|
MRI PELVIS W/O DYE
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
HCPCS 72195 26
|
| Hospital Charge Code |
5230005
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$139.10 |
| Max. Negotiated Rate |
$139.10 |
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Galaxy Health Commercial |
$139.10
|
|
|
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 |
$341.70 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,750.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,047.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$911.20
|
| 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 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 |
$911.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$911.20
|
| Rate for Payer: Humana Medicare |
$911.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,750.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,047.88
|
| 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 |
$956.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,328.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$341.70
|
| Rate for Payer: United Healthcare Commercial |
$2,328.00
|
| Rate for Payer: United Healthcare Medicare |
$911.20
|
| Rate for Payer: WellCare Medicare |
$1,252.90
|
|
|
MRI PELVIS W/O DYE
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
HCPCS 72195 26
|
| Hospital Charge Code |
5230005
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$171.20 |
| Rate for Payer: Aetna of NY Commercial |
$149.80
|
| Rate for Payer: Aetna of NY Medicare |
$98.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$85.60
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: CDPHP Medicare |
$79.18
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$171.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$171.20
|
| Rate for Payer: EmblemHealth Medicaid |
$171.20
|
| Rate for Payer: EmblemHealth Medicare |
$72.76
|
| Rate for Payer: Fidelis Medicare |
$85.60
|
| Rate for Payer: Galaxy Health Commercial |
$139.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$85.60
|
| Rate for Payer: Humana Medicare |
$85.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$149.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$98.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$160.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$120.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$89.88
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$32.10
|
| Rate for Payer: United Healthcare Medicare |
$85.60
|
| Rate for Payer: WellCare Medicare |
$117.70
|
|
|
MRI PELVIS W/O & W/ DYE
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
HCPCS 72197 26
|
| Hospital Charge Code |
5230007
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna of NY Commercial |
$226.10
|
| Rate for Payer: Aetna of NY Medicare |
$148.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$129.20
|
| Rate for Payer: Cash Price |
$242.25
|
| Rate for Payer: CDPHP Medicare |
$119.51
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$258.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$258.40
|
| Rate for Payer: EmblemHealth Medicaid |
$258.40
|
| Rate for Payer: EmblemHealth Medicare |
$109.82
|
| Rate for Payer: Fidelis Medicare |
$129.20
|
| Rate for Payer: Galaxy Health Commercial |
$209.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$129.20
|
| Rate for Payer: Humana Medicare |
$129.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$226.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$148.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$242.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$181.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$135.66
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.45
|
| Rate for Payer: United Healthcare Medicare |
$129.20
|
| Rate for Payer: WellCare Medicare |
$177.65
|
|
|
MRI PELVIS W/O & W/ DYE
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
HCPCS 72197 26
|
| Hospital Charge Code |
5230007
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$209.95 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Cash Price |
$242.25
|
| Rate for Payer: Galaxy Health Commercial |
$209.95
|
|
|
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 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 |
$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 THORACIC SPINE W/ DYE
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 72147 26
|
| Hospital Charge Code |
5230031
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$169.65 |
| Max. Negotiated Rate |
$169.65 |
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: Galaxy Health Commercial |
$169.65
|
|
|
MRI THORACIC SPINE W/ DYE
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS 72147 26
|
| Hospital Charge Code |
5230031
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$39.15 |
| Max. Negotiated Rate |
$208.80 |
| Rate for Payer: Aetna of NY Commercial |
$182.70
|
| Rate for Payer: Aetna of NY Medicare |
$120.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$104.40
|
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: CDPHP Medicare |
$96.57
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$208.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$208.80
|
| Rate for Payer: EmblemHealth Medicaid |
$208.80
|
| Rate for Payer: EmblemHealth Medicare |
$88.74
|
| Rate for Payer: Fidelis Medicare |
$104.40
|
| Rate for Payer: Galaxy Health Commercial |
$169.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$104.40
|
| Rate for Payer: Humana Medicare |
$104.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$182.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$120.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$146.94
|
| Rate for Payer: MVP Health Care of NY Medicare |
$109.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$104.40
|
| Rate for Payer: WellCare Medicare |
$143.55
|
|
|
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 |
$652.20 |
| Max. Negotiated Rate |
$3,478.40 |
| Rate for Payer: Aetna of NY Commercial |
$1,750.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,000.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,739.20
|
| 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 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 |
$1,739.20
|
| Rate for Payer: Galaxy Health Commercial |
$2,826.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,739.20
|
| Rate for Payer: Humana Medicare |
$1,739.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,750.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,000.08
|
| 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 |
$1,826.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,328.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$652.20
|
| Rate for Payer: United Healthcare Commercial |
$2,328.00
|
| Rate for Payer: United Healthcare Medicare |
$1,739.20
|
| Rate for Payer: WellCare Medicare |
$2,391.40
|
|
|
MRI THORACIC SPINE W/O DYE
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
HCPCS 72146 26
|
| Hospital Charge Code |
5230012
|
|
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 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
|
IP
|
$217.00
|
|
|
Service Code
|
HCPCS 72146 26
|
| Hospital Charge Code |
5230012
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$141.05 |
| Rate for Payer: Cash Price |
$162.75
|
| Rate for Payer: Galaxy Health Commercial |
$141.05
|
|
|
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 |
$341.70 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,750.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,047.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$911.20
|
| 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 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 |
$911.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,480.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$911.20
|
| Rate for Payer: Humana Medicare |
$911.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,750.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,047.88
|
| 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 |
$956.76
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,328.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$341.70
|
| Rate for Payer: United Healthcare Commercial |
$2,328.00
|
| Rate for Payer: United Healthcare Medicare |
$911.20
|
| Rate for Payer: WellCare Medicare |
$1,252.90
|
|
|
MRI THORACIC SPINE W/O & W/ DYE
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
HCPCS 72157 26
|
| Hospital Charge Code |
5230013
|
|
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 THORACIC SPINE W/O & W/ DYE
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
HCPCS 72157 26
|
| Hospital Charge Code |
5230013
|
|
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 THORACIC SPINE W/O & W/DYE
|
Facility
|
OP
|
$3,986.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
4230013
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$597.90 |
| Max. Negotiated Rate |
$3,188.80 |
| Rate for Payer: Aetna of NY Commercial |
$1,750.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,833.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,594.40
|
| Rate for Payer: Cash Price |
$2,989.50
|
| Rate for Payer: Cash Price |
$2,989.50
|
| Rate for Payer: Cash Price |
$2,989.50
|
| Rate for Payer: CDPHP Medicare |
$1,474.82
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,790.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$3,188.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$3,188.80
|
| Rate for Payer: EmblemHealth Medicaid |
$3,188.80
|
| Rate for Payer: EmblemHealth Medicare |
$1,355.24
|
| Rate for Payer: EmblemHealth Select Care |
$2,590.90
|
| Rate for Payer: Fidelis Medicare |
$1,594.40
|
| Rate for Payer: Galaxy Health Commercial |
$2,590.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,594.40
|
| Rate for Payer: Humana Medicare |
$1,594.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,750.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,833.56
|
| 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 |
$1,674.12
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,328.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$597.90
|
| Rate for Payer: United Healthcare Commercial |
$2,328.00
|
| Rate for Payer: United Healthcare Medicare |
$1,594.40
|
| Rate for Payer: WellCare Medicare |
$2,192.30
|
|
|
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
|
|
|
MRI UPPER EXT, ANY JOINT W/ DYE
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
HCPCS 73222 26
|
| Hospital Charge Code |
5230022
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$154.70 |
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Galaxy Health Commercial |
$154.70
|
|
|
MRI UPPER EXT, ANY JOINT W/ DYE
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
HCPCS 73222 26
|
| Hospital Charge Code |
5230022
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: Aetna of NY Commercial |
$166.60
|
| Rate for Payer: Aetna of NY Medicare |
$109.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$95.20
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: CDPHP Medicare |
$88.06
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$190.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$190.40
|
| Rate for Payer: EmblemHealth Medicaid |
$190.40
|
| Rate for Payer: EmblemHealth Medicare |
$80.92
|
| Rate for Payer: Fidelis Medicare |
$95.20
|
| Rate for Payer: Galaxy Health Commercial |
$154.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$95.20
|
| Rate for Payer: Humana Medicare |
$95.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$166.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$109.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$178.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$133.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$99.96
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$35.70
|
| Rate for Payer: United Healthcare Medicare |
$95.20
|
| Rate for Payer: WellCare Medicare |
$130.90
|
|
|
MRI UPPER EXT; ANY JOINT W DYE
|
Facility
|
IP
|
$3,572.00
|
|
|
Service Code
|
HCPCS 73222
|
| Hospital Charge Code |
4230022
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,321.80 |
| Max. Negotiated Rate |
$2,321.80 |
| Rate for Payer: Cash Price |
$2,679.00
|
| Rate for Payer: Galaxy Health Commercial |
$2,321.80
|
|
|
MRI UPPER EXT; ANY JOINT W DYE
|
Facility
|
OP
|
$3,572.00
|
|
|
Service Code
|
HCPCS 73222
|
| Hospital Charge Code |
4230022
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$535.80 |
| Max. Negotiated Rate |
$2,857.60 |
| Rate for Payer: Aetna of NY Commercial |
$1,750.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,643.12
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$1,428.80
|
| Rate for Payer: Cash Price |
$2,679.00
|
| Rate for Payer: Cash Price |
$2,679.00
|
| Rate for Payer: Cash Price |
$2,679.00
|
| Rate for Payer: CDPHP Medicare |
$1,321.64
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,500.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,857.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,857.60
|
| Rate for Payer: EmblemHealth Medicaid |
$2,857.60
|
| Rate for Payer: EmblemHealth Medicare |
$1,214.48
|
| Rate for Payer: EmblemHealth Select Care |
$2,321.80
|
| Rate for Payer: Fidelis Medicare |
$1,428.80
|
| Rate for Payer: Galaxy Health Commercial |
$2,321.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$1,428.80
|
| Rate for Payer: Humana Medicare |
$1,428.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,750.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,643.12
|
| 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 |
$1,500.24
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,328.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$535.80
|
| Rate for Payer: United Healthcare Commercial |
$2,328.00
|
| Rate for Payer: United Healthcare Medicare |
$1,428.80
|
| Rate for Payer: WellCare Medicare |
$1,964.60
|
|
|
MRI UPPER EXT, ANY JOINT W/O DYE
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS 73221 26
|
| Hospital Charge Code |
5230021
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$29.85 |
| Max. Negotiated Rate |
$159.20 |
| Rate for Payer: Aetna of NY Commercial |
$139.30
|
| Rate for Payer: Aetna of NY Medicare |
$91.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$79.60
|
| Rate for Payer: Cash Price |
$149.25
|
| Rate for Payer: CDPHP Medicare |
$73.63
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$159.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$159.20
|
| Rate for Payer: EmblemHealth Medicaid |
$159.20
|
| Rate for Payer: EmblemHealth Medicare |
$67.66
|
| Rate for Payer: Fidelis Medicare |
$79.60
|
| Rate for Payer: Galaxy Health Commercial |
$129.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$79.60
|
| Rate for Payer: Humana Medicare |
$79.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$139.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$91.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$149.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$112.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$83.58
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$29.85
|
| Rate for Payer: United Healthcare Medicare |
$79.60
|
| Rate for Payer: WellCare Medicare |
$109.45
|
|
