St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

NYSTATIN OINT 15 GRAMS

Facility

$3.82

Hospital Charge Code	41645052
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$3.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.91
Rate for Payer: Aetna Government	$1.91
Rate for Payer: Brighton Health Commercial	$2.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.60
Rate for Payer: Group Health Inc Commercial	$1.91
Rate for Payer: Group Health Inc Medicare	$1.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.91
Rate for Payer: Hamaspik Choice Inc Medicare	$1.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.48

NYSTATIN OINT 15 GRAMS

Facility

$3.82

Hospital Charge Code	41655052
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$3.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.91
Rate for Payer: Aetna Government	$1.91
Rate for Payer: Brighton Health Commercial	$2.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.60
Rate for Payer: Group Health Inc Commercial	$1.91
Rate for Payer: Group Health Inc Medicare	$1.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.91
Rate for Payer: Hamaspik Choice Inc Medicare	$1.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.48

NYSTATIN OINT 30 GRAMS

Facility

$4.00

Hospital Charge Code	41650650
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

NYSTATIN OINT 30 GRAMS

Facility

$4.00

Hospital Charge Code	41640650
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

NYSTATIN POWDER 15 GRAMS

Facility

$6.00

Hospital Charge Code	41650840
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.00
Rate for Payer: Aetna Government	$3.00
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

NYSTATIN POWDER 15 GRAMS

Facility

$6.00

Hospital Charge Code	41640840
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.00
Rate for Payer: Aetna Government	$3.00
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

OAE-LIMITED (SINGLE STIMULUS)

Facility

$766.58

Service Code	HCPCS 92587 TC
Hospital Charge Code	42004517
Hospital Revenue Code	471
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$613.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$421.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$362.98
Rate for Payer: Aetna Government	$362.98
Rate for Payer: Affinity Essential Plan 1&2	$254.09
Rate for Payer: Affinity Essential Plan 3&4	$254.09
Rate for Payer: Affinity Medicaid/CHP/HARP	$254.09
Rate for Payer: Brighton Health Commercial	$574.94
Rate for Payer: Cash Price	$362.98
Rate for Payer: Cash Price	$362.98
Rate for Payer: Cash Price	$362.98
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$362.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$613.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$521.27
Rate for Payer: Elderplan Medicare Advantage	$362.98
Rate for Payer: EmblemHealth Commercial	$362.98
Rate for Payer: Fidelis Essential Plan Aliesa	$308.53
Rate for Payer: Fidelis Essential Plan QHP	$323.05
Rate for Payer: Fidelis Medicare Advantage	$362.98
Rate for Payer: Fidelis Qualified Health Plan	$323.05
Rate for Payer: Group Health Inc Commercial	$362.98
Rate for Payer: Group Health Inc Medicare	$362.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$383.29
Rate for Payer: Hamaspik Choice Inc Medicare	$362.98
Rate for Payer: Healthfirst Medicare Advantage	$308.53
Rate for Payer: Healthfirst QHP	$362.98
Rate for Payer: Humana Medicare	$370.24
Rate for Payer: Senior Whole Health Medicare Advantage	$362.98
Rate for Payer: United Healthcare Commercial	$158.00
Rate for Payer: United Healthcare Medicare Advantage	$362.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$362.98
Rate for Payer: Wellcare CHP/FHP/Medicaid	$290.38
Rate for Payer: Wellcare Medicare	$344.83

OAE-LIMITED (SINGLE STIMULUS)

Facility

$766.58

Service Code	HCPCS 92587 TC
Hospital Charge Code	42004517
Hospital Revenue Code	471
Rate for Payer: Cash Price	$362.98

OASIS BURN MATRIX PER SQ CM

Facility

$20.43

Service Code	HCPCS Q4103
Hospital Charge Code	42500219
Hospital Revenue Code	636
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$10.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.22
Rate for Payer: Hamaspik Choice Inc Medicare	$10.22

OASIS BURN MATRIX PER SQ CM

Facility

$20.43

Service Code	HCPCS Q4103
Hospital Charge Code	42500219
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$13.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.28
Rate for Payer: Aetna Government	$1.28
Rate for Payer: Brighton Health Commercial	$12.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.75
Rate for Payer: Group Health Inc Commercial	$10.22
Rate for Payer: Group Health Inc Medicare	$7.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.22
Rate for Payer: Hamaspik Choice Inc Medicare	$10.22
Rate for Payer: SOMOS CHP/HARP/Medicaid	$13.31
Rate for Payer: SOMOS Essential	$13.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.28

OASIS TRILAYER WOUND MATRIX SQCM

Facility

$20.72

Service Code	HCPCS Q4124
Hospital Charge Code	42500218
Hospital Revenue Code	636
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$13.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.35
Rate for Payer: Aetna Government	$10.35
Rate for Payer: Brighton Health Commercial	$12.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.91
Rate for Payer: Group Health Inc Commercial	$10.36
Rate for Payer: Group Health Inc Medicare	$7.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.36
Rate for Payer: Hamaspik Choice Inc Medicare	$10.36
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.51
Rate for Payer: SOMOS Essential	$9.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.47

OASIS TRILAYER WOUND MATRIX SQCM

Facility

$20.72

Service Code	HCPCS Q4124
Hospital Charge Code	42500218
Hospital Revenue Code	636
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$10.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.36
Rate for Payer: Hamaspik Choice Inc Medicare	$10.36

OASIS ULTRA PER SQ CM

Facility

$28.20

Service Code	HCPCS Q4124
Hospital Charge Code	42500220
Hospital Revenue Code	636
Min. Negotiated Rate	$9.51
Max. Negotiated Rate	$18.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.35
Rate for Payer: Aetna Government	$10.35
Rate for Payer: Brighton Health Commercial	$16.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.22
Rate for Payer: Group Health Inc Commercial	$14.10
Rate for Payer: Group Health Inc Medicare	$9.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.10
Rate for Payer: Hamaspik Choice Inc Medicare	$14.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.51
Rate for Payer: SOMOS Essential	$9.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.33

OASIS ULTRA PER SQ CM

Facility

$28.20

Service Code	HCPCS Q4124
Hospital Charge Code	42500220
Hospital Revenue Code	636
Min. Negotiated Rate	$14.10
Max. Negotiated Rate	$14.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.10
Rate for Payer: Hamaspik Choice Inc Medicare	$14.10

OASIS WOUND MATRIX PER 1 SQ CM

Facility

$48.00

Service Code	HCPCS Q4102
Hospital Charge Code	42500214
Hospital Revenue Code	636
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$31.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.05
Rate for Payer: Aetna Government	$11.05
Rate for Payer: Brighton Health Commercial	$28.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.60
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$13.16
Rate for Payer: SOMOS Essential	$13.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

OASIS WOUND MATRIX PER 1 SQ CM

Facility

$48.00

Service Code	HCPCS Q4102
Hospital Charge Code	42500214
Hospital Revenue Code	636
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$24.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00

OBINUTUZUMAB 1000MG/40ML INJ

Facility

$155.15

Service Code	HCPCS J9301
Hospital Charge Code	41657836
Hospital Revenue Code	636
Min. Negotiated Rate	$49.24
Max. Negotiated Rate	$100.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$85.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.34
Rate for Payer: Aetna Government	$70.34
Rate for Payer: Affinity Essential Plan 1&2	$49.24
Rate for Payer: Affinity Essential Plan 3&4	$49.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.24
Rate for Payer: Brighton Health Commercial	$93.09
Rate for Payer: Cash Price	$70.34
Rate for Payer: Cash Price	$70.34
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$89.21
Rate for Payer: Elderplan Medicare Advantage	$70.34
Rate for Payer: EmblemHealth Commercial	$70.34
Rate for Payer: Fidelis CHP/HARP/Medicaid	$70.34
Rate for Payer: Fidelis Essential Plan Aliesa	$70.34
Rate for Payer: Fidelis Essential Plan QHP	$73.86
Rate for Payer: Fidelis Medicare Advantage	$70.34
Rate for Payer: Fidelis Qualified Health Plan	$73.86
Rate for Payer: Group Health Inc Commercial	$70.34
Rate for Payer: Group Health Inc Medicare	$70.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.58
Rate for Payer: Hamaspik Choice Inc Medicare	$77.58
Rate for Payer: Healthfirst Medicare Advantage	$59.79
Rate for Payer: Healthfirst QHP	$70.34
Rate for Payer: Humana Medicare	$71.75
Rate for Payer: Senior Whole Health Medicare Advantage	$70.34
Rate for Payer: SOMOS CHP/HARP/Medicaid	$74.43
Rate for Payer: SOMOS Essential	$74.43
Rate for Payer: United Healthcare Commercial	$66.95
Rate for Payer: United Healthcare Medicare Advantage	$70.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$100.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.27
Rate for Payer: Wellcare Medicare	$66.82

OBINUTUZUMAB 1000MG/40ML INJ

Facility

$155.15

Service Code	HCPCS J9301
Hospital Charge Code	41657836
Hospital Revenue Code	636
Min. Negotiated Rate	$77.58
Max. Negotiated Rate	$77.58
Rate for Payer: Cash Price	$70.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.58
Rate for Payer: Hamaspik Choice Inc Medicare	$77.58

OBINUTUZUMAB 1000MG/40ML INJ

Facility

$155.15

Service Code	HCPCS J9301
Hospital Charge Code	41647836
Hospital Revenue Code	636
Min. Negotiated Rate	$49.24
Max. Negotiated Rate	$100.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$85.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.34
Rate for Payer: Aetna Government	$70.34
Rate for Payer: Affinity Essential Plan 1&2	$49.24
Rate for Payer: Affinity Essential Plan 3&4	$49.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.24
Rate for Payer: Brighton Health Commercial	$93.09
Rate for Payer: Cash Price	$70.34
Rate for Payer: Cash Price	$70.34
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$89.21
Rate for Payer: Elderplan Medicare Advantage	$70.34
Rate for Payer: EmblemHealth Commercial	$70.34
Rate for Payer: Fidelis CHP/HARP/Medicaid	$70.34
Rate for Payer: Fidelis Essential Plan Aliesa	$70.34
Rate for Payer: Fidelis Essential Plan QHP	$73.86
Rate for Payer: Fidelis Medicare Advantage	$70.34
Rate for Payer: Fidelis Qualified Health Plan	$73.86
Rate for Payer: Group Health Inc Commercial	$70.34
Rate for Payer: Group Health Inc Medicare	$70.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.58
Rate for Payer: Hamaspik Choice Inc Medicare	$77.58
Rate for Payer: Healthfirst Medicare Advantage	$59.79
Rate for Payer: Healthfirst QHP	$70.34
Rate for Payer: Humana Medicare	$71.75
Rate for Payer: Senior Whole Health Medicare Advantage	$70.34
Rate for Payer: SOMOS CHP/HARP/Medicaid	$74.43
Rate for Payer: SOMOS Essential	$74.43
Rate for Payer: United Healthcare Commercial	$66.95
Rate for Payer: United Healthcare Medicare Advantage	$70.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$100.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.27
Rate for Payer: Wellcare Medicare	$66.82

OBINUTUZUMAB 1000MG/40ML INJ

Facility

$155.15

Service Code	HCPCS J9301
Hospital Charge Code	41647836
Hospital Revenue Code	636
Min. Negotiated Rate	$77.58
Max. Negotiated Rate	$77.58
Rate for Payer: Cash Price	$70.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.58
Rate for Payer: Hamaspik Choice Inc Medicare	$77.58

OBINUTUZUMAB 1000 MG/40ML IV SOLN [124767]

Facility

$247.26

Service Code	HCPCS J9301
Hospital Charge Code	50242007001
Hospital Revenue Code	278
Min. Negotiated Rate	$123.63
Max. Negotiated Rate	$123.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.63
Rate for Payer: Hamaspik Choice Inc Medicare	$123.63

OBINUTUZUMAB 1000 MG/40ML IV SOLN [124767]

Facility

$247.26

Service Code	HCPCS J9301
Hospital Charge Code	50242007001
Hospital Revenue Code	278
Min. Negotiated Rate	$56.27
Max. Negotiated Rate	$160.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$135.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.34
Rate for Payer: Aetna Government	$70.34
Rate for Payer: Brighton Health Commercial	$148.35
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$123.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.17
Rate for Payer: Elderplan Medicare Advantage	$70.34
Rate for Payer: EmblemHealth Commercial	$123.63
Rate for Payer: Fidelis Medicare Advantage	$70.34
Rate for Payer: Group Health Inc Commercial	$70.34
Rate for Payer: Group Health Inc Medicare	$70.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.63
Rate for Payer: Hamaspik Choice Inc Medicare	$123.63
Rate for Payer: Healthfirst Medicare Advantage	$59.79
Rate for Payer: Healthfirst QHP	$70.34
Rate for Payer: Humana Medicare	$71.75
Rate for Payer: Senior Whole Health Medicare Advantage	$70.34
Rate for Payer: United Healthcare Medicare Advantage	$70.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$160.72
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.27

OBLIQUE L-PLT 3X4H RGHT

Facility

$572.00

Service Code	HCPCS C1713
Hospital Charge Code	40205292
Hospital Revenue Code	278
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$286.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$286.00
Rate for Payer: Hamaspik Choice Inc Medicare	$286.00

OBLIQUE L-PLT 3X4H RGHT

Facility

$572.00

Service Code	HCPCS C1713
Hospital Charge Code	40205292
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$600.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$314.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$343.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$286.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$328.90
Rate for Payer: EmblemHealth Commercial	$286.00
Rate for Payer: Fidelis Medicare Advantage	$600.60
Rate for Payer: Group Health Inc Commercial	$286.00
Rate for Payer: Group Health Inc Medicare	$200.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$286.00
Rate for Payer: Hamaspik Choice Inc Medicare	$286.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$371.80

OBSERVATION PER HOUR

Facility

$115.00

Service Code	HCPCS G0378
Hospital Charge Code	30105155
Hospital Revenue Code	762
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2,500.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$835.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.68
Rate for Payer: Aetna Government	$1.68
Rate for Payer: Brighton Health Commercial	$1,927.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,983.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,685.77
Rate for Payer: Group Health Inc Commercial	$57.50
Rate for Payer: Group Health Inc Medicare	$40.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$57.50
Rate for Payer: Hamaspik Choice Inc Medicare	$57.50
Rate for Payer: Healthfirst Medicare Advantage	$2,500.00
Rate for Payer: United Healthcare Commercial	$2,278.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$350.00

Know your out-of-pocket cost for care.

All Charges