St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MALLET-200G

Facility

$700.00

Hospital Charge Code	40209528
Hospital Revenue Code	270
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$560.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$385.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$350.00
Rate for Payer: Aetna Government	$350.00
Rate for Payer: Brighton Health Commercial	$525.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$560.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$476.00
Rate for Payer: Group Health Inc Commercial	$350.00
Rate for Payer: Group Health Inc Medicare	$245.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$350.00

MA MAGSEED IMPLANTABLE

Facility

$1,275.00

Service Code	HCPCS A4648
Hospital Charge Code	41101965
Hospital Revenue Code	278
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$637.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$637.50
Rate for Payer: Hamaspik Choice Inc Medicare	$637.50

MA MAGSEED IMPLANTABLE

Facility

$1,275.00

Service Code	HCPCS A4648
Hospital Charge Code	41101965
Hospital Revenue Code	278
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$1,338.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$701.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.98
Rate for Payer: Aetna Government	$70.98
Rate for Payer: Brighton Health Commercial	$765.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$637.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$733.12
Rate for Payer: EmblemHealth Commercial	$637.50
Rate for Payer: Fidelis Medicare Advantage	$1,338.75
Rate for Payer: Group Health Inc Commercial	$637.50
Rate for Payer: Group Health Inc Medicare	$446.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$637.50
Rate for Payer: Hamaspik Choice Inc Medicare	$637.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$828.75

MA MAMMO DX DIGITAL, UNILATERAL

Facility

$399.85

Service Code	HCPCS 77065 TC
Hospital Charge Code	41108622
Hospital Revenue Code	401
Min. Negotiated Rate	$74.60
Max. Negotiated Rate	$319.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$219.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$74.60
Rate for Payer: Aetna Government	$74.60
Rate for Payer: Brighton Health Commercial	$299.89
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$319.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$271.90
Rate for Payer: Group Health Inc Commercial	$199.92
Rate for Payer: Group Health Inc Medicare	$139.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.92
Rate for Payer: Hamaspik Choice Inc Medicare	$199.92
Rate for Payer: United Healthcare Commercial	$78.82

MA MAMMOGRAPHY DX DIGITAL - BILAT

Facility

$502.90

Service Code	HCPCS 77066 TC
Hospital Charge Code	41108621
Hospital Revenue Code	401
Min. Negotiated Rate	$95.39
Max. Negotiated Rate	$402.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$276.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$95.39
Rate for Payer: Aetna Government	$95.39
Rate for Payer: Brighton Health Commercial	$377.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$402.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$341.97
Rate for Payer: Group Health Inc Commercial	$251.45
Rate for Payer: Group Health Inc Medicare	$176.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.45
Rate for Payer: Hamaspik Choice Inc Medicare	$251.45
Rate for Payer: United Healthcare Commercial	$100.57

MA MAMMOGRAPHY SCREENING DIGITAL

Facility

$402.90

Service Code	HCPCS 77067 TC
Hospital Charge Code	41108620
Hospital Revenue Code	403
Min. Negotiated Rate	$78.81
Max. Negotiated Rate	$322.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$221.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$78.81
Rate for Payer: Aetna Government	$78.81
Rate for Payer: Brighton Health Commercial	$302.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$322.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$273.97
Rate for Payer: Group Health Inc Commercial	$201.45
Rate for Payer: Group Health Inc Medicare	$141.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$201.45
Rate for Payer: Hamaspik Choice Inc Medicare	$201.45
Rate for Payer: United Healthcare Commercial	$83.18

MA MAMMO TOMO DIAGNOSTIC BILATERA

Facility

$502.90

Service Code	HCPCS 77066 TC
Hospital Charge Code	41101040
Hospital Revenue Code	401
Min. Negotiated Rate	$95.39
Max. Negotiated Rate	$402.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$276.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$95.39
Rate for Payer: Aetna Government	$95.39
Rate for Payer: Brighton Health Commercial	$377.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$402.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$341.97
Rate for Payer: Group Health Inc Commercial	$251.45
Rate for Payer: Group Health Inc Medicare	$176.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.45
Rate for Payer: Hamaspik Choice Inc Medicare	$251.45
Rate for Payer: United Healthcare Commercial	$100.57

MA MAMMO TOMO DIAGNOSTIC UNILATER

Facility

$399.85

Service Code	HCPCS 77065 TC
Hospital Charge Code	41101038
Hospital Revenue Code	401
Min. Negotiated Rate	$74.60
Max. Negotiated Rate	$319.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$219.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$74.60
Rate for Payer: Aetna Government	$74.60
Rate for Payer: Brighton Health Commercial	$299.89
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$319.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$271.90
Rate for Payer: Group Health Inc Commercial	$199.92
Rate for Payer: Group Health Inc Medicare	$139.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.92
Rate for Payer: Hamaspik Choice Inc Medicare	$199.92
Rate for Payer: United Healthcare Commercial	$78.82

MA MAMMO TOMO SCREENING BILATERAL

Facility

$420.90

Service Code	HCPCS 77067 TC
Hospital Charge Code	41101032
Hospital Revenue Code	403
Min. Negotiated Rate	$78.81
Max. Negotiated Rate	$336.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$231.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$78.81
Rate for Payer: Aetna Government	$78.81
Rate for Payer: Brighton Health Commercial	$315.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$336.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$286.21
Rate for Payer: Group Health Inc Commercial	$210.45
Rate for Payer: Group Health Inc Medicare	$147.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$210.45
Rate for Payer: Hamaspik Choice Inc Medicare	$210.45
Rate for Payer: United Healthcare Commercial	$83.18

MA MAMMO TOMO THREE DIMEN

Facility

$160.93

Service Code	HCPCS 77063 TC
Hospital Charge Code	41101099
Hospital Revenue Code	403
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$128.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$88.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.80
Rate for Payer: Aetna Government	$19.80
Rate for Payer: Brighton Health Commercial	$120.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$128.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$109.43
Rate for Payer: Group Health Inc Commercial	$80.46
Rate for Payer: Group Health Inc Medicare	$56.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$80.46
Rate for Payer: Hamaspik Choice Inc Medicare	$80.46
Rate for Payer: United Healthcare Commercial	$20.62

MA MAMMO TOMO THREE DIMENSIONAL

Facility

$160.93

Service Code	HCPCS G0279 TC
Hospital Charge Code	41101068
Hospital Revenue Code	401
Min. Negotiated Rate	$15.74
Max. Negotiated Rate	$128.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$88.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.74
Rate for Payer: Aetna Government	$15.74
Rate for Payer: Brighton Health Commercial	$120.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$128.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$109.43
Rate for Payer: Group Health Inc Commercial	$80.46
Rate for Payer: Group Health Inc Medicare	$56.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$80.46
Rate for Payer: Hamaspik Choice Inc Medicare	$80.46
Rate for Payer: United Healthcare Commercial	$20.62

MANDIBLE FRACTURE-CLOSED REDUCTIO

Facility

$1,450.00

Service Code	HCPCS D7740
Hospital Charge Code	42301915
Hospital Revenue Code	361
Min. Negotiated Rate	$507.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$797.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,011.89
Rate for Payer: Aetna Government	$1,011.89
Rate for Payer: Brighton Health Commercial	$1,087.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$725.00
Rate for Payer: Group Health Inc Medicare	$507.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$725.00
Rate for Payer: Hamaspik Choice Inc Medicare	$725.00

MANDIBLE FRACTURE-OPEN REDUCTION,

Facility

$7,796.00

Service Code	HCPCS D7730
Hospital Charge Code	42301910
Hospital Revenue Code	361
Min. Negotiated Rate	$2,045.04
Max. Negotiated Rate	$5,847.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,287.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,045.04
Rate for Payer: Aetna Government	$2,045.04
Rate for Payer: Brighton Health Commercial	$5,847.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$3,898.00
Rate for Payer: Group Health Inc Medicare	$2,728.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,898.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,898.00

MANDIBLE FX-CLOSED REDUCT (TEETH

Facility

$1,087.50

Service Code	HCPCS D7640
Hospital Charge Code	42301875
Hospital Revenue Code	361
Min. Negotiated Rate	$380.62
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$598.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$992.43
Rate for Payer: Aetna Government	$992.43
Rate for Payer: Brighton Health Commercial	$815.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$543.75
Rate for Payer: Group Health Inc Medicare	$380.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$543.75
Rate for Payer: Hamaspik Choice Inc Medicare	$543.75

MANDIBLE FX-OPEN REDUCT (TEETH IM

Facility

$3,262.50

Service Code	HCPCS D7630
Hospital Charge Code	42301870
Hospital Revenue Code	361
Min. Negotiated Rate	$1,141.88
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,794.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,564.25
Rate for Payer: Aetna Government	$1,564.25
Rate for Payer: Brighton Health Commercial	$2,446.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$1,631.25
Rate for Payer: Group Health Inc Medicare	$1,141.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,631.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,631.25

MANDIBULAR PLATE 2.0MM 4 HOLES

Facility

$190.00

Service Code	HCPCS C1713
Hospital Charge Code	40209901
Hospital Revenue Code	278
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$199.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$104.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$114.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$95.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$109.25
Rate for Payer: EmblemHealth Commercial	$95.00
Rate for Payer: Fidelis Medicare Advantage	$199.50
Rate for Payer: Group Health Inc Commercial	$95.00
Rate for Payer: Group Health Inc Medicare	$66.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$95.00
Rate for Payer: Hamaspik Choice Inc Medicare	$95.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$123.50

MANDIBULAR PLATE 2.0MM 4 HOLES

Facility

$190.00

Service Code	HCPCS C1713
Hospital Charge Code	40209901
Hospital Revenue Code	278
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$95.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$95.00
Rate for Payer: Hamaspik Choice Inc Medicare	$95.00

MANDIBULAR RESECTION PROSTHESIS/1

Facility

$11,340.00

Service Code	HCPCS D5935
Hospital Charge Code	42301310
Hospital Revenue Code	361
Min. Negotiated Rate	$1,717.20
Max. Negotiated Rate	$8,505.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,237.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,717.20
Rate for Payer: Aetna Government	$1,717.20
Rate for Payer: Brighton Health Commercial	$8,505.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$5,670.00
Rate for Payer: Group Health Inc Medicare	$3,969.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,670.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,670.00

MANDIBULAR RESECTION PROSTHESIS W

Facility

$12,049.00

Service Code	HCPCS D5934
Hospital Charge Code	42301305
Hospital Revenue Code	361
Min. Negotiated Rate	$1,973.25
Max. Negotiated Rate	$9,036.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,626.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,973.25
Rate for Payer: Aetna Government	$1,973.25
Rate for Payer: Brighton Health Commercial	$9,036.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$6,024.50
Rate for Payer: Group Health Inc Medicare	$4,217.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,024.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6,024.50

MANDIBULAR SCREWS 2.0MMX07MM

Facility

$108.00

Service Code	HCPCS C1713
Hospital Charge Code	40209902
Hospital Revenue Code	278
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.00
Rate for Payer: Hamaspik Choice Inc Medicare	$54.00

MANDIBULAR SCREWS 2.0MMX07MM

Facility

$108.00

Service Code	HCPCS C1713
Hospital Charge Code	40209902
Hospital Revenue Code	278
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$134.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$59.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$64.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$54.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$62.10
Rate for Payer: EmblemHealth Commercial	$54.00
Rate for Payer: Fidelis Medicare Advantage	$113.40
Rate for Payer: Group Health Inc Commercial	$54.00
Rate for Payer: Group Health Inc Medicare	$37.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.00
Rate for Payer: Hamaspik Choice Inc Medicare	$54.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.20

MAND PARTIAL DENTURE/FLEXIBLE BAS

Facility

$1,400.00

Service Code	HCPCS D5226
Hospital Charge Code	42300739
Hospital Revenue Code	361
Min. Negotiated Rate	$285.71
Max. Negotiated Rate	$28,571.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$770.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$395.13
Rate for Payer: Aetna Government	$395.13
Rate for Payer: Affinity Essential Plan 1&2	$642.85
Rate for Payer: Affinity Essential Plan 3&4	$642.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$285.71
Rate for Payer: Amida Care Medicaid	$285.71
Rate for Payer: Brighton Health Commercial	$1,050.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Fidelis CHP/HARP/Medicaid	$28,571.00
Rate for Payer: Fidelis Essential Plan Aliesa	$285.71
Rate for Payer: Fidelis Essential Plan QHP	$285.71
Rate for Payer: Fidelis Qualified Health Plan	$300.00
Rate for Payer: Group Health Inc Commercial	$700.00
Rate for Payer: Group Health Inc Medicare	$490.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$285.71
Rate for Payer: Hamaspik Choice Inc Medicare	$700.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$285.71
Rate for Payer: Healthfirst Essential Plan	$642.85
Rate for Payer: Healthfirst QHP	$285.71
Rate for Payer: SOMOS CHP/HARP/Medicaid	$285.71
Rate for Payer: SOMOS Essential	$642.85
Rate for Payer: United Healthcare Essential Plan 1&2	$642.85
Rate for Payer: United Healthcare Essential Plan 3&4	$314.28
Rate for Payer: United Healthcare Medicaid	$285.71
Rate for Payer: Wellcare CHP/FHP/Medicaid	$285.71

MA NEEDLE LOCALIZATION

Facility

$1,978.77

Service Code	HCPCS 77012
Hospital Charge Code	41108873
Hospital Revenue Code	329
Min. Negotiated Rate	$128.24
Max. Negotiated Rate	$1,583.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,088.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$128.24
Rate for Payer: Aetna Government	$128.24
Rate for Payer: Brighton Health Commercial	$1,484.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,583.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,345.56
Rate for Payer: Group Health Inc Commercial	$989.38
Rate for Payer: Group Health Inc Medicare	$692.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$989.38
Rate for Payer: Hamaspik Choice Inc Medicare	$989.38

MANIP, ELBOW W/ANESTHESIA

Facility

$4,105.13

Service Code	HCPCS 24300
Hospital Charge Code	30107818
Hospital Revenue Code	450
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,858.61
Rate for Payer: Aetna Government	$1,858.61
Rate for Payer: Affinity Essential Plan 1&2	$1,301.03
Rate for Payer: Affinity Essential Plan 3&4	$1,301.03
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,301.03
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$1,858.61
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$1,858.61
Rate for Payer: Cash Price	$1,858.61
Rate for Payer: Cash Price	$1,858.61
Rate for Payer: Cash Price	$1,858.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,858.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$1,858.61
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$1,579.82
Rate for Payer: Fidelis Essential Plan QHP	$1,654.16
Rate for Payer: Fidelis Medicare Advantage	$1,858.61
Rate for Payer: Fidelis Qualified Health Plan	$1,654.16
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,052.56
Rate for Payer: Hamaspik Choice Inc Medicare	$1,858.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$1,858.61
Rate for Payer: Humana Medicare	$1,895.78
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1,858.61
Rate for Payer: Senior Whole Health Medicare Advantage	$1,858.61
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$1,858.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,858.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,486.89
Rate for Payer: Wellcare Medicare	$1,765.68

MANIP, ELBOW W/ANESTHESIA

Facility

$4,105.13

Service Code	HCPCS 24300
Hospital Charge Code	30107818
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,858.61

Know your out-of-pocket cost for care.

All Charges