Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

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	$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, RIGHT

Facility

$320.00

Service Code	HCPCS 76641 RT,TC
Hospital Charge Code	4201057
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, RIGHT

Facility

$320.00

Service Code	HCPCS 76641 RT,TC
Hospital Charge Code	4201057
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 LIMITED

Facility

$267.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	4200006
Hospital Revenue Code	402
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$186.90
Rate for Payer: Aetna of NY Medicare	$122.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.80
Rate for Payer: Cash Price	$200.25
Rate for Payer: Cash Price	$200.25
Rate for Payer: CDPHP Medicare	$98.79
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$186.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$213.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$213.60
Rate for Payer: EmblemHealth Medicaid	$213.60
Rate for Payer: EmblemHealth Medicare	$90.78
Rate for Payer: EmblemHealth Select Care	$173.55
Rate for Payer: Fidelis Medicare	$106.80
Rate for Payer: Galaxy Health Commercial	$173.55
Rate for Payer: Hamaspik Choice Medicare	$106.80
Rate for Payer: Humana Medicare	$106.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$186.90
Rate for Payer: Local 1199SEIU Medicare	$122.82
Rate for Payer: MVP Health Care of NY Commercial	$200.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$150.32
Rate for Payer: MVP Health Care of NY Medicare	$112.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

US BREAST UNI REAL TIME WITH IMAGE LIMITED

Facility

$267.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	4200006
Hospital Revenue Code	402
Min. Negotiated Rate	$173.55
Max. Negotiated Rate	$173.55
Rate for Payer: Cash Price	$200.25
Rate for Payer: Galaxy Health Commercial	$173.55

US BREAST UNI REAL TIME WITH IMAGE LIMITED, BILATERAL

Facility

$101.00

Service Code	HCPCS 76642 26,50
Hospital Charge Code	5201061
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 LIMITED, BILATERAL

Facility

$267.00

Service Code	HCPCS 76642 50,TC
Hospital Charge Code	4201061
Hospital Revenue Code	402
Min. Negotiated Rate	$173.55
Max. Negotiated Rate	$173.55
Rate for Payer: Cash Price	$200.25
Rate for Payer: Galaxy Health Commercial	$173.55

US BREAST UNI REAL TIME WITH IMAGE LIMITED, BILATERAL

Facility

$101.00

Service Code	HCPCS 76642 26,50
Hospital Charge Code	5201061
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 WITH IMAGE LIMITED, BILATERAL

Facility

$267.00

Service Code	HCPCS 76642 50,TC
Hospital Charge Code	4201061
Hospital Revenue Code	402
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$186.90
Rate for Payer: Aetna of NY Medicare	$122.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.80
Rate for Payer: Cash Price	$200.25
Rate for Payer: Cash Price	$200.25
Rate for Payer: CDPHP Medicare	$98.79
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$186.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$213.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$213.60
Rate for Payer: EmblemHealth Medicaid	$213.60
Rate for Payer: EmblemHealth Medicare	$90.78
Rate for Payer: EmblemHealth Select Care	$173.55
Rate for Payer: Fidelis Medicare	$106.80
Rate for Payer: Galaxy Health Commercial	$173.55
Rate for Payer: Hamaspik Choice Medicare	$106.80
Rate for Payer: Humana Medicare	$106.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$186.90
Rate for Payer: Local 1199SEIU Medicare	$122.82
Rate for Payer: MVP Health Care of NY Commercial	$200.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$150.32
Rate for Payer: MVP Health Care of NY Medicare	$112.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

US BREAST UNI REAL TIME WITH IMAGE LIMITED, LEFT

Facility

$267.00

Service Code	HCPCS 76642 LT,TC
Hospital Charge Code	4201059
Hospital Revenue Code	402
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$186.90
Rate for Payer: Aetna of NY Medicare	$122.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.80
Rate for Payer: Cash Price	$200.25
Rate for Payer: Cash Price	$200.25
Rate for Payer: CDPHP Medicare	$98.79
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$186.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$213.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$213.60
Rate for Payer: EmblemHealth Medicaid	$213.60
Rate for Payer: EmblemHealth Medicare	$90.78
Rate for Payer: EmblemHealth Select Care	$173.55
Rate for Payer: Fidelis Medicare	$106.80
Rate for Payer: Galaxy Health Commercial	$173.55
Rate for Payer: Hamaspik Choice Medicare	$106.80
Rate for Payer: Humana Medicare	$106.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$186.90
Rate for Payer: Local 1199SEIU Medicare	$122.82
Rate for Payer: MVP Health Care of NY Commercial	$200.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$150.32
Rate for Payer: MVP Health Care of NY Medicare	$112.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

US BREAST UNI REAL TIME WITH IMAGE LIMITED, LEFT

Facility

$101.00

Service Code	HCPCS 76642 26,LT
Hospital Charge Code	5201059
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 LIMITED, LEFT

Facility

$101.00

Service Code	HCPCS 76642 26,LT
Hospital Charge Code	5201059
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 WITH IMAGE LIMITED, LEFT

Facility

$267.00

Service Code	HCPCS 76642 LT,TC
Hospital Charge Code	4201059
Hospital Revenue Code	402
Min. Negotiated Rate	$173.55
Max. Negotiated Rate	$173.55
Rate for Payer: Cash Price	$200.25
Rate for Payer: Galaxy Health Commercial	$173.55

US BREAST UNI REAL TIME WITH IMAGE LIMITED, RIGHT

Facility

$267.00

Service Code	HCPCS 76642 RT,TC
Hospital Charge Code	4201060
Hospital Revenue Code	402
Min. Negotiated Rate	$173.55
Max. Negotiated Rate	$173.55
Rate for Payer: Cash Price	$200.25
Rate for Payer: Galaxy Health Commercial	$173.55

US BREAST UNI REAL TIME WITH IMAGE LIMITED, RIGHT

Facility

$267.00

Service Code	HCPCS 76642 RT,TC
Hospital Charge Code	4201060
Hospital Revenue Code	402
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$186.90
Rate for Payer: Aetna of NY Medicare	$122.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.80
Rate for Payer: Cash Price	$200.25
Rate for Payer: Cash Price	$200.25
Rate for Payer: CDPHP Medicare	$98.79
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$186.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$213.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$213.60
Rate for Payer: EmblemHealth Medicaid	$213.60
Rate for Payer: EmblemHealth Medicare	$90.78
Rate for Payer: EmblemHealth Select Care	$173.55
Rate for Payer: Fidelis Medicare	$106.80
Rate for Payer: Galaxy Health Commercial	$173.55
Rate for Payer: Hamaspik Choice Medicare	$106.80
Rate for Payer: Humana Medicare	$106.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$186.90
Rate for Payer: Local 1199SEIU Medicare	$122.82
Rate for Payer: MVP Health Care of NY Commercial	$200.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$150.32
Rate for Payer: MVP Health Care of NY Medicare	$112.14
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

US BREAST UNI REAL TIME WITH LIMITED, RIGHT

Facility

$101.00

Service Code	HCPCS 76642 26,RT
Hospital Charge Code	5201060
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 LIMITED, RIGHT

Facility

$101.00

Service Code	HCPCS 76642 26,RT
Hospital Charge Code	5201060
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 CHEST REAL TIME W/IMAGE DOCUMENTATION

Facility

$84.00

Service Code	HCPCS 76604 26
Hospital Charge Code	5201047
Hospital Revenue Code	960
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$54.60
Rate for Payer: Cash Price	$63.00
Rate for Payer: Galaxy Health Commercial	$54.60

US CHEST REAL TIME W/IMAGE DOCUMENTATION

Facility

$84.00

Service Code	HCPCS 76604 26
Hospital Charge Code	5201047
Hospital Revenue Code	960
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of NY Commercial	$58.80
Rate for Payer: Aetna of NY Medicare	$38.64
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$33.60
Rate for Payer: Cash Price	$63.00
Rate for Payer: CDPHP Medicare	$31.08
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$67.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$67.20
Rate for Payer: EmblemHealth Medicaid	$67.20
Rate for Payer: EmblemHealth Medicare	$28.56
Rate for Payer: Fidelis Medicare	$33.60
Rate for Payer: Galaxy Health Commercial	$54.60
Rate for Payer: Hamaspik Choice Medicare	$33.60
Rate for Payer: Humana Medicare	$33.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$58.80
Rate for Payer: Local 1199SEIU Medicare	$38.64
Rate for Payer: MVP Health Care of NY Commercial	$63.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$47.29
Rate for Payer: MVP Health Care of NY Medicare	$35.28
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.60
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: WellCare Medicare	$46.20

US CHEST REAL TIME W/IMAGE DOCUMENTATION

Facility

$320.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	4201047
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 CHEST REAL TIME W/IMAGE DOCUMENTATION

Facility

$320.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	4201047
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 COMPL JOINT R-T W/ IMAGE DOCUMENTATION

Facility

$133.00

Service Code	HCPCS 76881 26
Hospital Charge Code	5200018
Hospital Revenue Code	960
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna of NY Commercial	$93.10
Rate for Payer: Aetna of NY Medicare	$61.18
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$53.20
Rate for Payer: Cash Price	$99.75
Rate for Payer: CDPHP Medicare	$49.21
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$106.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$106.40
Rate for Payer: EmblemHealth Medicaid	$106.40
Rate for Payer: EmblemHealth Medicare	$45.22
Rate for Payer: Fidelis Medicare	$53.20
Rate for Payer: Galaxy Health Commercial	$86.45
Rate for Payer: Hamaspik Choice Medicare	$53.20
Rate for Payer: Humana Medicare	$53.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$93.10
Rate for Payer: Local 1199SEIU Medicare	$61.18
Rate for Payer: MVP Health Care of NY Commercial	$99.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$74.88
Rate for Payer: MVP Health Care of NY Medicare	$55.86
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$19.95
Rate for Payer: United Healthcare Medicare	$53.20
Rate for Payer: WellCare Medicare	$73.15

US COMPL JOINT R-T W/ IMAGE DOCUMENTATION

Facility

$133.00

Service Code	HCPCS 76881 26
Hospital Charge Code	5200018
Hospital Revenue Code	960
Min. Negotiated Rate	$86.45
Max. Negotiated Rate	$86.45
Rate for Payer: Cash Price	$99.75
Rate for Payer: Galaxy Health Commercial	$86.45

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$320.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	4200018
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 COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$320.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	4200018
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

Know your out-of-pocket cost for care.

All Charges