St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MEDS RECONCILE W/CURRENT MEDS

Facility

$10.00

Service Code	HCPCS 1111F
Hospital Charge Code	30305575
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 STERILE CABLE

Facility

$70.88

Hospital Charge Code	40004035
Hospital Revenue Code	279
Min. Negotiated Rate	$24.81
Max. Negotiated Rate	$56.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.44
Rate for Payer: Aetna Government	$35.44
Rate for Payer: Brighton Health Commercial	$53.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$48.20
Rate for Payer: Group Health Inc Commercial	$35.44
Rate for Payer: Group Health Inc Medicare	$24.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.44
Rate for Payer: Hamaspik Choice Inc Medicare	$35.44

MED STRUT

Facility

$4,562.50

Service Code	HCPCS C1713
Hospital Charge Code	64903335
Hospital Revenue Code	278
Min. Negotiated Rate	$2,281.25
Max. Negotiated Rate	$2,281.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$2,281.25

MED STRUT

Facility

$4,562.50

Service Code	HCPCS C1713
Hospital Charge Code	64903335
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,790.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,509.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,737.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,281.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,623.44
Rate for Payer: EmblemHealth Commercial	$2,281.25
Rate for Payer: Fidelis Medicare Advantage	$4,790.62
Rate for Payer: Group Health Inc Commercial	$2,281.25
Rate for Payer: Group Health Inc Medicare	$1,596.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$2,281.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,965.62

MED SUR MISC CHRG

Facility

$1,709.86

Hospital Charge Code	40209999
Hospital Revenue Code	270
Min. Negotiated Rate	$598.45
Max. Negotiated Rate	$1,367.89
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$940.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$854.93
Rate for Payer: Aetna Government	$854.93
Rate for Payer: Brighton Health Commercial	$1,282.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,367.89
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,162.70
Rate for Payer: Group Health Inc Commercial	$854.93
Rate for Payer: Group Health Inc Medicare	$598.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$854.93
Rate for Payer: Hamaspik Choice Inc Medicare	$854.93

MEDTR LEAD INTRO KIT

Facility

$560.00

Service Code	HCPCS C1893
Hospital Charge Code	40008307
Hospital Revenue Code	272
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$448.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$308.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.60
Rate for Payer: Aetna Government	$2.60
Rate for Payer: Brighton Health Commercial	$420.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$448.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$380.80
Rate for Payer: Group Health Inc Commercial	$280.00
Rate for Payer: Group Health Inc Medicare	$196.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$280.00
Rate for Payer: Hamaspik Choice Inc Medicare	$280.00

MEDTRON CAP NOVUS 45CM LEAD 5076

Facility

$1,700.00

Service Code	HCPCS C1898
Hospital Charge Code	66573137
Hospital Revenue Code	278
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$1,785.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$935.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$1,020.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$850.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$977.50
Rate for Payer: EmblemHealth Commercial	$850.00
Rate for Payer: Fidelis Medicare Advantage	$1,785.00
Rate for Payer: Group Health Inc Commercial	$850.00
Rate for Payer: Group Health Inc Medicare	$595.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$850.00
Rate for Payer: Hamaspik Choice Inc Medicare	$850.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,105.00

MEDTRON CAP NOVUS 45CM LEAD 5076

Facility

$1,700.00

Service Code	HCPCS C1898
Hospital Charge Code	66573137
Hospital Revenue Code	278
Min. Negotiated Rate	$850.00
Max. Negotiated Rate	$850.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$850.00
Rate for Payer: Hamaspik Choice Inc Medicare	$850.00

MEDTRON CAPSUREFIX 65CM LEAD

Facility

$900.00

Service Code	HCPCS C1898
Hospital Charge Code	66573271
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$495.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$540.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.50
Rate for Payer: EmblemHealth Commercial	$450.00
Rate for Payer: Fidelis Medicare Advantage	$945.00
Rate for Payer: Group Health Inc Commercial	$450.00
Rate for Payer: Group Health Inc Medicare	$315.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$585.00

MEDTRON CAPSURE LEAD 4574-45

Facility

$900.00

Service Code	HCPCS C1898
Hospital Charge Code	66573447
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$495.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$540.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.50
Rate for Payer: EmblemHealth Commercial	$450.00
Rate for Payer: Fidelis Medicare Advantage	$945.00
Rate for Payer: Group Health Inc Commercial	$450.00
Rate for Payer: Group Health Inc Medicare	$315.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$585.00

MEDTRON CAPSURE SENSE LEAD 407458

Facility

$1,248.00

Service Code	HCPCS C1898
Hospital Charge Code	66576695
Hospital Revenue Code	278
Min. Negotiated Rate	$624.00
Max. Negotiated Rate	$624.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$624.00
Rate for Payer: Hamaspik Choice Inc Medicare	$624.00

MEDTRON CAPSURE SENSE LEAD 407458

Facility

$1,248.00

Service Code	HCPCS C1898
Hospital Charge Code	66576695
Hospital Revenue Code	278
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$1,310.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$686.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$748.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$624.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$717.60
Rate for Payer: EmblemHealth Commercial	$624.00
Rate for Payer: Fidelis Medicare Advantage	$1,310.40
Rate for Payer: Group Health Inc Commercial	$624.00
Rate for Payer: Group Health Inc Medicare	$436.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$624.00
Rate for Payer: Hamaspik Choice Inc Medicare	$624.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$811.20

MEDTRON CASURE SENSE LEAD 4574-45

Facility

$22,868.00

Service Code	HCPCS C1898
Hospital Charge Code	34476657
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$24,011.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12,577.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$13,720.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11,434.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$13,149.10
Rate for Payer: EmblemHealth Commercial	$11,434.00
Rate for Payer: Fidelis Medicare Advantage	$24,011.40
Rate for Payer: Group Health Inc Commercial	$11,434.00
Rate for Payer: Group Health Inc Medicare	$8,003.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$11,434.00
Rate for Payer: Hamaspik Choice Inc Medicare	$11,434.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14,864.20

MEDTRON CASURE SENSE LEAD 4574-53

Facility

$900.00

Service Code	HCPCS C1898
Hospital Charge Code	66573448
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$495.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$540.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.50
Rate for Payer: EmblemHealth Commercial	$450.00
Rate for Payer: Fidelis Medicare Advantage	$945.00
Rate for Payer: Group Health Inc Commercial	$450.00
Rate for Payer: Group Health Inc Medicare	$315.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$585.00

MEDTRON EVERA MRI XT DR DDMB1D4

Facility

$32,130.00

Service Code	HCPCS C1721
Hospital Charge Code	66573166
Hospital Revenue Code	275
Min. Negotiated Rate	$5,000.00
Max. Negotiated Rate	$33,736.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17,671.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,000.00
Rate for Payer: Aetna Government	$5,000.00
Rate for Payer: Brighton Health Commercial	$19,278.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16,065.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$18,474.75
Rate for Payer: EmblemHealth Commercial	$16,065.00
Rate for Payer: Fidelis Medicare Advantage	$33,736.50
Rate for Payer: Group Health Inc Commercial	$16,065.00
Rate for Payer: Group Health Inc Medicare	$11,245.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$16,065.00
Rate for Payer: Hamaspik Choice Inc Medicare	$16,065.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20,884.50

MEDTRONIC 5833SL DISP SURG CABLE

Facility

$150.00

Hospital Charge Code	40205149
Hospital Revenue Code	270
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$120.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$82.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$75.00
Rate for Payer: Aetna Government	$75.00
Rate for Payer: Brighton Health Commercial	$112.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$120.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$102.00
Rate for Payer: Group Health Inc Commercial	$75.00
Rate for Payer: Group Health Inc Medicare	$52.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$75.00
Rate for Payer: Hamaspik Choice Inc Medicare	$75.00

MEDTRONIC ADVISA SR MRI A3SR01

Facility

$8,950.20

Service Code	HCPCS C1786
Hospital Charge Code	66576682
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$9,397.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,922.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$5,370.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,475.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,146.36
Rate for Payer: EmblemHealth Commercial	$4,475.10
Rate for Payer: Fidelis Medicare Advantage	$9,397.71
Rate for Payer: Group Health Inc Commercial	$4,475.10
Rate for Payer: Group Health Inc Medicare	$3,132.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,475.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4,475.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,817.63

MEDTRONIC AMPLIA CRT

Facility

$42,320.00

Service Code	HCPCS C1882
Hospital Charge Code	66571497
Hospital Revenue Code	275
Min. Negotiated Rate	$4,752.01
Max. Negotiated Rate	$44,436.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23,276.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,752.01
Rate for Payer: Aetna Government	$4,752.01
Rate for Payer: Brighton Health Commercial	$25,392.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21,160.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$24,334.00
Rate for Payer: EmblemHealth Commercial	$21,160.00
Rate for Payer: Fidelis Medicare Advantage	$44,436.00
Rate for Payer: Group Health Inc Commercial	$21,160.00
Rate for Payer: Group Health Inc Medicare	$14,812.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,160.00
Rate for Payer: Hamaspik Choice Inc Medicare	$21,160.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27,508.00

MEDTRONIC ATRIAL LEAD 4592-53CM

Facility

$1,500.00

Service Code	HCPCS C1785
Hospital Charge Code	40201134
Hospital Revenue Code	278
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$1,575.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$825.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Brighton Health Commercial	$900.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$862.50
Rate for Payer: EmblemHealth Commercial	$750.00
Rate for Payer: Fidelis Medicare Advantage	$1,575.00
Rate for Payer: Group Health Inc Commercial	$750.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$975.00

MEDTRONIC ATRIAL LEAD 4592-53CM

Facility

$1,500.00

Service Code	HCPCS C1785
Hospital Charge Code	40201134
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$750.00

MEDTRONIC ATRIAL LEAD 53CM

Facility

$1,950.00

Service Code	HCPCS C1785
Hospital Charge Code	40209942
Hospital Revenue Code	278
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

MEDTRONIC ATRIAL LEAD 53CM

Facility

$1,950.00

Service Code	HCPCS C1785
Hospital Charge Code	40209942
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

MEDTRONIC AZUME S SR MRI W3SR01

Facility

$8,950.00

Service Code	HCPCS C1786
Hospital Charge Code	66573445
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$9,397.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,922.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$5,370.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,475.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,146.25
Rate for Payer: EmblemHealth Commercial	$4,475.00
Rate for Payer: Fidelis Medicare Advantage	$9,397.50
Rate for Payer: Group Health Inc Commercial	$4,475.00
Rate for Payer: Group Health Inc Medicare	$3,132.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,475.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,475.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,817.50

MEDTRONIC AZURE XT DR MRI

Facility

$10,450.00

Service Code	HCPCS C1785
Hospital Charge Code	66573342
Hospital Revenue Code	275
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$10,972.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,747.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Brighton Health Commercial	$6,270.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,225.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,008.75
Rate for Payer: EmblemHealth Commercial	$5,225.00
Rate for Payer: Fidelis Medicare Advantage	$10,972.50
Rate for Payer: Group Health Inc Commercial	$5,225.00
Rate for Payer: Group Health Inc Medicare	$3,657.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,225.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,225.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,792.50

MEDTRONIC AZURE XT SR MRI W1SR01

Facility

$9,150.00

Service Code	HCPCS C1786
Hospital Charge Code	66576563
Hospital Revenue Code	275
Min. Negotiated Rate	$1,116.69
Max. Negotiated Rate	$9,607.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,032.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,116.69
Rate for Payer: Aetna Government	$1,116.69
Rate for Payer: Brighton Health Commercial	$5,490.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,575.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,261.25
Rate for Payer: EmblemHealth Commercial	$4,575.00
Rate for Payer: Fidelis Medicare Advantage	$9,607.50
Rate for Payer: Group Health Inc Commercial	$4,575.00
Rate for Payer: Group Health Inc Medicare	$3,202.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,575.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,947.50

Know your out-of-pocket cost for care.

All Charges