Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Facility

$494.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	4200034
Hospital Revenue Code	402
Min. Negotiated Rate	$74.10
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$345.80
Rate for Payer: Aetna of NY Medicare	$227.24
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$197.60
Rate for Payer: Cash Price	$370.50
Rate for Payer: Cash Price	$370.50
Rate for Payer: CDPHP Medicare	$182.78
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$345.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$395.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$395.20
Rate for Payer: EmblemHealth Medicaid	$395.20
Rate for Payer: EmblemHealth Medicare	$167.96
Rate for Payer: EmblemHealth Select Care	$321.10
Rate for Payer: Fidelis Medicare	$197.60
Rate for Payer: Galaxy Health Commercial	$321.10
Rate for Payer: Hamaspik Choice Medicare	$197.60
Rate for Payer: Humana Medicare	$197.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$345.80
Rate for Payer: Local 1199SEIU Medicare	$227.24
Rate for Payer: MVP Health Care of NY Commercial	$370.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$278.12
Rate for Payer: MVP Health Care of NY Medicare	$207.48
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$74.10
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$197.60
Rate for Payer: WellCare Medicare	$271.70

US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Facility

$494.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	4200034
Hospital Revenue Code	402
Min. Negotiated Rate	$321.10
Max. Negotiated Rate	$321.10
Rate for Payer: Cash Price	$370.50
Rate for Payer: Galaxy Health Commercial	$321.10

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	$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 PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$621.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	4200086
Hospital Revenue Code	402
Min. Negotiated Rate	$93.15
Max. Negotiated Rate	$496.80
Rate for Payer: Aetna of NY Commercial	$434.70
Rate for Payer: Aetna of NY Medicare	$285.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$248.40
Rate for Payer: Cash Price	$465.75
Rate for Payer: Cash Price	$465.75
Rate for Payer: CDPHP Medicare	$229.77
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$434.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$496.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$496.80
Rate for Payer: EmblemHealth Medicaid	$496.80
Rate for Payer: EmblemHealth Medicare	$211.14
Rate for Payer: EmblemHealth Select Care	$403.65
Rate for Payer: Fidelis Medicare	$248.40
Rate for Payer: Galaxy Health Commercial	$403.65
Rate for Payer: Hamaspik Choice Medicare	$248.40
Rate for Payer: Humana Medicare	$248.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$434.70
Rate for Payer: Local 1199SEIU Medicare	$285.66
Rate for Payer: MVP Health Care of NY Commercial	$465.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$349.62
Rate for Payer: MVP Health Care of NY Medicare	$260.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$93.15
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$248.40
Rate for Payer: WellCare Medicare	$341.55

US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$146.00

Service Code	HCPCS 76801 26
Hospital Charge Code	5200086
Hospital Revenue Code	960
Min. Negotiated Rate	$94.90
Max. Negotiated Rate	$94.90
Rate for Payer: Cash Price	$109.50
Rate for Payer: Galaxy Health Commercial	$94.90

US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$621.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	4200086
Hospital Revenue Code	402
Min. Negotiated Rate	$403.65
Max. Negotiated Rate	$403.65
Rate for Payer: Cash Price	$465.75
Rate for Payer: Galaxy Health Commercial	$403.65

US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Facility

$146.00

Service Code	HCPCS 76801 26
Hospital Charge Code	5200086
Hospital Revenue Code	960
Min. Negotiated Rate	$21.90
Max. Negotiated Rate	$116.80
Rate for Payer: Aetna of NY Commercial	$102.20
Rate for Payer: Aetna of NY Medicare	$67.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$58.40
Rate for Payer: Cash Price	$109.50
Rate for Payer: CDPHP Medicare	$54.02
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$116.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$116.80
Rate for Payer: EmblemHealth Medicaid	$116.80
Rate for Payer: EmblemHealth Medicare	$49.64
Rate for Payer: Fidelis Medicare	$58.40
Rate for Payer: Galaxy Health Commercial	$94.90
Rate for Payer: Hamaspik Choice Medicare	$58.40
Rate for Payer: Humana Medicare	$58.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$102.20
Rate for Payer: Local 1199SEIU Medicare	$67.16
Rate for Payer: MVP Health Care of NY Commercial	$109.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$82.20
Rate for Payer: MVP Health Care of NY Medicare	$61.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$21.90
Rate for Payer: United Healthcare Medicare	$58.40
Rate for Payer: WellCare Medicare	$80.30

US PREGNANT UTERUS LIMITED 1/> FETUSES

Facility

$320.00

Service Code	HCPCS 76815 TC
Hospital Charge Code	4200023
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 PREGNANT UTERUS LIMITED 1/> FETUSES

Facility

$96.00

Service Code	HCPCS 76815 26
Hospital Charge Code	5200023
Hospital Revenue Code	960
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna of NY Commercial	$67.20
Rate for Payer: Aetna of NY Medicare	$44.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$38.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: CDPHP Medicare	$35.52
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$76.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$76.80
Rate for Payer: EmblemHealth Medicaid	$76.80
Rate for Payer: EmblemHealth Medicare	$32.64
Rate for Payer: Fidelis Medicare	$38.40
Rate for Payer: Galaxy Health Commercial	$62.40
Rate for Payer: Hamaspik Choice Medicare	$38.40
Rate for Payer: Humana Medicare	$38.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$67.20
Rate for Payer: Local 1199SEIU Medicare	$44.16
Rate for Payer: MVP Health Care of NY Commercial	$72.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$54.05
Rate for Payer: MVP Health Care of NY Medicare	$40.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$14.40
Rate for Payer: United Healthcare Medicare	$38.40
Rate for Payer: WellCare Medicare	$52.80

US PREGNANT UTERUS LIMITED 1/> FETUSES

Facility

$320.00

Service Code	HCPCS 76815 TC
Hospital Charge Code	4200023
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 PREGNANT UTERUS LIMITED 1/> FETUSES

Facility

$96.00

Service Code	HCPCS 76815 26
Hospital Charge Code	5200023
Hospital Revenue Code	960
Min. Negotiated Rate	$62.40
Max. Negotiated Rate	$62.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Galaxy Health Commercial	$62.40

US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

Facility

$705.00

Service Code	HCPCS 76802 TC
Hospital Charge Code	4200085
Hospital Revenue Code	402
Min. Negotiated Rate	$458.25
Max. Negotiated Rate	$458.25
Rate for Payer: Cash Price	$528.75
Rate for Payer: Galaxy Health Commercial	$458.25

US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

Facility

$122.00

Service Code	HCPCS 76802 26
Hospital Charge Code	5200085
Hospital Revenue Code	960
Min. Negotiated Rate	$79.30
Max. Negotiated Rate	$79.30
Rate for Payer: Cash Price	$91.50
Rate for Payer: Galaxy Health Commercial	$79.30

US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

Facility

$705.00

Service Code	HCPCS 76802 TC
Hospital Charge Code	4200085
Hospital Revenue Code	402
Min. Negotiated Rate	$105.75
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna of NY Commercial	$493.50
Rate for Payer: Aetna of NY Medicare	$324.30
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$282.00
Rate for Payer: Cash Price	$528.75
Rate for Payer: Cash Price	$528.75
Rate for Payer: CDPHP Medicare	$260.85
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$493.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$564.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$564.00
Rate for Payer: EmblemHealth Medicaid	$564.00
Rate for Payer: EmblemHealth Medicare	$239.70
Rate for Payer: EmblemHealth Select Care	$458.25
Rate for Payer: Fidelis Medicare	$282.00
Rate for Payer: Galaxy Health Commercial	$458.25
Rate for Payer: Hamaspik Choice Medicare	$282.00
Rate for Payer: Humana Medicare	$282.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$493.50
Rate for Payer: Local 1199SEIU Medicare	$324.30
Rate for Payer: MVP Health Care of NY Commercial	$528.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$396.92
Rate for Payer: MVP Health Care of NY Medicare	$296.10
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$105.75
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$282.00
Rate for Payer: WellCare Medicare	$387.75

US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

Facility

$122.00

Service Code	HCPCS 76802 26
Hospital Charge Code	5200085
Hospital Revenue Code	960
Min. Negotiated Rate	$18.30
Max. Negotiated Rate	$97.60
Rate for Payer: Aetna of NY Commercial	$85.40
Rate for Payer: Aetna of NY Medicare	$56.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$48.80
Rate for Payer: Cash Price	$91.50
Rate for Payer: CDPHP Medicare	$45.14
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$97.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$97.60
Rate for Payer: EmblemHealth Medicaid	$97.60
Rate for Payer: EmblemHealth Medicare	$41.48
Rate for Payer: Fidelis Medicare	$48.80
Rate for Payer: Galaxy Health Commercial	$79.30
Rate for Payer: Hamaspik Choice Medicare	$48.80
Rate for Payer: Humana Medicare	$48.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$85.40
Rate for Payer: Local 1199SEIU Medicare	$56.12
Rate for Payer: MVP Health Care of NY Commercial	$91.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$68.69
Rate for Payer: MVP Health Care of NY Medicare	$51.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$18.30
Rate for Payer: United Healthcare Medicare	$48.80
Rate for Payer: WellCare Medicare	$67.10

US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO

Facility

$374.00

Service Code	HCPCS 76810 TC
Hospital Charge Code	4200010
Hospital Revenue Code	402
Min. Negotiated Rate	$243.10
Max. Negotiated Rate	$243.10
Rate for Payer: Cash Price	$280.50
Rate for Payer: Galaxy Health Commercial	$243.10

US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO

Facility

$374.00

Service Code	HCPCS 76810 TC
Hospital Charge Code	4200010
Hospital Revenue Code	402
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$261.80
Rate for Payer: Aetna of NY Medicare	$172.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$149.60
Rate for Payer: Cash Price	$280.50
Rate for Payer: Cash Price	$280.50
Rate for Payer: CDPHP Medicare	$138.38
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$261.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$299.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$299.20
Rate for Payer: EmblemHealth Medicaid	$299.20
Rate for Payer: EmblemHealth Medicare	$127.16
Rate for Payer: EmblemHealth Select Care	$243.10
Rate for Payer: Fidelis Medicare	$149.60
Rate for Payer: Galaxy Health Commercial	$243.10
Rate for Payer: Hamaspik Choice Medicare	$149.60
Rate for Payer: Humana Medicare	$149.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$261.80
Rate for Payer: Local 1199SEIU Medicare	$172.04
Rate for Payer: MVP Health Care of NY Commercial	$280.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$210.56
Rate for Payer: MVP Health Care of NY Medicare	$157.08
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$56.10
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$149.60
Rate for Payer: WellCare Medicare	$205.70

US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATION

Facility

$143.00

Service Code	HCPCS 76810 26
Hospital Charge Code	5200010
Hospital Revenue Code	960
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$92.95
Rate for Payer: Cash Price	$107.25
Rate for Payer: Galaxy Health Commercial	$92.95

US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATION

Facility

$143.00

Service Code	HCPCS 76810 26
Hospital Charge Code	5200010
Hospital Revenue Code	960
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$114.40
Rate for Payer: Aetna of NY Commercial	$100.10
Rate for Payer: Aetna of NY Medicare	$65.78
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$57.20
Rate for Payer: Cash Price	$107.25
Rate for Payer: CDPHP Medicare	$52.91
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$114.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$114.40
Rate for Payer: EmblemHealth Medicaid	$114.40
Rate for Payer: EmblemHealth Medicare	$48.62
Rate for Payer: Fidelis Medicare	$57.20
Rate for Payer: Galaxy Health Commercial	$92.95
Rate for Payer: Hamaspik Choice Medicare	$57.20
Rate for Payer: Humana Medicare	$57.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$100.10
Rate for Payer: Local 1199SEIU Medicare	$65.78
Rate for Payer: MVP Health Care of NY Commercial	$107.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$80.51
Rate for Payer: MVP Health Care of NY Medicare	$60.06
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$21.45
Rate for Payer: United Healthcare Medicare	$57.20
Rate for Payer: WellCare Medicare	$78.65

US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION

Facility

$147.00

Service Code	HCPCS 76805 26
Hospital Charge Code	5200116
Hospital Revenue Code	960
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$117.60
Rate for Payer: Aetna of NY Commercial	$102.90
Rate for Payer: Aetna of NY Medicare	$67.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$58.80
Rate for Payer: Cash Price	$110.25
Rate for Payer: CDPHP Medicare	$54.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$117.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$117.60
Rate for Payer: EmblemHealth Medicaid	$117.60
Rate for Payer: EmblemHealth Medicare	$49.98
Rate for Payer: Fidelis Medicare	$58.80
Rate for Payer: Galaxy Health Commercial	$95.55
Rate for Payer: Hamaspik Choice Medicare	$58.80
Rate for Payer: Humana Medicare	$58.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$102.90
Rate for Payer: Local 1199SEIU Medicare	$67.62
Rate for Payer: MVP Health Care of NY Commercial	$110.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$82.76
Rate for Payer: MVP Health Care of NY Medicare	$61.74
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$22.05
Rate for Payer: United Healthcare Medicare	$58.80
Rate for Payer: WellCare Medicare	$80.85

US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION

Facility

$601.00

Service Code	HCPCS 76805 TC
Hospital Charge Code	4200116
Hospital Revenue Code	402
Min. Negotiated Rate	$390.65
Max. Negotiated Rate	$390.65
Rate for Payer: Cash Price	$450.75
Rate for Payer: Galaxy Health Commercial	$390.65

US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION

Facility

$147.00

Service Code	HCPCS 76805 26
Hospital Charge Code	5200116
Hospital Revenue Code	960
Min. Negotiated Rate	$95.55
Max. Negotiated Rate	$95.55
Rate for Payer: Cash Price	$110.25
Rate for Payer: Galaxy Health Commercial	$95.55

US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION

Facility

$601.00

Service Code	HCPCS 76805 TC
Hospital Charge Code	4200116
Hospital Revenue Code	402
Min. Negotiated Rate	$90.15
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna of NY Commercial	$420.70
Rate for Payer: Aetna of NY Medicare	$276.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$240.40
Rate for Payer: Cash Price	$450.75
Rate for Payer: Cash Price	$450.75
Rate for Payer: CDPHP Medicare	$222.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$420.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$480.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$480.80
Rate for Payer: EmblemHealth Medicaid	$480.80
Rate for Payer: EmblemHealth Medicare	$204.34
Rate for Payer: EmblemHealth Select Care	$390.65
Rate for Payer: Fidelis Medicare	$240.40
Rate for Payer: Galaxy Health Commercial	$390.65
Rate for Payer: Hamaspik Choice Medicare	$240.40
Rate for Payer: Humana Medicare	$240.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$420.70
Rate for Payer: Local 1199SEIU Medicare	$276.46
Rate for Payer: MVP Health Care of NY Commercial	$450.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$338.36
Rate for Payer: MVP Health Care of NY Medicare	$252.42
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$90.15
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$240.40
Rate for Payer: WellCare Medicare	$330.55

US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT

Facility

$807.00

Service Code	HCPCS 76812 TC
Hospital Charge Code	4200087
Hospital Revenue Code	402
Min. Negotiated Rate	$121.05
Max. Negotiated Rate	$645.60
Rate for Payer: Aetna of NY Commercial	$564.90
Rate for Payer: Aetna of NY Medicare	$371.22
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$322.80
Rate for Payer: Cash Price	$605.25
Rate for Payer: Cash Price	$605.25
Rate for Payer: CDPHP Medicare	$298.59
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$564.90
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$645.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$645.60
Rate for Payer: EmblemHealth Medicaid	$645.60
Rate for Payer: EmblemHealth Medicare	$274.38
Rate for Payer: EmblemHealth Select Care	$524.55
Rate for Payer: Fidelis Medicare	$322.80
Rate for Payer: Galaxy Health Commercial	$524.55
Rate for Payer: Hamaspik Choice Medicare	$322.80
Rate for Payer: Humana Medicare	$322.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$564.90
Rate for Payer: Local 1199SEIU Medicare	$371.22
Rate for Payer: MVP Health Care of NY Commercial	$605.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$454.34
Rate for Payer: MVP Health Care of NY Medicare	$338.94
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$489.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$121.05
Rate for Payer: United Healthcare Commercial	$489.00
Rate for Payer: United Healthcare Medicare	$322.80
Rate for Payer: WellCare Medicare	$443.85

US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT

Facility

$260.00

Service Code	HCPCS 76812 26
Hospital Charge Code	5200087
Hospital Revenue Code	960
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Galaxy Health Commercial	$169.00

Know your out-of-pocket cost for care.

All Charges