Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US EXAM ABDO BACK WALL LIM

Facility

$86.00

Service Code	HCPCS 76775 26
Hospital Charge Code	5200005
Hospital Revenue Code	960
Min. Negotiated Rate	$55.90
Max. Negotiated Rate	$55.90
Rate for Payer: Cash Price	$64.50
Rate for Payer: Galaxy Health Commercial	$55.90

US EXAM ABDO BACK WALL LIM

Facility

$320.00

Service Code	HCPCS 76775
Hospital Charge Code	4200005
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 EXAM ABDO BACK WALL LIM

Facility

$320.00

Service Code	HCPCS 76775
Hospital Charge Code	4200005
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 EXAM ABDO BACK WALL LIM

Facility

$86.00

Service Code	HCPCS 76775 26
Hospital Charge Code	5200005
Hospital Revenue Code	960
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$68.80
Rate for Payer: Aetna of NY Commercial	$60.20
Rate for Payer: Aetna of NY Medicare	$39.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$34.40
Rate for Payer: Cash Price	$64.50
Rate for Payer: CDPHP Medicare	$31.82
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$68.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$68.80
Rate for Payer: EmblemHealth Medicaid	$68.80
Rate for Payer: EmblemHealth Medicare	$29.24
Rate for Payer: Fidelis Medicare	$34.40
Rate for Payer: Galaxy Health Commercial	$55.90
Rate for Payer: Hamaspik Choice Medicare	$34.40
Rate for Payer: Humana Medicare	$34.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$60.20
Rate for Payer: Local 1199SEIU Medicare	$39.56
Rate for Payer: MVP Health Care of NY Commercial	$64.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$48.42
Rate for Payer: MVP Health Care of NY Medicare	$36.12
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$12.90
Rate for Payer: United Healthcare Medicare	$34.40
Rate for Payer: WellCare Medicare	$47.30

US EXAM ABDOM COMPLETE

Facility

$320.00

Service Code	HCPCS 76700
Hospital Charge Code	4201045
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 EXAM ABDOM COMPLETE

Facility

$119.00

Service Code	HCPCS 76700 26
Hospital Charge Code	5201045
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 EXAM ABDOM COMPLETE

Facility

$119.00

Service Code	HCPCS 76700 26
Hospital Charge Code	5201045
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 EXAM ABDOM COMPLETE

Facility

$320.00

Service Code	HCPCS 76700
Hospital Charge Code	4201045
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 EXAM INFANT HIPS DYNAMIC

Facility

$110.00

Service Code	HCPCS 76885 26
Hospital Charge Code	5201054
Hospital Revenue Code	960
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$71.50
Rate for Payer: Cash Price	$82.50
Rate for Payer: Galaxy Health Commercial	$71.50

US EXAM INFANT HIPS DYNAMIC

Facility

$267.00

Service Code	HCPCS 76885
Hospital Charge Code	4201054
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 EXAM INFANT HIPS DYNAMIC

Facility

$110.00

Service Code	HCPCS 76885 26
Hospital Charge Code	5201054
Hospital Revenue Code	960
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna of NY Commercial	$77.00
Rate for Payer: Aetna of NY Medicare	$50.60
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$44.00
Rate for Payer: Cash Price	$82.50
Rate for Payer: CDPHP Medicare	$40.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$88.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$88.00
Rate for Payer: EmblemHealth Medicaid	$88.00
Rate for Payer: EmblemHealth Medicare	$37.40
Rate for Payer: Fidelis Medicare	$44.00
Rate for Payer: Galaxy Health Commercial	$71.50
Rate for Payer: Hamaspik Choice Medicare	$44.00
Rate for Payer: Humana Medicare	$44.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$77.00
Rate for Payer: Local 1199SEIU Medicare	$50.60
Rate for Payer: MVP Health Care of NY Commercial	$82.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$61.93
Rate for Payer: MVP Health Care of NY Medicare	$46.20
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.50
Rate for Payer: United Healthcare Medicare	$44.00
Rate for Payer: WellCare Medicare	$60.50

US EXAM INFANT HIPS DYNAMIC

Facility

$267.00

Service Code	HCPCS 76885
Hospital Charge Code	4201054
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 EXAM INFANT HIPS STATIC

Facility

$92.00

Service Code	HCPCS 76886 26
Hospital Charge Code	5201055
Hospital Revenue Code	960
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$73.60
Rate for Payer: Aetna of NY Commercial	$64.40
Rate for Payer: Aetna of NY Medicare	$42.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$36.80
Rate for Payer: Cash Price	$69.00
Rate for Payer: CDPHP Medicare	$34.04
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$73.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$73.60
Rate for Payer: EmblemHealth Medicaid	$73.60
Rate for Payer: EmblemHealth Medicare	$31.28
Rate for Payer: Fidelis Medicare	$36.80
Rate for Payer: Galaxy Health Commercial	$59.80
Rate for Payer: Hamaspik Choice Medicare	$36.80
Rate for Payer: Humana Medicare	$36.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$64.40
Rate for Payer: Local 1199SEIU Medicare	$42.32
Rate for Payer: MVP Health Care of NY Commercial	$69.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$51.80
Rate for Payer: MVP Health Care of NY Medicare	$38.64
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$13.80
Rate for Payer: United Healthcare Medicare	$36.80
Rate for Payer: WellCare Medicare	$50.60

US EXAM INFANT HIPS STATIC

Facility

$267.00

Service Code	HCPCS 76886
Hospital Charge Code	4201055
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 EXAM INFANT HIPS STATIC

Facility

$92.00

Service Code	HCPCS 76886 26
Hospital Charge Code	5201055
Hospital Revenue Code	960
Min. Negotiated Rate	$59.80
Max. Negotiated Rate	$59.80
Rate for Payer: Cash Price	$69.00
Rate for Payer: Galaxy Health Commercial	$59.80

US EXAM INFANT HIPS STATIC

Facility

$267.00

Service Code	HCPCS 76886
Hospital Charge Code	4201055
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 EXAM K TRANSPL W/ DOPPLER

Facility

$112.00

Service Code	HCPCS 76776 26
Hospital Charge Code	5200019
Hospital Revenue Code	960
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$89.60
Rate for Payer: Aetna of NY Commercial	$78.40
Rate for Payer: Aetna of NY Medicare	$51.52
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$44.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: CDPHP Medicare	$41.44
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$89.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$89.60
Rate for Payer: EmblemHealth Medicaid	$89.60
Rate for Payer: EmblemHealth Medicare	$38.08
Rate for Payer: Fidelis Medicare	$44.80
Rate for Payer: Galaxy Health Commercial	$72.80
Rate for Payer: Hamaspik Choice Medicare	$44.80
Rate for Payer: Humana Medicare	$44.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$78.40
Rate for Payer: Local 1199SEIU Medicare	$51.52
Rate for Payer: MVP Health Care of NY Commercial	$84.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$63.06
Rate for Payer: MVP Health Care of NY Medicare	$47.04
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$16.80
Rate for Payer: United Healthcare Medicare	$44.80
Rate for Payer: WellCare Medicare	$61.60

US EXAM K TRANSPL W/ DOPPLER

Facility

$112.00

Service Code	HCPCS 76776 26
Hospital Charge Code	5200019
Hospital Revenue Code	960
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$72.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Galaxy Health Commercial	$72.80

US EXAM K TRANSPL W/DOPPLER

Facility

$320.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	4200019
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 EXAM K TRANSPL W/DOPPLER

Facility

$320.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	4200019
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 EXAM OF HEAD AND NECK

Facility

$320.00

Service Code	HCPCS 76536
Hospital Charge Code	4200039
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 EXAM OF HEAD AND NECK

Facility

$320.00

Service Code	HCPCS 76536
Hospital Charge Code	4200039
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 EXAM OF HEAD AND NECK

Facility

$84.00

Service Code	HCPCS 76536 26
Hospital Charge Code	5200039
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 EXAM OF HEAD AND NECK

Facility

$84.00

Service Code	HCPCS 76536 26
Hospital Charge Code	5200039
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 EXAM SPINAL CANAL

Facility

$199.00

Service Code	HCPCS 76800 26
Hospital Charge Code	5201049
Hospital Revenue Code	960
Min. Negotiated Rate	$129.35
Max. Negotiated Rate	$129.35
Rate for Payer: Cash Price	$149.25
Rate for Payer: Galaxy Health Commercial	$129.35

Know your out-of-pocket cost for care.

All Charges