Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

X-RAY EXAM OF ANKLE 3+ VIEWS, BILAT

Facility

$267.00

Service Code	HCPCS 73610 TC,50
Hospital Charge Code	4150228
Hospital Revenue Code	320
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$160.20
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	$160.20
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

X-RAY EXAM OF ANKLE 3+ VIEWS, BILAT

Facility

$267.00

Service Code	HCPCS 73610 TC,50
Hospital Charge Code	4150228
Hospital Revenue Code	320
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

X-RAY EXAM OF ANKLE 3+ VIEWS, LEFT

Facility

$267.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	4150059
Hospital Revenue Code	320
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$160.20
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	$160.20
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

X-RAY EXAM OF ANKLE 3+ VIEWS, LEFT

Facility

$267.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	4150059
Hospital Revenue Code	320
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

X-RAY EXAM OF ANKLE 3+ VIEWS, LEFT

Facility

$27.00

Service Code	HCPCS 73610 26,LT
Hospital Charge Code	5150059
Hospital Revenue Code	960
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of NY Commercial	$18.90
Rate for Payer: Aetna of NY Medicare	$12.42
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.80
Rate for Payer: Cash Price	$20.25
Rate for Payer: CDPHP Medicare	$9.99
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$21.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$21.60
Rate for Payer: EmblemHealth Medicaid	$21.60
Rate for Payer: EmblemHealth Medicare	$9.18
Rate for Payer: Fidelis Medicare	$10.80
Rate for Payer: Galaxy Health Commercial	$17.55
Rate for Payer: Hamaspik Choice Medicare	$10.80
Rate for Payer: Humana Medicare	$10.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.90
Rate for Payer: Local 1199SEIU Medicare	$12.42
Rate for Payer: MVP Health Care of NY Commercial	$20.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.20
Rate for Payer: MVP Health Care of NY Medicare	$11.34
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.05
Rate for Payer: United Healthcare Medicare	$10.80
Rate for Payer: WellCare Medicare	$14.85

X-RAY EXAM OF ANKLE 3+ VIEWS, LEFT

Facility

$27.00

Service Code	HCPCS 73610 26,LT
Hospital Charge Code	5150059
Hospital Revenue Code	960
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$17.55
Rate for Payer: Cash Price	$20.25
Rate for Payer: Galaxy Health Commercial	$17.55

X-RAY EXAM OF ANKLE 3+ VIEWS, RIGHT

Facility

$27.00

Service Code	HCPCS 73610 26,RT
Hospital Charge Code	5150014
Hospital Revenue Code	960
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of NY Commercial	$18.90
Rate for Payer: Aetna of NY Medicare	$12.42
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.80
Rate for Payer: Cash Price	$20.25
Rate for Payer: CDPHP Medicare	$9.99
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$21.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$21.60
Rate for Payer: EmblemHealth Medicaid	$21.60
Rate for Payer: EmblemHealth Medicare	$9.18
Rate for Payer: Fidelis Medicare	$10.80
Rate for Payer: Galaxy Health Commercial	$17.55
Rate for Payer: Hamaspik Choice Medicare	$10.80
Rate for Payer: Humana Medicare	$10.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.90
Rate for Payer: Local 1199SEIU Medicare	$12.42
Rate for Payer: MVP Health Care of NY Commercial	$20.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.20
Rate for Payer: MVP Health Care of NY Medicare	$11.34
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.05
Rate for Payer: United Healthcare Medicare	$10.80
Rate for Payer: WellCare Medicare	$14.85

X-RAY EXAM OF ANKLE 3+ VIEWS, RIGHT

Facility

$27.00

Service Code	HCPCS 73610 26,RT
Hospital Charge Code	5150014
Hospital Revenue Code	960
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$17.55
Rate for Payer: Cash Price	$20.25
Rate for Payer: Galaxy Health Commercial	$17.55

X-RAY EXAM OF ANKLE 3+ VIEWS, RIGHT

Facility

$267.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	4150014
Hospital Revenue Code	320
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$160.20
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	$160.20
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$40.05
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$106.80
Rate for Payer: WellCare Medicare	$146.85

X-RAY EXAM OF ANKLE 3+ VIEWS, RIGHT

Facility

$267.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	4150014
Hospital Revenue Code	320
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

X-RAY EXAM OF ANKLE, BILAT, 2 VIEWS

Facility

$24.00

Service Code	HCPCS 73600 26,50
Hospital Charge Code	5150338
Hospital Revenue Code	960
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$19.20
Rate for Payer: Aetna of NY Commercial	$16.80
Rate for Payer: Aetna of NY Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: CDPHP Medicare	$8.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$19.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$19.20
Rate for Payer: EmblemHealth Medicaid	$19.20
Rate for Payer: EmblemHealth Medicare	$8.16
Rate for Payer: Fidelis Medicare	$9.60
Rate for Payer: Galaxy Health Commercial	$15.60
Rate for Payer: Hamaspik Choice Medicare	$9.60
Rate for Payer: Humana Medicare	$9.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.80
Rate for Payer: Local 1199SEIU Medicare	$11.04
Rate for Payer: MVP Health Care of NY Commercial	$18.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.51
Rate for Payer: MVP Health Care of NY Medicare	$10.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.60
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: WellCare Medicare	$13.20

X-RAY EXAM OF ANKLE, BILAT, 2 VIEWS

Facility

$24.00

Service Code	HCPCS 73600 26,50
Hospital Charge Code	5150230
Hospital Revenue Code	960
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: Galaxy Health Commercial	$15.60

X-RAY EXAM OF ANKLE, BILAT, 2 VIEWS

Facility

$24.00

Service Code	HCPCS 73600 26,50
Hospital Charge Code	5150338
Hospital Revenue Code	960
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: Galaxy Health Commercial	$15.60

X-RAY EXAM OF ANKLE, BILAT, 2 VIEWS

Facility

$24.00

Service Code	HCPCS 73600 26,50
Hospital Charge Code	5150230
Hospital Revenue Code	960
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$19.20
Rate for Payer: Aetna of NY Commercial	$16.80
Rate for Payer: Aetna of NY Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: CDPHP Medicare	$8.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$19.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$19.20
Rate for Payer: EmblemHealth Medicaid	$19.20
Rate for Payer: EmblemHealth Medicare	$8.16
Rate for Payer: Fidelis Medicare	$9.60
Rate for Payer: Galaxy Health Commercial	$15.60
Rate for Payer: Hamaspik Choice Medicare	$9.60
Rate for Payer: Humana Medicare	$9.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.80
Rate for Payer: Local 1199SEIU Medicare	$11.04
Rate for Payer: MVP Health Care of NY Commercial	$18.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.51
Rate for Payer: MVP Health Care of NY Medicare	$10.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.60
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: WellCare Medicare	$13.20

X-RAY EXAM OF ANKLE, BILAT, 3+ VIEWS

Facility

$27.00

Service Code	HCPCS 73610 26,50
Hospital Charge Code	5150228
Hospital Revenue Code	960
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$17.55
Rate for Payer: Cash Price	$20.25
Rate for Payer: Galaxy Health Commercial	$17.55

X-RAY EXAM OF ANKLE, BILAT, 3+ VIEWS

Facility

$27.00

Service Code	HCPCS 73610 26,50
Hospital Charge Code	5150228
Hospital Revenue Code	960
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of NY Commercial	$18.90
Rate for Payer: Aetna of NY Medicare	$12.42
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$10.80
Rate for Payer: Cash Price	$20.25
Rate for Payer: CDPHP Medicare	$9.99
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$21.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$21.60
Rate for Payer: EmblemHealth Medicaid	$21.60
Rate for Payer: EmblemHealth Medicare	$9.18
Rate for Payer: Fidelis Medicare	$10.80
Rate for Payer: Galaxy Health Commercial	$17.55
Rate for Payer: Hamaspik Choice Medicare	$10.80
Rate for Payer: Humana Medicare	$10.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$18.90
Rate for Payer: Local 1199SEIU Medicare	$12.42
Rate for Payer: MVP Health Care of NY Commercial	$20.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$15.20
Rate for Payer: MVP Health Care of NY Medicare	$11.34
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$4.05
Rate for Payer: United Healthcare Medicare	$10.80
Rate for Payer: WellCare Medicare	$14.85

X-RAY EXAM OF ARM INFANT 2+ VIEWS, BILATERAL

Facility

$320.00

Service Code	HCPCS 73092 50
Hospital Charge Code	4150513
Hospital Revenue Code	320
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$192.00
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	$192.00
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

X-RAY EXAM OF ARM INFANT 2+ VIEWS, BILATERAL

Facility

$320.00

Service Code	HCPCS 73092 50
Hospital Charge Code	4150513
Hospital Revenue Code	320
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

X-RAY EXAM OF ARM INFANT, 2 VIEWS, LEFT

Facility

$24.00

Service Code	HCPCS 73092 26,LT
Hospital Charge Code	5150514
Hospital Revenue Code	960
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: Galaxy Health Commercial	$15.60

X-RAY EXAM OF ARM INFANT, 2 VIEWS, LEFT

Facility

$24.00

Service Code	HCPCS 73092 26,LT
Hospital Charge Code	5150514
Hospital Revenue Code	960
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$19.20
Rate for Payer: Aetna of NY Commercial	$16.80
Rate for Payer: Aetna of NY Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$9.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: CDPHP Medicare	$8.88
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$19.20
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$19.20
Rate for Payer: EmblemHealth Medicaid	$19.20
Rate for Payer: EmblemHealth Medicare	$8.16
Rate for Payer: Fidelis Medicare	$9.60
Rate for Payer: Galaxy Health Commercial	$15.60
Rate for Payer: Hamaspik Choice Medicare	$9.60
Rate for Payer: Humana Medicare	$9.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$16.80
Rate for Payer: Local 1199SEIU Medicare	$11.04
Rate for Payer: MVP Health Care of NY Commercial	$18.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$13.51
Rate for Payer: MVP Health Care of NY Medicare	$10.08
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$3.60
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: WellCare Medicare	$13.20

X-RAY EXAM OF ARM INFANT 2+ VIEWS, LEFT

Facility

$320.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	4150514
Hospital Revenue Code	320
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

X-RAY EXAM OF ARM INFANT 2+ VIEWS, LEFT

Facility

$320.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	4150514
Hospital Revenue Code	320
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$192.00
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	$192.00
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

X-RAY EXAM OF ARM INFANT 2+ VIEWS, RIGHT

Facility

$320.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	4150515
Hospital Revenue Code	320
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$402.00
Rate for Payer: Aetna of NY Commercial	$192.00
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	$192.00
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	$402.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.00
Rate for Payer: United Healthcare Commercial	$402.00
Rate for Payer: United Healthcare Medicare	$128.00
Rate for Payer: WellCare Medicare	$176.00

X-RAY EXAM OF ARM INFANT 2+ VIEWS, RIGHT

Facility

$320.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	4150515
Hospital Revenue Code	320
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

X-RAY EXAM OF ARM INFANT, 2+ VIEWS, RIGHT

Facility

$24.00

Service Code	HCPCS 73092 26,RT
Hospital Charge Code	5150515
Hospital Revenue Code	960
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$18.00
Rate for Payer: Galaxy Health Commercial	$15.60

Know your out-of-pocket cost for care.

All Charges