Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

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	$5.55
Max. Negotiated Rate	$29.60
Rate for Payer: Aetna of NY Commercial	$24.05
Rate for Payer: Aetna of NY Medicare	$17.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$14.80
Rate for Payer: Cash Price	$27.75
Rate for Payer: CDPHP Medicare	$13.69
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$29.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$29.60
Rate for Payer: EmblemHealth Medicaid	$29.60
Rate for Payer: EmblemHealth Medicare	$12.58
Rate for Payer: Fidelis Medicare	$14.80
Rate for Payer: Galaxy Health Commercial	$24.05
Rate for Payer: Hamaspik Choice Medicare	$14.80
Rate for Payer: Humana Medicare	$14.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$24.05
Rate for Payer: Local 1199SEIU Medicare	$17.02
Rate for Payer: MVP Health Care of NY Commercial	$27.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$20.83
Rate for Payer: MVP Health Care of NY Medicare	$15.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$5.55
Rate for Payer: United Healthcare Medicare	$14.80
Rate for Payer: WellCare Medicare	$20.35

UPR/L XTREMITY ART 2 LEVELS

Facility

$408.00

Service Code	HCPCS 93922
Hospital Charge Code	4201051
Hospital Revenue Code	921
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$326.40
Rate for Payer: Aetna of NY Commercial	$265.20
Rate for Payer: Aetna of NY Medicare	$187.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$163.20
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: CDPHP Medicare	$150.96
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$285.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$326.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$326.40
Rate for Payer: EmblemHealth Medicaid	$326.40
Rate for Payer: EmblemHealth Medicare	$138.72
Rate for Payer: EmblemHealth Select Care	$265.20
Rate for Payer: Fidelis Medicare	$163.20
Rate for Payer: Galaxy Health Commercial	$265.20
Rate for Payer: Hamaspik Choice Medicare	$163.20
Rate for Payer: Humana Medicare	$163.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$265.20
Rate for Payer: Local 1199SEIU Medicare	$187.68
Rate for Payer: MVP Health Care of NY Commercial	$306.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$229.70
Rate for Payer: MVP Health Care of NY Medicare	$171.36
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$61.20
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$163.20
Rate for Payer: WellCare Medicare	$224.40

UREA NITROGEN

Facility

$12.00

Service Code	HCPCS 84520
Hospital Charge Code	4300804
Hospital Revenue Code	301
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$7.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: Galaxy Health Commercial	$7.80

UREA NITROGEN

Facility

$12.00

Service Code	HCPCS 84520
Hospital Charge Code	4300804
Hospital Revenue Code	301
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna of NY Commercial	$7.80
Rate for Payer: Aetna of NY Medicare	$5.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.80
Rate for Payer: Cash Price	$9.00
Rate for Payer: CDPHP Medicare	$4.44
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$7.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$9.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$9.60
Rate for Payer: EmblemHealth Medicaid	$9.60
Rate for Payer: EmblemHealth Medicare	$4.08
Rate for Payer: EmblemHealth Select Care	$7.20
Rate for Payer: Fidelis Medicare	$4.80
Rate for Payer: Galaxy Health Commercial	$7.80
Rate for Payer: Hamaspik Choice Medicare	$4.80
Rate for Payer: Humana Medicare	$4.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.80
Rate for Payer: Local 1199SEIU Medicare	$5.52
Rate for Payer: MVP Health Care of NY Commercial	$9.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.76
Rate for Payer: MVP Health Care of NY Medicare	$5.04
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$9.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.80
Rate for Payer: United Healthcare Commercial	$9.00
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: WellCare Medicare	$6.60

URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT

Facility

$10,804.00

Service Code	HCPCS 53450
Hospital Charge Code	4002039
Hospital Revenue Code	490
Min. Negotiated Rate	$1,620.60
Max. Negotiated Rate	$8,643.20
Rate for Payer: Aetna of NY Commercial	$1,900.00
Rate for Payer: Aetna of NY Medicare	$4,969.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4,321.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: CDPHP Medicare	$3,997.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8,643.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8,643.20
Rate for Payer: EmblemHealth Medicaid	$8,643.20
Rate for Payer: EmblemHealth Medicare	$3,673.36
Rate for Payer: EmblemHealth Select Care	$7,778.88
Rate for Payer: Fidelis Medicare	$4,321.60
Rate for Payer: Galaxy Health Commercial	$7,022.60
Rate for Payer: Hamaspik Choice Medicare	$4,321.60
Rate for Payer: Humana Medicare	$4,321.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,900.00
Rate for Payer: Local 1199SEIU Medicare	$4,969.84
Rate for Payer: Multiplan Commercial	$8,643.20
Rate for Payer: MVP Health Care of NY Commercial	$8,103.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6,082.65
Rate for Payer: MVP Health Care of NY Medicare	$4,537.68
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,097.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1,620.60
Rate for Payer: United Healthcare Commercial	$2,097.00
Rate for Payer: United Healthcare Medicare	$4,321.60
Rate for Payer: WellCare Medicare	$5,942.20

URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT

Facility

$10,804.00

Service Code	HCPCS 53450
Hospital Charge Code	4002039
Hospital Revenue Code	490
Min. Negotiated Rate	$7,022.60
Max. Negotiated Rate	$7,022.60
Rate for Payer: Cash Price	$8,103.00
Rate for Payer: Galaxy Health Commercial	$7,022.60

URIC ACID; BLOOD

Facility

$54.00

Service Code	HCPCS 84550
Hospital Charge Code	4301202
Hospital Revenue Code	301
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of NY Commercial	$35.10
Rate for Payer: Aetna of NY Medicare	$24.84
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$21.60
Rate for Payer: Cash Price	$40.50
Rate for Payer: CDPHP Medicare	$19.98
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$32.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$43.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$43.20
Rate for Payer: EmblemHealth Medicaid	$43.20
Rate for Payer: EmblemHealth Medicare	$18.36
Rate for Payer: EmblemHealth Select Care	$32.40
Rate for Payer: Fidelis Medicare	$21.60
Rate for Payer: Galaxy Health Commercial	$35.10
Rate for Payer: Hamaspik Choice Medicare	$21.60
Rate for Payer: Humana Medicare	$21.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$35.10
Rate for Payer: Local 1199SEIU Medicare	$24.84
Rate for Payer: MVP Health Care of NY Commercial	$40.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$30.40
Rate for Payer: MVP Health Care of NY Medicare	$22.68
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$40.50
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$8.10
Rate for Payer: United Healthcare Commercial	$40.50
Rate for Payer: United Healthcare Medicare	$21.60
Rate for Payer: WellCare Medicare	$29.70

URIC ACID; BLOOD

Facility

$54.00

Service Code	HCPCS 84550
Hospital Charge Code	4301202
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Cash Price	$40.50
Rate for Payer: Galaxy Health Commercial	$35.10

URINALYSIS (NO MICROSCOPE)

Facility

$19.00

Service Code	HCPCS 81003
Hospital Charge Code	4300812
Hospital Revenue Code	307
Min. Negotiated Rate	$12.35
Max. Negotiated Rate	$12.35
Rate for Payer: Cash Price	$14.25
Rate for Payer: Galaxy Health Commercial	$12.35

URINALYSIS (NO MICROSCOPE)

Facility

$19.00

Service Code	HCPCS 81003
Hospital Charge Code	4300812
Hospital Revenue Code	307
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$15.20
Rate for Payer: Aetna of NY Commercial	$12.35
Rate for Payer: Aetna of NY Medicare	$8.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.60
Rate for Payer: Cash Price	$14.25
Rate for Payer: CDPHP Medicare	$7.03
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$11.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$15.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$15.20
Rate for Payer: EmblemHealth Medicaid	$15.20
Rate for Payer: EmblemHealth Medicare	$6.46
Rate for Payer: EmblemHealth Select Care	$11.40
Rate for Payer: Fidelis Medicare	$7.60
Rate for Payer: Galaxy Health Commercial	$12.35
Rate for Payer: Hamaspik Choice Medicare	$7.60
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.35
Rate for Payer: Local 1199SEIU Medicare	$8.74
Rate for Payer: MVP Health Care of NY Commercial	$14.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$10.70
Rate for Payer: MVP Health Care of NY Medicare	$7.98
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$14.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.85
Rate for Payer: United Healthcare Commercial	$14.25
Rate for Payer: United Healthcare Medicare	$7.60
Rate for Payer: WellCare Medicare	$10.45

URINE COLLECTION FEE

Facility

$17.51

Hospital Charge Code	4304865
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$11.38
Rate for Payer: Cash Price	$13.13
Rate for Payer: Galaxy Health Commercial	$11.38

URINE COLLECTION FEE

Facility

$17.51

Hospital Charge Code	4304865
Hospital Revenue Code	270
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$14.01
Rate for Payer: Aetna of NY Commercial	$12.26
Rate for Payer: Aetna of NY Medicare	$8.05
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$7.00
Rate for Payer: Cash Price	$13.13
Rate for Payer: CDPHP Medicare	$6.48
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$14.01
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$14.01
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$14.01
Rate for Payer: EmblemHealth Medicaid	$14.01
Rate for Payer: EmblemHealth Medicare	$5.95
Rate for Payer: EmblemHealth Select Care	$12.61
Rate for Payer: Fidelis Medicare	$7.00
Rate for Payer: Galaxy Health Commercial	$11.38
Rate for Payer: Hamaspik Choice Medicare	$7.00
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$12.26
Rate for Payer: Local 1199SEIU Medicare	$8.05
Rate for Payer: MVP Health Care of NY Commercial	$13.13
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.86
Rate for Payer: MVP Health Care of NY Medicare	$7.35
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.63
Rate for Payer: United Healthcare Medicare	$7.00
Rate for Payer: WellCare Medicare	$9.63

URINE CULTURE

Facility

$32.00

Service Code	HCPCS 87088
Hospital Charge Code	4301089
Hospital Revenue Code	300
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$25.60
Rate for Payer: Aetna of NY Commercial	$20.80
Rate for Payer: Aetna of NY Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: CDPHP Medicare	$11.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$19.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$25.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$25.60
Rate for Payer: EmblemHealth Medicaid	$25.60
Rate for Payer: EmblemHealth Medicare	$10.88
Rate for Payer: EmblemHealth Select Care	$19.20
Rate for Payer: Fidelis Medicare	$12.80
Rate for Payer: Galaxy Health Commercial	$20.80
Rate for Payer: Hamaspik Choice Medicare	$12.80
Rate for Payer: Humana Medicare	$12.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$20.80
Rate for Payer: Local 1199SEIU Medicare	$14.72
Rate for Payer: MVP Health Care of NY Commercial	$24.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.02
Rate for Payer: MVP Health Care of NY Medicare	$13.44
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$24.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.80
Rate for Payer: United Healthcare Commercial	$24.00
Rate for Payer: United Healthcare Medicare	$12.80
Rate for Payer: WellCare Medicare	$17.60

URINE CULTURE

Facility

$32.00

Service Code	HCPCS 87088
Hospital Charge Code	4301089
Hospital Revenue Code	300
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Galaxy Health Commercial	$20.80

URINE CULTURE ID

Facility

$32.00

Service Code	HCPCS 87088
Hospital Charge Code	4301137
Hospital Revenue Code	300
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$25.60
Rate for Payer: Aetna of NY Commercial	$20.80
Rate for Payer: Aetna of NY Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$12.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: CDPHP Medicare	$11.84
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$19.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$25.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$25.60
Rate for Payer: EmblemHealth Medicaid	$25.60
Rate for Payer: EmblemHealth Medicare	$10.88
Rate for Payer: EmblemHealth Select Care	$19.20
Rate for Payer: Fidelis Medicare	$12.80
Rate for Payer: Galaxy Health Commercial	$20.80
Rate for Payer: Hamaspik Choice Medicare	$12.80
Rate for Payer: Humana Medicare	$12.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$20.80
Rate for Payer: Local 1199SEIU Medicare	$14.72
Rate for Payer: MVP Health Care of NY Commercial	$24.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$18.02
Rate for Payer: MVP Health Care of NY Medicare	$13.44
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$24.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.80
Rate for Payer: United Healthcare Commercial	$24.00
Rate for Payer: United Healthcare Medicare	$12.80
Rate for Payer: WellCare Medicare	$17.60

URINE CULTURE ID

Facility

$32.00

Service Code	HCPCS 87088
Hospital Charge Code	4301137
Hospital Revenue Code	300
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Galaxy Health Commercial	$20.80

URINE PHOSPHATE

Facility

$17.00

Service Code	HCPCS 84105
Hospital Charge Code	4300628
Hospital Revenue Code	301
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$13.60
Rate for Payer: Aetna of NY Commercial	$11.05
Rate for Payer: Aetna of NY Medicare	$7.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$6.80
Rate for Payer: Cash Price	$12.75
Rate for Payer: CDPHP Medicare	$6.29
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$10.20
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$13.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$13.60
Rate for Payer: EmblemHealth Medicaid	$13.60
Rate for Payer: EmblemHealth Medicare	$5.78
Rate for Payer: EmblemHealth Select Care	$10.20
Rate for Payer: Fidelis Medicare	$6.80
Rate for Payer: Galaxy Health Commercial	$11.05
Rate for Payer: Hamaspik Choice Medicare	$6.80
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$11.05
Rate for Payer: Local 1199SEIU Medicare	$7.82
Rate for Payer: MVP Health Care of NY Commercial	$12.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$9.57
Rate for Payer: MVP Health Care of NY Medicare	$7.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$12.75
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$2.55
Rate for Payer: United Healthcare Commercial	$12.75
Rate for Payer: United Healthcare Medicare	$6.80
Rate for Payer: WellCare Medicare	$9.35

URINE PHOSPHATE

Facility

$17.00

Service Code	HCPCS 84105
Hospital Charge Code	4300628
Hospital Revenue Code	301
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$12.75
Rate for Payer: Galaxy Health Commercial	$11.05

URINE TOTAL PROTEIN

Facility

$11.00

Service Code	HCPCS 84156
Hospital Charge Code	4300665
Hospital Revenue Code	301
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$8.80
Rate for Payer: Aetna of NY Commercial	$7.15
Rate for Payer: Aetna of NY Medicare	$5.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$4.40
Rate for Payer: Cash Price	$8.25
Rate for Payer: CDPHP Medicare	$4.07
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$6.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$8.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$8.80
Rate for Payer: EmblemHealth Medicaid	$8.80
Rate for Payer: EmblemHealth Medicare	$3.74
Rate for Payer: EmblemHealth Select Care	$6.60
Rate for Payer: Fidelis Medicare	$4.40
Rate for Payer: Galaxy Health Commercial	$7.15
Rate for Payer: Hamaspik Choice Medicare	$4.40
Rate for Payer: Humana Medicare	$4.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$7.15
Rate for Payer: Local 1199SEIU Medicare	$5.06
Rate for Payer: MVP Health Care of NY Commercial	$8.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$6.19
Rate for Payer: MVP Health Care of NY Medicare	$4.62
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$8.25
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$1.65
Rate for Payer: United Healthcare Commercial	$8.25
Rate for Payer: United Healthcare Medicare	$4.40
Rate for Payer: WellCare Medicare	$6.05

URINE TOTAL PROTEIN

Facility

$11.00

Service Code	HCPCS 84156
Hospital Charge Code	4300665
Hospital Revenue Code	301
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$7.15
Rate for Payer: Cash Price	$8.25
Rate for Payer: Galaxy Health Commercial	$7.15

URSODIOL 300 MG

Facility

$23.69

Service Code	NDC 51079038320
Hospital Charge Code	4409057
Hospital Revenue Code	250
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$15.40
Rate for Payer: Cash Price	$17.77
Rate for Payer: Galaxy Health Commercial	$15.40
Rate for Payer: WellCare Medicare	$13.03

URSODIOL 300 MG

Facility

$23.69

Service Code	NDC 51079038320
Hospital Charge Code	4409057
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$18.95
Rate for Payer: Aetna of NY Commercial	$16.58
Rate for Payer: Aetna of NY Medicare	$10.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.48
Rate for Payer: Cash Price	$17.77
Rate for Payer: CDPHP Medicare	$8.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$18.95
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$18.95
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$18.95
Rate for Payer: EmblemHealth Medicaid	$18.95
Rate for Payer: EmblemHealth Medicare	$8.05
Rate for Payer: EmblemHealth Select Care	$17.06
Rate for Payer: Fidelis Medicare	$9.48
Rate for Payer: Galaxy Health Commercial	$15.40
Rate for Payer: Hamaspik Choice Medicare	$9.48
Rate for Payer: Humana Medicare	$9.48
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.58
Rate for Payer: Local 1199SEIU Medicare	$10.90
Rate for Payer: MVP Health Care of NY Commercial	$17.77
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.34
Rate for Payer: MVP Health Care of NY Medicare	$9.95
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.55
Rate for Payer: United Healthcare Medicare	$9.48
Rate for Payer: WellCare Medicare	$13.03

ursodioL 300 MG CAPSULE 300 unit, 100 eaches

Facility

$62.84

Service Code	NDC 69238154001
Hospital Charge Code	4401460
Hospital Revenue Code	250
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$40.85
Rate for Payer: Cash Price	$47.13
Rate for Payer: Galaxy Health Commercial	$40.85
Rate for Payer: WellCare Medicare	$34.56

ursodioL 300 MG CAPSULE 300 unit, 100 eaches

Facility

$62.84

Service Code	NDC 69238154001
Hospital Charge Code	4401460
Hospital Revenue Code	250
Min. Negotiated Rate	$9.43
Max. Negotiated Rate	$50.27
Rate for Payer: Aetna of NY Commercial	$43.99
Rate for Payer: Aetna of NY Medicare	$28.91
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$25.14
Rate for Payer: Cash Price	$47.13
Rate for Payer: CDPHP Medicare	$23.25
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.27
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.27
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.27
Rate for Payer: EmblemHealth Medicaid	$50.27
Rate for Payer: EmblemHealth Medicare	$21.37
Rate for Payer: EmblemHealth Select Care	$45.24
Rate for Payer: Fidelis Medicare	$25.14
Rate for Payer: Galaxy Health Commercial	$40.85
Rate for Payer: Hamaspik Choice Medicare	$25.14
Rate for Payer: Humana Medicare	$25.14
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$43.99
Rate for Payer: Local 1199SEIU Medicare	$28.91
Rate for Payer: MVP Health Care of NY Commercial	$47.13
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$35.38
Rate for Payer: MVP Health Care of NY Medicare	$26.39
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$9.43
Rate for Payer: United Healthcare Medicare	$25.14
Rate for Payer: WellCare Medicare	$34.56

US ABDOMEN DUPLEX

Facility

$731.00

Service Code	HCPCS 93978
Hospital Charge Code	4201040
Hospital Revenue Code	921
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$475.15
Rate for Payer: Cash Price	$548.25
Rate for Payer: Galaxy Health Commercial	$475.15

Know your out-of-pocket cost for care.

All Charges