Does Nicholas H Noyes Memorial Hospital have an emergency room?

Yes. Medicare (CMS) data lists emergency services at Nicholas H Noyes Memorial Hospital. In a medical emergency, call 911.

Where is Nicholas H Noyes Memorial Hospital?

111 Clara Barton Street, Dansville, NY 14437, in Livingston County, New York.

What is the phone number of Nicholas H Noyes Memorial Hospital?

(585) 335-6001, as listed by Medicare (CMS).

What is the Medicare star rating of Nicholas H Noyes Memorial Hospital?

3 out of 5 stars in the CMS overall hospital quality rating (CMS data updated 2026-07-22).

Nicholas H Noyes Memorial Hospital

Quick answers

Does Nicholas H Noyes Memorial Hospital have an emergency room?: Yes. Medicare (CMS) data lists emergency services at Nicholas H Noyes Memorial Hospital. In a medical emergency, call 911.
Where is Nicholas H Noyes Memorial Hospital?: 111 Clara Barton Street, Dansville, NY 14437, in Livingston County, New York.
What is the phone number of Nicholas H Noyes Memorial Hospital?: (585) 335-6001, as listed by Medicare (CMS).
What is the Medicare star rating of Nicholas H Noyes Memorial Hospital?: 3 out of 5 stars in the CMS overall hospital quality rating (CMS data updated 2026-07-22).

Specialties and care areas^{[4][5][6][9][11][13][14][15]}

Emergency medicine
Cancer care (Ann and Carl Myers Cancer Center)
Orthopedics
Physical therapy
Orthopaedics
Radiation oncology
General surgery
Obstetrics and gynecology
Diagnostic imaging
Interventional radiology
Nuclear medicine
Laboratory services

Conditions treated^[6]

Cancer

Treatments^[6][9][14]

Robot-assisted joint replacement
Total joint replacement (shoulder, knee, hip)
Shoulder replacement and repair
Fracture surgery
Arthroscopic surgery (shoulder and knee)
ACL reconstruction
Radiation oncology
Infusion services

Procedures^{[4][11][12][13][14][15]}

Outpatient surgery (Saunders Surgical Center)
PET/CT
MRI
CT scan
Mammography
Ultrasound
X-ray
Nuclear stress test
Interventional radiology procedures
Cesarean section
Gynecological surgery
Eye surgery
Ear, nose and throat surgery
Urology procedures
Gastroenterological procedures
Pre-surgical testing

Programs and centers^[6][14][15]

Family Birthing Center
Ann and Carl Myers Cancer Center
Saunders Surgical Center (inpatient and outpatient surgery)
Breastfeeding classes (B.A.B.E. program)

Emergency care (hospital website)^{[4][5][8][10]}

Emergency room	Yes
Open 24/7	Yes
Stroke designation	Joint Commission Primary Stroke Center

Visiting and practical information

Parking	Free parking lots for patients and visitors; free parking at the Emergency Department^[10][14]
Interpreters and languages	Free language assistance for patients who speak other languages; call 1-585-275-4778 (video phone 1-585-206-1922)^[7]

Recognition^[6][8][11]

Joint Commission Gold Seal of Approval for Hospital Accreditation
Joint Commission Primary Stroke Center
ACR accreditation (radiation oncology clinic and imaging)

Doctors and clinicians (457)

457 doctors and other clinicians list Nicholas H Noyes Memorial Hospital as a hospital where they work, in Medicare's official clinician data (updated 2026-10-02). It is not a complete staff list.

Main specialties

And 433 more: the button below opens the full list.

Other emergency rooms nearby

Hospitals that list emergency services, by straight-line distance (not driving distance).

St James Hospital15 mi · Hornell, NY · Acute Care Hospital
Wyoming County23 mi · Warsaw, NY · Critical Access Hospital
Ira Davenport Memorial Hospital27 mi · Bath, NY · Rural Emergency Hospital
F F Thompson Hospital31 mi · Canandaigua, NY · Acute Care Hospital
Jones Memorial Hospital33 mi · Wellsville, NY · Acute Care Hospital

Other hospitals nearby

Bath VA Medical Center25 mi · Bath, NY · Federal/VA Acute Care Hospital

Nursing homes, hospice, home health and dialysis nearby

Medicare-certified providers within 25 miles, by straight-line distance. Hospice and home health care is given at home: their address is the office.

Nursing homes

Livingston County Center for Nursing and Rehabilit13 mi · Mount Morris, NY · 2 of 5 stars
Elderwood at Hornell16 mi · Hornell, NY · 1 of 5 stars
Conesus Lake Nursing Home, LLC18 mi · Livonia, NY · 5 of 5 stars

All nursing homes in the state →

Hospice providers

Livingston County Hospice11 mi · Mount Morris, NY · 5 of 5 stars

All hospice providers in the state →

Dialysis facilities

NOYES CENTER for KIDNEY DISEASE and DIALYSIS16 mi · Geneseo, NY · 1 of 5 stars
Fresenius Kidney Care - Hornell17 mi · Hornell, NY · 1 of 5 stars

All dialysis facilities in the state →

Community care nearby

Health centers, clinics, urgent care and pharmacies closest to this hospital, by straight-line distance, from official HRSA, Medicare and NPI Registry data. In a medical emergency, call 911.

Community health centers

TCFM Dansville2.3 mi · Dansville, NY · Community health center
TCFM Wayland7.3 mi · Wayland, NY · Community health center
TCFM Canaseraga7.8 mi · Canaseraga, NY · Community health center

Clinics and urgent care

Ur Medicine Primary Care17 mi · Hornell, NY · Rural health clinic
Wyoming County18 mi · Perry, NY · Rural health clinic

Pharmacies

CVS Albany LLC0.0 mi · Dansville, NY · Pharmacy
Tri-County Family Medicine Program, Inc.0.0 mi · Dansville, NY · Community/retail pharmacy
Walgreen Co0.0 mi · Dansville, NY · Pharmacy

About the Medicare star rating

CMS (the federal Medicare agency) gives many hospitals an overall rating from 1 to 5 stars, based on measures of mortality, safety, readmissions, patient experience and timely care. It is one piece of information: ask your doctor what matters for your care. See the full Medicare profile →

Medicare quality data

What Nicholas H Noyes Memorial Hospital reported to Medicare (CMS), the federal agency that publishes these results for hospitals nationwide. These are averages for many patients, not a prediction for any one person: ask your doctor what matters for your care. In a medical emergency, call 911.

What patients said (patient survey)

What this means: Patients who stayed overnight answered a national survey (HCAHPS) about their stay. More stars mean patients reported a better experience than at other hospitals. The percentages show how often patients gave the best answer, next to the national average.

Summary star rating (all survey topics)	3 of 5 stars
Overall rating of the hospital	3 of 5 stars
Would recommend the hospital	3 of 5 stars
Nurses communicated well	4 of 5 stars
Doctors communicated well	3 of 5 stars
Staff explained medicines	3 of 5 stars
Information about recovery at home	3 of 5 stars
Room and bathroom kept clean	3 of 5 stars
Quiet at night	2 of 5 stars
Rated the hospital 9 or 10 out of 10	67%National average: 72%
Would definitely recommend the hospital	65%National average: 71%
Nurses “always” communicated well	78%National average: 80%
Doctors “always” communicated well	77%National average: 80%
Staff “always” explained medicines before giving them	61%National average: 62%
Were given information about recovery at home	87%National average: 86%
Room and bathroom “always” clean	67%National average: 74%
Area around the room “always” quiet at night	45%National average: 60%
Completed surveys	425Response rate: 25%

Source: Patient survey (HCAHPS) - Hospital — CMS, released July 22, 2026; patients discharged October 2024 to September 2025.

Infections caught in the hospital

What this means: CMS compares the number of infections patients caught in this hospital with the number expected for a hospital like it. The number shown is that ratio: below 1 means fewer infections than expected, above 1 means more. “Better” or “worse” is shown only when the difference is clear in the data.

Central line bloodstream infections (CLABSI)	Not reported to Medicare
Catheter-associated urinary tract infections (CAUTI)	0.959No different from the national benchmark
Surgical site infections after colon surgery	0No different from the national benchmark
Surgical site infections after abdominal hysterectomy	Not reported to Medicare
MRSA bloodstream infections	Not reported to Medicare
Clostridioides difficile (C. diff) intestinal infections	0.312No different from the national benchmark

Source: Healthcare Associated Infections - Hospital — CMS, released July 22, 2026; data from October 2024 to September 2025.

Complications and deaths

What this means: Death rates are the share of patients who died within 30 days of going into the hospital for that condition, adjusted for how sick they were. PSI-90 combines several serious complications (a lower number is better). “No different from the national rate” is the most common result and means the hospital is in line with hospitals nationwide.

Deaths within 30 days: heart attack patients	Too few cases to report
Deaths within 30 days: heart failure patients	11.5%
Deaths within 30 days: pneumonia patients	18.1%
Deaths within 30 days: COPD patients	9.9%
Deaths within 30 days: stroke patients	12.6%
Deaths within 30 days: coronary bypass surgery (CABG)	Not reported to Medicare
Serious complications (patient safety indicator PSI-90)	0.93No different from the national rate
Complications after hip or knee replacement	Too few cases to report

Source: Complications and Deaths - Hospital — CMS, released September 10, 2026; data from July 2022 to June 2025.

Return visits to the hospital (readmissions)

What this means: The share of patients who had to be admitted to a hospital again within 30 days after going home, adjusted for how sick they were. A lower percentage is better.

Returned to any hospital within 30 days (all patients)	Not reported to Medicare
Readmitted within 30 days: heart attack	Too few cases to report
Readmitted within 30 days: heart failure	22.3%
Readmitted within 30 days: pneumonia	16.9%
Readmitted within 30 days: COPD	20.8%
Readmitted within 30 days: coronary bypass surgery	Not reported to Medicare
Readmitted within 30 days: hip or knee replacement	Too few cases to report

Source: Unplanned Hospital Visits - Hospital — CMS, released September 10, 2026; data from July 2023 to June 2025.

Emergency room times and sepsis care

What this means: ER time is the middle (median) time from arriving at the emergency room to leaving it; busier ERs usually have longer times, so the ER volume is shown too. Leaving before being seen: a lower percentage is better. Sepsis is a life-threatening reaction to an infection; a higher percentage means more patients got every recommended early step.

Emergency room volume (patients per year)	Low (under 20,000)
Average (median) time patients spent in the emergency room before leaving (OP-18b)	202 minutesNational average: 162 minutes
Patients who left the emergency room before being seen (OP-22)	5%National average: 2%
Sepsis patients who got all the recommended early care (SEP-1)	58%National average: 65%

Source: Timely and Effective Care - Hospital — CMS, released July 22, 2026; data from January 2024 to December 2024.

See every measure on Medicare Care Compare →

ER wait times and Medicare ratings nearby

How this hospital compares with others in the area, ranked only by official Medicare (CMS) numbers.

ER wait times in New York Best hospitals in New York

Prices

Every US hospital must publish its standard charges in a file that follows a federal (CMS) format. Below are 85 common services exactly as Nicholas H Noyes Memorial Hospital lists them in its file. This is not a quote: what you pay depends on your insurance and plan, the doctors involved and the care you actually receive. Prices change: ask the hospital for an estimate before you schedule care (if you are uninsured or paying yourself, you have the right to a written “good faith estimate”). In a medical emergency, call 911.

What the prices mean

Hospital charge: The hospital’s list price (“gross charge”) before any discount or insurance. Few people pay this amount.
Cash price: The price the hospital offers if you pay yourself, without insurance (“discounted cash price”).
Insurance rates: The lowest and highest amounts the hospital has agreed with any insurance plan for the service (“de-identified minimum and maximum”), and some of the rates it lists by insurer and plan. Your share depends on your deductible, copay and coinsurance.
Hospital and doctor fees: A service can have a hospital (facility) fee and a separate doctor (professional) fee; the total for your care can include both, plus other services.

How to use hospital prices: estimates, financial assistance and your rights →

Office and emergency visits

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
New patient office visit (about 30–44 minutes) CPT 99203 · Outpatient (no overnight stay) In the file: OFFICE O/P NEW LOW 30 MIN	Not listed in the file	Not listed in the file	$24.60 – $274.23
New patient office visit (about 30–44 minutes): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $122.81 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $113.04 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $45.54 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $101.74 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $274.23 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $115.30 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $113.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $113.04 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $99.74 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $144.98
New patient office visit (about 30–44 minutes) CPT 99203 · Outpatient (no overnight stay) In the file: Office o/p new low 30 min	Not listed in the file	Not listed in the file	$56.79 – $183
New patient office visit (about 30–44 minutes): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $69.26 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $74.80 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $69.26 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $119.87 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $119.87 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $69.26 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $69.26 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $69.26 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $56.79 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $183
New patient office visit (about 30–44 minutes) CPT 99203 · Inpatient or outpatient In the file: PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES	$190	$113.30	Not listed in the file
New patient office visit (about 45–59 minutes) CPT 99204 · Outpatient (no overnight stay) In the file: OFFICE O/P NEW MOD 45 MIN	Not listed in the file	Not listed in the file	$40.88 – $408.14
New patient office visit (about 45–59 minutes): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $156.76 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $170.85 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $69.13 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $153.77 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $408.14 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $174.27 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $174.25 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $170.85 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $147.88 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $217.70
New patient office visit (about 45–59 minutes) CPT 99204 · Outpatient (no overnight stay) In the file: Office o/p new mod 45 min	Not listed in the file	Not listed in the file	$93 – $360
New patient office visit (about 45–59 minutes): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $113.42 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $122.49 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $113.42 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $196.30 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $196.30 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $113.42 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $113.42 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $113.42 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $93 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $360
New patient office visit (about 45–59 minutes) CPT 99204 · Inpatient or outpatient In the file: PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES	$240	$143.11	Not listed in the file
New patient office visit (about 60–74 minutes) CPT 99205 · Outpatient (no overnight stay) In the file: OFFICE O/P NEW HI 60 MIN	Not listed in the file	Not listed in the file	$53.17 – $538.85
New patient office visit (about 60–74 minutes): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $243.52 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $227.85 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $86.68 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $205.07 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $538.85 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $232.41 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $220.32 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $227.85 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $195.47 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $287.12
New patient office visit (about 60–74 minutes) CPT 99205 · Outpatient (no overnight stay) In the file: Office o/p new hi 60 min	Not listed in the file	Not listed in the file	$127.25 – $496
New patient office visit (about 60–74 minutes): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $155.18 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $167.59 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $155.18 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $268.57 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $268.57 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $155.18 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $155.18 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $155.18 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $127.25 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $496
New patient office visit (about 60–74 minutes) CPT 99205 · Inpatient or outpatient In the file: PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES	$290	$172.93	Not listed in the file
Established patient office visit (about 20–29 minutes) CPT 99213 · Outpatient (no overnight stay) In the file: OFFICE O/P EST LOW 20 MIN	Not listed in the file	Not listed in the file	$17.57 – $221.41
Established patient office visit (about 20–29 minutes): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $100.45 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $91.86 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $29.93 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $82.67 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $221.41 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $93.70 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $54.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $91.86 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $80.06 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $85.59
Established patient office visit (about 20–29 minutes) CPT 99213 · Outpatient (no overnight stay) In the file: Office o/p est low 20 min	Not listed in the file	Not listed in the file	$45.93 – $143
Established patient office visit (about 20–29 minutes): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $56.01 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $60.49 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $56.01 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $96.94 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $96.94 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $56.01 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $56.01 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $56.01 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $45.93 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $143
Established patient office visit (about 20–29 minutes) CPT 99213 · Inpatient or outpatient In the file: PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN	$170	$101.37	Not listed in the file
Established patient office visit (about 30–39 minutes) CPT 99214 · Outpatient (no overnight stay) In the file: OFFICE O/P EST MOD 30 MIN	Not listed in the file	Not listed in the file	$24.59 – $313.46
Established patient office visit (about 30–39 minutes): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $141.47 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $130.88 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $44.94 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $117.79 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $313.46 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $133.50 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $115.34 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $82.33 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $112.37 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $167.22
Established patient office visit (about 30–39 minutes) CPT 99214 · Outpatient (no overnight stay) In the file: Office o/p est mod 30 min	Not listed in the file	Not listed in the file	$63.72 – $191
Established patient office visit (about 30–39 minutes): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $82.33 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $88.92 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $82.33 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $142.49 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $142.49 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $82.33 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $82.33 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $82.33 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $67.51 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $191
Established patient office visit (about 30–39 minutes) CPT 99214 · Inpatient or outpatient In the file: PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN	$240	$143.11	Not listed in the file
Office consultation with a specialist (moderate to high) CPT 99244 · Outpatient (no overnight stay) In the file: OFF/OP CNSLTJ NEW/EST MOD 40	Not listed in the file	Not listed in the file	$64.28 – $399.82
Office consultation with a specialist (moderate to high): 10 of 12 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $89.20 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $399.82 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $75.62 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $209.74 FIDELIS MEDICAID 1708, FIDELIS 5155 — FIDELIS ESSENTIAL (W/ MEDICAID) 170804, FIDELIS ESSENTIAL (N: $163.13 FIDELIS MEDICAID 1708, FIDELIS 5155 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $155.36 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICAID 1702, — HIGHMARK BC/BS OF WESTERN NY MEDICAID 170201, COMMUNITY CARE: $111.50 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601,NOVA HEALTHCARE ADMIN: $233.58 MVP 2900 — MVP PREMIER INDIVIDUAL 290002, MVP PREMIER GROUP 290003: $186.75 MVP 2900, CIGNA 5144 — MVP COMMERCIAL NON PPO FULLY INSURED 290001, MVP COMMERCIAL : $257.76
Preventive checkup, new patient, age 18–39 CPT 99385 · Outpatient (no overnight stay) In the file: PREV VISIT NEW AGE 18-39	Not listed in the file	Not listed in the file	$30.04 – $317.09
Preventive checkup, new patient, age 18–39: 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $142.71 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $130.09 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $51.90 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $117.08 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $317.09 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $132.69 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $141.35 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $130.09 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $65.52 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $168.28
Preventive checkup, new patient, age 18–39 CPT 99385 · Inpatient or outpatient In the file: PR INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS	$257	$153.25	Not listed in the file
Preventive checkup, new patient, age 18–39 CPT 99385 · Inpatient or outpatient In the file: HB Initial Preventive Medicine New Pt Age 18-39yrs	$64	Not listed in the file	Not listed in the file
Preventive checkup, new patient, age 40–64 CPT 99386 · Outpatient (no overnight stay) In the file: PREV VISIT NEW AGE 40-64	Not listed in the file	Not listed in the file	$36.91 – $365.55
Preventive checkup, new patient, age 40–64: 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $164.52 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $150.52 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $60.58 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $135.47 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $365.55 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $153.53 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $163.71 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $150.52 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $76.49 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $194.17
Preventive checkup, new patient, age 40–64 CPT 99386 · Inpatient or outpatient In the file: PR INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS	$321	$191.41	Not listed in the file
Preventive checkup, new patient, age 40–64 CPT 99386 · Inpatient or outpatient In the file: HB Initial Preventive Medicine New Patient 40-64yrs	$75	Not listed in the file	Not listed in the file
Emergency room visit (moderate) CPT 99283 · Outpatient (no overnight stay) In the file: EMERGENCY DEPT VISIT LOW MDM	Not listed in the file	Not listed in the file	$17.64 – $176.50
Emergency room visit (moderate): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $77.56 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $67.02 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $25.95 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $60.32 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $176.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $68.36 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $69.64 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $67.02 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $24.41 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $91.99
Emergency room visit (moderate) CPT 99283 · Outpatient (no overnight stay) In the file: Emergency dept visit low mdm	Not listed in the file	Not listed in the file	$279.42 – $810.31
Emergency room visit (moderate): 10 of 18 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $340.75 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $368.01 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $547.93 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $589.74 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $589.74 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $340.75 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $340.75 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $155 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $340.75 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $279.42
Emergency room visit (moderate) CPT 99283 · Outpatient (no overnight stay) In the file: PR EMERGENCY DEPARTMENT VISIT LOW MDM	Not listed in the file	Not listed in the file	$155 – $388
Emergency room visit (moderate): rates for 3 insurance plans AETNA 2700 — AETNA 270002: $388 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Emergency room visit (moderately high) CPT 99284 · Outpatient (no overnight stay) In the file: EMERGENCY DEPT VISIT MOD MDM	Not listed in the file	Not listed in the file	$32.52 – $297.44
Emergency room visit (moderately high): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $132.20 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $114.02 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $40.54 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $102.62 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $297.44 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $116.30 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $127.56 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $114.02 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $45.02 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $156.55
Emergency room visit (moderately high) CPT 99284 · Outpatient (no overnight stay) In the file: Emergency dept visit mod mdm	Not listed in the file	Not listed in the file	$427.11 – $1,238.61
Emergency room visit (moderately high): 10 of 18 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $520.86 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $562.53 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $837.54 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $901.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $901.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $520.86 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $520.86 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $155 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $520.86 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $427.11
Emergency room visit (moderately high) CPT 99284 · Outpatient (no overnight stay) In the file: PR EMERGENCY DEPARTMENT VISIT MODERATE MDM	Not listed in the file	Not listed in the file	$155 – $623
Emergency room visit (moderately high): rates for 3 insurance plans AETNA 2700 — AETNA 270002: $623 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Emergency room visit (high) CPT 99285 · Outpatient (no overnight stay) In the file: EMERGENCY DEPT VISIT HI MDM	Not listed in the file	Not listed in the file	$48.54 – $432.43
Emergency room visit (high): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $191.67 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $165.50 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $63.46 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $148.95 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $432.43 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $168.81 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $185.26 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $165.50 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $67.19 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $226.83
Emergency room visit (high) CPT 99285 · Outpatient (no overnight stay) In the file: Emergency dept visit hi mdm	Not listed in the file	Not listed in the file	$609.58 – $1,767.79
Emergency room visit (high): 10 of 18 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $743.39 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $802.86 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,195.37 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,286.59 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,286.59 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $743.39 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $743.39 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $155 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $743.39 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $609.58
Emergency room visit (high) CPT 99285 · Outpatient (no overnight stay) In the file: PR EMERGENCY DEPARTMENT VISIT HIGH MDM	Not listed in the file	Not listed in the file	$155 – $856
Emergency room visit (high): rates for 3 insurance plans AETNA 2700 — AETNA 270002: $856 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)

Lab tests

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Basic metabolic panel (blood test) CPT 80048 · Outpatient (no overnight stay) In the file: Metabolic panel total ca	Not listed in the file	Not listed in the file	$5.92 – $16.48
Basic metabolic panel (blood test): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $9.56 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $8.46 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $8.46 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $10.49 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $5.92 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $5.92 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $8.46 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $8.46 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $8.46 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $8.46
Basic metabolic panel (blood test) CPT 80048 · Outpatient (no overnight stay) In the file: BASIC METABOLIC PANEL (CALCIUM, TOTAL)	Not listed in the file	Not listed in the file	$5.92 – $16.48
Basic metabolic panel (blood test): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $7.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $7.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $7.32 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $7.32 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $16.48 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $7.32 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $7.32 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $7.32 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $7.32 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $16.48
Basic metabolic panel (blood test) CPT 80048 · Outpatient (no overnight stay) In the file: CHG BASIC METABOLIC PANEL CALCIUM TOTAL	Not listed in the file	Not listed in the file	$5.92 – $16.48
Basic metabolic panel (blood test): rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $9.50 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $9.50 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Comprehensive metabolic panel (blood test) CPT 80053 · Outpatient (no overnight stay) In the file: Comprehen metabolic panel	Not listed in the file	Not listed in the file	$7.39 – $22.72
Comprehensive metabolic panel (blood test): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $11.93 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $10.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $10.56 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $13.09 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $7.39 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $7.39 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $10.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $10.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $10.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $10.56
Comprehensive metabolic panel (blood test) CPT 80053 · Outpatient (no overnight stay) In the file: COMPREHENSIVE METABOLIC PANEL	Not listed in the file	Not listed in the file	$7.39 – $22.72
Comprehensive metabolic panel (blood test): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $10.10 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $10.10 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $10.10 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $10.10 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $22.72 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $10.10 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $10.10 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $10.10 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $10.10 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $22.72
Comprehensive metabolic panel (blood test) CPT 80053 · Outpatient (no overnight stay) In the file: CHG COMPREHENSIVE METABOLIC PANEL	Not listed in the file	Not listed in the file	$7.39 – $22.72
Comprehensive metabolic panel (blood test): rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $11.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $11.86 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Obstetric blood test panel CPT 80055 · Outpatient (no overnight stay) In the file: Obstetric panel	Not listed in the file	Not listed in the file	$33.47 – $65.40
Obstetric blood test panel: 10 of 23 insurance plan rates AETNA 2700 — AETNA 270002: $54.03 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $47.81 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $47.81 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $59.28 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $33.47 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $33.47 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $47.81 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $47.81 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $47.81 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $47.81
Obstetric blood test panel CPT 80055 · Outpatient (no overnight stay) In the file: CHG OBSTETRIC PANEL	Not listed in the file	Not listed in the file	$33.47 – $65.40
Obstetric blood test panel: rates for 2 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $53.70 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $53.70
Cholesterol panel (lipid panel) CPT 80061 · Outpatient (no overnight stay) In the file: Lipid panel	Not listed in the file	Not listed in the file	$6.10 – $18.32
Cholesterol panel (lipid panel): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $15.13 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $13.39 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $13.39 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $16.60 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $9.37 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $9.37 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $13.39 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $13.39 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $13.39 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $13.39
Cholesterol panel (lipid panel) CPT 80061 · Outpatient (no overnight stay) In the file: LIPID PANEL	Not listed in the file	Not listed in the file	$6.10 – $18.32
Cholesterol panel (lipid panel): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $6.10 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $6.10 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $6.10 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $6.10 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $13.73 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $6.10 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $6.10 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $6.10 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $6.10 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $13.73
Cholesterol panel (lipid panel) CPT 80061 · Outpatient (no overnight stay) In the file: CHG LIPID PANEL	Not listed in the file	Not listed in the file	$6.10 – $18.32
Cholesterol panel (lipid panel): rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $15.04 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $15.04 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Kidney function panel CPT 80069 · Outpatient (no overnight stay) In the file: Renal function panel	Not listed in the file	Not listed in the file	$6.08 – $19.53
Kidney function panel: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $9.81 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $8.68 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $8.68 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $10.76 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $6.08 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $6.08 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $8.68 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $8.68 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $8.68 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $8.68
Kidney function panel CPT 80069 · Outpatient (no overnight stay) In the file: RENAL FUNCTION PANEL	Not listed in the file	Not listed in the file	$6.08 – $19.53
Kidney function panel: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $8.68 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $8.68 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $8.68 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $8.68 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $19.53 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $8.68 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $8.68 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $8.68 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $8.68 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $19.53
Kidney function panel CPT 80069 · Outpatient (no overnight stay) In the file: CHG RENAL FUNCTION PANEL	Not listed in the file	Not listed in the file	$6.08 – $19.53
Kidney function panel: rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $9.75 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $9.75 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Liver function panel CPT 80076 · Outpatient (no overnight stay) In the file: Hepatic function panel	Not listed in the file	Not listed in the file	$5.72 – $16.48
Liver function panel: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $9.23 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $8.17 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $8.17 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $10.13 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $5.72 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $5.72 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $8.17 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $8.17 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $8.17 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $8.17
Liver function panel CPT 80076 · Outpatient (no overnight stay) In the file: HEPATIC FUNCTION PANEL	Not listed in the file	Not listed in the file	$5.72 – $16.48
Liver function panel: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $7.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $7.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $7.32 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $7.32 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $16.48 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $7.32 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $7.32 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $7.32 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $7.32 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $16.48
Liver function panel CPT 80076 · Outpatient (no overnight stay) In the file: CHG HEPATIC FUNCTION PANEL	Not listed in the file	Not listed in the file	$5.72 – $16.48
Liver function panel: rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $9.18 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $9.18 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Urine test (automated, with microscope) CPT 81001 · Outpatient (no overnight stay) In the file: Urinalysis auto w/scope	Not listed in the file	Not listed in the file	$2.22 – $7.13
Urine test (automated, with microscope): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $3.58 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $3.17 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $3.17 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $3.93 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $2.22 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $2.22 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $3.17 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $3.17 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $3.17 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3.17
Urine test (automated, with microscope) CPT 81001 · Outpatient (no overnight stay) In the file: URINALYSIS, BY DIP STICK OR TABLET REAGE	Not listed in the file	Not listed in the file	$2.22 – $7.13
Urine test (automated, with microscope): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $3.17 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $3.17 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $3.17 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $3.17 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $7.13 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $3.17 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $3.17 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $3.17 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $3.17 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $7.13
Urine test (automated, with microscope) CPT 81001 · Outpatient (no overnight stay) In the file: CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY	Not listed in the file	Not listed in the file	$2.22 – $7.13
Urine test (automated, with microscope): rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $3.56 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $3.56 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Urine test (manual, without microscope) CPT 81002 · Outpatient (no overnight stay) In the file: URINALYSIS NONAUTO W/O SCOPE	Not listed in the file	Not listed in the file	$1.72 – $3.76
Urine test (manual, without microscope): 10 of 23 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $3.48 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $3.48 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $2 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $2.29 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $2.44 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $3.48 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $3.48 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $3.76 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $3.48 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $2.02
Urine test (manual, without microscope) CPT 81002 · Outpatient (no overnight stay) In the file: Urinalysis nonauto w/o scope	Not listed in the file	Not listed in the file	$2.02 – $4.76
Urine test (manual, without microscope): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $3.93 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $3.48 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $3.48 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $4.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $2.44 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $2.44 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $3.48 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $3.48 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $3.48 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3.48
Urine test (manual, without microscope) CPT 81002 · Outpatient (no overnight stay) In the file: URINALYSIS, BY DIP STICK OR TABLET REAGE	Not listed in the file	Not listed in the file	$2.02 – $4.76
Urine test (manual, without microscope): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $2.02 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $2.02 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $2.02 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $2.02 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $4.54 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $2.02 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $2.02 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $2.02 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $2.02 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $4.54
Urine test (automated, without microscope) CPT 81003 · Outpatient (no overnight stay) In the file: URINALYSIS AUTO W/O SCOPE	Not listed in the file	Not listed in the file	$1.35 – $2.58
Urine test (automated, without microscope): 10 of 23 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $2.25 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $2.25 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $2 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $1.48 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $1.58 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $2.25 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2.25 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $2.43 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $2.25 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $1.72
Urine test (automated, without microscope) CPT 81003 · Outpatient (no overnight stay) In the file: Urinalysis auto w/o scope	Not listed in the file	Not listed in the file	$1.58 – $4.54
Urine test (automated, without microscope): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $2.54 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $2.25 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2.25 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $2.79 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $1.58 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $1.58 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $2.25 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $2.25 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $2.25 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $2.25
Urine test (automated, without microscope) CPT 81003 · Outpatient (no overnight stay) In the file: URINALYSIS, BY DIP STICK OR TABLET REAGE	Not listed in the file	Not listed in the file	$1.58 – $4.54
Urine test (automated, without microscope): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $2.02 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $2.02 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $2.02 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $2.02 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $4.54 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $2.02 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $2.02 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $2.02 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $2.02 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $4.54
PSA (prostate specific antigen) blood test CPT 84153 · Outpatient (no overnight stay) In the file: Assay of psa total	Not listed in the file	Not listed in the file	$12.87 – $41.38
PSA (prostate specific antigen) blood test: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $20.78 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $18.39 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $18.39 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $22.80 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $12.87 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $12.87 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $18.39 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $18.39 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $18.39 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $18.39
PSA (prostate specific antigen) blood test CPT 84153 · Outpatient (no overnight stay) In the file: PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL	Not listed in the file	Not listed in the file	$12.87 – $41.38
PSA (prostate specific antigen) blood test: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $18.39 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $18.39 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $18.39 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $18.39 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $41.38 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $18.39 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $18.39 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $18.39 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $18.39 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $41.38
PSA (prostate specific antigen) blood test CPT 84153 · Outpatient (no overnight stay) In the file: CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL	Not listed in the file	Not listed in the file	$12.87 – $41.38
PSA (prostate specific antigen) blood test: rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $20.65 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $20.65 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Thyroid stimulating hormone (TSH) test CPT 84443 · Outpatient (no overnight stay) In the file: ASSAY THYROID STIM HORMONE	Not listed in the file	Not listed in the file	$7.06 – $18.17
Thyroid stimulating hormone (TSH) test: 10 of 23 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $16.80 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $16.80 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $10.80 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $11.08 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $11.76 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $16.80 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $16.80 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $18.17 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $16.80 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $9.09
Thyroid stimulating hormone (TSH) test CPT 84443 · Outpatient (no overnight stay) In the file: Assay thyroid stim hormone	Not listed in the file	Not listed in the file	$9.09 – $22.98
Thyroid stimulating hormone (TSH) test: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $18.98 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $16.80 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $16.80 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $20.83 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $11.76 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $11.76 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $16.80 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $16.80 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $16.80 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $16.80
Thyroid stimulating hormone (TSH) test CPT 84443 · Outpatient (no overnight stay) In the file: THYROID STIMULATING HORMONE (TSH)	Not listed in the file	Not listed in the file	$9.09 – $22.98
Thyroid stimulating hormone (TSH) test: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $9.09 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $9.09 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $9.09 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $9.09 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $20.45 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $9.09 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $9.09 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $9.09 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $9.09 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $20.45
Complete blood count (CBC) with differential CPT 85025 · Outpatient (no overnight stay) In the file: Complete cbc w/auto diff wbc	Not listed in the file	Not listed in the file	$3.20 – $10.63
Complete blood count (CBC) with differential: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $8.78 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $7.77 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $7.77 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $9.63 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $5.44 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $5.44 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $7.77 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $7.77 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $7.77 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $7.77
Complete blood count (CBC) with differential CPT 85025 · Outpatient (no overnight stay) In the file: BLOOD COUNT; COMPLETE (CBC), AUTOMATED (	Not listed in the file	Not listed in the file	$3.20 – $10.63
Complete blood count (CBC) with differential: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $3.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $3.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $3.20 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $3.20 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $7.20 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $3.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $3.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $3.20 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $3.20 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $7.20
Complete blood count (CBC) with differential CPT 85025 · Outpatient (no overnight stay) In the file: CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC	Not listed in the file	Not listed in the file	$3.20 – $10.63
Complete blood count (CBC) with differential: rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $8.73 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $8.73 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Complete blood count (CBC), automated CPT 85027 · Outpatient (no overnight stay) In the file: Complete cbc automated	Not listed in the file	Not listed in the file	$3.20 – $8.85
Complete blood count (CBC), automated: 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $7.31 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $6.47 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $6.47 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $8.02 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $4.53 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $4.53 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $6.47 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $6.47 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $6.47 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $6.47
Complete blood count (CBC), automated CPT 85027 · Outpatient (no overnight stay) In the file: BLOOD COUNT; COMPLETE (CBC), AUTOMATED (	Not listed in the file	Not listed in the file	$3.20 – $8.85
Complete blood count (CBC), automated: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $3.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $3.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $3.20 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $3.20 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $7.20 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $3.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $3.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $3.20 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $3.20 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $7.20
Complete blood count (CBC), automated CPT 85027 · Outpatient (no overnight stay) In the file: CHG BLOOD COUNT COMPLETE AUTOMATED	Not listed in the file	Not listed in the file	$3.20 – $8.85
Complete blood count (CBC), automated: rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $7.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $7.27 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)
Blood clotting time test (prothrombin time, PT) CPT 85610 · Outpatient (no overnight stay) In the file: PROTHROMBIN TIME	Not listed in the file	Not listed in the file	$2.57 – $5.04
Blood clotting time test (prothrombin time, PT): 10 of 23 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $4.29 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $4.29 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $4.14 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $2.83 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $3 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $4.29 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4.29 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $4.64 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $4.29 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $3.95
Blood clotting time test (prothrombin time, PT) CPT 85610 · Outpatient (no overnight stay) In the file: Prothrombin time	Not listed in the file	Not listed in the file	$3 – $8.89
Blood clotting time test (prothrombin time, PT): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $4.85 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4.29 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $5.32 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $3 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $3 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4.29 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4.29 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4.29 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $4.29
Blood clotting time test (prothrombin time, PT) CPT 85610 · Outpatient (no overnight stay) In the file: PROTHROMBIN TIME;	Not listed in the file	Not listed in the file	$3 – $8.89
Blood clotting time test (prothrombin time, PT): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $3.95 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $3.95 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $3.95 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $3.95 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $8.89 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $3.95 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $3.95 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $3.95 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $3.95 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $8.89
Blood clotting test (partial thromboplastin time, PTT) CPT 85730 · Outpatient (no overnight stay) In the file: Thromboplastin time partial	Not listed in the file	Not listed in the file	$4.21 – $13.52
Blood clotting test (partial thromboplastin time, PTT): 10 of 20 insurance plan rates AETNA 2700 — AETNA 270002: $6.79 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $6.01 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $6.01 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $7.45 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $4.21 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $4.21 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $6.01 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $6.01 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $6.01 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $6.01
Blood clotting test (partial thromboplastin time, PTT) CPT 85730 · Outpatient (no overnight stay) In the file: THROMBOPLASTIN TIME, PARTIAL (PTT); PLAS	Not listed in the file	Not listed in the file	$4.21 – $13.52
Blood clotting test (partial thromboplastin time, PTT): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $6.01 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $6.01 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $6.01 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $6.01 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $13.52 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $6.01 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $6.01 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $6.01 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $6.01 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $13.52
Blood clotting test (partial thromboplastin time, PTT) CPT 85730 · Outpatient (no overnight stay) In the file: CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD	Not listed in the file	Not listed in the file	$4.21 – $13.52
Blood clotting test (partial thromboplastin time, PTT): rates for 5 insurance plans EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $6.75 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $6.75 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount) INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: 80% (a percentage in the contract, not a dollar amount)

Imaging (X-ray, CT, MRI, ultrasound, mammogram)

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
CT scan of the head or brain, without contrast CPT 70450 · Outpatient (no overnight stay) In the file: Ct head/brain w/o dye	Not listed in the file	Not listed in the file	$72.72 – $310.34
CT scan of the head or brain, without contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $130.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $140.94 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $209.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $225.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $225.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $130.50 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $130.50 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $130.50 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $107.01 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $300.55
CT scan of the head or brain, without contrast CPT 70450 · Outpatient (no overnight stay) In the file: COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH	Not listed in the file	Not listed in the file	$72.72 – $310.34
CT scan of the head or brain, without contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $121.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $121.20 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $121.20 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $121.20 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $272.70 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $121.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $121.20 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $121.20 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $121.20 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $272.70
CT scan of the head or brain, without contrast CPT 70450 · Inpatient or outpatient In the file: HB CT Head/Brain W/O Contrast Material	$315	Not listed in the file	Not listed in the file
MRI of the brain, before and after contrast CPT 70553 · Outpatient (no overnight stay) In the file: Mri brain stem w/o & w/dye	Not listed in the file	Not listed in the file	$303 – $1,136.25
MRI of the brain, before and after contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $435.49 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $470.33 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $700.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $753.71 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $753.71 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $435.49 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $435.49 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $435.49 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $357.10 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $1,002.94
MRI of the brain, before and after contrast CPT 70553 · Outpatient (no overnight stay) In the file: MAGNETIC RESONANCE (EG, PROTON) IMAGING,	Not listed in the file	Not listed in the file	$303 – $1,136.25
MRI of the brain, before and after contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $505 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $505 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $1,136.25 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $505 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $505 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $1,136.25
MRI of the brain, before and after contrast CPT 70553 · Inpatient or outpatient In the file: HB MRI Brain Brain Stem W/O W/Contrast Material	$1,057	Not listed in the file	Not listed in the file
Chest X-ray, 2 views CPT 71046 · Outpatient (no overnight stay) In the file: X-RAY EXAM CHEST 2 VIEWS	Not listed in the file	Not listed in the file	$7.57 – $82.66
Chest X-ray, 2 views: 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $42.78 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $31.60 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $24.65 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $34.68 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $28.44 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $82.66 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $32.23 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $34.39 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $31.60 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $30.42
Chest X-ray, 2 views CPT 71046 · Outpatient (no overnight stay) In the file: X-ray exam chest 2 views	Not listed in the file	Not listed in the file	$9.09 – $258.33
Chest X-ray, 2 views: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $108.63 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $117.32 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $174.68 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $188.01 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $188.01 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $108.63 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $108.63 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $108.63 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $89.08 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $250.18
Chest X-ray, 2 views CPT 71046 · Outpatient (no overnight stay) In the file: RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS	Not listed in the file	Not listed in the file	$9.09 – $258.33
Chest X-ray, 2 views: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $15.15 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $15.15 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $15.15 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $15.15 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $34.09 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $15.15 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $15.15 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $15.15 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $15.15 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $34.09
X-ray of the lower spine, at least 4 views CPT 72110 · Outpatient (no overnight stay) In the file: X-RAY EXAM L-2 SPINE 4/>VWS	Not listed in the file	Not listed in the file	$8.68 – $125.90
X-ray of the lower spine, at least 4 views: 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $66 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $12.31 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $42.71 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $53.63 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $45.85 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $125.90 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $51.96 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $50.81 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $50.94 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $46.54
X-ray of the lower spine, at least 4 views CPT 72110 · Outpatient (no overnight stay) In the file: X-ray exam l-2 spine 4/>vws	Not listed in the file	Not listed in the file	$18.18 – $310.34
X-ray of the lower spine, at least 4 views: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $130.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $140.94 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $209.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $225.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $225.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $130.50 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $130.50 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $130.50 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $107.01 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $300.55
X-ray of the lower spine, at least 4 views CPT 72110 · Outpatient (no overnight stay) In the file: RADIOLOGIC EXAMINATION, SPINE, LUMBOSACR	Not listed in the file	Not listed in the file	$18.18 – $310.34
X-ray of the lower spine, at least 4 views: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $30.30 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $30.30 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $30.30 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $30.30 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $68.18 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $30.30 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $30.30 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $30.30 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $30.30 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $68.18
MRI of the lower back (lumbar spine), without contrast CPT 72148 · Outpatient (no overnight stay) In the file: Mri lumbar spine w/o dye	Not listed in the file	Not listed in the file	$244.23 – $1,136.25
MRI of the lower back (lumbar spine), without contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $297.84 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $321.67 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $478.93 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $515.48 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $515.48 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $297.84 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $297.84 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $297.84 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $244.23 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $685.93
MRI of the lower back (lumbar spine), without contrast CPT 72148 · Outpatient (no overnight stay) In the file: MAGNETIC RESONANCE (EG, PROTON) IMAGING,	Not listed in the file	Not listed in the file	$244.23 – $1,136.25
MRI of the lower back (lumbar spine), without contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $505 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $505 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $1,136.25 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $505 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $505 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $1,136.25
MRI of the lower back (lumbar spine), without contrast CPT 72148 · Inpatient or outpatient In the file: HB MRI Spinal Canal Lumbar W/O Contrast Material	$715	Not listed in the file	Not listed in the file
CT scan of the pelvis, with contrast CPT 72193 · Outpatient (no overnight stay) In the file: Ct pelvis w/dye	Not listed in the file	Not listed in the file	$103.02 – $520.66
CT scan of the pelvis, with contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $218.95 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $236.47 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $352.07 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $378.94 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $378.94 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $218.95 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $218.95 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $218.95 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $179.54 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $504.24
CT scan of the pelvis, with contrast CPT 72193 · Outpatient (no overnight stay) In the file: COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRA	Not listed in the file	Not listed in the file	$103.02 – $520.66
CT scan of the pelvis, with contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $171.70 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $171.70 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $171.70 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $171.70 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $386.32 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $171.70 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $171.70 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $171.70 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $171.70 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $386.32
CT scan of the pelvis, with contrast CPT 72193 · Inpatient or outpatient In the file: HB CT Pelvis W/Contrast Material	$527	Not listed in the file	Not listed in the file
MRI of a leg joint (such as the knee), without contrast CPT 73721 · Outpatient (no overnight stay) In the file: Mri jnt of lwr extre w/o dye	Not listed in the file	Not listed in the file	$244.23 – $1,136.25
MRI of a leg joint (such as the knee), without contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $297.84 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $321.67 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $478.93 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $515.48 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $515.48 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $297.84 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $297.84 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $297.84 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $244.23 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $685.93
MRI of a leg joint (such as the knee), without contrast CPT 73721 · Outpatient (no overnight stay) In the file: MAGNETIC RESONANCE (EG, PROTON) IMAGING,	Not listed in the file	Not listed in the file	$244.23 – $1,136.25
MRI of a leg joint (such as the knee), without contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $505 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $505 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $505 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $1,136.25 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $505 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $505 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $505 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $1,136.25
MRI of a leg joint (such as the knee), without contrast CPT 73721 · Inpatient or outpatient In the file: HB MRI Any Jt Lower Extrem W/O Contrast Matrl	$715	Not listed in the file	Not listed in the file
CT scan of the abdomen and pelvis, with contrast CPT 74177 · Outpatient (no overnight stay) In the file: Ct abd & pelvis w/contrast	Not listed in the file	Not listed in the file	$65.41 – $1,035.60
CT scan of the abdomen and pelvis, with contrast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $435.49 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $470.33 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $700.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $753.71 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $753.71 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $435.49 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $435.49 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $435.49 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $357.10 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $1,002.94
CT scan of the abdomen and pelvis, with contrast CPT 74177 · Outpatient (no overnight stay) In the file: COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS;	Not listed in the file	Not listed in the file	$65.41 – $1,035.60
CT scan of the abdomen and pelvis, with contrast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $109.01 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $109.01 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $109.01 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $109.01 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $245.27 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $109.01 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $109.01 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $109.01 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $109.01 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $245.27
CT scan of the abdomen and pelvis, with contrast CPT 74177 · Inpatient or outpatient In the file: HB CT Abdomen & Pelvis W/Contrast Material	$1,057	Not listed in the file	Not listed in the file
Ultrasound of the abdomen, complete CPT 76700 · Outpatient (no overnight stay) In the file: US EXAM ABDOM COMPLETE	Not listed in the file	Not listed in the file	$21.84 – $287.78
Ultrasound of the abdomen, complete: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $146.76 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $109.34 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $105.69 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $133.35 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $98.41 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $287.78 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $111.53 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $129.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $109.34 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $90.94
Ultrasound of the abdomen, complete CPT 76700 · Outpatient (no overnight stay) In the file: Us exam abdom complete	Not listed in the file	Not listed in the file	$36.36 – $310.34
Ultrasound of the abdomen, complete: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $130.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $140.94 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $209.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $225.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $225.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $130.50 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $130.50 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $130.50 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $107.01 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $300.55
Ultrasound of the abdomen, complete CPT 76700 · Outpatient (no overnight stay) In the file: ULTRASOUND, ABDOMINAL, REAL TIME WITH IM	Not listed in the file	Not listed in the file	$36.36 – $310.34
Ultrasound of the abdomen, complete: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $60.60 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $60.60 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $60.60 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $60.60 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $136.35 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $60.60 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $60.60 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $60.60 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $60.60 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $136.35
Pregnancy ultrasound (after the first trimester) CPT 76805 · Outpatient (no overnight stay) In the file: Ob us >/= 14 wks sngl fetus	Not listed in the file	Not listed in the file	$33.33 – $310.34
Pregnancy ultrasound (after the first trimester): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $130.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $140.94 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $209.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $225.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $225.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $130.50 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $130.50 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $130.50 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $107.01 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $300.55
Pregnancy ultrasound (after the first trimester) CPT 76805 · Outpatient (no overnight stay) In the file: ULTRASOUND, PREGNANT UTERUS, REAL TIME W	Not listed in the file	Not listed in the file	$33.33 – $310.34
Pregnancy ultrasound (after the first trimester): 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $55.55 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $55.55 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $55.55 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $55.55 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $124.99 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $55.55 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $55.55 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $55.55 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $55.55 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $124.99
Pregnancy ultrasound (after the first trimester) CPT 76805 · Inpatient or outpatient In the file: HB US Preg Uterus After 1st Trimest 1/1st Gestation	$754	Not listed in the file	Not listed in the file
Transvaginal ultrasound CPT 76830 · Outpatient (no overnight stay) In the file: Transvaginal us non-ob	Not listed in the file	Not listed in the file	$36.36 – $310.34
Transvaginal ultrasound: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $130.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $140.94 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $209.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $225.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $225.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $130.50 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $130.50 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $130.50 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $107.01 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $300.55
Transvaginal ultrasound CPT 76830 · Outpatient (no overnight stay) In the file: TRANSVAGINAL US NON-OB	Not listed in the file	Not listed in the file	$24.58 – $169.60
Transvaginal ultrasound: 10 of 17 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $149.53 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA CHICKERING 270001,AETNA 270002,: $112.32 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $90.85 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $101.09 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $114.57 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $129.83 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $112.32 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICAID 1702, — HIGHMARK BC/BS OF WESTERN NY MEDICAID 170201, COMMUNITY CARE: $90.85 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICARE 1301 — HIGHMARK BC/BS MEDICARE 130101: $109.15 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601,NOVA HEALTHCARE ADMIN: $168.13
Transvaginal ultrasound CPT 76830 · Outpatient (no overnight stay) In the file: ULTRASOUND, TRANSVAGINAL	Not listed in the file	Not listed in the file	$36.36 – $310.34
Transvaginal ultrasound: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $60.60 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $60.60 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $60.60 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $60.60 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $136.35 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $60.60 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $60.60 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $60.60 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $60.60 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $136.35
Diagnostic mammogram, one breast CPT 77065 · Outpatient (no overnight stay) In the file: Dx mammo incl cad uni	Not listed in the file	Not listed in the file	$58.78 – $220.43
Diagnostic mammogram, one breast: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $81.78 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $88.32 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $81.78 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $141.54 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $141.54 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $81.78 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $81.78 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $81.78 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $67.06 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $126.99
Diagnostic mammogram, one breast CPT 77065 · Outpatient (no overnight stay) In the file: DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMP	Not listed in the file	Not listed in the file	$58.78 – $220.43
Diagnostic mammogram, one breast: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $97.97 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $97.97 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $220.43 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $97.97 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $97.97 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $220.43
Diagnostic mammogram, one breast CPT 77065 · Inpatient or outpatient In the file: HB Diagnostic Mammography Computer-Aided Detcj Uni	$352	Not listed in the file	Not listed in the file
Diagnostic mammogram, both breasts CPT 77066 · Outpatient (no overnight stay) In the file: Dx mammo incl cad bi	Not listed in the file	Not listed in the file	$58.78 – $220.43
Diagnostic mammogram, both breasts: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $104.86 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $113.25 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $104.86 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $181.48 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $181.48 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $104.86 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $104.86 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $104.86 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $85.99 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $162.18
Diagnostic mammogram, both breasts CPT 77066 · Outpatient (no overnight stay) In the file: DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMP	Not listed in the file	Not listed in the file	$58.78 – $220.43
Diagnostic mammogram, both breasts: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $97.97 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $97.97 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $220.43 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $97.97 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $97.97 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $220.43
Diagnostic mammogram, both breasts CPT 77066 · Inpatient or outpatient In the file: HB Diagnostic Mammography Computer-Aided Detcj Bi	$415	Not listed in the file	Not listed in the file
Screening mammogram, both breasts CPT 77067 · Outpatient (no overnight stay) In the file: Scr mammo bi incl cad	Not listed in the file	Not listed in the file	$58.78 – $220.43
Screening mammogram, both breasts: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $86.54 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $93.46 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $86.54 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $149.77 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $149.77 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $86.54 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $86.54 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $86.54 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $70.96 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $134.13
Screening mammogram, both breasts CPT 77067 · Outpatient (no overnight stay) In the file: SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW	Not listed in the file	Not listed in the file	$58.78 – $220.43
Screening mammogram, both breasts: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $97.97 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $97.97 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $97.97 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $220.43 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $97.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $97.97 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $97.97 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $220.43
Screening mammogram, both breasts CPT 77067 · Inpatient or outpatient In the file: HB Screening Mammography Bi 2-View Breast Inc Cad	$332	Not listed in the file	Not listed in the file

Heart tests and sleep study

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Electrocardiogram (ECG/EKG) with reading CPT 93000 · Outpatient (no overnight stay) In the file: ELECTROCARDIOGRAM COMPLETE	Not listed in the file	Not listed in the file	$10.30 – $35.31
Electrocardiogram (ECG/EKG) with reading: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $18.28 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $14.72 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $14.40 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $19.19 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $13.25 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $35.31 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $15.01 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $17.94 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $14.72 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $15.15
Electrocardiogram (ECG/EKG) with reading CPT 93000 · Outpatient (no overnight stay) In the file: Electrocardiogram complete	Not listed in the file	Not listed in the file	$12.07 – $34.09
Electrocardiogram (ECG/EKG) with reading: 10 of 21 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $14.72 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $15.90 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $14.72 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $25.48 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $25.48 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $14.72 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $14.72 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $14.72 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $12.07 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $14.72
Electrocardiogram (ECG/EKG) with reading CPT 93000 · Outpatient (no overnight stay) In the file: ELECTROCARDIOGRAM, ROUTINE ECG WITH AT L	Not listed in the file	Not listed in the file	$12.07 – $34.09
Electrocardiogram (ECG/EKG) with reading: 10 of 15 insurance plan rates AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $15.15 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — BLUE CHOICE OPTION MEDICAID 170601: $15.15 EXCELLUS BLUE CROSS BLUE SHIELD MEDICAID 1706 — EXCELLUS ESSENTIAL 3-4 170604, EXCELLUS ESSENTIAL 1-2 200-25: $15.15 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $15.15 FIDELIS MEDICAID 1708 — FIDELIS ESSENTIAL 3-4 170804, FIDELIS ESSENTIAL 1-2 200-250 : $34.09 FIDELIS MEDICAID 1708 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $15.15 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 1702 — HIGHMARK BCBS MEDICAID 170201 CHILD HEALTH PLUS 170204: $15.15 HIGHMARK BLUE CROSS BLUE SHIELD MEDICAID 5143 — HIGHMARK BCBS ESSENTIAL 1-2 200-250 5143: $15.15 INDEPENDENT HEALTH ASSOC MEDICAID 1710 — INDEPENDENT HEALTH MEDICAID 171001, INDEPENDENT HEALTH CHILD: $15.15 MOLINA HEALTHCARE 1723 — MOLINA ESSENTIAL 3-4 172302, MOLINA ESSENTIAL 1-2 200-250 51: $34.09
Left heart catheterization (diagnostic) CPT 93452 · Outpatient (no overnight stay) In the file: Left hrt cath w/ventrclgrphy	Not listed in the file	Not listed in the file	$3,318.42 – $9,623.41
Left heart catheterization (diagnostic): 10 of 21 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4,046.85 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4,370.60 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $6,507.33 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $7,003.89 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $7,003.89 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4,046.85 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4,046.85 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4,046.85 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3,318.42 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $9,319.90
Heart rhythm study (electrophysiology evaluation) CPT 93619 · Outpatient (no overnight stay) In the file: Comprehensive ep evaluation	Not listed in the file	Not listed in the file	$7,983.68 – $23,152.67
Heart rhythm study (electrophysiology evaluation): 10 of 21 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $9,736.20 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $10,515.09 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $15,655.81 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $16,850.43 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $16,850.43 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $9,736.20 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $9,736.20 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $9,736.20 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $7,983.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $22,422.46
Heart rhythm study with ablation for atrial fibrillation CPT 93656 · Outpatient (no overnight stay) In the file: Compre ep eval abltj atr fib	Not listed in the file	Not listed in the file	$26,754.52 – $77,588.12
Heart rhythm study with ablation for atrial fibrillation: 10 of 21 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $32,627.47 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $35,237.67 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $52,464.97 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $56,468.36 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $56,468.36 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $32,627.47 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $32,627.47 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $32,627.47 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $26,754.52 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $75,141.06
Sleep study (overnight, in a sleep lab) CPT 95810 · Outpatient (no overnight stay) In the file: POLYSOM 6/> YRS 4/> PARAM	Not listed in the file	Not listed in the file	$84.91 – $1,481.48
Sleep study (overnight, in a sleep lab): 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $794.39 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $641.94 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $414.61 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $715.90 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $577.75 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,481.48 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $654.78 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $642.17 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $641.94 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $654.30
Sleep study (overnight, in a sleep lab) CPT 95810 · Outpatient (no overnight stay) In the file: Polysom 6/> yrs 4/> param	Not listed in the file	Not listed in the file	$879 – $2,549.10
Sleep study (overnight, in a sleep lab): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,071.95 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,157.71 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,723.70 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,855.23 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,855.23 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,071.95 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,071.95 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,071.95 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $879 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,468.71
Sleep study (overnight, in a sleep lab) CPT 95810 · Inpatient or outpatient In the file: PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND	$345	$205.72	Not listed in the file

Physical therapy and mental health

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Physical therapy: therapeutic exercise (each 15 minutes) CPT 97110 · Outpatient (no overnight stay) In the file: Therapeutic exercises	Not listed in the file	Not listed in the file	$22.95 – $48.44
Physical therapy: therapeutic exercise (each 15 minutes): 10 of 15 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $27.99 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $30.23 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $27.99 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $48.44 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $48.44 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $27.99 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $27.99 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $27.99 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $22.95 MVP MEDICAID 1712 — MVP ESSENTIAL 3-4 171204, MVP ESSENTIAL 1-2 200-250 2900: $27.99
Physical therapy: therapeutic exercise (each 15 minutes) CPT 97110 · Outpatient (no overnight stay) In the file: Therapeutic px 1/> areas each 15 min exercises	Not listed in the file	Not listed in the file	$22.95 – $48.44
Physical therapy: therapeutic exercise (each 15 minutes): rates for 4 insurance plans MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $42.84 MVP 2900 — MVP PREMIER INDIVIDUAL 290002: $31.04 MVP 2900, CIGNA 5144 — MVP COMMERCIAL PPO FULLY INSURED 290006, CIGNA HEALTHCARE (P: $42.84 MVP MEDICARE 1307 — MVP MEDICARE 130701: $31.08
Physical therapy: therapeutic exercise (each 15 minutes) CPT 97110 · Inpatient or outpatient In the file: HB Therapeutic Px 1/> Areas Each 15 Min Exercises	$84	Not listed in the file	Not listed in the file
Physical therapy evaluation (low complexity) CPT 97161 · Outpatient (no overnight stay) In the file: PT EVAL LOW COMPLEX 20 MIN	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (low complexity): 10 of 15 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $95.27 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $102.89 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $95.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $164.88 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $164.88 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $95.27 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $95.27 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $95.27 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $78.12 MVP MEDICAID 1712 — MVP ESSENTIAL 3-4 171204, MVP ESSENTIAL 1-2 200-250 2900: $95.27
Physical therapy evaluation (low complexity) CPT 97161 · Outpatient (no overnight stay) In the file: Physical therapy evaluation low complex 20 mins	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (low complexity): rates for 4 insurance plans MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $120.36 MVP 2900 — MVP PREMIER INDIVIDUAL 290002: $87.20 MVP 2900, CIGNA 5144 — MVP COMMERCIAL PPO FULLY INSURED 290006, CIGNA HEALTHCARE (P: $120.36 MVP MEDICARE 1307 — MVP MEDICARE 130701: $87.32
Physical therapy evaluation (low complexity) CPT 97161 · Inpatient or outpatient In the file: HB Physical Therapy Evaluation Low Complex 20 Mins	$195	Not listed in the file	Not listed in the file
Physical therapy evaluation (moderate complexity) CPT 97162 · Outpatient (no overnight stay) In the file: PT EVAL MOD COMPLEX 30 MIN	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (moderate complexity): 10 of 15 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $95.27 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $102.89 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $95.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $164.88 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $164.88 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $95.27 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $95.27 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $95.27 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $78.12 MVP MEDICAID 1712 — MVP ESSENTIAL 3-4 171204, MVP ESSENTIAL 1-2 200-250 2900: $95.27
Physical therapy evaluation (moderate complexity) CPT 97162 · Outpatient (no overnight stay) In the file: Physical therapy evaluation mod complex 30 mins	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (moderate complexity): rates for 4 insurance plans MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $120.36 MVP 2900 — MVP PREMIER INDIVIDUAL 290002: $87.20 MVP 2900, CIGNA 5144 — MVP COMMERCIAL PPO FULLY INSURED 290006, CIGNA HEALTHCARE (P: $120.36 MVP MEDICARE 1307 — MVP MEDICARE 130701: $87.32
Physical therapy evaluation (moderate complexity) CPT 97162 · Inpatient or outpatient In the file: HB Physical Therapy Evaluation Mod Complex 30 Mins	$195	Not listed in the file	Not listed in the file
Physical therapy evaluation (high complexity) CPT 97163 · Outpatient (no overnight stay) In the file: PT EVAL HIGH COMPLEX 45 MIN	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (high complexity): 10 of 15 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $95.27 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $102.89 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $95.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $164.88 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $164.88 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $95.27 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $95.27 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $95.27 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $78.12 MVP MEDICAID 1712 — MVP ESSENTIAL 3-4 171204, MVP ESSENTIAL 1-2 200-250 2900: $95.27
Physical therapy evaluation (high complexity) CPT 97163 · Outpatient (no overnight stay) In the file: Physical therapy evaluation high complex 45 mins	Not listed in the file	Not listed in the file	$78.12 – $164.88
Physical therapy evaluation (high complexity): rates for 4 insurance plans MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $120.36 MVP 2900 — MVP PREMIER INDIVIDUAL 290002: $87.20 MVP 2900, CIGNA 5144 — MVP COMMERCIAL PPO FULLY INSURED 290006, CIGNA HEALTHCARE (P: $120.36 MVP MEDICARE 1307 — MVP MEDICARE 130701: $87.32
Physical therapy evaluation (high complexity) CPT 97163 · Inpatient or outpatient In the file: HB Physical Therapy Evaluation High Complex 45 Mins	$195	Not listed in the file	Not listed in the file
Psychotherapy, 30 minutes CPT 90832 · Outpatient (no overnight stay) In the file: PSYTX W PT 30 MINUTES	Not listed in the file	Not listed in the file	$18.22 – $187.54
Psychotherapy, 30 minutes: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $106.43 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $84.71 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $22.71 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $78.30 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $76.24 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $187.54 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $86.40 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $75.38 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $84.71 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $18.22
Psychotherapy, 30 minutes CPT 90832 · Outpatient (no overnight stay) In the file: Psytx w pt 30 minutes	Not listed in the file	Not listed in the file	$80.36 – $496.75
Psychotherapy, 30 minutes: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $221.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $239.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $356.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $383.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $383.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $221.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $221.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $221.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $181.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $178
Psychotherapy, 30 minutes CPT 90832 · Inpatient or outpatient In the file: PR PSYCHOTHERAPY W/PATIENT 30 MINUTES	$205	$122.24	Not listed in the file
Psychotherapy, 45 minutes CPT 90834 · Outpatient (no overnight stay) In the file: PSYTX W PT 45 MINUTES	Not listed in the file	Not listed in the file	$27.31 – $247.94
Psychotherapy, 45 minutes: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $140.47 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $77.66 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $29.08 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $104.08 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $101.08 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $247.94 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $114.56 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $100.26 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $112.31 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $87.37
Psychotherapy, 45 minutes CPT 90834 · Outpatient (no overnight stay) In the file: Psytx w pt 45 minutes	Not listed in the file	Not listed in the file	$107.25 – $496.75
Psychotherapy, 45 minutes: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $221.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $239.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $356.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $383.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $383.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $221.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $221.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $221.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $181.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $262
Psychotherapy, 45 minutes CPT 90834 · Inpatient or outpatient In the file: PR PSYCHOTHERAPY W/PATIENT 45 MINUTES	$270	$161	Not listed in the file
Psychotherapy, 60 minutes CPT 90837 · Outpatient (no overnight stay) In the file: PSYTX W PT 60 MINUTES	Not listed in the file	Not listed in the file	$41.23 – $364.97
Psychotherapy, 60 minutes: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $208.04 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $164.80 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $42.54 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $156.49 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $148.32 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $364.97 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $168.10 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $150.12 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $164.80 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $127.88
Psychotherapy, 60 minutes CPT 90837 · Outpatient (no overnight stay) In the file: Psytx w pt 60 minutes	Not listed in the file	Not listed in the file	$160.99 – $496.75
Psychotherapy, 60 minutes: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $221.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $239.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $356.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $383.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $383.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $221.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $221.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $221.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $181.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $249
Psychotherapy, 60 minutes CPT 90837 · Inpatient or outpatient In the file: PR PSYCHOTHERAPY W/PATIENT 60 MINUTES	$399	$237.92	Not listed in the file
Family psychotherapy, without the patient CPT 90846 · Outpatient (no overnight stay) In the file: FAMILY PSYTX W/O PT 50 MIN	Not listed in the file	Not listed in the file	$31.31 – $237.84
Family psychotherapy, without the patient: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $133.63 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $104.92 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $68 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $106 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $94.43 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $237.84 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $107.02 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $110.19 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $104.92 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $83.05
Family psychotherapy, without the patient CPT 90846 · Outpatient (no overnight stay) In the file: Family psytx w/o pt 50 min	Not listed in the file	Not listed in the file	$129.93 – $496.75
Family psychotherapy, without the patient: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $221.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $239.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $356.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $383.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $383.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $221.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $221.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $221.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $181.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $262
Family psychotherapy, without the patient CPT 90846 · Inpatient or outpatient In the file: PR FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT 50 MINS	$292	$174.12	Not listed in the file
Family psychotherapy, with the patient CPT 90847 · Outpatient (no overnight stay) In the file: FAMILY PSYTX W/PT 50 MIN	Not listed in the file	Not listed in the file	$51.09 – $247.99
Family psychotherapy, with the patient: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $138.93 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $102.34 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $68 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $109.77 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $97.82 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $247.99 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $110.86 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $96.98 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $108.69 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $85.89
Family psychotherapy, with the patient CPT 90847 · Outpatient (no overnight stay) In the file: Family psytx w/pt 50 min	Not listed in the file	Not listed in the file	$135.01 – $496.75
Family psychotherapy, with the patient: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $221.56 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $239.29 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $356.27 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $383.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $383.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $221.56 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $221.56 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $221.56 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $181.68 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $262
Family psychotherapy, with the patient CPT 90847 · Inpatient or outpatient In the file: PR FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS	$304	$181.28	Not listed in the file
Group psychotherapy CPT 90853 · Outpatient (no overnight stay) In the file: GROUP PSYCHOTHERAPY	Not listed in the file	Not listed in the file	$10.61 – $66.28
Group psychotherapy: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $37.86 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $29.91 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $28 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $29.39 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $26.92 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $66.28 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $30.51 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $29.88 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $29.91 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $23.19
Group psychotherapy CPT 90853 · Outpatient (no overnight stay) In the file: Group psychotherapy	Not listed in the file	Not listed in the file	$31.94 – $284.31
Group psychotherapy: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $126.81 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $136.96 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $203.91 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $219.48 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $219.48 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $126.81 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $126.81 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $126.81 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $103.99 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $130
Group psychotherapy CPT 90853 · Inpatient or outpatient In the file: PR GROUP PSYCHOTHERAPY	$72	$42.93	Not listed in the file

Procedures and surgery

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Removal of breast growth (open surgery) CPT 19120 · Outpatient (no overnight stay) In the file: REMOVAL OF BREAST LESION	Not listed in the file	Not listed in the file	$152.88 – $1,267.48
Removal of breast growth (open surgery): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $662.96 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $542.18 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $203.10 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $579.57 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $487.96 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,267.48 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $553.02 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $535.63 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $867.18 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $484.03
Removal of breast growth (open surgery) CPT 19120 · Outpatient (no overnight stay) In the file: Removal of breast lesion	Not listed in the file	Not listed in the file	$4,007.81 – $11,622.65
Removal of breast growth (open surgery): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4,887.57 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $5,278.58 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $7,859.21 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $8,458.92 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $8,458.92 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4,887.57 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4,887.57 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4,887.57 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $4,007.81 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $11,256.08
Removal of breast growth (open surgery) CPT 19120 · Outpatient (no overnight stay) In the file: PR EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LESION	Not listed in the file	Not listed in the file	$493 – $1,003
Removal of breast growth (open surgery): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,003 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $493 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Total hip replacement CPT 27130 · Outpatient (no overnight stay) In the file: TOTAL HIP ARTHROPLASTY	Not listed in the file	Not listed in the file	$579.91 – $3,130.67
Total hip replacement: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,643.12 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $1,102.42 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $662.75 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $1,755.25 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $992.18 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $3,130.67 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,124.47 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $1,451.41 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $1,102.42 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $1,180.84
Total hip replacement CPT 27130 · Outpatient (no overnight stay) In the file: Total hip arthroplasty	Not listed in the file	Not listed in the file	$13,141.58 – $34,168.11
Total hip replacement: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $16,026.32 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $17,308.43 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $25,770.32 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $27,736.75 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $27,736.75 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $16,026.32 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $16,026.32 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $16,026.32 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $13,141.58 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $26,499
Total hip replacement CPT 27130 · Outpatient (no overnight stay) In the file: PR ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT	Not listed in the file	Not listed in the file	$959 – $1,433
Total hip replacement: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,433 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $959 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Total knee replacement CPT 27447 · Outpatient (no overnight stay) In the file: TOTAL KNEE ARTHROPLASTY	Not listed in the file	Not listed in the file	$623 – $3,127.60
Total knee replacement: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,641.11 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $1,100.13 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $712 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $1,754.48 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $990.12 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $3,127.60 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,122.13 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $1,449.76 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $1,100.13 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $1,179.46
Total knee replacement CPT 27447 · Outpatient (no overnight stay) In the file: Total knee arthroplasty	Not listed in the file	Not listed in the file	$13,141.58 – $34,168.11
Total knee replacement: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $16,026.32 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $17,308.43 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $25,770.32 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $27,736.75 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $27,736.75 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $16,026.32 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $16,026.32 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $16,026.32 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $13,141.58 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $26,499
Total knee replacement CPT 27447 · Outpatient (no overnight stay) In the file: PR ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT COMPARTMENTS	Not listed in the file	Not listed in the file	$692 – $1,290
Total knee replacement: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,290 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $692 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Shoulder arthroscopy: shaving of shoulder bone CPT 29826 · Outpatient (no overnight stay) In the file: SHO ARTHRS SRG DECOMPRESSION	Not listed in the file	Not listed in the file	$119.31 – $574.74
Shoulder arthroscopy: shaving of shoulder bone: 10 of 26 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $217.69 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $140.36 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $310.67 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $126.32 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $417.31 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $143.17 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $187.11 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $140.36 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $392.22 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $218.71
Shoulder arthroscopy: shaving of shoulder bone CPT 29826 · Outpatient (no overnight stay) In the file: PR SURGICAL ARTHROSCOPY SHO W/CORACOACRM LIGM RLS	Not listed in the file	Not listed in the file	$493 – $1,003
Shoulder arthroscopy: shaving of shoulder bone: rates for 7 insurance plans AETNA 2700 — AETNA 270002: $1,003 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $140.36 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $493 POMCO INS CO 5157 — POMCO INS CO 515701: $140.36 UNITED HEALTHCARE 5158 — UNITED HEALTHCARE 515803: $140.36 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Shoulder arthroscopy: shaving of shoulder bone CPT 29826 · Inpatient or outpatient In the file: PR SURGICAL ARTHROSCOPY SHO W/CORACOACRM LIGM RLS	$505	$301.13	Not listed in the file
Knee arthroscopy: removal of torn cartilage (meniscus) CPT 29881 · Outpatient (no overnight stay) In the file: KNEE ARTHROSCOPY/SURGERY	Not listed in the file	Not listed in the file	$256.22 – $1,332
Knee arthroscopy: removal of torn cartilage (meniscus): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $702.31 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $489.81 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $292.82 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $749.44 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $440.83 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,332 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $499.61 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $578.18 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $489.81 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $499.08
Knee arthroscopy: removal of torn cartilage (meniscus) CPT 29881 · Outpatient (no overnight stay) In the file: Arthrs kne srg mnisectmy m/l	Not listed in the file	Not listed in the file	$3,349.20 – $9,712.67
Knee arthroscopy: removal of torn cartilage (meniscus): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4,084.38 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4,411.14 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $6,567.68 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $7,068.85 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $7,068.85 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4,084.38 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4,084.38 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4,084.38 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3,349.20 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $9,406.34
Knee arthroscopy: removal of torn cartilage (meniscus) CPT 29881 · Outpatient (no overnight stay) In the file: PR ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG	Not listed in the file	Not listed in the file	$634 – $1,146
Knee arthroscopy: removal of torn cartilage (meniscus): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,146 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $634 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Removal of tonsils and adenoids (under age 12) CPT 42820 · Outpatient (no overnight stay) In the file: Remove tonsils and adenoids	Not listed in the file	Not listed in the file	$6,059.49 – $17,572.54
Removal of tonsils and adenoids (under age 12): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $7,389.63 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $7,980.80 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $11,882.53 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $12,789.23 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $12,789.23 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $7,389.63 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $7,389.63 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $7,389.63 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $6,059.49 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $17,018.31
Removal of tonsils and adenoids (under age 12) CPT 42820 · Outpatient (no overnight stay) In the file: REMOVE TONSILS AND ADENOIDS	Not listed in the file	Not listed in the file	$117.30 – $403.26
Removal of tonsils and adenoids (under age 12): 10 of 17 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $377.54 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA CHICKERING 270001,AETNA 270002,: $249.81 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $134.05 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $224.83 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $254.81 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $308.70 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $249.81 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICAID 1702, — HIGHMARK BC/BS OF WESTERN NY MEDICAID 170201, COMMUNITY CARE: $167.56 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICARE 1301 — HIGHMARK BC/BS MEDICARE 130101: $275.57 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601,NOVA HEALTHCARE ADMIN: $373.96
Removal of tonsils and adenoids (under age 12) CPT 42820 · Outpatient (no overnight stay) In the file: PR TONSILLECTOMY & ADENOIDECTOMY <AGE 12	Not listed in the file	Not listed in the file	$493 – $1,003
Removal of tonsils and adenoids (under age 12): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,003 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $493 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Upper GI endoscopy (diagnostic) CPT 43235 · Outpatient (no overnight stay) In the file: EGD DIAGNOSTIC BRUSH WASH	Not listed in the file	Not listed in the file	$67.20 – $800
Upper GI endoscopy (diagnostic): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $800 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $307.95 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $145.32 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $379.76 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $277.16 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $707.94 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $314.11 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $297.68 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $532.95 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $277.31
Upper GI endoscopy (diagnostic) CPT 43235 · Outpatient (no overnight stay) In the file: Egd diagnostic brush wash	Not listed in the file	Not listed in the file	$928.38 – $2,692.31
Upper GI endoscopy (diagnostic): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,132.18 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,222.75 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,820.55 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,959.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,959.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,132.18 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,132.18 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,132.18 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $928.38 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,607.40
Upper GI endoscopy (diagnostic) CPT 43235 · Outpatient (no overnight stay) In the file: PR ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC	Not listed in the file	Not listed in the file	$336 – $616
Upper GI endoscopy (diagnostic): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $616 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $336 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Upper GI endoscopy with biopsy CPT 43239 · Outpatient (no overnight stay) In the file: EGD BIOPSY SINGLE/MULTIPLE	Not listed in the file	Not listed in the file	$84 – $935
Upper GI endoscopy with biopsy: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $935 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $399.57 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $166.82 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $508.45 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $359.61 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $926.50 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $407.56 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $396.52 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $749.57 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $354.66
Upper GI endoscopy with biopsy CPT 43239 · Outpatient (no overnight stay) In the file: Egd biopsy single/multiple	Not listed in the file	Not listed in the file	$928.38 – $2,692.31
Upper GI endoscopy with biopsy: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,132.18 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,222.75 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,820.55 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,959.46 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,959.46 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,132.18 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,132.18 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,132.18 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $928.38 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,607.40
Upper GI endoscopy with biopsy CPT 43239 · Outpatient (no overnight stay) In the file: PR EGD TRANSORAL BIOPSY SINGLE/MULTIPLE	Not listed in the file	Not listed in the file	$448 – $839
Upper GI endoscopy with biopsy: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Colonoscopy (diagnostic) CPT 45378 · Outpatient (no overnight stay) In the file: DIAGNOSTIC COLONOSCOPY	Not listed in the file	Not listed in the file	$85.86 – $915
Colonoscopy (diagnostic): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $915 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $361.12 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $189.09 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $578.10 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $325.01 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $834.25 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $368.34 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $351.76 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $711.12 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $314.66
Colonoscopy (diagnostic) CPT 45378 · Outpatient (no overnight stay) In the file: Diagnostic colonoscopy	Not listed in the file	Not listed in the file	$951.90 – $2,760.50
Colonoscopy (diagnostic): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,160.85 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,253.72 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,866.65 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $2,009.08 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $2,009.08 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,160.85 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,160.85 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,160.85 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $951.90 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,673.44
Colonoscopy (diagnostic) CPT 45378 · Outpatient (no overnight stay) In the file: PR COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD	Not listed in the file	Not listed in the file	$448 – $839
Colonoscopy (diagnostic): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Colonoscopy with biopsy CPT 45380 · Outpatient (no overnight stay) In the file: COLONOSCOPY AND BIOPSY	Not listed in the file	Not listed in the file	$134.40 – $1,066.82
Colonoscopy with biopsy: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,020 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $458.30 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $225.86 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $747.22 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $412.47 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,066.82 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $467.47 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $453.05 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $808.30 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $405.33
Colonoscopy with biopsy CPT 45380 · Outpatient (no overnight stay) In the file: Colonoscopy and biopsy	Not listed in the file	Not listed in the file	$1,224.87 – $3,552.13
Colonoscopy with biopsy: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,493.75 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,613.25 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $2,401.95 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $2,585.23 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $2,585.23 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,493.75 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,493.75 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,493.75 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $1,224.87 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $3,440.10
Colonoscopy with biopsy CPT 45380 · Outpatient (no overnight stay) In the file: PR COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE	Not listed in the file	Not listed in the file	$448 – $839
Colonoscopy with biopsy: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Colonoscopy with removal of polyps (snare) CPT 45385 · Outpatient (no overnight stay) In the file: COLONOSCOPY W/LESION REMOVAL	Not listed in the file	Not listed in the file	$122.15 – $1,115.33
Colonoscopy with removal of polyps (snare): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,100 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $478.25 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $253.41 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $775.21 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $430.43 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,115.33 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $487.82 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $473.82 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $828.25 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $124.84
Colonoscopy with removal of polyps (snare) CPT 45385 · Outpatient (no overnight stay) In the file: Colonoscopy w/lesion removal	Not listed in the file	Not listed in the file	$1,224.87 – $3,552.13
Colonoscopy with removal of polyps (snare): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,493.75 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,613.25 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $2,401.95 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $2,585.23 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $2,585.23 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,493.75 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,493.75 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,493.75 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $1,224.87 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $3,440.10
Colonoscopy with removal of polyps (snare) CPT 45385 · Outpatient (no overnight stay) In the file: PR COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ	Not listed in the file	Not listed in the file	$448 – $839
Colonoscopy with removal of polyps (snare): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Ultrasound of the lower bowel by endoscope CPT 45391 · Outpatient (no overnight stay) In the file: Colonoscopy w/endoscope us	Not listed in the file	Not listed in the file	$1,224.87 – $3,552.13
Ultrasound of the lower bowel by endoscope: 10 of 21 insurance plan rates AETNA 2700 — AETNA 270002: $839 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,493.75 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,613.25 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $2,401.95 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $2,585.23 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $2,585.23 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,493.75 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,493.75 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,493.75
Screening colonoscopy (not high risk) HCPCS G0121 · Outpatient (no overnight stay) In the file: COLON CA SCRN NOT HI RSK IND	Not listed in the file	Not listed in the file	$132 – $915
Screening colonoscopy (not high risk): 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $915 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $361.36 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $244.69 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $348.52 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $325.22 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $834.88 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $368.59 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $299.21 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $711.36 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $281.56
Screening colonoscopy (not high risk) HCPCS G0121 · Outpatient (no overnight stay) In the file: Colon ca scrn not hi rsk ind	Not listed in the file	Not listed in the file	$951.90 – $2,760.50
Screening colonoscopy (not high risk): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,160.85 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,253.72 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,866.65 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $2,009.08 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $2,009.08 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,160.85 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,160.85 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,160.85 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $951.90 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,673.44
Screening colonoscopy (not high risk) HCPCS G0121 · Inpatient or outpatient In the file: PR COLON CA SCRN NOT HI RSK IND	$777	$463.33	Not listed in the file
Gallbladder removal by laparoscope CPT 47562 · Outpatient (no overnight stay) In the file: LAPAROSCOPIC CHOLECYSTECTOMY	Not listed in the file	Not listed in the file	$272.97 – $1,603.43
Gallbladder removal by laparoscope: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $842.08 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $595.37 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $317.07 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $768.51 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $535.83 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,603.43 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $607.28 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $705.64 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $595.37 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $620.98
Gallbladder removal by laparoscope CPT 47562 · Outpatient (no overnight stay) In the file: Laparoscopic cholecystectomy	Not listed in the file	Not listed in the file	$6,188.16 – $17,945.66
Gallbladder removal by laparoscope: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $7,546.54 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $8,150.26 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $12,134.84 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $13,060.79 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $13,060.79 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $7,546.54 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $7,546.54 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $7,546.54 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $6,188.16 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $17,379.67
Gallbladder removal by laparoscope CPT 47562 · Outpatient (no overnight stay) In the file: PR LAPAROSCOPY SURG CHOLECYSTECTOMY	Not listed in the file	Not listed in the file	$692 – $1,290
Gallbladder removal by laparoscope: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,290 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $692 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Groin (inguinal) hernia repair, age 5 or older CPT 49505 · Outpatient (no overnight stay) In the file: PRP I/HERN INIT REDUC >5 YR	Not listed in the file	Not listed in the file	$192.43 – $1,274.46
Groin (inguinal) hernia repair, age 5 or older: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $669.20 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $478.67 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $222.18 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $607.76 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $430.80 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,274.46 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $488.24 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $558.17 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $478.67 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $491.54
Groin (inguinal) hernia repair, age 5 or older CPT 49505 · Outpatient (no overnight stay) In the file: Prp i/hern init reduc >5 yr	Not listed in the file	Not listed in the file	$3,664.87 – $10,628.13
Groin (inguinal) hernia repair, age 5 or older: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4,469.36 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4,826.90 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $7,186.73 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $7,735.11 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $7,735.11 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4,469.36 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4,469.36 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4,469.36 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3,664.87 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $10,292.93
Groin (inguinal) hernia repair, age 5 or older CPT 49505 · Outpatient (no overnight stay) In the file: PR RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE	Not listed in the file	Not listed in the file	$634 – $1,146
Groin (inguinal) hernia repair, age 5 or older: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,146 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $634 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Prostate biopsy CPT 55700 · Outpatient (no overnight stay) In the file: BIOPSY OF PROSTATE	Not listed in the file	Not listed in the file	$56.66 – $591.02
Prostate biopsy: rates for 10 insurance plans BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $293.84 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $591.02 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $219.82 FIDELIS 5155 — FIDELIS METAL TIERS 515501: $311.04 FIDELIS MEDICAID 1708, FIDELIS 5155 — FIDELIS ESSENTIAL (W/ MEDICAID) 170804, FIDELIS ESSENTIAL (N: $241.92 FIDELIS MEDICAID 1708, FIDELIS 5155 — FIDELIS MEDICAID 170801, FIDELIS CHILD HEALTH PLUS 515502: $230.40 MOLINA MEDICAID 1723, MOLINA HEALTHCARE 5189 — MOLINA MEDICAID 172301, MOLINA ESSENTIAL (W/MEDICAID) 172302: $222.80 UMR 5142, POMCO INS CO 5157, UNITED HEALTHCARE 5158 — UMR 514201, POMCO INS CO 515701, UNITED HEALTH CARE STUDENT : $306.38 UNITED HEALTHCARE MEDICAID 1716, UNITED HEALTHCARE 5158 — UNITED HEALTHCARE MEDICAID 171601, UNITED HEALTHCARE ESSENTI: $95.54 UNITED HEALTHCARE MEDICARE 1309 — UNITED HEALTHCARE MEDICARE 130901, SECUREHORIZONS DIRECT 130: $207.36
Prostate biopsy CPT 55700 · Outpatient (no overnight stay) In the file: PR PROSTATE NEEDLE BIOPSY ANY APPROACH	Not listed in the file	Not listed in the file	$448 – $839
Prostate biopsy: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Prostate removal by laparoscope (radical prostatectomy) CPT 55866 · Outpatient (no overnight stay) In the file: Laps surg prst8ect rpbic rad	Not listed in the file	Not listed in the file	$10,880.62 – $31,553.80
Prostate removal by laparoscope (radical prostatectomy): 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $13,269.05 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $14,330.58 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $21,336.63 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $22,964.75 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $22,964.75 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $13,269.05 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $13,269.05 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $13,269.05 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $10,880.62 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $30,558.62
Prostate removal by laparoscope (radical prostatectomy) CPT 55866 · Outpatient (no overnight stay) In the file: LAPS SURG PRST8ECT RPBIC RAD	Not listed in the file	Not listed in the file	$733.05 – $2,045.77
Prostate removal by laparoscope (radical prostatectomy): 10 of 17 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,528.29 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA CHICKERING 270001,AETNA 270002,: $1,040.99 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $837.78 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $936.89 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,061.81 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $1,566.09 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $1,040.99 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICAID 1702, — HIGHMARK BC/BS OF WESTERN NY MEDICAID 170201, COMMUNITY CARE: $1,047.22 HIGHMARK BLUE CROSS BLUE SHIELD OF WESTERN NY MEDICARE 1301 — HIGHMARK BC/BS MEDICARE 130101: $1,115.54 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601,NOVA HEALTHCARE ADMIN: $1,557.97
Prostate removal by laparoscope (radical prostatectomy) CPT 55866 · Outpatient (no overnight stay) In the file: PR LAPS SURG PRST8ECT RPBIC RAD W/NRV SPARING ROBOT	Not listed in the file	Not listed in the file	$959 – $1,433
Prostate removal by laparoscope (radical prostatectomy): rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,433 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $959 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Hysteroscopy with biopsy of the uterus lining CPT 58558 · Outpatient (no overnight stay) In the file: HYSTEROSCOPY BIOPSY	Not listed in the file	Not listed in the file	$109.51 – $3,297.24
Hysteroscopy with biopsy of the uterus lining: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $1,572.08 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $1,207.26 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $144.64 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $1,495.51 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $1,086.53 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $3,297.24 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,231.41 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $1,473.05 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $1,207.26 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $1,272.74
Hysteroscopy with biopsy of the uterus lining CPT 58558 · Outpatient (no overnight stay) In the file: Hysteroscopy biopsy	Not listed in the file	Not listed in the file	$3,313.50 – $9,609.15
Hysteroscopy with biopsy of the uterus lining: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $4,040.85 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $4,364.12 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $6,497.69 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $6,993.50 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $6,993.50 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $4,040.85 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $4,040.85 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $4,040.85 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $3,313.50 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $9,306.08
Hysteroscopy with biopsy of the uterus lining CPT 58558 · Outpatient (no overnight stay) In the file: PR HYSTEROSCOPY BX ENDOMETRIUM&/POLYPC W/WO D&C	Not listed in the file	Not listed in the file	$493 – $1,003
Hysteroscopy with biopsy of the uterus lining: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,003 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $493 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Spinal injection, lower back (epidural), with imaging guidance CPT 62323 · Outpatient (no overnight stay) In the file: NJX INTERLAMINAR LMBR/SAC	Not listed in the file	Not listed in the file	$47.10 – $633.38
Spinal injection, lower back (epidural), with imaging guidance: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $108.24 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $261.10 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $123.34 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $347.85 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $234.99 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $633.38 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $266.32 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $272.36 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $461.10 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $237.88
Spinal injection, lower back (epidural), with imaging guidance CPT 62323 · Outpatient (no overnight stay) In the file: Njx interlaminar lmbr/sac	Not listed in the file	Not listed in the file	$722.53 – $2,095.35
Spinal injection, lower back (epidural), with imaging guidance: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $881.14 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $951.63 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,416.87 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,524.99 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,524.99 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $881.14 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $881.14 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $881.14 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $722.53 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,029.27
Spinal injection, lower back (epidural), with imaging guidance CPT 62323 · Outpatient (no overnight stay) In the file: PR NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN	Not listed in the file	Not listed in the file	$336 – $616
Spinal injection, lower back (epidural), with imaging guidance: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $616 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $336 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Nerve root injection, lower back, with imaging guidance CPT 64483 · Outpatient (no overnight stay) In the file: NJX AA&/STRD TFRM EPI L/S 1	Not listed in the file	Not listed in the file	$42.43 – $602.91
Nerve root injection, lower back, with imaging guidance: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $309.75 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $253.31 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $148.31 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $324.65 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $227.98 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $602.91 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $258.38 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $251.73 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $253.31 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $226.34
Nerve root injection, lower back, with imaging guidance CPT 64483 · Outpatient (no overnight stay) In the file: Njx aa&/strd tfrm epi l/s 1	Not listed in the file	Not listed in the file	$905.34 – $2,625.49
Nerve root injection, lower back, with imaging guidance: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $1,104.07 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $1,192.40 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,775.34 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,910.82 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,910.82 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $1,104.07 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $1,104.07 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $1,104.07 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $905.34 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $2,542.68
Nerve root injection, lower back, with imaging guidance CPT 64483 · Outpatient (no overnight stay) In the file: PR NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL	Not listed in the file	Not listed in the file	$336 – $616
Nerve root injection, lower back, with imaging guidance: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $616 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $336 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Carpal tunnel release CPT 64721 · Outpatient (no overnight stay) In the file: CARPAL TUNNEL SURGERY	Not listed in the file	Not listed in the file	$158.31 – $1,095.60
Carpal tunnel release: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $578.70 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $458.44 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $191.32 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $617.45 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $412.60 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $1,095.60 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $467.61 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $464.94 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $758.44 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $347.24
Carpal tunnel release CPT 64721 · Outpatient (no overnight stay) In the file: Carpal tunnel surgery	Not listed in the file	Not listed in the file	$1,998.80 – $5,796.51
Carpal tunnel release: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $2,437.55 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2,632.56 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $3,919.58 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $4,218.68 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $4,218.68 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $2,437.55 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $2,437.55 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $2,437.55 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $1,998.80 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $5,613.69
Carpal tunnel release CPT 64721 · Outpatient (no overnight stay) In the file: PR NEUROPLASTY &/TRANSPOS MEDIAN NRV CARPAL TUNNE	Not listed in the file	Not listed in the file	$448 – $839
Carpal tunnel release: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $839 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Laser treatment of clouding after cataract surgery CPT 66821 · Outpatient (no overnight stay) In the file: After cataract laser surgery	Not listed in the file	Not listed in the file	$562.97 – $1,632.62
Laser treatment of clouding after cataract surgery: 10 of 21 insurance plan rates AETNA 2700 — AETNA 270002: $839 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $686.55 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $741.48 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $1,103.97 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $1,188.22 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $1,188.22 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $686.55 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $686.55 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $448 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $686.55
Cataract removal with lens implant CPT 66984 · Outpatient (no overnight stay) In the file: Xcapsl ctrc rmvl w/o ecp	Not listed in the file	Not listed in the file	$2,362.27 – $6,850.59
Cataract removal with lens implant: 10 of 17 insurance plan rates AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $2,880.82 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $3,111.28 EMPIRE PLAN 5179 — EMPIRE PLAN 517901: $4,632.36 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS 220101, EXCELLUS SIMPLY BLUE 220106, EXCELLUS BLUE : $4,985.83 EXCELLUS BLUE CROSS BLUE SHIELD 2201, OUT AREA BLUE CROSS BL — EXCELLUS METAL TIERS 220102: $4,985.83 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $2,880.82 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $2,880.82 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $2,880.82 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $2,362.27 MVP 2900 — MVP HEALTH CARE 290001, MVP PREMIER GROUP 290003: $6,634.53
Cataract removal with lens implant CPT 66984 · Outpatient (no overnight stay) In the file: PR XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP	Not listed in the file	Not listed in the file	$1,012 – $1,578
Cataract removal with lens implant: rates for 4 insurance plans AETNA 2700 — AETNA 270002: $1,578 INDEPENDENT HEALTH 5156 — INDEPENDENT HEALTH (BUFFALO NY) 515601: $1,012 HIGHMARK BLUE CROSS BLUE SHIELD 5143 — HIGHMARK BCBS 514301: 85% (a percentage in the contract, not a dollar amount) HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: 85% (a percentage in the contract, not a dollar amount)
Cataract removal with lens implant CPT 66984 · Inpatient or outpatient In the file: PR XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP	$5,402	$3,221.21	Not listed in the file

Pregnancy and childbirth

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Vaginal delivery, with care before and after CPT 59400 · Outpatient (no overnight stay) In the file: OBSTETRICAL CARE	Not listed in the file	Not listed in the file	$773.59 – $5,817.45
Vaginal delivery, with care before and after: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $3,049.30 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $2,078.59 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $1,420.74 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $2,390.18 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $1,870.73 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $5,817.45 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2,120.16 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $2,258.64 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $2,078.59 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $2,238.52
Cesarean delivery (C-section), with care before and after CPT 59510 · Outpatient (no overnight stay) In the file: CESAREAN DELIVERY	Not listed in the file	Not listed in the file	$876.78 – $6,416.42
Cesarean delivery (C-section), with care before and after: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $3,376.30 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $2,310.97 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $1,420.74 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $2,390.18 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $2,079.87 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $6,416.42 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2,357.19 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $2,497.02 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $1,964.32 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $2,486.34
Vaginal delivery after a previous C-section, with care before and after CPT 59610 · Outpatient (no overnight stay) In the file: VBAC DELIVERY	Not listed in the file	Not listed in the file	$817.26 – $6,073
Vaginal delivery after a previous C-section, with care before and after: 10 of 27 insurance plan rates AETNA 2700 — AETNA CHICKERING 270001,AETNA 270002,AETNA UR 270003,AETNA M: $3,182.52 AETNA MEDICARE 1300, AETNA 2700 — AETNA MEDICARE 130001, AETNA SENIOR SUPPLEMENTAL 270006: $2,176.20 AMERIGROUP (BLUE CROSS BLUE SHIELD WNY ALTERNATE) 1720 — AMERIGROUP (BSWNY ALTERNATE) 172001: $1,420.74 BLUE CROSS BLUE SHIELD OF WESTERN NY 5143, OUT OF AREA BLUE — BC/BS OF WESTERN NY 514301, COMMUNITY BLUE (BUFFALO NY) 5143: $2,390.18 CAPITAL DISTRICT PHYSICIANS (CDPHP) MEDICAID 1704 — CAPITAL DISTRICT PHYSICIANS MEDICAID 170401: $1,958.58 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) 5149 — CAPITAL DISTRICT PHYSICIANS (CDPHP) 514901: $6,073 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $2,219.72 EMPIRE PLAN 5179, EMPIRE PLAN UHC 5180 — EMPIRE PLAN 517901, EMPIRE PLAN UHC 518001: $2,367.76 EXCELLUS BLUE CROSS BLUE SHIELD 2201 — EXCELLUS METAL TIERS 220102, UNIVERA METAL TIERS INDIVIDUAL : $2,176.20 EXCELLUS MEDICAID 1706, EXCELLUS BLUE CROSS BLUE SHIELD 2201 — BLUE CHOICE OPTION MEDICAID 170601, EXCELLUS ESSENTIAL (W/ M: $2,356.27

Hospital stays (whole stay, MS-DRG)

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Heart valve or major heart-chest surgery with heart catheterization, with major complications MS-DRG 216 · Inpatient (hospital stay) In the file: CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC	Not listed in the file	$102,870.86	$52,386.89 – $137,614.65
Heart valve or major heart-chest surgery with heart catheterization, with major complications: 10 of 12 insurance plan rates AETNA 2700 — AETNA 270002: $52,386.89 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $102,870.86 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $102,870.86 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $102,870.86 HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: $102,870.86 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $102,870.86 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $102,870.86 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $84,354.11 MVP MEDICARE 1307 — MVP MEDICARE 130701: $102,870.86 UNITED HEALTHCARE 5158 — UNITED HEALTHCARE 515803: $137,614.65
Hip or knee replacement (major joint of the leg), without major complications MS-DRG 470 · Inpatient (hospital stay) In the file: MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC	Not listed in the file	$20,812.37	$10,329.26 – $27,133.84
Hip or knee replacement (major joint of the leg), without major complications: 10 of 12 insurance plan rates AETNA 2700 — AETNA 270002: $10,329.26 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $20,812.37 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $20,812.37 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $20,812.37 HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: $20,812.37 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $20,812.37 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $20,812.37 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $17,066.14 MVP MEDICARE 1307 — MVP MEDICARE 130701: $20,812.37 UNITED HEALTHCARE 5158 — UNITED HEALTHCARE 515803: $27,133.84
Neck (cervical) spinal fusion, without complications MS-DRG 473 · Inpatient (hospital stay) In the file: CERVICAL SPINAL FUSION WITHOUT CC/MCC	Not listed in the file	$26,165.99	$13,073.16 – $34,341.77
Neck (cervical) spinal fusion, without complications: 10 of 12 insurance plan rates AETNA 2700 — AETNA 270002: $13,073.16 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $26,165.99 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $26,165.99 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $26,165.99 HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: $26,165.99 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $26,165.99 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $26,165.99 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $21,456.11 MVP MEDICARE 1307 — MVP MEDICARE 130701: $26,165.99 UNITED HEALTHCARE 5158 — UNITED HEALTHCARE 515803: $34,341.77
Uterus and ovary surgery (not for cancer), without complications MS-DRG 743 · Inpatient (hospital stay) In the file: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC	Not listed in the file	$13,621.97	$6,643.95 – $17,452.93
Uterus and ovary surgery (not for cancer), without complications: 10 of 12 insurance plan rates AETNA 2700 — AETNA 270002: $6,643.95 AETNA MEDICARE 1300 — AETNA MEDICARE 130001: $13,621.97 CDPHP MEDICARE 1320 — CDPHP MEDICARE 132001: $13,621.97 FIDELIS MEDICARE 1311 — FIDELIS MEDICARE 131101: $13,621.97 HIGHMARK BLUE CROSS BLUE SHIELD MEDICARE 1301 — HIGHMARK BCBS MEDICARE 130101: $13,621.97 HUMANA MEDICARE 1312 — HUMANA MEDICARE 131201: $13,621.97 INDEPENDENT HEALTH MEDICARE 1305 — INDEPENDENT HEALTH MEDICARE 130501: $13,621.97 MEDICARE BLUE CHOICE 1306 — MEDICARE BLUE CHOICE 130601: $11,170.02 MVP MEDICARE 1307 — MVP MEDICARE 130701: $13,621.97 UNITED HEALTHCARE 5158 — UNITED HEALTHCARE 515803: $17,452.93

Source: Nicholas H Noyes Memorial Hospital’s standard charges file (urmc.rochester.edu, CSV, CMS template 3.0.0; it can be a very large file), last updated by the hospital on January 1, 2026; retrieved November 1, 2026. The hospital’s price transparency page →

Found through the hospital’s cms-hpt.txt file, as required by the federal hospital price transparency rule (CMS). We show a selection of common services; the file has every item and service.

Hospital information

Hospital type	Acute Care Hospital
Address	111 Clara Barton Street, Dansville, NY 14437
County	Livingston County
State	New York
Phone	(585) 335‑6001
Emergency services	Yes
Ownership	Voluntary non-profit - Private
Medicare overall rating	3 of 5 stars
Birthing-friendly designation	Yes (meets CMS criteria)
CMS Certification Number	330238
Name in Medicare records	NICHOLAS H NOYES MEMORIAL HOSPITAL
Profile level	Medicare data + hospital website
Official website	urmc.rochester.edu
Corrections	Report an error or suggest an update →

Sources

Hospital General Information — Centers for Medicare & Medicaid Services (CMS), data updated 2026-07-22, retrieved 2026-10-29
Medicare Care Compare — official Medicare profile of this hospital
U.S. Census Bureau ZIP code areas (Gazetteer) — approximate position (center of the ZIP code area) used for distances

From the hospital’s website

Numbers match the citations above. Checked 2026-10-30.

Welcome - UR Medicine Noyes Health — urmc.rochester.edu
Noyes Memorial Hospital Emergency Room — urmc.rochester.edu
Medical and Radiation Oncology - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Language Services & Auxiliary Aids & Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Quality and Patient Safety - About Noyes - Noyes Health - URochester Medicine — urmc.rochester.edu
Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Mary Saunders Beirmann Emergency Department - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
UR Medicine Imaging at Noyes Health - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Positron Emission Tomography CT (PET/CT) - Diagnostic Imaging - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Interventional Radiology (IR) - Diagnostic Imaging - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Surgery - Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu
Healthcare Services - Noyes Health - URochester Medicine — urmc.rochester.edu