Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

MRI LUMBAR SPINE W/O DYE

Facility

$217.00

Service Code	HCPCS 72148 26
Hospital Charge Code	5230014
Hospital Revenue Code	960
Min. Negotiated Rate	$32.55
Max. Negotiated Rate	$173.60
Rate for Payer: Aetna of NY Commercial	$151.90
Rate for Payer: Aetna of NY Medicare	$99.82
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$86.80
Rate for Payer: Cash Price	$162.75
Rate for Payer: CDPHP Medicare	$80.29
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$173.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$173.60
Rate for Payer: EmblemHealth Medicaid	$173.60
Rate for Payer: EmblemHealth Medicare	$73.78
Rate for Payer: Fidelis Medicare	$86.80
Rate for Payer: Galaxy Health Commercial	$141.05
Rate for Payer: Hamaspik Choice Medicare	$86.80
Rate for Payer: Humana Medicare	$86.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$151.90
Rate for Payer: Local 1199SEIU Medicare	$99.82
Rate for Payer: MVP Health Care of NY Commercial	$162.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$122.17
Rate for Payer: MVP Health Care of NY Medicare	$91.14
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$32.55
Rate for Payer: United Healthcare Medicare	$86.80
Rate for Payer: WellCare Medicare	$119.35

MRI LUMBAR SPINE W/O & W/ DYE

Facility

$338.00

Service Code	HCPCS 72158 26
Hospital Charge Code	5230015
Hospital Revenue Code	960
Min. Negotiated Rate	$50.70
Max. Negotiated Rate	$270.40
Rate for Payer: Aetna of NY Commercial	$236.60
Rate for Payer: Aetna of NY Medicare	$155.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$135.20
Rate for Payer: Cash Price	$253.50
Rate for Payer: CDPHP Medicare	$125.06
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$270.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$270.40
Rate for Payer: EmblemHealth Medicaid	$270.40
Rate for Payer: EmblemHealth Medicare	$114.92
Rate for Payer: Fidelis Medicare	$135.20
Rate for Payer: Galaxy Health Commercial	$219.70
Rate for Payer: Hamaspik Choice Medicare	$135.20
Rate for Payer: Humana Medicare	$135.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$236.60
Rate for Payer: Local 1199SEIU Medicare	$155.48
Rate for Payer: MVP Health Care of NY Commercial	$253.50
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$190.29
Rate for Payer: MVP Health Care of NY Medicare	$141.96
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$50.70
Rate for Payer: United Healthcare Medicare	$135.20
Rate for Payer: WellCare Medicare	$185.90

MRI LUMBAR SPINE W/O & W/ DYE

Facility

$338.00

Service Code	HCPCS 72158 26
Hospital Charge Code	5230015
Hospital Revenue Code	960
Min. Negotiated Rate	$219.70
Max. Negotiated Rate	$219.70
Rate for Payer: Cash Price	$253.50
Rate for Payer: Galaxy Health Commercial	$219.70

MRI LUMBAR SPINE W/O & W/DYE

Facility

$3,882.00

Service Code	HCPCS 72158
Hospital Charge Code	4230015
Hospital Revenue Code	612
Min. Negotiated Rate	$582.30
Max. Negotiated Rate	$3,105.60
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,785.72
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,552.80
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 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	$1,552.80
Rate for Payer: Galaxy Health Commercial	$2,523.30
Rate for Payer: Hamaspik Choice Medicare	$1,552.80
Rate for Payer: Humana Medicare	$1,552.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,785.72
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,630.44
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$582.30
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,552.80
Rate for Payer: WellCare Medicare	$2,135.10

MRI LUMBAR SPINE W/O & W/DYE

Facility

$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 OF TMJ(S)

Facility

$215.00

Service Code	HCPCS 70336 26
Hospital Charge Code	5230040
Hospital Revenue Code	960
Min. Negotiated Rate	$32.25
Max. Negotiated Rate	$172.00
Rate for Payer: Aetna of NY Commercial	$150.50
Rate for Payer: Aetna of NY Medicare	$98.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$86.00
Rate for Payer: Cash Price	$161.25
Rate for Payer: CDPHP Medicare	$79.55
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$172.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$172.00
Rate for Payer: EmblemHealth Medicaid	$172.00
Rate for Payer: EmblemHealth Medicare	$73.10
Rate for Payer: Fidelis Medicare	$86.00
Rate for Payer: Galaxy Health Commercial	$139.75
Rate for Payer: Hamaspik Choice Medicare	$86.00
Rate for Payer: Humana Medicare	$86.00
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$150.50
Rate for Payer: Local 1199SEIU Medicare	$98.90
Rate for Payer: MVP Health Care of NY Commercial	$161.25
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$121.05
Rate for Payer: MVP Health Care of NY Medicare	$90.30
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$32.25
Rate for Payer: United Healthcare Medicare	$86.00
Rate for Payer: WellCare Medicare	$118.25

MRI OF TMJ(S)

Facility

$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

$215.00

Service Code	HCPCS 70336 26
Hospital Charge Code	5230040
Hospital Revenue Code	960
Min. Negotiated Rate	$139.75
Max. Negotiated Rate	$139.75
Rate for Payer: Cash Price	$161.25
Rate for Payer: Galaxy Health Commercial	$139.75

MRI OF TMJ(S)

Facility

$2,847.00

Service Code	HCPCS 70336
Hospital Charge Code	4230040
Hospital Revenue Code	610
Min. Negotiated Rate	$427.05
Max. Negotiated Rate	$2,328.00
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,309.62
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,138.80
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 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	$1,138.80
Rate for Payer: Galaxy Health Commercial	$1,850.55
Rate for Payer: Hamaspik Choice Medicare	$1,138.80
Rate for Payer: Humana Medicare	$1,138.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,309.62
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,195.74
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$427.05
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,138.80
Rate for Payer: WellCare Medicare	$1,565.85

MRI ORBIT/FACE/NECK W/ DYE

Facility

$237.00

Service Code	HCPCS 70542 26
Hospital Charge Code	5230042
Hospital Revenue Code	960
Min. Negotiated Rate	$154.05
Max. Negotiated Rate	$154.05
Rate for Payer: Cash Price	$177.75
Rate for Payer: Galaxy Health Commercial	$154.05

MRI ORBIT/FACE/NECK W/ DYE

Facility

$237.00

Service Code	HCPCS 70542 26
Hospital Charge Code	5230042
Hospital Revenue Code	960
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$189.60
Rate for Payer: Aetna of NY Commercial	$165.90
Rate for Payer: Aetna of NY Medicare	$109.02
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$94.80
Rate for Payer: Cash Price	$177.75
Rate for Payer: CDPHP Medicare	$87.69
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$189.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$189.60
Rate for Payer: EmblemHealth Medicaid	$189.60
Rate for Payer: EmblemHealth Medicare	$80.58
Rate for Payer: Fidelis Medicare	$94.80
Rate for Payer: Galaxy Health Commercial	$154.05
Rate for Payer: Hamaspik Choice Medicare	$94.80
Rate for Payer: Humana Medicare	$94.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$165.90
Rate for Payer: Local 1199SEIU Medicare	$109.02
Rate for Payer: MVP Health Care of NY Commercial	$177.75
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$133.43
Rate for Payer: MVP Health Care of NY Medicare	$99.54
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$35.55
Rate for Payer: United Healthcare Medicare	$94.80
Rate for Payer: WellCare Medicare	$130.35

MRI ORBIT/FACE/NECK W/DYE

Facility

$3,779.00

Service Code	HCPCS 70542
Hospital Charge Code	4230042
Hospital Revenue Code	610
Min. Negotiated Rate	$566.85
Max. Negotiated Rate	$3,023.20
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,738.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,511.60
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 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	$1,511.60
Rate for Payer: Galaxy Health Commercial	$2,456.35
Rate for Payer: Hamaspik Choice Medicare	$1,511.60
Rate for Payer: Humana Medicare	$1,511.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,738.34
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,587.18
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$566.85
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,511.60
Rate for Payer: WellCare Medicare	$2,078.45

MRI ORBIT/FACE/NECK W/DYE

Facility

$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/O DYE

Facility

$2,588.00

Service Code	HCPCS 70540
Hospital Charge Code	4230041
Hospital Revenue Code	610
Min. Negotiated Rate	$388.20
Max. Negotiated Rate	$2,328.00
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,190.48
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,035.20
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 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	$1,035.20
Rate for Payer: Galaxy Health Commercial	$1,682.20
Rate for Payer: Hamaspik Choice Medicare	$1,035.20
Rate for Payer: Humana Medicare	$1,035.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,190.48
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,086.96
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$388.20
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,035.20
Rate for Payer: WellCare Medicare	$1,423.40

MRI ORBIT/FACE/NECK W/O DYE

Facility

$196.00

Service Code	HCPCS 70540 26
Hospital Charge Code	5230041
Hospital Revenue Code	960
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$127.40
Rate for Payer: Cash Price	$147.00
Rate for Payer: Galaxy Health Commercial	$127.40

MRI ORBIT/FACE/NECK W/O DYE

Facility

$196.00

Service Code	HCPCS 70540 26
Hospital Charge Code	5230041
Hospital Revenue Code	960
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$156.80
Rate for Payer: Aetna of NY Commercial	$137.20
Rate for Payer: Aetna of NY Medicare	$90.16
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$78.40
Rate for Payer: Cash Price	$147.00
Rate for Payer: CDPHP Medicare	$72.52
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$156.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$156.80
Rate for Payer: EmblemHealth Medicaid	$156.80
Rate for Payer: EmblemHealth Medicare	$66.64
Rate for Payer: Fidelis Medicare	$78.40
Rate for Payer: Galaxy Health Commercial	$127.40
Rate for Payer: Hamaspik Choice Medicare	$78.40
Rate for Payer: Humana Medicare	$78.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$137.20
Rate for Payer: Local 1199SEIU Medicare	$90.16
Rate for Payer: MVP Health Care of NY Commercial	$147.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$110.35
Rate for Payer: MVP Health Care of NY Medicare	$82.32
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$29.40
Rate for Payer: United Healthcare Medicare	$78.40
Rate for Payer: WellCare Medicare	$107.80

MRI ORBIT/FACE/NECK W/O DYE

Facility

$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 ORBIT/FACE/NECK W/O & W/ DYE

Facility

$316.00

Service Code	HCPCS 70543 26
Hospital Charge Code	5230043
Hospital Revenue Code	960
Min. Negotiated Rate	$205.40
Max. Negotiated Rate	$205.40
Rate for Payer: Cash Price	$237.00
Rate for Payer: Galaxy Health Commercial	$205.40

MRI ORBIT/FACE/NECK W/O & W/ DYE

Facility

$316.00

Service Code	HCPCS 70543 26
Hospital Charge Code	5230043
Hospital Revenue Code	960
Min. Negotiated Rate	$47.40
Max. Negotiated Rate	$252.80
Rate for Payer: Aetna of NY Commercial	$221.20
Rate for Payer: Aetna of NY Medicare	$145.36
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$126.40
Rate for Payer: Cash Price	$237.00
Rate for Payer: CDPHP Medicare	$116.92
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$252.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$252.80
Rate for Payer: EmblemHealth Medicaid	$252.80
Rate for Payer: EmblemHealth Medicare	$107.44
Rate for Payer: Fidelis Medicare	$126.40
Rate for Payer: Galaxy Health Commercial	$205.40
Rate for Payer: Hamaspik Choice Medicare	$126.40
Rate for Payer: Humana Medicare	$126.40
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$221.20
Rate for Payer: Local 1199SEIU Medicare	$145.36
Rate for Payer: MVP Health Care of NY Commercial	$237.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$177.91
Rate for Payer: MVP Health Care of NY Medicare	$132.72
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$47.40
Rate for Payer: United Healthcare Medicare	$126.40
Rate for Payer: WellCare Medicare	$173.80

MRI ORBT/FAC/NCK W/O &W/DYE

Facility

$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

$3,903.00

Service Code	HCPCS 70543
Hospital Charge Code	4230043
Hospital Revenue Code	610
Min. Negotiated Rate	$585.45
Max. Negotiated Rate	$3,122.40
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,795.38
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,561.20
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 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	$1,561.20
Rate for Payer: Galaxy Health Commercial	$2,536.95
Rate for Payer: Hamaspik Choice Medicare	$1,561.20
Rate for Payer: Humana Medicare	$1,561.20
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,795.38
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,639.26
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$585.45
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,561.20
Rate for Payer: WellCare Medicare	$2,146.65

MRI PELVIS W/ DYE

Facility

$252.00

Service Code	HCPCS 72196 26
Hospital Charge Code	5230006
Hospital Revenue Code	960
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of NY Commercial	$176.40
Rate for Payer: Aetna of NY Medicare	$115.92
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$100.80
Rate for Payer: Cash Price	$189.00
Rate for Payer: CDPHP Medicare	$93.24
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$201.60
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$201.60
Rate for Payer: EmblemHealth Medicaid	$201.60
Rate for Payer: EmblemHealth Medicare	$85.68
Rate for Payer: Fidelis Medicare	$100.80
Rate for Payer: Galaxy Health Commercial	$163.80
Rate for Payer: Hamaspik Choice Medicare	$100.80
Rate for Payer: Humana Medicare	$100.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$176.40
Rate for Payer: Local 1199SEIU Medicare	$115.92
Rate for Payer: MVP Health Care of NY Commercial	$189.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$141.88
Rate for Payer: MVP Health Care of NY Medicare	$105.84
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$37.80
Rate for Payer: United Healthcare Medicare	$100.80
Rate for Payer: WellCare Medicare	$138.60

MRI PELVIS W/ DYE

Facility

$252.00

Service Code	HCPCS 72196 26
Hospital Charge Code	5230006
Hospital Revenue Code	960
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$163.80
Rate for Payer: Cash Price	$189.00
Rate for Payer: Galaxy Health Commercial	$163.80

MRI PELVIS W/DYE

Facility

$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/DYE

Facility

$3,779.00

Service Code	HCPCS 72196
Hospital Charge Code	4230006
Hospital Revenue Code	610
Min. Negotiated Rate	$566.85
Max. Negotiated Rate	$3,023.20
Rate for Payer: Aetna of NY Commercial	$1,750.00
Rate for Payer: Aetna of NY Medicare	$1,738.34
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$1,511.60
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 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	$1,511.60
Rate for Payer: Galaxy Health Commercial	$2,456.35
Rate for Payer: Hamaspik Choice Medicare	$1,511.60
Rate for Payer: Humana Medicare	$1,511.60
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$1,750.00
Rate for Payer: Local 1199SEIU Medicare	$1,738.34
Rate for Payer: MVP Health Care of NY Commercial	$1,334.00
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan	$964.00
Rate for Payer: MVP Health Care of NY Medicare	$1,587.18
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro	$2,328.00
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid	$566.85
Rate for Payer: United Healthcare Commercial	$2,328.00
Rate for Payer: United Healthcare Medicare	$1,511.60
Rate for Payer: WellCare Medicare	$2,078.45

Know your out-of-pocket cost for care.

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