St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MMD X-RAY-GLOBAL FEE

Facility

$50.00

Hospital Charge Code	46359035
Hospital Revenue Code	456
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$874.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$694.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25.00
Rate for Payer: Aetna Government	$25.00
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$747.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$635.21
Rate for Payer: EmblemHealth Commercial	$525.00
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	$25.00
Rate for Payer: Hamaspik Choice Inc Medicare	$25.00
Rate for Payer: United Healthcare Commercial	$50.00

MMF 12MM SCREW 4/PK

Facility

$214.00

Service Code	HCPCS C1713
Hospital Charge Code	40201248
Hospital Revenue Code	278
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$107.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$107.00
Rate for Payer: Hamaspik Choice Inc Medicare	$107.00

MMF 12MM SCREW 4/PK

Facility

$214.00

Service Code	HCPCS C1713
Hospital Charge Code	40201248
Hospital Revenue Code	278
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$224.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$117.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$128.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$107.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$123.05
Rate for Payer: EmblemHealth Commercial	$107.00
Rate for Payer: Fidelis Medicare Advantage	$224.70
Rate for Payer: Group Health Inc Commercial	$107.00
Rate for Payer: Group Health Inc Medicare	$74.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$107.00
Rate for Payer: Hamaspik Choice Inc Medicare	$107.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$139.10

MMRV 0.5ML SQ VIAL

Facility

$401.00

Service Code	HCPCS 90710
Hospital Charge Code	41649581
Hospital Revenue Code	636
Min. Negotiated Rate	$112.74
Max. Negotiated Rate	$260.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$161.05
Rate for Payer: Aetna Government	$161.05
Rate for Payer: Affinity Essential Plan 1&2	$112.74
Rate for Payer: Affinity Essential Plan 3&4	$112.74
Rate for Payer: Affinity Medicaid/CHP/HARP	$112.74
Rate for Payer: Brighton Health Commercial	$240.60
Rate for Payer: Cash Price	$161.05
Rate for Payer: Cash Price	$161.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$161.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$200.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.58
Rate for Payer: Elderplan Medicare Advantage	$161.05
Rate for Payer: EmblemHealth Commercial	$161.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$161.05
Rate for Payer: Fidelis Essential Plan Aliesa	$161.05
Rate for Payer: Fidelis Essential Plan QHP	$169.10
Rate for Payer: Fidelis Medicare Advantage	$161.05
Rate for Payer: Fidelis Qualified Health Plan	$169.10
Rate for Payer: Group Health Inc Commercial	$161.05
Rate for Payer: Group Health Inc Medicare	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.50
Rate for Payer: Hamaspik Choice Inc Medicare	$200.50
Rate for Payer: Healthfirst Medicare Advantage	$136.89
Rate for Payer: Healthfirst QHP	$161.05
Rate for Payer: Humana Medicare	$164.27
Rate for Payer: Senior Whole Health Medicare Advantage	$161.05
Rate for Payer: United Healthcare Commercial	$160.00
Rate for Payer: United Healthcare Medicare Advantage	$161.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$128.84
Rate for Payer: Wellcare Medicare	$153.00

MMRV 0.5ML SQ VIAL

Facility

$401.00

Service Code	HCPCS 90710
Hospital Charge Code	41649581
Hospital Revenue Code	636
Min. Negotiated Rate	$200.50
Max. Negotiated Rate	$200.50
Rate for Payer: Cash Price	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.50
Rate for Payer: Hamaspik Choice Inc Medicare	$200.50

MMRV 0.5ML SQ VIAL

Facility

$401.00

Service Code	HCPCS 90710
Hospital Charge Code	41659581
Hospital Revenue Code	636
Min. Negotiated Rate	$200.50
Max. Negotiated Rate	$200.50
Rate for Payer: Cash Price	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.50
Rate for Payer: Hamaspik Choice Inc Medicare	$200.50

MMRV 0.5ML SQ VIAL

Facility

$401.00

Service Code	HCPCS 90710
Hospital Charge Code	41659581
Hospital Revenue Code	636
Min. Negotiated Rate	$112.74
Max. Negotiated Rate	$260.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$161.05
Rate for Payer: Aetna Government	$161.05
Rate for Payer: Affinity Essential Plan 1&2	$112.74
Rate for Payer: Affinity Essential Plan 3&4	$112.74
Rate for Payer: Affinity Medicaid/CHP/HARP	$112.74
Rate for Payer: Brighton Health Commercial	$240.60
Rate for Payer: Cash Price	$161.05
Rate for Payer: Cash Price	$161.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$161.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$200.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.58
Rate for Payer: Elderplan Medicare Advantage	$161.05
Rate for Payer: EmblemHealth Commercial	$161.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$161.05
Rate for Payer: Fidelis Essential Plan Aliesa	$161.05
Rate for Payer: Fidelis Essential Plan QHP	$169.10
Rate for Payer: Fidelis Medicare Advantage	$161.05
Rate for Payer: Fidelis Qualified Health Plan	$169.10
Rate for Payer: Group Health Inc Commercial	$161.05
Rate for Payer: Group Health Inc Medicare	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.50
Rate for Payer: Hamaspik Choice Inc Medicare	$200.50
Rate for Payer: Healthfirst Medicare Advantage	$136.89
Rate for Payer: Healthfirst QHP	$161.05
Rate for Payer: Humana Medicare	$164.27
Rate for Payer: Senior Whole Health Medicare Advantage	$161.05
Rate for Payer: United Healthcare Commercial	$160.00
Rate for Payer: United Healthcare Medicare Advantage	$161.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$128.84
Rate for Payer: Wellcare Medicare	$153.00

MMR VACCINE SC

Facility

$47.18

Service Code	HCPCS 90707
Hospital Charge Code	30301213
Hospital Revenue Code	636
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$23.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.59
Rate for Payer: Hamaspik Choice Inc Medicare	$23.59

MMR VACCINE SC

Facility

$47.18

Service Code	HCPCS 90707
Hospital Charge Code	30301213
Hospital Revenue Code	636
Min. Negotiated Rate	$16.51
Max. Negotiated Rate	$89.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$89.72
Rate for Payer: Aetna Government	$89.72
Rate for Payer: Brighton Health Commercial	$28.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.13
Rate for Payer: Group Health Inc Commercial	$23.59
Rate for Payer: Group Health Inc Medicare	$16.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.59
Rate for Payer: Hamaspik Choice Inc Medicare	$23.59
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30.67

MMR VACC (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90707
Hospital Charge Code	41659588
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

MMR VACC (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90707
Hospital Charge Code	41649588
Hospital Revenue Code	636
Max. Negotiated Rate	$89.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$89.72
Rate for Payer: Aetna Government	$89.72
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

MMR VACC (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90707
Hospital Charge Code	41659588
Hospital Revenue Code	636
Max. Negotiated Rate	$89.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$89.72
Rate for Payer: Aetna Government	$89.72
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

MMR VACC (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90707
Hospital Charge Code	41649588
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

MMRV (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90710
Hospital Charge Code	41659574
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$169.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$161.05
Rate for Payer: Aetna Government	$161.05
Rate for Payer: Affinity Essential Plan 1&2	$112.74
Rate for Payer: Affinity Essential Plan 3&4	$112.74
Rate for Payer: Affinity Medicaid/CHP/HARP	$112.74
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cash Price	$161.05
Rate for Payer: Cash Price	$161.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$161.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Elderplan Medicare Advantage	$161.05
Rate for Payer: EmblemHealth Commercial	$161.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$161.05
Rate for Payer: Fidelis Essential Plan Aliesa	$161.05
Rate for Payer: Fidelis Essential Plan QHP	$169.10
Rate for Payer: Fidelis Medicare Advantage	$161.05
Rate for Payer: Fidelis Qualified Health Plan	$169.10
Rate for Payer: Group Health Inc Commercial	$161.05
Rate for Payer: Group Health Inc Medicare	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: Healthfirst Medicare Advantage	$136.89
Rate for Payer: Healthfirst QHP	$161.05
Rate for Payer: Humana Medicare	$164.27
Rate for Payer: Senior Whole Health Medicare Advantage	$161.05
Rate for Payer: United Healthcare Commercial	$160.00
Rate for Payer: United Healthcare Medicare Advantage	$161.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01
Rate for Payer: Wellcare CHP/FHP/Medicaid	$128.84
Rate for Payer: Wellcare Medicare	$153.00

MMRV (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90710
Hospital Charge Code	41659574
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

MMRV (VFC) O.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90710
Hospital Charge Code	41649574
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$169.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$161.05
Rate for Payer: Aetna Government	$161.05
Rate for Payer: Affinity Essential Plan 1&2	$112.74
Rate for Payer: Affinity Essential Plan 3&4	$112.74
Rate for Payer: Affinity Medicaid/CHP/HARP	$112.74
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cash Price	$161.05
Rate for Payer: Cash Price	$161.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$161.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Elderplan Medicare Advantage	$161.05
Rate for Payer: EmblemHealth Commercial	$161.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$161.05
Rate for Payer: Fidelis Essential Plan Aliesa	$161.05
Rate for Payer: Fidelis Essential Plan QHP	$169.10
Rate for Payer: Fidelis Medicare Advantage	$161.05
Rate for Payer: Fidelis Qualified Health Plan	$169.10
Rate for Payer: Group Health Inc Commercial	$161.05
Rate for Payer: Group Health Inc Medicare	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: Healthfirst Medicare Advantage	$136.89
Rate for Payer: Healthfirst QHP	$161.05
Rate for Payer: Humana Medicare	$164.27
Rate for Payer: Senior Whole Health Medicare Advantage	$161.05
Rate for Payer: United Healthcare Commercial	$160.00
Rate for Payer: United Healthcare Medicare Advantage	$161.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01
Rate for Payer: Wellcare CHP/FHP/Medicaid	$128.84
Rate for Payer: Wellcare Medicare	$153.00

MMRV (VFC) O.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90710
Hospital Charge Code	41649574
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$161.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

MMTP STANDARD VISIT

Facility

$0.01

Service Code	HCPCS 99213
Hospital Charge Code	30400363
Hospital Revenue Code	510
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$39.90
Rate for Payer: Aetna Government	$39.90
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
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	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$222.00

MNPJ OF TMJ W/ANESTH

Facility

$4,086.83

Service Code	HCPCS 21073
Hospital Charge Code	40005000
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,763.60

MNPJ OF TMJ W/ANESTH

Facility

$4,086.83

Service Code	HCPCS 21073
Hospital Charge Code	40005000
Hospital Revenue Code	360
Min. Negotiated Rate	$780.00
Max. Negotiated Rate	$3,065.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,763.60
Rate for Payer: Aetna Government	$1,763.60
Rate for Payer: Affinity Essential Plan 1&2	$1,234.52
Rate for Payer: Affinity Essential Plan 3&4	$1,234.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,234.52
Rate for Payer: Brighton Health Commercial	$3,065.12
Rate for Payer: Cash Price	$1,763.60
Rate for Payer: Cash Price	$1,763.60
Rate for Payer: Cash Price	$1,763.60
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,763.60
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	$1,763.60
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$1,499.06
Rate for Payer: Fidelis Essential Plan QHP	$1,569.60
Rate for Payer: Fidelis Medicare Advantage	$1,763.60
Rate for Payer: Fidelis Qualified Health Plan	$1,569.60
Rate for Payer: Group Health Inc Commercial	$1,763.60
Rate for Payer: Group Health Inc Medicare	$1,763.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,043.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1,763.60
Rate for Payer: Healthfirst Medicare Advantage	$1,499.06
Rate for Payer: Healthfirst QHP	$1,763.60
Rate for Payer: Humana Medicare	$1,798.87
Rate for Payer: Senior Whole Health Medicare Advantage	$1,763.60
Rate for Payer: United Healthcare Commercial	$1,409.00
Rate for Payer: United Healthcare Medicare Advantage	$1,763.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,763.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,410.88
Rate for Payer: Wellcare Medicare	$1,675.42

MOBILIZATION ERUPT/MALPOS TOOTH

Facility

$350.00

Service Code	HCPCS D7282
Hospital Charge Code	42303446
Hospital Revenue Code	361
Min. Negotiated Rate	$64.33
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$64.33
Rate for Payer: Aetna Government	$64.33
Rate for Payer: Brighton Health Commercial	$262.50
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	$175.00
Rate for Payer: Group Health Inc Medicare	$122.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

MOD CS BY SAME PHYS 5 YEARS +

Facility

$73.20

Service Code	HCPCS 99152
Hospital Charge Code	40019683
Hospital Revenue Code	370
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$58.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.66
Rate for Payer: Aetna Government	$10.66
Rate for Payer: Brighton Health Commercial	$54.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.78
Rate for Payer: Group Health Inc Commercial	$36.60
Rate for Payer: Group Health Inc Medicare	$25.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.60
Rate for Payer: Hamaspik Choice Inc Medicare	$36.60

MOD CS BY SAME PHYS 5 YEARS+

Facility

$73.20

Service Code	HCPCS 99152
Hospital Charge Code	30103255
Hospital Revenue Code	370
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$58.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.66
Rate for Payer: Aetna Government	$10.66
Rate for Payer: Brighton Health Commercial	$54.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.78
Rate for Payer: Group Health Inc Commercial	$36.60
Rate for Payer: Group Health Inc Medicare	$25.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.60
Rate for Payer: Hamaspik Choice Inc Medicare	$36.60

MOD CS BY SAME PHYS< 5 YEARS

Facility

$73.20

Service Code	HCPCS 99151
Hospital Charge Code	40019682
Hospital Revenue Code	370
Min. Negotiated Rate	$20.49
Max. Negotiated Rate	$58.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.49
Rate for Payer: Aetna Government	$20.49
Rate for Payer: Brighton Health Commercial	$54.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.78
Rate for Payer: Group Health Inc Commercial	$36.60
Rate for Payer: Group Health Inc Medicare	$25.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.60
Rate for Payer: Hamaspik Choice Inc Medicare	$36.60

MOD CS DIFF PHYS < 5 YRS

Facility

$135.05

Service Code	HCPCS 99155
Hospital Charge Code	30103326
Hospital Revenue Code	379
Min. Negotiated Rate	$47.27
Max. Negotiated Rate	$108.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$74.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$80.29
Rate for Payer: Aetna Government	$80.29
Rate for Payer: Brighton Health Commercial	$101.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$108.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$91.83
Rate for Payer: Group Health Inc Commercial	$67.52
Rate for Payer: Group Health Inc Medicare	$47.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$67.52
Rate for Payer: Hamaspik Choice Inc Medicare	$67.52

Know your out-of-pocket cost for care.

All Charges