St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

KNEE PERSONA ASF 11MM L 3-5

Facility

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	64905665
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,462.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,337.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,550.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,125.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,443.75
Rate for Payer: EmblemHealth Commercial	$2,125.00
Rate for Payer: Fidelis Medicare Advantage	$4,462.50
Rate for Payer: Group Health Inc Commercial	$2,125.00
Rate for Payer: Group Health Inc Medicare	$1,487.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,762.50

KNEE PERSONA ASF 11MM L 3-5

Facility

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	64905665
Hospital Revenue Code	278
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00

KNEE PERSONA ASF PS 11MM VEL3-5CD

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204654
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00

KNEE PERSONA ASF PS 11MM VEL3-5CD

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204654
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,570.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,870.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,040.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,955.00
Rate for Payer: EmblemHealth Commercial	$1,700.00
Rate for Payer: Fidelis Medicare Advantage	$3,570.00
Rate for Payer: Group Health Inc Commercial	$1,700.00
Rate for Payer: Group Health Inc Medicare	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,210.00

KNEE PERSONA ASF PS 13MMVEL 3-5CD

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204601
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00

KNEE PERSONA ASF PS 13MMVEL 3-5CD

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204601
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,570.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,870.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,040.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,955.00
Rate for Payer: EmblemHealth Commercial	$1,700.00
Rate for Payer: Fidelis Medicare Advantage	$3,570.00
Rate for Payer: Group Health Inc Commercial	$1,700.00
Rate for Payer: Group Health Inc Medicare	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,210.00

KNEE PERSONA ASFPS14MMVEL 6-9EF

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204595
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,570.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,870.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,040.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,955.00
Rate for Payer: EmblemHealth Commercial	$1,700.00
Rate for Payer: Fidelis Medicare Advantage	$3,570.00
Rate for Payer: Group Health Inc Commercial	$1,700.00
Rate for Payer: Group Health Inc Medicare	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,210.00

KNEE PERSONA ASFPS14MMVEL 6-9EF

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204595
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00

KNEE PERSON L 12MM 6-9, E-F

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	64906544
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00

KNEE PERSON L 12MM 6-9, E-F

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	64906544
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,570.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,870.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,040.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,955.00
Rate for Payer: EmblemHealth Commercial	$1,700.00
Rate for Payer: Fidelis Medicare Advantage	$3,570.00
Rate for Payer: Group Health Inc Commercial	$1,700.00
Rate for Payer: Group Health Inc Medicare	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,210.00

KNEE P/F BOWD STM

Facility

$16,252.50

Service Code	HCPCS C1776
Hospital Charge Code	64907297
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$17,065.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,938.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$9,751.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,126.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$9,345.19
Rate for Payer: EmblemHealth Commercial	$8,126.25
Rate for Payer: Fidelis Medicare Advantage	$17,065.12
Rate for Payer: Group Health Inc Commercial	$8,126.25
Rate for Payer: Group Health Inc Medicare	$5,688.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,126.25
Rate for Payer: Hamaspik Choice Inc Medicare	$8,126.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10,564.12

KNEE P/F BOWD STM

Facility

$16,252.50

Service Code	HCPCS C1776
Hospital Charge Code	64907297
Hospital Revenue Code	278
Min. Negotiated Rate	$8,126.25
Max. Negotiated Rate	$8,126.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,126.25
Rate for Payer: Hamaspik Choice Inc Medicare	$8,126.25

KNEE PLATE TIB STEM SZ F GRN

Facility

$5,530.00

Service Code	HCPCS C1713
Hospital Charge Code	40202111
Hospital Revenue Code	278
Min. Negotiated Rate	$2,765.00
Max. Negotiated Rate	$2,765.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,765.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,765.00

KNEE PLATE TIB STEM SZ F GRN

Facility

$5,530.00

Service Code	HCPCS C1713
Hospital Charge Code	40202111
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,806.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,041.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,318.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,765.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,179.75
Rate for Payer: EmblemHealth Commercial	$2,765.00
Rate for Payer: Fidelis Medicare Advantage	$5,806.50
Rate for Payer: Group Health Inc Commercial	$2,765.00
Rate for Payer: Group Health Inc Medicare	$1,935.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,765.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,765.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,594.50

KNEE POST HINGED SZ C 12MM

Facility

$2,704.00

Service Code	HCPCS C1776
Hospital Charge Code	64906288
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,839.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,487.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,622.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,352.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,554.80
Rate for Payer: EmblemHealth Commercial	$1,352.00
Rate for Payer: Fidelis Medicare Advantage	$2,839.20
Rate for Payer: Group Health Inc Commercial	$1,352.00
Rate for Payer: Group Health Inc Medicare	$946.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,352.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,352.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,757.60

KNEE POST HINGED SZ C 12MM

Facility

$2,704.00

Service Code	HCPCS C1776
Hospital Charge Code	64906288
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.00
Max. Negotiated Rate	$1,352.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,352.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,352.00

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$50,243.72

Service Code	MSDRG 488
Min. Negotiated Rate	$16,991.51
Max. Negotiated Rate	$50,243.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31,061.82
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$36,540.89
Rate for Payer: Aetna Government	$36,540.89
Rate for Payer: Brighton Health Commercial	$30,545.70
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$37,271.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36,378.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$30,021.41
Rate for Payer: Elderplan Medicare Advantage	$34,713.85
Rate for Payer: EmblemHealth Commercial	$18,064.10
Rate for Payer: Fidelis Medicare Advantage	$36,540.89
Rate for Payer: Group Health Inc Commercial	$36,540.89
Rate for Payer: Group Health Inc Medicare	$36,540.89
Rate for Payer: Hamaspik Choice Inc Medicare	$36,540.89
Rate for Payer: Healthfirst Medicare Advantage	$16,991.51
Rate for Payer: Humana Medicare	$50,243.72
Rate for Payer: Senior Whole Health Medicare Advantage	$36,540.89
Rate for Payer: United Healthcare Commercial	$41,893.95
Rate for Payer: United Healthcare Medicare Advantage	$36,540.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$36,540.89
Rate for Payer: Wellcare Medicare	$34,713.85

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$33,675.83

Service Code	MSDRG 489
Min. Negotiated Rate	$10,613.30
Max. Negotiated Rate	$33,675.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18,249.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24,491.51
Rate for Payer: Aetna Government	$24,491.51
Rate for Payer: Brighton Health Commercial	$17,946.65
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$24,981.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21,373.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$17,638.61
Rate for Payer: Elderplan Medicare Advantage	$23,266.93
Rate for Payer: EmblemHealth Commercial	$10,613.30
Rate for Payer: Fidelis Medicare Advantage	$24,491.51
Rate for Payer: Group Health Inc Commercial	$24,491.51
Rate for Payer: Group Health Inc Medicare	$24,491.51
Rate for Payer: Hamaspik Choice Inc Medicare	$24,491.51
Rate for Payer: Healthfirst Medicare Advantage	$11,388.55
Rate for Payer: Humana Medicare	$33,675.83
Rate for Payer: Senior Whole Health Medicare Advantage	$24,491.51
Rate for Payer: United Healthcare Commercial	$24,614.14
Rate for Payer: United Healthcare Medicare Advantage	$24,491.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$24,491.51
Rate for Payer: Wellcare Medicare	$23,266.93

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$48,369.35

Service Code	MSDRG 486
Min. Negotiated Rate	$16,357.64
Max. Negotiated Rate	$48,369.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29,612.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35,177.71
Rate for Payer: Aetna Government	$35,177.71
Rate for Payer: Brighton Health Commercial	$29,120.35
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$35,881.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$34,681.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$28,620.52
Rate for Payer: Elderplan Medicare Advantage	$33,418.82
Rate for Payer: EmblemHealth Commercial	$17,221.20
Rate for Payer: Fidelis Medicare Advantage	$35,177.71
Rate for Payer: Group Health Inc Commercial	$35,177.71
Rate for Payer: Group Health Inc Medicare	$35,177.71
Rate for Payer: Hamaspik Choice Inc Medicare	$35,177.71
Rate for Payer: Healthfirst Medicare Advantage	$16,357.64
Rate for Payer: Humana Medicare	$48,369.35
Rate for Payer: Senior Whole Health Medicare Advantage	$35,177.71
Rate for Payer: United Healthcare Commercial	$39,939.06
Rate for Payer: United Healthcare Medicare Advantage	$35,177.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35,177.71
Rate for Payer: Wellcare Medicare	$33,418.82

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$72,884.61

Service Code	MSDRG 485
Min. Negotiated Rate	$24,648.25
Max. Negotiated Rate	$72,884.61
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48,570.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$53,006.99
Rate for Payer: Aetna Government	$53,006.99
Rate for Payer: Brighton Health Commercial	$47,763.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$54,067.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56,884.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$46,943.19
Rate for Payer: Elderplan Medicare Advantage	$50,356.64
Rate for Payer: EmblemHealth Commercial	$28,246.10
Rate for Payer: Fidelis Medicare Advantage	$53,006.99
Rate for Payer: Group Health Inc Commercial	$53,006.99
Rate for Payer: Group Health Inc Medicare	$53,006.99
Rate for Payer: Hamaspik Choice Inc Medicare	$53,006.99
Rate for Payer: Healthfirst Medicare Advantage	$24,648.25
Rate for Payer: Humana Medicare	$72,884.61
Rate for Payer: Senior Whole Health Medicare Advantage	$53,006.99
Rate for Payer: United Healthcare Commercial	$65,507.78
Rate for Payer: United Healthcare Medicare Advantage	$53,006.99
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$53,006.99
Rate for Payer: Wellcare Medicare	$50,356.64

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$39,533.38

Service Code	MSDRG 487
Min. Negotiated Rate	$13,247.50
Max. Negotiated Rate	$39,533.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22,779.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28,751.55
Rate for Payer: Aetna Government	$28,751.55
Rate for Payer: Brighton Health Commercial	$22,401.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29,326.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26,678.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$22,016.56
Rate for Payer: Elderplan Medicare Advantage	$27,313.97
Rate for Payer: EmblemHealth Commercial	$13,247.50
Rate for Payer: Fidelis Medicare Advantage	$28,751.55
Rate for Payer: Group Health Inc Commercial	$28,751.55
Rate for Payer: Group Health Inc Medicare	$28,751.55
Rate for Payer: Hamaspik Choice Inc Medicare	$28,751.55
Rate for Payer: Healthfirst Medicare Advantage	$13,369.47
Rate for Payer: Humana Medicare	$39,533.38
Rate for Payer: Senior Whole Health Medicare Advantage	$28,751.55
Rate for Payer: United Healthcare Commercial	$30,723.43
Rate for Payer: United Healthcare Medicare Advantage	$28,751.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28,751.55
Rate for Payer: Wellcare Medicare	$27,313.97

KNEE PSN 11MM VE L 6-9 GH

Facility

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	64905660
Hospital Revenue Code	278
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00

KNEE PSN 11MM VE L 6-9 GH

Facility

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	64905660
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,462.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,337.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,550.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,125.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,443.75
Rate for Payer: EmblemHealth Commercial	$2,125.00
Rate for Payer: Fidelis Medicare Advantage	$4,462.50
Rate for Payer: Group Health Inc Commercial	$2,125.00
Rate for Payer: Group Health Inc Medicare	$1,487.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,762.50

KNEE PSN ASF 11NN RT 6-9 EF

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	64906811
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,570.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,870.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,040.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,955.00
Rate for Payer: EmblemHealth Commercial	$1,700.00
Rate for Payer: Fidelis Medicare Advantage	$3,570.00
Rate for Payer: Group Health Inc Commercial	$1,700.00
Rate for Payer: Group Health Inc Medicare	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,210.00

KNEE PSN ASF 11NN RT 6-9 EF

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Charge Code	64906811
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,700.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,700.00

Know your out-of-pocket cost for care.

All Charges