Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

CTA HEAD & NECK C+ W/ NON CONTRAST IMG & POST-PXESSING

Facility

$378.00

Service Code	HCPCS 70471 26
Hospital Charge Code	5224312
Hospital Revenue Code	960
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$245.70
Rate for Payer: Cash Price	$283.50
Rate for Payer: Galaxy Health Commercial	$245.70

CTA HEAD & NECK C+ W/ NON CONTRAST IMG & POST-PXESSING

Facility

$378.00

Service Code	HCPCS 70471 26
Hospital Charge Code	5224312
Hospital Revenue Code	960
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$173.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$151.20
Rate for Payer: Cash Price	$283.50
Rate for Payer: Cash Price	$283.50
Rate for Payer: CDPHP Medicare	$139.86
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$302.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$302.40
Rate for Payer: EmblemHealth Medicaid	$302.40
Rate for Payer: EmblemHealth Medicare	$128.52
Rate for Payer: Fidelis Medicare	$151.20
Rate for Payer: Galaxy Health Commercial	$245.70
Rate for Payer: Hamaspik Choice Medicare	$151.20
Rate for Payer: Humana Medicare	$151.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$173.88
Rate for Payer: MVP Health Care of NY Commercial	$283.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$212.81
Rate for Payer: MVP Health Care of NY Medicare	$158.76
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$56.70
Rate for Payer: United Healthcare Medicare	$151.20
Rate for Payer: WellCare Medicare	$207.90

CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSING

Facility

$713.00

Service Code	HCPCS 70471 TC
Hospital Charge Code	4224312
Hospital Revenue Code	350
Min. Negotiated Rate	$106.95
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$327.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$285.20
Rate for Payer: Cash Price	$534.75
Rate for Payer: Cash Price	$534.75
Rate for Payer: Cash Price	$534.75
Rate for Payer: CDPHP Medicare	$263.81
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$499.10
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$570.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$570.40
Rate for Payer: EmblemHealth Medicaid	$570.40
Rate for Payer: EmblemHealth Medicare	$242.42
Rate for Payer: EmblemHealth Select Care	$463.45
Rate for Payer: Fidelis Medicare	$285.20
Rate for Payer: Galaxy Health Commercial	$463.45
Rate for Payer: Hamaspik Choice Medicare	$285.20
Rate for Payer: Humana Medicare	$285.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$327.98
Rate for Payer: MVP Health Care of NY Commercial	$534.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$401.42
Rate for Payer: MVP Health Care of NY Medicare	$299.46
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$106.95
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$285.20
Rate for Payer: WellCare Medicare	$392.15

CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSING

Facility

$713.00

Service Code	HCPCS 70471 TC
Hospital Charge Code	4224312
Hospital Revenue Code	350
Min. Negotiated Rate	$463.45
Max. Negotiated Rate	$463.45
Rate for Payer: Cash Price	$534.75
Rate for Payer: Galaxy Health Commercial	$463.45

CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST

Facility

$350.00

Service Code	HCPCS 75574 26
Hospital Charge Code	5220102
Hospital Revenue Code	960
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$161.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$140.00
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: CDPHP Medicare	$129.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$280.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$280.00
Rate for Payer: EmblemHealth Medicaid	$280.00
Rate for Payer: EmblemHealth Medicare	$119.00
Rate for Payer: Fidelis Medicare	$140.00
Rate for Payer: Galaxy Health Commercial	$227.50
Rate for Payer: Hamaspik Choice Medicare	$140.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$161.00
Rate for Payer: MVP Health Care of NY Commercial	$262.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$197.05
Rate for Payer: MVP Health Care of NY Medicare	$147.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$52.50
Rate for Payer: United Healthcare Medicare	$140.00
Rate for Payer: WellCare Medicare	$192.50

CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST

Facility

$350.00

Service Code	HCPCS 75574 26
Hospital Charge Code	5220102
Hospital Revenue Code	960
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$227.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Galaxy Health Commercial	$227.50

CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST

Facility

$1,071.00

Service Code	HCPCS 75574 TC
Hospital Charge Code	4220102
Hospital Revenue Code	350
Min. Negotiated Rate	$696.15
Max. Negotiated Rate	$696.15
Rate for Payer: Cash Price	$803.25
Rate for Payer: Galaxy Health Commercial	$696.15

CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST

Facility

$1,071.00

Service Code	HCPCS 75574 TC
Hospital Charge Code	4220102
Hospital Revenue Code	350
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$492.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$428.40
Rate for Payer: Cash Price	$803.25
Rate for Payer: Cash Price	$803.25
Rate for Payer: Cash Price	$803.25
Rate for Payer: CDPHP Medicare	$396.27
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$749.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$856.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$856.80
Rate for Payer: EmblemHealth Medicaid	$856.80
Rate for Payer: EmblemHealth Medicare	$364.14
Rate for Payer: EmblemHealth Select Care	$696.15
Rate for Payer: Fidelis Medicare	$428.40
Rate for Payer: Galaxy Health Commercial	$696.15
Rate for Payer: Hamaspik Choice Medicare	$428.40
Rate for Payer: Humana Medicare	$428.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$492.66
Rate for Payer: MVP Health Care of NY Commercial	$803.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$602.97
Rate for Payer: MVP Health Care of NY Medicare	$449.82
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$160.65
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$428.40
Rate for Payer: WellCare Medicare	$589.05

CT ANGIO ABDOMINAL ARTERIES

Facility

$3,168.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	4220077
Hospital Revenue Code	352
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$2,534.40
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$1,457.28
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,267.20
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: CDPHP Medicare	$1,172.16
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$2,217.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,534.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,534.40
Rate for Payer: EmblemHealth Medicaid	$2,534.40
Rate for Payer: EmblemHealth Medicare	$1,077.12
Rate for Payer: EmblemHealth Select Care	$2,059.20
Rate for Payer: Fidelis Medicare	$1,267.20
Rate for Payer: Galaxy Health Commercial	$2,059.20
Rate for Payer: Hamaspik Choice Medicare	$1,267.20
Rate for Payer: Humana Medicare	$1,267.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$1,457.28
Rate for Payer: MVP Health Care of NY Commercial	$2,376.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,783.58
Rate for Payer: MVP Health Care of NY Medicare	$1,330.56
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$475.20
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$1,267.20
Rate for Payer: WellCare Medicare	$1,742.40

CT ANGIO ABDOMINAL ARTERIES

Facility

$347.00

Service Code	HCPCS 75635 26
Hospital Charge Code	5220077
Hospital Revenue Code	960
Min. Negotiated Rate	$225.55
Max. Negotiated Rate	$225.55
Rate for Payer: Cash Price	$260.25
Rate for Payer: Galaxy Health Commercial	$225.55

CT ANGIO ABDOMINAL ARTERIES

Facility

$3,168.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	4220077
Hospital Revenue Code	352
Min. Negotiated Rate	$2,059.20
Max. Negotiated Rate	$2,059.20
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: Galaxy Health Commercial	$2,059.20

CT ANGIO ABDOMINAL ARTERIES

Facility

$347.00

Service Code	HCPCS 75635 26
Hospital Charge Code	5220077
Hospital Revenue Code	960
Min. Negotiated Rate	$52.05
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$159.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$138.80
Rate for Payer: Cash Price	$260.25
Rate for Payer: Cash Price	$260.25
Rate for Payer: CDPHP Medicare	$128.39
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$277.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$277.60
Rate for Payer: EmblemHealth Medicaid	$277.60
Rate for Payer: EmblemHealth Medicare	$117.98
Rate for Payer: Fidelis Medicare	$138.80
Rate for Payer: Galaxy Health Commercial	$225.55
Rate for Payer: Hamaspik Choice Medicare	$138.80
Rate for Payer: Humana Medicare	$138.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$159.62
Rate for Payer: MVP Health Care of NY Commercial	$260.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$195.36
Rate for Payer: MVP Health Care of NY Medicare	$145.74
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$52.05
Rate for Payer: United Healthcare Medicare	$138.80
Rate for Payer: WellCare Medicare	$190.85

CT ANGIO ABDOM W/O & W/DYE

Facility

$2,692.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	4220075
Hospital Revenue Code	352
Min. Negotiated Rate	$1,749.80
Max. Negotiated Rate	$1,749.80
Rate for Payer: Cash Price	$2,019.00
Rate for Payer: Galaxy Health Commercial	$1,749.80

CT ANGIO ABDOM W/O & W/DYE

Facility

$2,692.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	4220075
Hospital Revenue Code	352
Min. Negotiated Rate	$403.80
Max. Negotiated Rate	$2,153.60
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$1,238.32
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,076.80
Rate for Payer: Cash Price	$2,019.00
Rate for Payer: Cash Price	$2,019.00
Rate for Payer: Cash Price	$2,019.00
Rate for Payer: CDPHP Medicare	$996.04
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$1,884.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$2,153.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$2,153.60
Rate for Payer: EmblemHealth Medicaid	$2,153.60
Rate for Payer: EmblemHealth Medicare	$915.28
Rate for Payer: EmblemHealth Select Care	$1,749.80
Rate for Payer: Fidelis Medicare	$1,076.80
Rate for Payer: Galaxy Health Commercial	$1,749.80
Rate for Payer: Hamaspik Choice Medicare	$1,076.80
Rate for Payer: Humana Medicare	$1,076.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$1,238.32
Rate for Payer: MVP Health Care of NY Commercial	$2,019.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$1,515.60
Rate for Payer: MVP Health Care of NY Medicare	$1,130.64
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$403.80
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$1,076.80
Rate for Payer: WellCare Medicare	$1,480.60

CT ANGIO ABDOM W/O W/ DYE

Facility

$266.00

Service Code	HCPCS 74175 26
Hospital Charge Code	5220075
Hospital Revenue Code	960
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$172.90
Rate for Payer: Cash Price	$199.50
Rate for Payer: Galaxy Health Commercial	$172.90

CT ANGIO ABDOM W/O W/ DYE

Facility

$266.00

Service Code	HCPCS 74175 26
Hospital Charge Code	5220075
Hospital Revenue Code	960
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$122.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$106.40
Rate for Payer: Cash Price	$199.50
Rate for Payer: Cash Price	$199.50
Rate for Payer: CDPHP Medicare	$98.42
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$212.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$212.80
Rate for Payer: EmblemHealth Medicaid	$212.80
Rate for Payer: EmblemHealth Medicare	$90.44
Rate for Payer: Fidelis Medicare	$106.40
Rate for Payer: Galaxy Health Commercial	$172.90
Rate for Payer: Hamaspik Choice Medicare	$106.40
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$122.36
Rate for Payer: MVP Health Care of NY Commercial	$199.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$149.76
Rate for Payer: MVP Health Care of NY Medicare	$111.72
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$39.90
Rate for Payer: United Healthcare Medicare	$106.40
Rate for Payer: WellCare Medicare	$146.30

CT ANGIO ABD & PELVIS CNTRST MTRL W/WO CNTRST IMG

Facility

$322.00

Service Code	HCPCS 74174 26
Hospital Charge Code	5224311
Hospital Revenue Code	960
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$148.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.80
Rate for Payer: Cash Price	$241.50
Rate for Payer: Cash Price	$241.50
Rate for Payer: CDPHP Medicare	$119.14
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$257.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$257.60
Rate for Payer: EmblemHealth Medicaid	$257.60
Rate for Payer: EmblemHealth Medicare	$109.48
Rate for Payer: Fidelis Medicare	$128.80
Rate for Payer: Galaxy Health Commercial	$209.30
Rate for Payer: Hamaspik Choice Medicare	$128.80
Rate for Payer: Humana Medicare	$128.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$148.12
Rate for Payer: MVP Health Care of NY Commercial	$241.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$181.29
Rate for Payer: MVP Health Care of NY Medicare	$135.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.30
Rate for Payer: United Healthcare Medicare	$128.80
Rate for Payer: WellCare Medicare	$177.10

CT ANGIO ABD & PELVIS CNTRST MTRL W/WO CNTRST IMG

Facility

$322.00

Service Code	HCPCS 74174 26
Hospital Charge Code	5224311
Hospital Revenue Code	960
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$209.30
Rate for Payer: Cash Price	$241.50
Rate for Payer: Galaxy Health Commercial	$209.30

CT ANGIO ABD & PELV W/O & W/ DYE

Facility

$322.00

Service Code	HCPCS 74174 26
Hospital Charge Code	5220101
Hospital Revenue Code	960
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$209.30
Rate for Payer: Cash Price	$241.50
Rate for Payer: Galaxy Health Commercial	$209.30

CT ANGIO ABD & PELV W/O & W/ DYE

Facility

$322.00

Service Code	HCPCS 74174 26
Hospital Charge Code	5220101
Hospital Revenue Code	960
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$148.12
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$128.80
Rate for Payer: Cash Price	$241.50
Rate for Payer: Cash Price	$241.50
Rate for Payer: CDPHP Medicare	$119.14
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$257.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$257.60
Rate for Payer: EmblemHealth Medicaid	$257.60
Rate for Payer: EmblemHealth Medicare	$109.48
Rate for Payer: Fidelis Medicare	$128.80
Rate for Payer: Galaxy Health Commercial	$209.30
Rate for Payer: Hamaspik Choice Medicare	$128.80
Rate for Payer: Humana Medicare	$128.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$148.12
Rate for Payer: MVP Health Care of NY Commercial	$241.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$181.29
Rate for Payer: MVP Health Care of NY Medicare	$135.24
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$48.30
Rate for Payer: United Healthcare Medicare	$128.80
Rate for Payer: WellCare Medicare	$177.10

CT ANGIO ABD&PELV W/O&W/DYE

Facility

$1,128.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	4220101
Hospital Revenue Code	350
Min. Negotiated Rate	$733.20
Max. Negotiated Rate	$733.20
Rate for Payer: Cash Price	$846.00
Rate for Payer: Galaxy Health Commercial	$733.20

CT ANGIO ABD&PELV W/O&W/DYE

Facility

$1,128.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	4220101
Hospital Revenue Code	350
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$518.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$451.20
Rate for Payer: Cash Price	$846.00
Rate for Payer: Cash Price	$846.00
Rate for Payer: Cash Price	$846.00
Rate for Payer: CDPHP Medicare	$417.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$789.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$902.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$902.40
Rate for Payer: EmblemHealth Medicaid	$902.40
Rate for Payer: EmblemHealth Medicare	$383.52
Rate for Payer: EmblemHealth Select Care	$733.20
Rate for Payer: Fidelis Medicare	$451.20
Rate for Payer: Galaxy Health Commercial	$733.20
Rate for Payer: Hamaspik Choice Medicare	$451.20
Rate for Payer: Humana Medicare	$451.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$518.88
Rate for Payer: MVP Health Care of NY Commercial	$846.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$635.06
Rate for Payer: MVP Health Care of NY Medicare	$473.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$169.20
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$451.20
Rate for Payer: WellCare Medicare	$620.40

CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG

Facility

$1,128.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	4224311
Hospital Revenue Code	352
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$518.88
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$451.20
Rate for Payer: Cash Price	$846.00
Rate for Payer: Cash Price	$846.00
Rate for Payer: Cash Price	$846.00
Rate for Payer: CDPHP Medicare	$417.36
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$789.60
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$902.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$902.40
Rate for Payer: EmblemHealth Medicaid	$902.40
Rate for Payer: EmblemHealth Medicare	$383.52
Rate for Payer: EmblemHealth Select Care	$733.20
Rate for Payer: Fidelis Medicare	$451.20
Rate for Payer: Galaxy Health Commercial	$733.20
Rate for Payer: Hamaspik Choice Medicare	$451.20
Rate for Payer: Humana Medicare	$451.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$518.88
Rate for Payer: MVP Health Care of NY Commercial	$846.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$635.06
Rate for Payer: MVP Health Care of NY Medicare	$473.76
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$798.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$169.20
Rate for Payer: United Healthcare Commercial	$798.00
Rate for Payer: United Healthcare Medicare	$451.20
Rate for Payer: WellCare Medicare	$620.40

CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG

Facility

$1,128.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	4224311
Hospital Revenue Code	352
Min. Negotiated Rate	$733.20
Max. Negotiated Rate	$733.20
Rate for Payer: Cash Price	$846.00
Rate for Payer: Galaxy Health Commercial	$733.20

CT ANGIOGRAPH PELV W/O & W/ DYE

Facility

$263.00

Service Code	HCPCS 72191 26
Hospital Charge Code	5220015
Hospital Revenue Code	960
Min. Negotiated Rate	$39.45
Max. Negotiated Rate	$1,076.00
Rate for Payer: Aetna of NY Commercial	$1,076.00
Rate for Payer: Aetna of NY Medicare	$120.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$105.20
Rate for Payer: Cash Price	$197.25
Rate for Payer: Cash Price	$197.25
Rate for Payer: CDPHP Medicare	$97.31
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$210.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$210.40
Rate for Payer: EmblemHealth Medicaid	$210.40
Rate for Payer: EmblemHealth Medicare	$89.42
Rate for Payer: Fidelis Medicare	$105.20
Rate for Payer: Galaxy Health Commercial	$170.95
Rate for Payer: Hamaspik Choice Medicare	$105.20
Rate for Payer: Humana Medicare	$105.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,076.00
Rate for Payer: Local 1199SEIU Medicare	$120.98
Rate for Payer: MVP Health Care of NY Commercial	$197.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$148.07
Rate for Payer: MVP Health Care of NY Medicare	$110.46
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$39.45
Rate for Payer: United Healthcare Medicare	$105.20
Rate for Payer: WellCare Medicare	$144.65

Know your out-of-pocket cost for care.

All Charges