Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US ARTERY EXTREMITY LOWER, BILATERAL

Facility

$115.00

Service Code	HCPCS 93925 26,50
Hospital Charge Code	5201035
Hospital Revenue Code	960
Min. Negotiated Rate	$17.25
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna of NY Commercial	$74.75
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$46.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: Fidelis Medicare	$46.00
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$46.00
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$74.75
Rate for Payer: Local 1199SEIU Medicare	$52.90
Rate for Payer: MVP Health Care of NY Commercial	$86.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$64.75
Rate for Payer: MVP Health Care of NY Medicare	$48.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.25
Rate for Payer: United Healthcare Medicare	$46.00
Rate for Payer: WellCare Medicare	$63.25

US ARTERY EXTREMITY LOWER, BILATERAL

Facility

$115.00

Service Code	HCPCS 93925 26,50
Hospital Charge Code	5201035
Hospital Revenue Code	960
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

US ARTERY EXTREMITY LOWER LEFT

Facility

$320.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	4201037
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 ARTERY EXTREMITY LOWER LEFT

Facility

$320.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	4201037
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 ARTERY EXTREMITY LOWER, LEFT

Facility

$70.00

Service Code	HCPCS 93926 26,LT
Hospital Charge Code	5201037
Hospital Revenue Code	960
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$45.50
Rate for Payer: Cash Price	$52.50
Rate for Payer: Galaxy Health Commercial	$45.50

US ARTERY EXTREMITY LOWER, LEFT

Facility

$70.00

Service Code	HCPCS 93926 26,LT
Hospital Charge Code	5201037
Hospital Revenue Code	960
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna of NY Commercial	$45.50
Rate for Payer: Aetna of NY Medicare	$32.20
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$28.00
Rate for Payer: Cash Price	$52.50
Rate for Payer: CDPHP Medicare	$25.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$56.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$56.00
Rate for Payer: EmblemHealth Medicaid	$56.00
Rate for Payer: EmblemHealth Medicare	$23.80
Rate for Payer: Fidelis Medicare	$28.00
Rate for Payer: Galaxy Health Commercial	$45.50
Rate for Payer: Hamaspik Choice Medicare	$28.00
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$45.50
Rate for Payer: Local 1199SEIU Medicare	$32.20
Rate for Payer: MVP Health Care of NY Commercial	$52.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$39.41
Rate for Payer: MVP Health Care of NY Medicare	$29.40
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.50
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: WellCare Medicare	$38.50

US ARTERY EXTREMITY UPPER BILAT

Facility

$731.00

Service Code	HCPCS 93930 50
Hospital Charge Code	4201038
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

US ARTERY EXTREMITY UPPER BILAT

Facility

$731.00

Service Code	HCPCS 93930 50
Hospital Charge Code	4201038
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 UPPER, BILAT

Facility

$117.00

Service Code	HCPCS 93930 26,50
Hospital Charge Code	5201038
Hospital Revenue Code	960
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$76.05
Rate for Payer: Cash Price	$87.75
Rate for Payer: Galaxy Health Commercial	$76.05

US ARTERY EXTREMITY UPPER, BILAT

Facility

$117.00

Service Code	HCPCS 93930 26,50
Hospital Charge Code	5201038
Hospital Revenue Code	960
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of NY Commercial	$76.05
Rate for Payer: Aetna of NY Medicare	$53.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$46.80
Rate for Payer: Cash Price	$87.75
Rate for Payer: CDPHP Medicare	$43.29
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$93.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$93.60
Rate for Payer: EmblemHealth Medicaid	$93.60
Rate for Payer: EmblemHealth Medicare	$39.78
Rate for Payer: Fidelis Medicare	$46.80
Rate for Payer: Galaxy Health Commercial	$76.05
Rate for Payer: Hamaspik Choice Medicare	$46.80
Rate for Payer: Humana Medicare	$46.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$76.05
Rate for Payer: Local 1199SEIU Medicare	$53.82
Rate for Payer: MVP Health Care of NY Commercial	$87.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$65.87
Rate for Payer: MVP Health Care of NY Medicare	$49.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$17.55
Rate for Payer: United Healthcare Medicare	$46.80
Rate for Payer: WellCare Medicare	$64.35

US BREAST UNI REAL TIME W/ IMAGE COMPLETE

Facility

$108.00

Service Code	HCPCS 76641 26
Hospital Charge Code	5201048
Hospital Revenue Code	960
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of NY Commercial	$75.60
Rate for Payer: Aetna of NY Medicare	$49.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$43.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: CDPHP Medicare	$39.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$86.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$86.40
Rate for Payer: EmblemHealth Medicaid	$86.40
Rate for Payer: EmblemHealth Medicare	$36.72
Rate for Payer: Fidelis Medicare	$43.20
Rate for Payer: Galaxy Health Commercial	$70.20
Rate for Payer: Hamaspik Choice Medicare	$43.20
Rate for Payer: Humana Medicare	$43.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$75.60
Rate for Payer: Local 1199SEIU Medicare	$49.68
Rate for Payer: MVP Health Care of NY Commercial	$81.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$60.80
Rate for Payer: MVP Health Care of NY Medicare	$45.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.20
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: WellCare Medicare	$59.40

US BREAST UNI REAL TIME W/ IMAGE COMPLETE

Facility

$108.00

Service Code	HCPCS 76641 26
Hospital Charge Code	5201048
Hospital Revenue Code	960
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: Galaxy Health Commercial	$70.20

US BREAST UNI REAL TIME W/ IMAGE LIMITED

Facility

$101.00

Service Code	HCPCS 76642 26
Hospital Charge Code	5200006
Hospital Revenue Code	960
Min. Negotiated Rate	$65.65
Max. Negotiated Rate	$65.65
Rate for Payer: Cash Price	$75.75
Rate for Payer: Galaxy Health Commercial	$65.65

US BREAST UNI REAL TIME W/ IMAGE LIMITED

Facility

$101.00

Service Code	HCPCS 76642 26
Hospital Charge Code	5200006
Hospital Revenue Code	960
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$80.80
Rate for Payer: Aetna of NY Commercial	$70.70
Rate for Payer: Aetna of NY Medicare	$46.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.40
Rate for Payer: Cash Price	$75.75
Rate for Payer: CDPHP Medicare	$37.37
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$80.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$80.80
Rate for Payer: EmblemHealth Medicaid	$80.80
Rate for Payer: EmblemHealth Medicare	$34.34
Rate for Payer: Fidelis Medicare	$40.40
Rate for Payer: Galaxy Health Commercial	$65.65
Rate for Payer: Hamaspik Choice Medicare	$40.40
Rate for Payer: Humana Medicare	$40.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$70.70
Rate for Payer: Local 1199SEIU Medicare	$46.46
Rate for Payer: MVP Health Care of NY Commercial	$75.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$56.86
Rate for Payer: MVP Health Care of NY Medicare	$42.42
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.15
Rate for Payer: United Healthcare Medicare	$40.40
Rate for Payer: WellCare Medicare	$55.55

US BREAST UNI REAL TIME WITH IMAGE COMPELTE, RIGHT

Facility

$108.00

Service Code	HCPCS 76641 26,RT
Hospital Charge Code	5201057
Hospital Revenue Code	960
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: Galaxy Health Commercial	$70.20

US BREAST UNI REAL TIME WITH IMAGE COMPELTE, RIGHT

Facility

$108.00

Service Code	HCPCS 76641 26,RT
Hospital Charge Code	5201057
Hospital Revenue Code	960
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of NY Commercial	$75.60
Rate for Payer: Aetna of NY Medicare	$49.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$43.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: CDPHP Medicare	$39.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$86.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$86.40
Rate for Payer: EmblemHealth Medicaid	$86.40
Rate for Payer: EmblemHealth Medicare	$36.72
Rate for Payer: Fidelis Medicare	$43.20
Rate for Payer: Galaxy Health Commercial	$70.20
Rate for Payer: Hamaspik Choice Medicare	$43.20
Rate for Payer: Humana Medicare	$43.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$75.60
Rate for Payer: Local 1199SEIU Medicare	$49.68
Rate for Payer: MVP Health Care of NY Commercial	$81.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$60.80
Rate for Payer: MVP Health Care of NY Medicare	$45.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.20
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: WellCare Medicare	$59.40

US BREAST UNI REAL TIME WITH IMAGE COMPLETE

Facility

$320.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	4201048
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 BREAST UNI REAL TIME WITH IMAGE COMPLETE

Facility

$320.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	4201048
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 BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$108.00

Service Code	HCPCS 76641 26,50
Hospital Charge Code	5201058
Hospital Revenue Code	960
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of NY Commercial	$75.60
Rate for Payer: Aetna of NY Medicare	$49.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$43.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: CDPHP Medicare	$39.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$86.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$86.40
Rate for Payer: EmblemHealth Medicaid	$86.40
Rate for Payer: EmblemHealth Medicare	$36.72
Rate for Payer: Fidelis Medicare	$43.20
Rate for Payer: Galaxy Health Commercial	$70.20
Rate for Payer: Hamaspik Choice Medicare	$43.20
Rate for Payer: Humana Medicare	$43.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$75.60
Rate for Payer: Local 1199SEIU Medicare	$49.68
Rate for Payer: MVP Health Care of NY Commercial	$81.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$60.80
Rate for Payer: MVP Health Care of NY Medicare	$45.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.20
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: WellCare Medicare	$59.40

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$108.00

Service Code	HCPCS 76641 26,50
Hospital Charge Code	5201058
Hospital Revenue Code	960
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: Galaxy Health Commercial	$70.20

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$320.00

Service Code	HCPCS 76641 50,TC
Hospital Charge Code	4201058
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 BREAST UNI REAL TIME WITH IMAGE COMPLETE, BILATERAL

Facility

$320.00

Service Code	HCPCS 76641 50,TC
Hospital Charge Code	4201058
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 BREAST UNI REAL TIME WITH IMAGE COMPLETE, LEFT

Facility

$320.00

Service Code	HCPCS 76641 LT,TC
Hospital Charge Code	4201056
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 BREAST UNI REAL TIME WITH IMAGE COMPLETE, LEFT

Facility

$108.00

Service Code	HCPCS 76641 26,LT
Hospital Charge Code	5201056
Hospital Revenue Code	960
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of NY Commercial	$75.60
Rate for Payer: Aetna of NY Medicare	$49.68
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$43.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: CDPHP Medicare	$39.96
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$86.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$86.40
Rate for Payer: EmblemHealth Medicaid	$86.40
Rate for Payer: EmblemHealth Medicare	$36.72
Rate for Payer: Fidelis Medicare	$43.20
Rate for Payer: Galaxy Health Commercial	$70.20
Rate for Payer: Hamaspik Choice Medicare	$43.20
Rate for Payer: Humana Medicare	$43.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$75.60
Rate for Payer: Local 1199SEIU Medicare	$49.68
Rate for Payer: MVP Health Care of NY Commercial	$81.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$60.80
Rate for Payer: MVP Health Care of NY Medicare	$45.36
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.20
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: WellCare Medicare	$59.40

US BREAST UNI REAL TIME WITH IMAGE COMPLETE, LEFT

Facility

$108.00

Service Code	HCPCS 76641 26,LT
Hospital Charge Code	5201056
Hospital Revenue Code	960
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Cash Price	$81.00
Rate for Payer: Galaxy Health Commercial	$70.20

Know your out-of-pocket cost for care.

All Charges