Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

DUPLEX ARTERIAL FLOW; LIMITED

Facility

$315.00

Service Code	HCPCS 93976
Hospital Charge Code	4201025
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX ARTERIAL FLOW; LIMITED

Facility

$315.00

Service Code	HCPCS 93976
Hospital Charge Code	4201025
Hospital Revenue Code	921
Min. Negotiated Rate	$58.58
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$58.58
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX EXT VEINS; BILAT

Facility

$701.00

Service Code	HCPCS 93970
Hospital Charge Code	4200022
Hospital Revenue Code	921
Min. Negotiated Rate	$109.08
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$455.65
Rate for Payer: Aetna of NY Medicare	$322.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$259.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$350.50
Rate for Payer: Cash Price	$525.75
Rate for Payer: Cash Price	$525.75
Rate for Payer: CDPHP Commercial	$564.30
Rate for Payer: CDPHP Medicare	$259.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$490.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$560.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$560.80
Rate for Payer: EmblemHealth Medicaid	$560.80
Rate for Payer: EmblemHealth Medicare	$238.34
Rate for Payer: EmblemHealth Select Care	$455.65
Rate for Payer: Fidelis Medicare	$267.15
Rate for Payer: Galaxy Health Commercial	$455.65
Rate for Payer: Hamaspik Choice Medicare	$259.37
Rate for Payer: Humana Medicare	$259.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.65
Rate for Payer: Local 1199SEIU Medicare	$322.46
Rate for Payer: MVP Health Care of NY Commercial	$525.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$394.66
Rate for Payer: MVP Health Care of NY Medicare	$272.34
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$109.08
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

DUPLEX EXT VEINS; BILAT

Facility

$701.00

Service Code	HCPCS 93970
Hospital Charge Code	4200022
Hospital Revenue Code	921
Min. Negotiated Rate	$455.65
Max. Negotiated Rate	$455.65
Rate for Payer: Cash Price	$525.75
Rate for Payer: Galaxy Health Commercial	$455.65

DUPLEX EXT VEINS; UNIL/LIMIT

Facility

$315.00

Service Code	HCPCS 93971
Hospital Charge Code	4201023
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX EXT VEINS; UNIL/LIMIT

Facility

$315.00

Service Code	HCPCS 93971
Hospital Charge Code	4201023
Hospital Revenue Code	921
Min. Negotiated Rate	$93.93
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$93.93
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX EXT VEINS; UNIL/LIMIT

Facility

$315.00

Service Code	HCPCS 93971
Hospital Charge Code	4480081
Hospital Revenue Code	921
Min. Negotiated Rate	$93.93
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$93.93
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX EXT VEINS; UNIL/LIMIT

Facility

$315.00

Service Code	HCPCS 93971
Hospital Charge Code	4480081
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY

Facility

$1,171.00

Service Code	HCPCS 93880 TC
Hospital Charge Code	4200066
Hospital Revenue Code	921
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$942.66
Rate for Payer: Aetna of NY Commercial	$761.15
Rate for Payer: Aetna of NY Medicare	$538.66
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$878.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$878.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$433.27
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$585.50
Rate for Payer: Cash Price	$878.25
Rate for Payer: Cash Price	$878.25
Rate for Payer: CDPHP Commercial	$942.66
Rate for Payer: CDPHP Medicare	$433.27
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$819.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$936.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$936.80
Rate for Payer: EmblemHealth Medicaid	$936.80
Rate for Payer: EmblemHealth Medicare	$398.14
Rate for Payer: EmblemHealth Select Care	$761.15
Rate for Payer: Fidelis Medicare	$446.27
Rate for Payer: Galaxy Health Commercial	$761.15
Rate for Payer: Hamaspik Choice Medicare	$433.27
Rate for Payer: Humana Medicare	$433.27
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$761.15
Rate for Payer: Local 1199SEIU Medicare	$538.66
Rate for Payer: MVP Health Care of NY Commercial	$878.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$659.27
Rate for Payer: MVP Health Care of NY Medicare	$454.93
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$433.27
Rate for Payer: WellCare Medicare	$644.05

DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY

Facility

$1,171.00

Service Code	HCPCS 93880 TC
Hospital Charge Code	4200066
Hospital Revenue Code	921
Min. Negotiated Rate	$761.15
Max. Negotiated Rate	$761.15
Rate for Payer: Cash Price	$878.25
Rate for Payer: Galaxy Health Commercial	$761.15

DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY, LEFT

Facility

$315.00

Service Code	HCPCS 93882 LT,TC
Hospital Charge Code	4201064
Hospital Revenue Code	921
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY, LEFT

Facility

$315.00

Service Code	HCPCS 93882 LT,TC
Hospital Charge Code	4201064
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY, RIGHT

Facility

$315.00

Service Code	HCPCS 93882 RT,TC
Hospital Charge Code	4201065
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY, RIGHT

Facility

$315.00

Service Code	HCPCS 93882 RT,TC
Hospital Charge Code	4201065
Hospital Revenue Code	921
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX SCAN HEMODIALYSIS ACCESS

Facility

$315.00

Service Code	HCPCS 93990
Hospital Charge Code	4201089
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUPLEX SCAN HEMODIALYSIS ACCESS

Facility

$315.00

Service Code	HCPCS 93990
Hospital Charge Code	4201089
Hospital Revenue Code	921
Min. Negotiated Rate	$42.42
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$42.42
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX UE ART/BPG; UNIL/LIMIT RT

Facility

$315.00

Service Code	HCPCS 93931 TC
Hospital Charge Code	4200127
Hospital Revenue Code	921
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUPLEX UE ART/BPG; UNIL/LIMIT RT

Facility

$315.00

Service Code	HCPCS 93931 TC
Hospital Charge Code	4200127
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM

Facility

$701.00

Service Code	HCPCS 93975 TC
Hospital Charge Code	4201024
Hospital Revenue Code	921
Min. Negotiated Rate	$238.34
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$455.65
Rate for Payer: Aetna of NY Medicare	$322.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$259.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$350.50
Rate for Payer: Cash Price	$525.75
Rate for Payer: Cash Price	$525.75
Rate for Payer: CDPHP Commercial	$564.30
Rate for Payer: CDPHP Medicare	$259.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$490.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$560.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$560.80
Rate for Payer: EmblemHealth Medicaid	$560.80
Rate for Payer: EmblemHealth Medicare	$238.34
Rate for Payer: EmblemHealth Select Care	$455.65
Rate for Payer: Fidelis Medicare	$267.15
Rate for Payer: Galaxy Health Commercial	$455.65
Rate for Payer: Hamaspik Choice Medicare	$259.37
Rate for Payer: Humana Medicare	$259.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.65
Rate for Payer: Local 1199SEIU Medicare	$322.46
Rate for Payer: MVP Health Care of NY Commercial	$525.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$394.66
Rate for Payer: MVP Health Care of NY Medicare	$272.34
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM

Facility

$701.00

Service Code	HCPCS 93975 TC
Hospital Charge Code	4201024
Hospital Revenue Code	921
Min. Negotiated Rate	$455.65
Max. Negotiated Rate	$455.65
Rate for Payer: Cash Price	$525.75
Rate for Payer: Galaxy Health Commercial	$455.65

DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT

Facility

$315.00

Service Code	HCPCS 93976 TC
Hospital Charge Code	4200051
Hospital Revenue Code	921
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of NY Commercial	$204.75
Rate for Payer: Aetna of NY Medicare	$144.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$236.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$116.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$157.50
Rate for Payer: Cash Price	$236.25
Rate for Payer: Cash Price	$236.25
Rate for Payer: CDPHP Commercial	$253.58
Rate for Payer: CDPHP Medicare	$116.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$220.50
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.00
Rate for Payer: EmblemHealth Medicaid	$252.00
Rate for Payer: EmblemHealth Medicare	$107.10
Rate for Payer: EmblemHealth Select Care	$204.75
Rate for Payer: Fidelis Medicare	$120.05
Rate for Payer: Galaxy Health Commercial	$204.75
Rate for Payer: Hamaspik Choice Medicare	$116.55
Rate for Payer: Humana Medicare	$116.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$204.75
Rate for Payer: Local 1199SEIU Medicare	$144.90
Rate for Payer: MVP Health Care of NY Commercial	$236.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.34
Rate for Payer: MVP Health Care of NY Medicare	$122.38
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$116.55
Rate for Payer: WellCare Medicare	$173.25

DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT

Facility

$315.00

Service Code	HCPCS 93976 TC
Hospital Charge Code	4200051
Hospital Revenue Code	921
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$236.25
Rate for Payer: Galaxy Health Commercial	$204.75

DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY

Facility

$701.00

Service Code	HCPCS 93925 TC
Hospital Charge Code	4200043
Hospital Revenue Code	921
Min. Negotiated Rate	$238.34
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of NY Commercial	$455.65
Rate for Payer: Aetna of NY Medicare	$322.46
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$525.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$259.37
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$350.50
Rate for Payer: Cash Price	$525.75
Rate for Payer: Cash Price	$525.75
Rate for Payer: CDPHP Commercial	$564.30
Rate for Payer: CDPHP Medicare	$259.37
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$490.70
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$560.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$560.80
Rate for Payer: EmblemHealth Medicaid	$560.80
Rate for Payer: EmblemHealth Medicare	$238.34
Rate for Payer: EmblemHealth Select Care	$455.65
Rate for Payer: Fidelis Medicare	$267.15
Rate for Payer: Galaxy Health Commercial	$455.65
Rate for Payer: Hamaspik Choice Medicare	$259.37
Rate for Payer: Humana Medicare	$259.37
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$455.65
Rate for Payer: Local 1199SEIU Medicare	$322.46
Rate for Payer: MVP Health Care of NY Commercial	$525.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$394.66
Rate for Payer: MVP Health Care of NY Medicare	$272.34
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$279.00
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Medicare	$259.37
Rate for Payer: WellCare Medicare	$385.55

DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY

Facility

$701.00

Service Code	HCPCS 93925 TC
Hospital Charge Code	4200043
Hospital Revenue Code	921
Min. Negotiated Rate	$455.65
Max. Negotiated Rate	$455.65
Rate for Payer: Cash Price	$525.75
Rate for Payer: Galaxy Health Commercial	$455.65

DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, LEFT

Facility

$442.00

Service Code	HCPCS 93926 LT,TC
Hospital Charge Code	4200044
Hospital Revenue Code	921
Min. Negotiated Rate	$287.30
Max. Negotiated Rate	$287.30
Rate for Payer: Cash Price	$331.50
Rate for Payer: Galaxy Health Commercial	$287.30

Know your out-of-pocket cost for care.

All Charges