United Healthcare Medicare	$7.83
Rate for Payer: WellCare Medicare	$10.76

UPPER EXTREMITY PACK

Facility

$116.39

Hospital Charge Code	4479183
Hospital Revenue Code	270
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna of NY Commercial	$81.47
Rate for Payer: Aetna of NY Medicare	$53.54
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$46.56
Rate for Payer: Cash Price	$87.29
Rate for Payer: CDPHP Medicare	$43.06
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$93.11
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$93.11
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$93.11
Rate for Payer: EmblemHealth Medicaid	$93.11
Rate for Payer: EmblemHealth Medicare	$39.57
Rate for Payer: EmblemHealth Select Care	$83.80
Rate for Payer: Fidelis Medicare	$46.56
Rate for Payer: Galaxy Health Commercial	$75.65
Rate for Payer: Hamaspik Choice Medicare	$46.56
Rate for Payer: Humana Medicare	$46.56
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$81.47
Rate for Payer: Local 1199SEIU Medicare	$53.54
Rate for Payer: MVP Health Care of NY Commercial	$87.29
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$65.53
Rate for Payer: MVP Health Care of NY Medicare	$48.88
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.46
Rate for Payer: United Healthcare Medicare	$46.56
Rate for Payer: WellCare Medicare	$64.01

UPPER EXTREMITY PACK

Facility

$116.39

Hospital Charge Code	4479183
Hospital Revenue Code	270
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$75.65
Rate for Payer: Cash Price	$87.29
Rate for Payer: Galaxy Health Commercial	$75.65

UPR/LXTR ART STDY 3+ LVLS

Facility

$66.00

Service Code	HCPCS 93923 26
Hospital Charge Code	5201052
Hospital Revenue Code	960
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$42.90
Rate for Payer: Cash Price	$49.50
Rate for Payer: Galaxy Health Commercial	$42.90

UPR/LXTR ART STDY 3+ LVLS

Facility

$662.00

Service Code	HCPCS 93923
Hospital Charge Code	4201052
Hospital Revenue Code	921
Min. Negotiated Rate	$99.30
Max. Negotiated Rate	$529.60
Rate for Payer: Aetna of NY Commercial	$430.30
Rate for Payer: Aetna of NY Medicare	$304.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$264.80
Rate for Payer: Cash Price	$496.50
Rate for Payer: Cash Price	$496.50
Rate for Payer: CDPHP Medicare	$244.94
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$463.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$529.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$529.60
Rate for Payer: EmblemHealth Medicaid	$529.60
Rate for Payer: EmblemHealth Medicare	$225.08
Rate for Payer: EmblemHealth Select Care	$430.30
Rate for Payer: Fidelis Medicare	$264.80
Rate for Payer: Galaxy Health Commercial	$430.30
Rate for Payer: Hamaspik Choice Medicare	$264.80
Rate for Payer: Humana Medicare	$264.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$430.30
Rate for Payer: Local 1199SEIU Medicare	$304.52
Rate for Payer: MVP Health Care of NY Commercial	$496.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$372.71
Rate for Payer: MVP Health Care of NY Medicare	$278.04
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$99.30
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$264.80
Rate for Payer: WellCare Medicare	$364.10

UPR/LXTR ART STDY 3+ LVLS

Facility

$66.00

Service Code	HCPCS 93923 26
Hospital Charge Code	5201052
Hospital Revenue Code	960
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$52.80
Rate for Payer: Aetna of NY Commercial	$42.90
Rate for Payer: Aetna of NY Medicare	$30.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$26.40
Rate for Payer: Cash Price	$49.50
Rate for Payer: CDPHP Medicare	$24.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$52.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$52.80
Rate for Payer: EmblemHealth Medicaid	$52.80
Rate for Payer: EmblemHealth Medicare	$22.44
Rate for Payer: Fidelis Medicare	$26.40
Rate for Payer: Galaxy Health Commercial	$42.90
Rate for Payer: Hamaspik Choice Medicare	$26.40
Rate for Payer: Humana Medicare	$26.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$42.90
Rate for Payer: Local 1199SEIU Medicare	$30.36
Rate for Payer: MVP Health Care of NY Commercial	$49.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$37.16
Rate for Payer: MVP Health Care of NY Medicare	$27.72
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.90
Rate for Payer: United Healthcare Medicare	$26.40
Rate for Payer: WellCare Medicare	$36.30

UPR/LXTR ART STDY 3+ LVLS

Facility

$662.00

Service Code	HCPCS 93923
Hospital Charge Code	4201052
Hospital Revenue Code	921
Min. Negotiated Rate	$430.30
Max. Negotiated Rate	$430.30
Rate for Payer: Cash Price	$496.50
Rate for Payer: Galaxy Health Commercial	$430.30

UPR/L XTREMITY ART 2 LEVELS

Facility

$37.00

Service Code	HCPCS 93922 26
Hospital Charge Code	5201051
Hospital Revenue Code	960
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: Cash Price	$27.75
Rate for Payer: Galaxy Health Commercial	$24.05

UPR/L XTREMITY ART 2 LEVELS

Facility

$408.00

Service Code	HCPCS 93922
Hospital Charge Code	4201051
Hospital Revenue Code	921
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Galaxy Health Commercial	$265.20

Know your out-of-pocket cost for care.

All Charges