Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US ABDOMEN DUPLEX

Facility

$120.00

Service Code	HCPCS 93978 26
Hospital Charge Code	5201040
Hospital Revenue Code	960
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$78.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Galaxy Health Commercial	$78.00

US ABDOMEN DUPLEX

Facility

$731.00

Service Code	HCPCS 93978
Hospital Charge Code	4201040
Hospital Revenue Code	921
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$584.80
Rate for Payer: Aetna of NY Commercial	$475.15
Rate for Payer: Aetna of NY Medicare	$336.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$292.40
Rate for Payer: Cash Price	$548.25
Rate for Payer: Cash Price	$548.25
Rate for Payer: CDPHP Medicare	$270.47
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$511.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$584.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$584.80
Rate for Payer: EmblemHealth Medicaid	$584.80
Rate for Payer: EmblemHealth Medicare	$248.54
Rate for Payer: EmblemHealth Select Care	$475.15
Rate for Payer: Fidelis Medicare	$292.40
Rate for Payer: Galaxy Health Commercial	$475.15
Rate for Payer: Hamaspik Choice Medicare	$292.40
Rate for Payer: Humana Medicare	$292.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$475.15
Rate for Payer: Local 1199SEIU Medicare	$336.26
Rate for Payer: MVP Health Care of NY Commercial	$548.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$411.55
Rate for Payer: MVP Health Care of NY Medicare	$307.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.65
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$292.40
Rate for Payer: WellCare Medicare	$402.05

US ABDOMEN DUPLEX

Facility

$120.00

Service Code	HCPCS 93978 26
Hospital Charge Code	5201040
Hospital Revenue Code	960
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna of NY Commercial	$78.00
Rate for Payer: Aetna of NY Medicare	$55.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$48.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: CDPHP Medicare	$44.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$96.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$96.00
Rate for Payer: EmblemHealth Medicaid	$96.00
Rate for Payer: EmblemHealth Medicare	$40.80
Rate for Payer: Fidelis Medicare	$48.00
Rate for Payer: Galaxy Health Commercial	$78.00
Rate for Payer: Hamaspik Choice Medicare	$48.00
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$78.00
Rate for Payer: Local 1199SEIU Medicare	$55.20
Rate for Payer: MVP Health Care of NY Commercial	$90.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$67.56
Rate for Payer: MVP Health Care of NY Medicare	$50.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.00
Rate for Payer: United Healthcare Medicare	$48.00
Rate for Payer: WellCare Medicare	$66.00

US ABDOMEN DUPLEX LIMITED

Facility

$320.00

Service Code	HCPCS 93979
Hospital Charge Code	4201041
Hospital Revenue Code	921
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna of NY Commercial	$208.00
Rate for Payer: Aetna of NY Medicare	$147.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: CDPHP Medicare	$118.40
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$224.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$256.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$256.00
Rate for Payer: EmblemHealth Medicaid	$256.00
Rate for Payer: EmblemHealth Medicare	$108.80
Rate for Payer: EmblemHealth Select Care	$208.00
Rate for Payer: Fidelis Medicare	$128.00
Rate for Payer: Galaxy Health Commercial	$208.00
Rate for Payer: Hamaspik Choice Medicare	$128.00
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$208.00
Rate for Payer: Local 1199SEIU Medicare	$147.20
Rate for Payer: MVP Health Care of NY Commercial	$240.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$180.16
Rate for Payer: MVP Health Care of NY Medicare	$134.40
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

US ABDOMEN DUPLEX LIMITED

Facility

$320.00

Service Code	HCPCS 93979
Hospital Charge Code	4201041
Hospital Revenue Code	921
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Galaxy Health Commercial	$208.00

US ABDOMEN DUPLEX LIMITED

Facility

$72.00

Service Code	HCPCS 93979 26
Hospital Charge Code	5201041
Hospital Revenue Code	960
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of NY Commercial	$46.80
Rate for Payer: Aetna of NY Medicare	$33.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$28.80
Rate for Payer: Cash Price	$54.00
Rate for Payer: CDPHP Medicare	$26.64
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$57.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$57.60
Rate for Payer: EmblemHealth Medicaid	$57.60
Rate for Payer: EmblemHealth Medicare	$24.48
Rate for Payer: Fidelis Medicare	$28.80
Rate for Payer: Galaxy Health Commercial	$46.80
Rate for Payer: Hamaspik Choice Medicare	$28.80
Rate for Payer: Humana Medicare	$28.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$46.80
Rate for Payer: Local 1199SEIU Medicare	$33.12
Rate for Payer: MVP Health Care of NY Commercial	$54.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$40.54
Rate for Payer: MVP Health Care of NY Medicare	$30.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.80
Rate for Payer: United Healthcare Medicare	$28.80
Rate for Payer: WellCare Medicare	$39.60

US ABDOMEN DUPLEX LIMITED

Facility

$72.00

Service Code	HCPCS 93979 26
Hospital Charge Code	5201041
Hospital Revenue Code	960
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$46.80
Rate for Payer: Cash Price	$54.00
Rate for Payer: Galaxy Health Commercial	$46.80

US ABDOMEN LIMITED

Facility

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200011
Hospital Revenue Code	960
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$69.60
Rate for Payer: Aetna of NY Commercial	$60.90
Rate for Payer: Aetna of NY Medicare	$40.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$34.80
Rate for Payer: Cash Price	$65.25
Rate for Payer: CDPHP Medicare	$32.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$69.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$69.60
Rate for Payer: EmblemHealth Medicaid	$69.60
Rate for Payer: EmblemHealth Medicare	$29.58
Rate for Payer: Fidelis Medicare	$34.80
Rate for Payer: Galaxy Health Commercial	$56.55
Rate for Payer: Hamaspik Choice Medicare	$34.80
Rate for Payer: Humana Medicare	$34.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$60.90
Rate for Payer: Local 1199SEIU Medicare	$40.02
Rate for Payer: MVP Health Care of NY Commercial	$65.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$48.98
Rate for Payer: MVP Health Care of NY Medicare	$36.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$13.05
Rate for Payer: United Healthcare Medicare	$34.80
Rate for Payer: WellCare Medicare	$47.85

US ABDOMEN LIMITED

Facility

$600.00

Service Code	HCPCS 76705
Hospital Charge Code	4200011
Hospital Revenue Code	402
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$489.00
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) Medicare	$240.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
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	$240.00
Rate for Payer: Galaxy Health Commercial	$390.00
Rate for Payer: Hamaspik Choice Medicare	$240.00
Rate for Payer: Humana Medicare	$240.00
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	$252.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$90.00
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$240.00
Rate for Payer: WellCare Medicare	$330.00

US ABDOMEN LIMITED

Facility

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200011
Hospital Revenue Code	960
Min. Negotiated Rate	$56.55
Max. Negotiated Rate	$56.55
Rate for Payer: Cash Price	$65.25
Rate for Payer: Galaxy Health Commercial	$56.55

US ABDOMEN LIMITED

Facility

$600.00

Service Code	HCPCS 76705
Hospital Charge Code	4200011
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 AORTA REAL TIME SCREEN STUDY AAA

Facility

$80.00

Service Code	HCPCS 76706 26
Hospital Charge Code	5201050
Hospital Revenue Code	960
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna of NY Commercial	$56.00
Rate for Payer: Aetna of NY Medicare	$36.80
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$32.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: CDPHP Medicare	$29.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$64.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$64.00
Rate for Payer: EmblemHealth Medicaid	$64.00
Rate for Payer: EmblemHealth Medicare	$27.20
Rate for Payer: Fidelis Medicare	$32.00
Rate for Payer: Galaxy Health Commercial	$52.00
Rate for Payer: Hamaspik Choice Medicare	$32.00
Rate for Payer: Humana Medicare	$32.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$56.00
Rate for Payer: Local 1199SEIU Medicare	$36.80
Rate for Payer: MVP Health Care of NY Commercial	$60.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$45.04
Rate for Payer: MVP Health Care of NY Medicare	$33.60
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.00
Rate for Payer: United Healthcare Medicare	$32.00
Rate for Payer: WellCare Medicare	$44.00

US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA

Facility

$320.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	4201050
Hospital Revenue Code	402
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Galaxy Health Commercial	$208.00

US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA

Facility

$320.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	4201050
Hospital Revenue Code	402
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$224.00
Rate for Payer: Aetna of NY Medicare	$147.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: CDPHP Medicare	$118.40
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$224.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$256.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$256.00
Rate for Payer: EmblemHealth Medicaid	$256.00
Rate for Payer: EmblemHealth Medicare	$108.80
Rate for Payer: EmblemHealth Select Care	$208.00
Rate for Payer: Fidelis Medicare	$128.00
Rate for Payer: Galaxy Health Commercial	$208.00
Rate for Payer: Hamaspik Choice Medicare	$128.00
Rate for Payer: Humana Medicare	$128.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$224.00
Rate for Payer: Local 1199SEIU Medicare	$147.20
Rate for Payer: MVP Health Care of NY Commercial	$240.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$180.16
Rate for Payer: MVP Health Care of NY Medicare	$134.40
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA

Facility

$80.00

Service Code	HCPCS 76706 26
Hospital Charge Code	5201050
Hospital Revenue Code	960
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Galaxy Health Commercial	$52.00

US ABDOMINAL REAL TIME W/ IMAGE DOCUMENTATION

Facility

$119.00

Service Code	HCPCS 76700 26
Hospital Charge Code	5200012
Hospital Revenue Code	960
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$77.35
Rate for Payer: Cash Price	$89.25
Rate for Payer: Galaxy Health Commercial	$77.35

US ABDOMINAL REAL TIME W/ IMAGE DOCUMENTATION

Facility

$119.00

Service Code	HCPCS 76700 26
Hospital Charge Code	5200012
Hospital Revenue Code	960
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$95.20
Rate for Payer: Aetna of NY Commercial	$83.30
Rate for Payer: Aetna of NY Medicare	$54.74
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$47.60
Rate for Payer: Cash Price	$89.25
Rate for Payer: CDPHP Medicare	$44.03
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$95.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$95.20
Rate for Payer: EmblemHealth Medicaid	$95.20
Rate for Payer: EmblemHealth Medicare	$40.46
Rate for Payer: Fidelis Medicare	$47.60
Rate for Payer: Galaxy Health Commercial	$77.35
Rate for Payer: Hamaspik Choice Medicare	$47.60
Rate for Payer: Humana Medicare	$47.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$83.30
Rate for Payer: Local 1199SEIU Medicare	$54.74
Rate for Payer: MVP Health Care of NY Commercial	$89.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$67.00
Rate for Payer: MVP Health Care of NY Medicare	$49.98
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.85
Rate for Payer: United Healthcare Medicare	$47.60
Rate for Payer: WellCare Medicare	$65.45

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 DOCUMENTATION

Facility

$600.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	4200012
Hospital Revenue Code	402
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$489.00
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) Medicare	$240.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
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	$240.00
Rate for Payer: Galaxy Health Commercial	$390.00
Rate for Payer: Hamaspik Choice Medicare	$240.00
Rate for Payer: Humana Medicare	$240.00
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	$252.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$90.00
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$240.00
Rate for Payer: WellCare Medicare	$330.00

US ABDOMINAL REAL TIME W/IMAGE LIMITED

Facility

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200198
Hospital Revenue Code	960
Min. Negotiated Rate	$56.55
Max. Negotiated Rate	$56.55
Rate for Payer: Cash Price	$65.25
Rate for Payer: Galaxy Health Commercial	$56.55

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

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200198
Hospital Revenue Code	960
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$69.60
Rate for Payer: Aetna of NY Commercial	$60.90
Rate for Payer: Aetna of NY Medicare	$40.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$34.80
Rate for Payer: Cash Price	$65.25
Rate for Payer: CDPHP Medicare	$32.19
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$69.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$69.60
Rate for Payer: EmblemHealth Medicaid	$69.60
Rate for Payer: EmblemHealth Medicare	$29.58
Rate for Payer: Fidelis Medicare	$34.80
Rate for Payer: Galaxy Health Commercial	$56.55
Rate for Payer: Hamaspik Choice Medicare	$34.80
Rate for Payer: Humana Medicare	$34.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$60.90
Rate for Payer: Local 1199SEIU Medicare	$40.02
Rate for Payer: MVP Health Care of NY Commercial	$65.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$48.98
Rate for Payer: MVP Health Care of NY Medicare	$36.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$13.05
Rate for Payer: United Healthcare Medicare	$34.80
Rate for Payer: WellCare Medicare	$47.85

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	$90.00
Max. Negotiated Rate	$489.00
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) Medicare	$240.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
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	$240.00
Rate for Payer: Galaxy Health Commercial	$390.00
Rate for Payer: Hamaspik Choice Medicare	$240.00
Rate for Payer: Humana Medicare	$240.00
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	$252.00
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$90.00
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$240.00
Rate for Payer: WellCare Medicare	$330.00

US ARTERY EXTREMITY LOWER BILATERAL

Facility

$731.00

Service Code	HCPCS 93925 50
Hospital Charge Code	4201035
Hospital Revenue Code	921
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$584.80
Rate for Payer: Aetna of NY Commercial	$475.15
Rate for Payer: Aetna of NY Medicare	$336.26
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$292.40
Rate for Payer: Cash Price	$548.25
Rate for Payer: Cash Price	$548.25
Rate for Payer: CDPHP Medicare	$270.47
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$511.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$584.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$584.80
Rate for Payer: EmblemHealth Medicaid	$584.80
Rate for Payer: EmblemHealth Medicare	$248.54
Rate for Payer: EmblemHealth Select Care	$475.15
Rate for Payer: Fidelis Medicare	$292.40
Rate for Payer: Galaxy Health Commercial	$475.15
Rate for Payer: Hamaspik Choice Medicare	$292.40
Rate for Payer: Humana Medicare	$292.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$475.15
Rate for Payer: Local 1199SEIU Medicare	$336.26
Rate for Payer: MVP Health Care of NY Commercial	$548.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$411.55
Rate for Payer: MVP Health Care of NY Medicare	$307.02
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$287.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.65
Rate for Payer: United Healthcare Commercial	$287.00
Rate for Payer: United Healthcare Medicare	$292.40
Rate for Payer: WellCare Medicare	$402.05

US ARTERY EXTREMITY LOWER BILATERAL

Facility

$731.00

Service Code	HCPCS 93925 50
Hospital Charge Code	4201035
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