St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MEDIUM 34-36 MEDEBRA WHTE

Facility

$63.13

Hospital Charge Code	64905835
Hospital Revenue Code	270
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$50.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$34.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$31.56
Rate for Payer: Aetna Government	$31.56
Rate for Payer: Brighton Health Commercial	$47.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$50.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$42.93
Rate for Payer: Group Health Inc Commercial	$31.56
Rate for Payer: Group Health Inc Medicare	$22.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.56
Rate for Payer: Hamaspik Choice Inc Medicare	$31.56

MEDIUM STAPLE 15 X 12MM

Facility

$610.00

Service Code	HCPCS C1713
Hospital Charge Code	40200801
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$640.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$335.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$366.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$305.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$350.75
Rate for Payer: EmblemHealth Commercial	$305.00
Rate for Payer: Fidelis Medicare Advantage	$640.50
Rate for Payer: Group Health Inc Commercial	$305.00
Rate for Payer: Group Health Inc Medicare	$213.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$305.00
Rate for Payer: Hamaspik Choice Inc Medicare	$305.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$396.50

MEDIUM STAPLE 15 X 12MM

Facility

$610.00

Service Code	HCPCS C1713
Hospital Charge Code	40200801
Hospital Revenue Code	278
Min. Negotiated Rate	$305.00
Max. Negotiated Rate	$305.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$305.00
Rate for Payer: Hamaspik Choice Inc Medicare	$305.00

MEDIUM TISSUE EXPANDER 450CC

Facility

$3,412.50

Service Code	HCPCS C1789
Hospital Charge Code	64903233
Hospital Revenue Code	278
Min. Negotiated Rate	$1,706.25
Max. Negotiated Rate	$1,706.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,706.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,706.25

MEDIUM TISSUE EXPANDER 450CC

Facility

$3,412.50

Service Code	HCPCS C1789
Hospital Charge Code	64903233
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$3,583.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,876.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Brighton Health Commercial	$2,047.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,706.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,962.19
Rate for Payer: EmblemHealth Commercial	$1,706.25
Rate for Payer: Fidelis Medicare Advantage	$3,583.12
Rate for Payer: Group Health Inc Commercial	$1,706.25
Rate for Payer: Group Health Inc Medicare	$1,194.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,706.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,706.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,218.12

MED LEAD A

Facility

$1,984.50

Hospital Charge Code	40004038
Hospital Revenue Code	279
Min. Negotiated Rate	$694.58
Max. Negotiated Rate	$1,587.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,091.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$992.25
Rate for Payer: Aetna Government	$992.25
Rate for Payer: Brighton Health Commercial	$1,488.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,587.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,349.46
Rate for Payer: Group Health Inc Commercial	$992.25
Rate for Payer: Group Health Inc Medicare	$694.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$992.25
Rate for Payer: Hamaspik Choice Inc Medicare	$992.25

MED LEAD CAPSURE V

Facility

$2,693.25

Hospital Charge Code	40004034
Hospital Revenue Code	279
Min. Negotiated Rate	$942.64
Max. Negotiated Rate	$2,154.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,481.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,346.62
Rate for Payer: Aetna Government	$1,346.62
Rate for Payer: Brighton Health Commercial	$2,019.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,154.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,831.41
Rate for Payer: Group Health Inc Commercial	$1,346.62
Rate for Payer: Group Health Inc Medicare	$942.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,346.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1,346.62

MED LEAD V

Facility

$1,984.50

Hospital Charge Code	40004037
Hospital Revenue Code	279
Min. Negotiated Rate	$694.58
Max. Negotiated Rate	$1,587.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,091.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$992.25
Rate for Payer: Aetna Government	$992.25
Rate for Payer: Brighton Health Commercial	$1,488.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,587.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,349.46
Rate for Payer: Group Health Inc Commercial	$992.25
Rate for Payer: Group Health Inc Medicare	$694.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$992.25
Rate for Payer: Hamaspik Choice Inc Medicare	$992.25

MED LEAD VITATRON

Facility

$1,984.50

Hospital Charge Code	40004050
Hospital Revenue Code	279
Min. Negotiated Rate	$694.58
Max. Negotiated Rate	$1,587.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,091.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$992.25
Rate for Payer: Aetna Government	$992.25
Rate for Payer: Brighton Health Commercial	$1,488.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,587.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,349.46
Rate for Payer: Group Health Inc Commercial	$992.25
Rate for Payer: Group Health Inc Medicare	$694.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$992.25
Rate for Payer: Hamaspik Choice Inc Medicare	$992.25

MEDLINE ARM SLING STANDARD-LARGE

Facility

$333.00

Hospital Charge Code	64906241
Hospital Revenue Code	270
Min. Negotiated Rate	$116.55
Max. Negotiated Rate	$266.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$183.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$166.50
Rate for Payer: Aetna Government	$166.50
Rate for Payer: Brighton Health Commercial	$249.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$266.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$226.44
Rate for Payer: Group Health Inc Commercial	$166.50
Rate for Payer: Group Health Inc Medicare	$116.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$166.50
Rate for Payer: Hamaspik Choice Inc Medicare	$166.50

MEDLINE A-V FIST/GRAFT PK

Facility

$139.16

Hospital Charge Code	40008262
Hospital Revenue Code	270
Min. Negotiated Rate	$48.71
Max. Negotiated Rate	$111.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$76.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.58
Rate for Payer: Aetna Government	$69.58
Rate for Payer: Brighton Health Commercial	$104.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$111.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$94.63
Rate for Payer: Group Health Inc Commercial	$69.58
Rate for Payer: Group Health Inc Medicare	$48.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$69.58
Rate for Payer: Hamaspik Choice Inc Medicare	$69.58

MED LIST DOCD IN RCRD

Facility

$10.00

Service Code	HCPCS 1159F
Hospital Charge Code	30305810
Hospital Revenue Code	969
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$7.50
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	$5.00
Rate for Payer: Group Health Inc Medicare	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00

MED MINI KIT

Facility

$2,978.00

Hospital Charge Code	40200257
Hospital Revenue Code	270
Min. Negotiated Rate	$1,042.30
Max. Negotiated Rate	$2,382.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,637.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,489.00
Rate for Payer: Aetna Government	$1,489.00
Rate for Payer: Brighton Health Commercial	$2,233.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,382.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,025.04
Rate for Payer: Group Health Inc Commercial	$1,489.00
Rate for Payer: Group Health Inc Medicare	$1,042.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,489.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,489.00

MED NUTRITION INDIV SUBSEQ

Facility

$82.65

Service Code	HCPCS 97803
Hospital Charge Code	30303206
Hospital Revenue Code	942
Min. Negotiated Rate	$23.69
Max. Negotiated Rate	$3,885.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$45.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.69
Rate for Payer: Aetna Government	$23.69
Rate for Payer: Affinity Essential Plan 1&2	$87.41
Rate for Payer: Affinity Essential Plan 3&4	$87.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$38.85
Rate for Payer: Amida Care Medicaid	$38.85
Rate for Payer: Brighton Health Commercial	$61.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$66.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.20
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,885.00
Rate for Payer: Fidelis Essential Plan Aliesa	$38.85
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Qualified Health Plan	$40.79
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.85
Rate for Payer: Hamaspik Choice Inc Medicare	$41.32
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38.85
Rate for Payer: Healthfirst Essential Plan	$87.41
Rate for Payer: Healthfirst QHP	$38.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38.85
Rate for Payer: SOMOS Essential	$87.41
Rate for Payer: United Healthcare Commercial	$41.32
Rate for Payer: United Healthcare Essential Plan 1&2	$87.41
Rate for Payer: United Healthcare Essential Plan 3&4	$42.74
Rate for Payer: United Healthcare Medicaid	$38.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38.85

MED NUT THERAPY, INITIAL, 15 MIN

Facility

$97.78

Service Code	HCPCS 97802
Hospital Charge Code	30304501
Hospital Revenue Code	942
Min. Negotiated Rate	$27.89
Max. Negotiated Rate	$3,885.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.89
Rate for Payer: Aetna Government	$27.89
Rate for Payer: Affinity Essential Plan 1&2	$87.41
Rate for Payer: Affinity Essential Plan 3&4	$87.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$38.85
Rate for Payer: Amida Care Medicaid	$38.85
Rate for Payer: Brighton Health Commercial	$73.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$78.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$66.49
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,885.00
Rate for Payer: Fidelis Essential Plan Aliesa	$38.85
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Qualified Health Plan	$40.79
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.85
Rate for Payer: Hamaspik Choice Inc Medicare	$48.89
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38.85
Rate for Payer: Healthfirst Essential Plan	$87.41
Rate for Payer: Healthfirst QHP	$38.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38.85
Rate for Payer: SOMOS Essential	$87.41
Rate for Payer: United Healthcare Commercial	$48.89
Rate for Payer: United Healthcare Essential Plan 1&2	$87.41
Rate for Payer: United Healthcare Essential Plan 3&4	$42.74
Rate for Payer: United Healthcare Medicaid	$38.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38.85

MED NUT THERAPY RE-ASS, EA 15 MIN

Facility

$82.65

Service Code	HCPCS G0270
Hospital Charge Code	30305706
Hospital Revenue Code	942
Min. Negotiated Rate	$16.52
Max. Negotiated Rate	$3,885.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$45.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.52
Rate for Payer: Aetna Government	$16.52
Rate for Payer: Affinity Essential Plan 1&2	$87.41
Rate for Payer: Affinity Essential Plan 3&4	$87.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$38.85
Rate for Payer: Amida Care Medicaid	$38.85
Rate for Payer: Brighton Health Commercial	$61.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$66.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.20
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,885.00
Rate for Payer: Fidelis Essential Plan Aliesa	$38.85
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Qualified Health Plan	$40.79
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.85
Rate for Payer: Hamaspik Choice Inc Medicare	$41.32
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38.85
Rate for Payer: Healthfirst Essential Plan	$87.41
Rate for Payer: Healthfirst QHP	$38.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38.85
Rate for Payer: SOMOS Essential	$87.41
Rate for Payer: United Healthcare Commercial	$41.32
Rate for Payer: United Healthcare Essential Plan 1&2	$87.41
Rate for Payer: United Healthcare Essential Plan 3&4	$42.74
Rate for Payer: United Healthcare Medicaid	$38.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38.85

MED PACEMAKER

Facility

$17,846.33

Service Code	HCPCS C1786
Hospital Charge Code	40004036
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$18,738.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9,815.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$10,707.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,923.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$10,261.64
Rate for Payer: EmblemHealth Commercial	$8,923.16
Rate for Payer: Fidelis Medicare Advantage	$18,738.65
Rate for Payer: Group Health Inc Commercial	$8,923.16
Rate for Payer: Group Health Inc Medicare	$6,246.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,923.16
Rate for Payer: Hamaspik Choice Inc Medicare	$8,923.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,600.11

MED PACEMAKER 860

Facility

$17,988.08

Service Code	HCPCS C1785
Hospital Charge Code	40004030
Hospital Revenue Code	275
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$18,887.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9,893.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Brighton Health Commercial	$10,792.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,994.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$10,343.15
Rate for Payer: EmblemHealth Commercial	$8,994.04
Rate for Payer: Fidelis Medicare Advantage	$18,887.48
Rate for Payer: Group Health Inc Commercial	$8,994.04
Rate for Payer: Group Health Inc Medicare	$6,295.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,994.04
Rate for Payer: Hamaspik Choice Inc Medicare	$8,994.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,692.25

MED PACEMAKER M# 3D

Facility

$16,995.83

Service Code	HCPCS C1785
Hospital Charge Code	40004039
Hospital Revenue Code	275
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$17,845.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9,347.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Brighton Health Commercial	$10,197.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,497.92
Rate for Payer: Cigna LocalPlus Benefit Plan	$9,772.60
Rate for Payer: EmblemHealth Commercial	$8,497.92
Rate for Payer: Fidelis Medicare Advantage	$17,845.62
Rate for Payer: Group Health Inc Commercial	$8,497.92
Rate for Payer: Group Health Inc Medicare	$5,948.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,497.92
Rate for Payer: Hamaspik Choice Inc Medicare	$8,497.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,047.29

MED PACEMAKER VITA

Facility

$17,988.08

Service Code	HCPCS C1786
Hospital Charge Code	40004033
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$18,887.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9,893.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$10,792.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,994.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$10,343.15
Rate for Payer: EmblemHealth Commercial	$8,994.04
Rate for Payer: Fidelis Medicare Advantage	$18,887.48
Rate for Payer: Group Health Inc Commercial	$8,994.04
Rate for Payer: Group Health Inc Medicare	$6,295.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,994.04
Rate for Payer: Hamaspik Choice Inc Medicare	$8,994.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,692.25

MEDPOR CUSTOM MID FCE

Facility

$34,825.70

Service Code	HCPCS C1713
Hospital Charge Code	64904131
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$36,566.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19,154.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$20,895.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17,412.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$20,024.78
Rate for Payer: EmblemHealth Commercial	$17,412.85
Rate for Payer: Fidelis Medicare Advantage	$36,566.98
Rate for Payer: Group Health Inc Commercial	$17,412.85
Rate for Payer: Group Health Inc Medicare	$12,189.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$17,412.85
Rate for Payer: Hamaspik Choice Inc Medicare	$17,412.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22,636.70

MEDPOR CUSTOM MID FCE

Facility

$34,825.70

Service Code	HCPCS C1713
Hospital Charge Code	64904131
Hospital Revenue Code	278
Min. Negotiated Rate	$17,412.85
Max. Negotiated Rate	$17,412.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$17,412.85
Rate for Payer: Hamaspik Choice Inc Medicare	$17,412.85

MEDPOR CUSTOM PRI AUG

Facility

$18,260.00

Service Code	HCPCS C1889
Hospital Charge Code	64907482
Hospital Revenue Code	278
Min. Negotiated Rate	$6,391.00
Max. Negotiated Rate	$19,173.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10,043.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9,130.00
Rate for Payer: Aetna Government	$9,130.00
Rate for Payer: Brighton Health Commercial	$10,956.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9,130.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10,499.50
Rate for Payer: EmblemHealth Commercial	$9,130.00
Rate for Payer: Fidelis Medicare Advantage	$19,173.00
Rate for Payer: Group Health Inc Commercial	$9,130.00
Rate for Payer: Group Health Inc Medicare	$6,391.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9,130.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9,130.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,869.00

MEDPOR CUSTOM PRI AUG

Facility

$18,260.00

Service Code	HCPCS C1889
Hospital Charge Code	64907482
Hospital Revenue Code	278
Min. Negotiated Rate	$9,130.00
Max. Negotiated Rate	$9,130.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9,130.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9,130.00

MEDPOR SURGICAL IMPLANT SHEET

Facility

$1,150.00

Service Code	HCPCS C1781
Hospital Charge Code	40209971
Hospital Revenue Code	278
Min. Negotiated Rate	$575.00
Max. Negotiated Rate	$575.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$575.00

Know your out-of-pocket cost for care.

All Charges