St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OBSTETRIC BLOOD TEST PANEL

Facility

$0.01

Service Code	HCPCS 80055
Hospital Charge Code	40609636
Hospital Revenue Code	300
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$66.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.81
Rate for Payer: Aetna Government	$47.81
Rate for Payer: Affinity Essential Plan 1&2	$33.47
Rate for Payer: Affinity Essential Plan 3&4	$33.47
Rate for Payer: Affinity Medicaid/CHP/HARP	$33.47
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cash Price	$47.81
Rate for Payer: Cash Price	$47.81
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$47.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$66.79
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.52
Rate for Payer: Elderplan Medicare Advantage	$47.81
Rate for Payer: EmblemHealth Commercial	$47.81
Rate for Payer: Fidelis Essential Plan Aliesa	$40.64
Rate for Payer: Fidelis Essential Plan QHP	$42.55
Rate for Payer: Fidelis Medicare Advantage	$47.81
Rate for Payer: Fidelis Qualified Health Plan	$42.55
Rate for Payer: Group Health Inc Commercial	$47.81
Rate for Payer: Group Health Inc Medicare	$47.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$47.81
Rate for Payer: Healthfirst Medicare Advantage	$47.81
Rate for Payer: Healthfirst QHP	$47.81
Rate for Payer: Humana Medicare	$48.77
Rate for Payer: Senior Whole Health Medicare Advantage	$47.81
Rate for Payer: United Healthcare Commercial	$53.21
Rate for Payer: United Healthcare Medicare Advantage	$47.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$47.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38.25
Rate for Payer: Wellcare Medicare	$43.03

OBSTETRIC BLOOD TEST PANEL

Facility

$0.01

Service Code	HCPCS 80055
Hospital Charge Code	40609636
Hospital Revenue Code	300
Rate for Payer: Cash Price	$47.81

OBSTURCTION TRAY (RU)

Facility

$38.63

Hospital Charge Code	40207817
Hospital Revenue Code	270
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$30.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.32
Rate for Payer: Aetna Government	$19.32
Rate for Payer: Brighton Health Commercial	$28.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.27
Rate for Payer: Group Health Inc Commercial	$19.32
Rate for Payer: Group Health Inc Medicare	$13.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.32
Rate for Payer: Hamaspik Choice Inc Medicare	$19.32

OBTAINING SCREEN PAP SMEAR

Facility

$69.63

Service Code	HCPCS Q0091
Hospital Charge Code	30303203
Hospital Revenue Code	923
Rate for Payer: Cash Price	$34.43

OBTAINING SCREEN PAP SMEAR

Facility

$69.63

Service Code	HCPCS Q0091
Hospital Charge Code	30303203
Hospital Revenue Code	923
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$55.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34.43
Rate for Payer: Aetna Government	$34.43
Rate for Payer: Affinity Essential Plan 1&2	$24.10
Rate for Payer: Affinity Essential Plan 3&4	$24.10
Rate for Payer: Affinity Medicaid/CHP/HARP	$24.10
Rate for Payer: Brighton Health Commercial	$52.22
Rate for Payer: Cash Price	$34.43
Rate for Payer: Cash Price	$34.43
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$34.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.35
Rate for Payer: Elderplan Medicare Advantage	$34.43
Rate for Payer: EmblemHealth Commercial	$34.43
Rate for Payer: Fidelis Essential Plan Aliesa	$29.27
Rate for Payer: Fidelis Essential Plan QHP	$30.64
Rate for Payer: Fidelis Medicare Advantage	$34.43
Rate for Payer: Fidelis Qualified Health Plan	$30.64
Rate for Payer: Group Health Inc Commercial	$34.43
Rate for Payer: Group Health Inc Medicare	$34.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$34.82
Rate for Payer: Hamaspik Choice Inc Medicare	$34.43
Rate for Payer: Healthfirst Medicare Advantage	$29.27
Rate for Payer: Healthfirst QHP	$34.43
Rate for Payer: Humana Medicare	$35.12
Rate for Payer: Senior Whole Health Medicare Advantage	$34.43
Rate for Payer: United Healthcare Commercial	$8.96
Rate for Payer: United Healthcare Medicare Advantage	$34.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$27.54
Rate for Payer: Wellcare Medicare	$32.71

OBTURATOR PROSTHESIS, DEFINITIVE

Facility

$2,826.00

Service Code	HCPCS D5932
Hospital Charge Code	42301295
Hospital Revenue Code	361
Min. Negotiated Rate	$989.10
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,554.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,165.36
Rate for Payer: Aetna Government	$2,165.36
Rate for Payer: Brighton Health Commercial	$2,119.50
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	$1,413.00
Rate for Payer: Group Health Inc Medicare	$989.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,413.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,413.00

OBTURATOR PROSTHESIS, INTERIM

Facility

$1,572.00

Service Code	HCPCS D5936
Hospital Charge Code	42301315
Hospital Revenue Code	361
Min. Negotiated Rate	$550.20
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$864.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,928.63
Rate for Payer: Aetna Government	$1,928.63
Rate for Payer: Brighton Health Commercial	$1,179.00
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	$786.00
Rate for Payer: Group Health Inc Medicare	$550.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$786.00
Rate for Payer: Hamaspik Choice Inc Medicare	$786.00

OBTURATOR PROSTHESIS, MODIFICATIO

Facility

$210.00

Service Code	HCPCS D5933
Hospital Charge Code	42301300
Hospital Revenue Code	361
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$115.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,452.81
Rate for Payer: Aetna Government	$1,452.81
Rate for Payer: Brighton Health Commercial	$157.50
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	$105.00
Rate for Payer: Group Health Inc Medicare	$73.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.00
Rate for Payer: Hamaspik Choice Inc Medicare	$105.00

OBTURATOR PROSTHESIS, SURGICAL

Facility

$1,306.00

Service Code	HCPCS D5931
Hospital Charge Code	42301290
Hospital Revenue Code	361
Min. Negotiated Rate	$457.10
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$718.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,157.60
Rate for Payer: Aetna Government	$1,157.60
Rate for Payer: Brighton Health Commercial	$979.50
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	$653.00
Rate for Payer: Group Health Inc Medicare	$457.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$653.00
Rate for Payer: Hamaspik Choice Inc Medicare	$653.00

OCCIP HDACHE CHILD

Facility

$0.01

Service Code	HCPCS G2195
Hospital Charge Code	30300323
Hospital Revenue Code	929
Max. Negotiated Rate	$94.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
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: United Healthcare Commercial	$94.00

OCCLUSAL GUARD ADJUSTMENT

Facility

$150.00

Service Code	HCPCS D9943
Hospital Charge Code	42303479
Hospital Revenue Code	361
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$82.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$65.54
Rate for Payer: Aetna Government	$65.54
Rate for Payer: Brighton Health Commercial	$112.50
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	$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

OCCLUSAL GUARD –HARD APPLNCE,FULL

Facility

$362.50

Service Code	HCPCS D9944
Hospital Charge Code	42300758
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

OCCLUSAL GUARD –HARD APPLNCE,FULL

Facility

$362.50

Service Code	HCPCS D9944
Hospital Charge Code	42300758
Hospital Revenue Code	361
Min. Negotiated Rate	$181.25
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$199.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$271.88
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$181.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

OCCLUSAL GURD– SOFT APPLNCE,FULL

Facility

$362.50

Service Code	HCPCS D9945
Hospital Charge Code	42300759
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

OCCLUSAL GURD– SOFT APPLNCE,FULL

Facility

$362.50

Service Code	HCPCS D9945
Hospital Charge Code	42300759
Hospital Revenue Code	361
Min. Negotiated Rate	$181.25
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$199.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$271.88
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$181.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

OCCLUSAL ORTHOTIC DEVICE, BY REPO

Facility

$1,357.00

Service Code	HCPCS D7880
Hospital Charge Code	42302030
Hospital Revenue Code	361
Min. Negotiated Rate	$202.78
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$746.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$202.78
Rate for Payer: Aetna Government	$202.78
Rate for Payer: Brighton Health Commercial	$1,017.75
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	$678.50
Rate for Payer: Group Health Inc Medicare	$474.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$678.50
Rate for Payer: Hamaspik Choice Inc Medicare	$678.50

OCCLUSION ADJUSTMENT-COMPLETE

Facility

$1,015.00

Service Code	HCPCS D9952
Hospital Charge Code	42302400
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

OCCLUSION ADJUSTMENT-COMPLETE

Facility

$1,015.00

Service Code	HCPCS D9952
Hospital Charge Code	42302400
Hospital Revenue Code	361
Min. Negotiated Rate	$507.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$558.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$761.25
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$507.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

OCCLUSION ADJUSTMENT-LIMITED

Facility

$173.00

Service Code	HCPCS D9951
Hospital Charge Code	42302395
Hospital Revenue Code	361
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$95.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$129.75
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$86.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

OCCLUSION ADJUSTMENT-LIMITED

Facility

$173.00

Service Code	HCPCS D9951
Hospital Charge Code	42302395
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

OCCLUSION ANAYLSIS-MOUNTED CASE

Facility

$588.00

Service Code	HCPCS D9950
Hospital Charge Code	42302390
Hospital Revenue Code	361
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$323.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$441.00
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$294.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

OCCLUSION ANAYLSIS-MOUNTED CASE

Facility

$588.00

Service Code	HCPCS D9950
Hospital Charge Code	42302390
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

OCC ORTHOTIC DEVICE ADJUST

Facility

$200.00

Service Code	HCPCS D7881
Hospital Charge Code	42303471
Hospital Revenue Code	361
Min. Negotiated Rate	$42.80
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$42.80
Rate for Payer: Aetna Government	$42.80
Rate for Payer: Brighton Health Commercial	$150.00
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	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

OCTREOTIDE 1000 MCG/ML INJ

Facility

$338.00

Service Code	HCPCS J2354
Hospital Charge Code	41642980
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$219.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.95
Rate for Payer: Aetna Government	$0.95
Rate for Payer: Brighton Health Commercial	$202.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$169.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$194.35
Rate for Payer: Group Health Inc Commercial	$169.00
Rate for Payer: Group Health Inc Medicare	$118.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.00
Rate for Payer: Hamaspik Choice Inc Medicare	$169.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.19
Rate for Payer: SOMOS Essential	$1.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$219.70

OCTREOTIDE 1000 MCG/ML INJ

Facility

$338.00

Service Code	HCPCS J2354
Hospital Charge Code	41642980
Hospital Revenue Code	636
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.00
Rate for Payer: Hamaspik Choice Inc Medicare	$169.00

Know your out-of-pocket cost for care.

All Charges