Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$320.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	4200071
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$320.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	4200071
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$102.00

Service Code	HCPCS 76882 26
Hospital Charge Code	5200071
Hospital Revenue Code	960
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$66.30
Rate for Payer: Cash Price	$76.50
Rate for Payer: Galaxy Health Commercial	$66.30

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG

Facility

$102.00

Service Code	HCPCS 76882 26
Hospital Charge Code	5200071
Hospital Revenue Code	960
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna of NY Commercial	$71.40
Rate for Payer: Aetna of NY Medicare	$46.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.80
Rate for Payer: Cash Price	$76.50
Rate for Payer: CDPHP Medicare	$37.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$81.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$81.60
Rate for Payer: EmblemHealth Medicaid	$81.60
Rate for Payer: EmblemHealth Medicare	$34.68
Rate for Payer: Fidelis Medicare	$40.80
Rate for Payer: Galaxy Health Commercial	$66.30
Rate for Payer: Hamaspik Choice Medicare	$40.80
Rate for Payer: Humana Medicare	$40.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$71.40
Rate for Payer: Local 1199SEIU Medicare	$46.92
Rate for Payer: MVP Health Care of NY Commercial	$76.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$57.43
Rate for Payer: MVP Health Care of NY Medicare	$42.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.30
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: WellCare Medicare	$56.10

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$320.00

Service Code	HCPCS 76882 LT,TC
Hospital Charge Code	4201063
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$320.00

Service Code	HCPCS 76882 LT,TC
Hospital Charge Code	4201063
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$102.00

Service Code	HCPCS 76882 26,LT
Hospital Charge Code	5201063
Hospital Revenue Code	960
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna of NY Commercial	$71.40
Rate for Payer: Aetna of NY Medicare	$46.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.80
Rate for Payer: Cash Price	$76.50
Rate for Payer: CDPHP Medicare	$37.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$81.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$81.60
Rate for Payer: EmblemHealth Medicaid	$81.60
Rate for Payer: EmblemHealth Medicare	$34.68
Rate for Payer: Fidelis Medicare	$40.80
Rate for Payer: Galaxy Health Commercial	$66.30
Rate for Payer: Hamaspik Choice Medicare	$40.80
Rate for Payer: Humana Medicare	$40.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$71.40
Rate for Payer: Local 1199SEIU Medicare	$46.92
Rate for Payer: MVP Health Care of NY Commercial	$76.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$57.43
Rate for Payer: MVP Health Care of NY Medicare	$42.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.30
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: WellCare Medicare	$56.10

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, LEFT

Facility

$102.00

Service Code	HCPCS 76882 26,LT
Hospital Charge Code	5201063
Hospital Revenue Code	960
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$66.30
Rate for Payer: Cash Price	$76.50
Rate for Payer: Galaxy Health Commercial	$66.30

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$320.00

Service Code	HCPCS 76882 RT,TC
Hospital Charge Code	4201062
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$320.00

Service Code	HCPCS 76882 RT,TC
Hospital Charge Code	4201062
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 LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$102.00

Service Code	HCPCS 76882 26,RT
Hospital Charge Code	5201062
Hospital Revenue Code	960
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna of NY Commercial	$71.40
Rate for Payer: Aetna of NY Medicare	$46.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$40.80
Rate for Payer: Cash Price	$76.50
Rate for Payer: CDPHP Medicare	$37.74
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$81.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$81.60
Rate for Payer: EmblemHealth Medicaid	$81.60
Rate for Payer: EmblemHealth Medicare	$34.68
Rate for Payer: Fidelis Medicare	$40.80
Rate for Payer: Galaxy Health Commercial	$66.30
Rate for Payer: Hamaspik Choice Medicare	$40.80
Rate for Payer: Humana Medicare	$40.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$71.40
Rate for Payer: Local 1199SEIU Medicare	$46.92
Rate for Payer: MVP Health Care of NY Commercial	$76.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$57.43
Rate for Payer: MVP Health Care of NY Medicare	$42.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$15.30
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: WellCare Medicare	$56.10

US LMTD JOINT/OTH NONVASC XTR STRUX R-T W/IMG, RIGHT

Facility

$102.00

Service Code	HCPCS 76882 26,RT
Hospital Charge Code	5201062
Hospital Revenue Code	960
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$66.30
Rate for Payer: Cash Price	$76.50
Rate for Payer: Galaxy Health Commercial	$66.30

US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$320.00

Service Code	HCPCS 76883
Hospital Charge Code	4201091
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 NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$179.00

Service Code	HCPCS 76883 26
Hospital Charge Code	5201091
Hospital Revenue Code	960
Min. Negotiated Rate	$116.35
Max. Negotiated Rate	$116.35
Rate for Payer: Cash Price	$134.25
Rate for Payer: Galaxy Health Commercial	$116.35

US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$320.00

Service Code	HCPCS 76883
Hospital Charge Code	4201091
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 NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY

Facility

$179.00

Service Code	HCPCS 76883 26
Hospital Charge Code	5201091
Hospital Revenue Code	960
Min. Negotiated Rate	$26.85
Max. Negotiated Rate	$143.20
Rate for Payer: Aetna of NY Commercial	$125.30
Rate for Payer: Aetna of NY Medicare	$82.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$71.60
Rate for Payer: Cash Price	$134.25
Rate for Payer: CDPHP Medicare	$66.23
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$143.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$143.20
Rate for Payer: EmblemHealth Medicaid	$143.20
Rate for Payer: EmblemHealth Medicare	$60.86
Rate for Payer: Fidelis Medicare	$71.60
Rate for Payer: Galaxy Health Commercial	$116.35
Rate for Payer: Hamaspik Choice Medicare	$71.60
Rate for Payer: Humana Medicare	$71.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$125.30
Rate for Payer: Local 1199SEIU Medicare	$82.34
Rate for Payer: MVP Health Care of NY Commercial	$134.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$100.78
Rate for Payer: MVP Health Care of NY Medicare	$75.18
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$26.85
Rate for Payer: United Healthcare Medicare	$71.60
Rate for Payer: WellCare Medicare	$98.45

US OF GALLBLADDER

Facility

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200025
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 OF GALLBLADDER

Facility

$87.00

Service Code	HCPCS 76705 26
Hospital Charge Code	5200025
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 OF GALLBLADDER

Facility

$320.00

Service Code	HCPCS 76705
Hospital Charge Code	4200025
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 OF GALLBLADDER

Facility

$320.00

Service Code	HCPCS 76705
Hospital Charge Code	4200025
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 PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED / F/U

Facility

$73.00

Service Code	HCPCS 76857 26
Hospital Charge Code	5200015
Hospital Revenue Code	960
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$58.40
Rate for Payer: Aetna of NY Commercial	$51.10
Rate for Payer: Aetna of NY Medicare	$33.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$29.20
Rate for Payer: Cash Price	$54.75
Rate for Payer: CDPHP Medicare	$27.01
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$58.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$58.40
Rate for Payer: EmblemHealth Medicaid	$58.40
Rate for Payer: EmblemHealth Medicare	$24.82
Rate for Payer: Fidelis Medicare	$29.20
Rate for Payer: Galaxy Health Commercial	$47.45
Rate for Payer: Hamaspik Choice Medicare	$29.20
Rate for Payer: Humana Medicare	$29.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$51.10
Rate for Payer: Local 1199SEIU Medicare	$33.58
Rate for Payer: MVP Health Care of NY Commercial	$54.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$41.10
Rate for Payer: MVP Health Care of NY Medicare	$30.66
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$10.95
Rate for Payer: United Healthcare Medicare	$29.20
Rate for Payer: WellCare Medicare	$40.15

US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED / F/U

Facility

$73.00

Service Code	HCPCS 76857 26
Hospital Charge Code	5200015
Hospital Revenue Code	960
Min. Negotiated Rate	$47.45
Max. Negotiated Rate	$47.45
Rate for Payer: Cash Price	$54.75
Rate for Payer: Galaxy Health Commercial	$47.45

US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U

Facility

$461.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	4200015
Hospital Revenue Code	402
Min. Negotiated Rate	$299.65
Max. Negotiated Rate	$299.65
Rate for Payer: Cash Price	$345.75
Rate for Payer: Galaxy Health Commercial	$299.65

US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U

Facility

$461.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	4200015
Hospital Revenue Code	402
Min. Negotiated Rate	$69.15
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$322.70
Rate for Payer: Aetna of NY Medicare	$212.06
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$184.40
Rate for Payer: Cash Price	$345.75
Rate for Payer: Cash Price	$345.75
Rate for Payer: CDPHP Medicare	$170.57
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$322.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$368.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$368.80
Rate for Payer: EmblemHealth Medicaid	$368.80
Rate for Payer: EmblemHealth Medicare	$156.74
Rate for Payer: EmblemHealth Select Care	$299.65
Rate for Payer: Fidelis Medicare	$184.40
Rate for Payer: Galaxy Health Commercial	$299.65
Rate for Payer: Hamaspik Choice Medicare	$184.40
Rate for Payer: Humana Medicare	$184.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$322.70
Rate for Payer: Local 1199SEIU Medicare	$212.06
Rate for Payer: MVP Health Care of NY Commercial	$345.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$259.54
Rate for Payer: MVP Health Care of NY Medicare	$193.62
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$69.15
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$184.40
Rate for Payer: WellCare Medicare	$253.55

US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Facility

$101.00

Service Code	HCPCS 76856 26
Hospital Charge Code	5200034
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

Know your out-of-pocket cost for care.

All Charges