|
MRI LUMBAR SPINE W/DYE
|
Facility
|
IP
|
$2,951.00
|
|
|
Service Code
|
HCPCS 72149
|
| Hospital Charge Code |
4230032
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,918.15 |
| Max. Negotiated Rate |
$1,918.15 |
| Rate for Payer: Cash Price |
$2,213.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,918.15
|
|
|
MRI LUMBAR SPINE W/DYE
|
Facility
|
OP
|
$2,951.00
|
|
|
Service Code
|
HCPCS 72149
|
| Hospital Charge Code |
4230032
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$2,375.56 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,357.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,213.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,213.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,091.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,213.25
|
| Rate for Payer: Cash Price |
$2,213.25
|
| Rate for Payer: Cash Price |
$2,213.25
|
| Rate for Payer: CDPHP Commercial |
$2,375.56
|
| Rate for Payer: CDPHP Medicare |
$1,091.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,065.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$2,360.80
|
| Rate for Payer: EmblemHealth Medicare |
$1,003.34
|
| Rate for Payer: EmblemHealth Select Care |
$1,918.15
|
| Rate for Payer: Fidelis Medicare |
$1,124.63
|
| Rate for Payer: Galaxy Health Commercial |
$1,918.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,091.87
|
| Rate for Payer: Humana Medicare |
$1,091.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,357.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,146.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,091.87
|
| Rate for Payer: WellCare Medicare |
$1,623.05
|
|
|
MRI LUMBAR SPINE W/O DYE
|
Facility
|
IP
|
$2,381.00
|
|
|
Service Code
|
HCPCS 72148 TC
|
| Hospital Charge Code |
4230014
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,547.65 |
| Max. Negotiated Rate |
$1,547.65 |
| Rate for Payer: Cash Price |
$1,785.75
|
| Rate for Payer: Galaxy Health Commercial |
$1,547.65
|
|
|
MRI LUMBAR SPINE W/O DYE
|
Facility
|
OP
|
$2,381.00
|
|
|
Service Code
|
HCPCS 72148 TC
|
| Hospital Charge Code |
4230014
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$794.00 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,095.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,785.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,785.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$880.97
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$1,785.75
|
| Rate for Payer: Cash Price |
$1,785.75
|
| Rate for Payer: Cash Price |
$1,785.75
|
| Rate for Payer: CDPHP Commercial |
$1,916.70
|
| Rate for Payer: CDPHP Medicare |
$880.97
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,666.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,904.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,904.80
|
| Rate for Payer: EmblemHealth Medicaid |
$1,904.80
|
| Rate for Payer: EmblemHealth Medicare |
$809.54
|
| Rate for Payer: EmblemHealth Select Care |
$1,547.65
|
| Rate for Payer: Fidelis Medicare |
$907.40
|
| Rate for Payer: Galaxy Health Commercial |
$1,547.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$880.97
|
| Rate for Payer: Humana Medicare |
$880.97
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,095.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$925.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$880.97
|
| Rate for Payer: WellCare Medicare |
$1,309.55
|
|
|
MRI LUMBAR SPINE W/O & W/DYE
|
Facility
|
IP
|
$3,882.00
|
|
|
Service Code
|
HCPCS 72158
|
| Hospital Charge Code |
4230015
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,523.30 |
| Max. Negotiated Rate |
$2,523.30 |
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Galaxy Health Commercial |
$2,523.30
|
|
|
MRI LUMBAR SPINE W/O & W/DYE
|
Facility
|
OP
|
$3,882.00
|
|
|
Service Code
|
HCPCS 72158
|
| Hospital Charge Code |
4230015
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,125.01 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,785.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,911.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,911.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,436.34
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: CDPHP Commercial |
$3,125.01
|
| Rate for Payer: CDPHP Medicare |
$1,436.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,717.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,105.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,105.60
|
| Rate for Payer: EmblemHealth Medicaid |
$3,105.60
|
| Rate for Payer: EmblemHealth Medicare |
$1,319.88
|
| Rate for Payer: EmblemHealth Select Care |
$2,523.30
|
| Rate for Payer: Fidelis Medicare |
$1,479.43
|
| Rate for Payer: Galaxy Health Commercial |
$2,523.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,436.34
|
| Rate for Payer: Humana Medicare |
$1,436.34
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,785.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,508.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,436.34
|
| Rate for Payer: WellCare Medicare |
$2,135.10
|
|
|
MRI OF TMJ(S)
|
Facility
|
IP
|
$2,847.00
|
|
|
Service Code
|
HCPCS 70336
|
| Hospital Charge Code |
4230040
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,850.55 |
| Max. Negotiated Rate |
$1,850.55 |
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
|
|
MRI OF TMJ(S)
|
Facility
|
OP
|
$2,847.00
|
|
|
Service Code
|
HCPCS 70336
|
| Hospital Charge Code |
4230040
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$2,291.84 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,309.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,135.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,053.39
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: Cash Price |
$2,135.25
|
| Rate for Payer: CDPHP Commercial |
$2,291.84
|
| Rate for Payer: CDPHP Medicare |
$1,053.39
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,992.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,277.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicaid |
$2,277.60
|
| Rate for Payer: EmblemHealth Medicare |
$967.98
|
| Rate for Payer: EmblemHealth Select Care |
$1,850.55
|
| Rate for Payer: Fidelis Medicare |
$1,084.99
|
| Rate for Payer: Galaxy Health Commercial |
$1,850.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,053.39
|
| Rate for Payer: Humana Medicare |
$1,053.39
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,309.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,106.06
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,053.39
|
| Rate for Payer: WellCare Medicare |
$1,565.85
|
|
|
MRI ORBIT/FACE/NECK W/DYE
|
Facility
|
IP
|
$3,779.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
4230042
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,456.35 |
| Max. Negotiated Rate |
$2,456.35 |
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Galaxy Health Commercial |
$2,456.35
|
|
|
MRI ORBIT/FACE/NECK W/DYE
|
Facility
|
OP
|
$3,779.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
4230042
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,042.10 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,738.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,834.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,834.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,398.23
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: CDPHP Commercial |
$3,042.10
|
| Rate for Payer: CDPHP Medicare |
$1,398.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,645.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,023.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,023.20
|
| Rate for Payer: EmblemHealth Medicaid |
$3,023.20
|
| Rate for Payer: EmblemHealth Medicare |
$1,284.86
|
| Rate for Payer: EmblemHealth Select Care |
$2,456.35
|
| Rate for Payer: Fidelis Medicare |
$1,440.18
|
| Rate for Payer: Galaxy Health Commercial |
$2,456.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,398.23
|
| Rate for Payer: Humana Medicare |
$1,398.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,738.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,468.14
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,398.23
|
| Rate for Payer: WellCare Medicare |
$2,078.45
|
|
|
MRI ORBIT/FACE/NECK W/O DYE
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
4230041
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,190.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,941.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,941.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$957.56
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$1,941.00
|
| Rate for Payer: Cash Price |
$1,941.00
|
| Rate for Payer: Cash Price |
$1,941.00
|
| Rate for Payer: CDPHP Commercial |
$2,083.34
|
| Rate for Payer: CDPHP Medicare |
$957.56
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,811.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,070.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,070.40
|
| Rate for Payer: EmblemHealth Medicaid |
$2,070.40
|
| Rate for Payer: EmblemHealth Medicare |
$879.92
|
| Rate for Payer: EmblemHealth Select Care |
$1,682.20
|
| Rate for Payer: Fidelis Medicare |
$986.29
|
| Rate for Payer: Galaxy Health Commercial |
$1,682.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$957.56
|
| Rate for Payer: Humana Medicare |
$957.56
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,190.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,005.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$957.56
|
| Rate for Payer: WellCare Medicare |
$1,423.40
|
|
|
MRI ORBIT/FACE/NECK W/O DYE
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
4230041
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,682.20 |
| Max. Negotiated Rate |
$1,682.20 |
| Rate for Payer: Cash Price |
$1,941.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,682.20
|
|
|
MRI ORBT/FAC/NCK W/O &W/DYE
|
Facility
|
IP
|
$3,903.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
4230043
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,536.95 |
| Max. Negotiated Rate |
$2,536.95 |
| Rate for Payer: Cash Price |
$2,927.25
|
| Rate for Payer: Galaxy Health Commercial |
$2,536.95
|
|
|
MRI ORBT/FAC/NCK W/O &W/DYE
|
Facility
|
OP
|
$3,903.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
4230043
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,141.92 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,795.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,927.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,927.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,444.11
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,927.25
|
| Rate for Payer: Cash Price |
$2,927.25
|
| Rate for Payer: Cash Price |
$2,927.25
|
| Rate for Payer: CDPHP Commercial |
$3,141.92
|
| Rate for Payer: CDPHP Medicare |
$1,444.11
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,732.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,122.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,122.40
|
| Rate for Payer: EmblemHealth Medicaid |
$3,122.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,327.02
|
| Rate for Payer: EmblemHealth Select Care |
$2,536.95
|
| Rate for Payer: Fidelis Medicare |
$1,487.43
|
| Rate for Payer: Galaxy Health Commercial |
$2,536.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,444.11
|
| Rate for Payer: Humana Medicare |
$1,444.11
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,795.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,516.32
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,444.11
|
| Rate for Payer: WellCare Medicare |
$2,146.65
|
|
|
MRI PELVIS W/DYE
|
Facility
|
OP
|
$3,779.00
|
|
|
Service Code
|
HCPCS 72196
|
| Hospital Charge Code |
4230006
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,042.10 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,738.34
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,834.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,834.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,398.23
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: CDPHP Commercial |
$3,042.10
|
| Rate for Payer: CDPHP Medicare |
$1,398.23
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,645.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,023.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,023.20
|
| Rate for Payer: EmblemHealth Medicaid |
$3,023.20
|
| Rate for Payer: EmblemHealth Medicare |
$1,284.86
|
| Rate for Payer: EmblemHealth Select Care |
$2,456.35
|
| Rate for Payer: Fidelis Medicare |
$1,440.18
|
| Rate for Payer: Galaxy Health Commercial |
$2,456.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,398.23
|
| Rate for Payer: Humana Medicare |
$1,398.23
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,738.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,468.14
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,398.23
|
| Rate for Payer: WellCare Medicare |
$2,078.45
|
|
|
MRI PELVIS W/DYE
|
Facility
|
IP
|
$3,779.00
|
|
|
Service Code
|
HCPCS 72196
|
| Hospital Charge Code |
4230006
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,456.35 |
| Max. Negotiated Rate |
$2,456.35 |
| Rate for Payer: Cash Price |
$2,834.25
|
| Rate for Payer: Galaxy Health Commercial |
$2,456.35
|
|
|
MRI PELVIS W/O DYE
|
Facility
|
IP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 72195
|
| Hospital Charge Code |
4230005
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,480.70 |
| Max. Negotiated Rate |
$1,480.70 |
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
|
|
MRI PELVIS W/O DYE
|
Facility
|
OP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 72195
|
| Hospital Charge Code |
4230005
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,047.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,708.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,708.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$842.86
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: CDPHP Commercial |
$1,833.79
|
| Rate for Payer: CDPHP Medicare |
$842.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,594.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,822.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,822.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,822.40
|
| Rate for Payer: EmblemHealth Medicare |
$774.52
|
| Rate for Payer: EmblemHealth Select Care |
$1,480.70
|
| Rate for Payer: Fidelis Medicare |
$868.15
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$842.86
|
| Rate for Payer: Humana Medicare |
$842.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,047.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$885.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$842.86
|
| Rate for Payer: WellCare Medicare |
$1,252.90
|
|
|
MRI PELVIS W/O & W/DYE
|
Facility
|
OP
|
$3,882.00
|
|
|
Service Code
|
HCPCS 72197
|
| Hospital Charge Code |
4230007
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,125.01 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,785.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,911.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,911.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,436.34
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: CDPHP Commercial |
$3,125.01
|
| Rate for Payer: CDPHP Medicare |
$1,436.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,717.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,105.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,105.60
|
| Rate for Payer: EmblemHealth Medicaid |
$3,105.60
|
| Rate for Payer: EmblemHealth Medicare |
$1,319.88
|
| Rate for Payer: EmblemHealth Select Care |
$2,523.30
|
| Rate for Payer: Fidelis Medicare |
$1,479.43
|
| Rate for Payer: Galaxy Health Commercial |
$2,523.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,436.34
|
| Rate for Payer: Humana Medicare |
$1,436.34
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,785.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,508.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,436.34
|
| Rate for Payer: WellCare Medicare |
$2,135.10
|
|
|
MRI PELVIS W/O & W/DYE
|
Facility
|
IP
|
$3,882.00
|
|
|
Service Code
|
HCPCS 72197
|
| Hospital Charge Code |
4230007
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,523.30 |
| Max. Negotiated Rate |
$2,523.30 |
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Galaxy Health Commercial |
$2,523.30
|
|
|
MRI THORACIC SPINE W/DYE
|
Facility
|
IP
|
$4,348.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
4230031
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,826.20 |
| Max. Negotiated Rate |
$2,826.20 |
| Rate for Payer: Cash Price |
$3,261.00
|
| Rate for Payer: Galaxy Health Commercial |
$2,826.20
|
|
|
MRI THORACIC SPINE W/DYE
|
Facility
|
OP
|
$4,348.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
4230031
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$3,500.14 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,000.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$3,261.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3,261.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,608.76
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$3,261.00
|
| Rate for Payer: Cash Price |
$3,261.00
|
| Rate for Payer: Cash Price |
$3,261.00
|
| Rate for Payer: CDPHP Commercial |
$3,500.14
|
| Rate for Payer: CDPHP Medicare |
$1,608.76
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$3,043.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,478.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,478.40
|
| Rate for Payer: EmblemHealth Medicaid |
$3,478.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,478.32
|
| Rate for Payer: EmblemHealth Select Care |
$2,826.20
|
| Rate for Payer: Fidelis Medicare |
$1,657.02
|
| Rate for Payer: Galaxy Health Commercial |
$2,826.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,608.76
|
| Rate for Payer: Humana Medicare |
$1,608.76
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,000.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,689.20
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$1,608.76
|
| Rate for Payer: WellCare Medicare |
$2,391.40
|
|
|
MRI THORACIC SPINE W/O DYE
|
Facility
|
IP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
4230012
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,480.70 |
| Max. Negotiated Rate |
$1,480.70 |
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
|
|
MRI THORACIC SPINE W/O DYE
|
Facility
|
OP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
4230012
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$505.00 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,738.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,047.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,708.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,708.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$842.86
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$794.00
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: Cash Price |
$1,708.50
|
| Rate for Payer: CDPHP Commercial |
$1,833.79
|
| Rate for Payer: CDPHP Medicare |
$842.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,594.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,822.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,822.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,822.40
|
| Rate for Payer: EmblemHealth Medicare |
$774.52
|
| Rate for Payer: EmblemHealth Select Care |
$1,480.70
|
| Rate for Payer: Fidelis Medicare |
$868.15
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$842.86
|
| Rate for Payer: Humana Medicare |
$842.86
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,738.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,047.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$918.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$885.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,260.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$505.00
|
| Rate for Payer: United Healthcare Commercial |
$2,260.00
|
| Rate for Payer: United Healthcare Medicare |
$842.86
|
| Rate for Payer: WellCare Medicare |
$1,252.90
|
|
|
MRI THORACIC SPINE W/O & W/DYE
|
Facility
|
IP
|
$3,986.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
4230013
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,590.90 |
| Max. Negotiated Rate |
$2,590.90 |
| Rate for Payer: Cash Price |
$2,989.50
|
| Rate for Payer: Galaxy Health Commercial |
$2,590.90
|
|
