St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OFFICE CONSULTATION LEVEL4

Facility

$528.33

Service Code	HCPCS 99244
Hospital Charge Code	40500005
Hospital Revenue Code	510
Min. Negotiated Rate	$113.18
Max. Negotiated Rate	$290.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$290.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$113.18
Rate for Payer: Aetna Government	$113.18
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	$264.16
Rate for Payer: Hamaspik Choice Inc Medicare	$264.16
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE CONSULTATION LEVEL 5

Facility

$559.74

Service Code	HCPCS 99245
Hospital Charge Code	40509883
Hospital Revenue Code	510
Min. Negotiated Rate	$139.91
Max. Negotiated Rate	$307.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$307.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$139.91
Rate for Payer: Aetna Government	$139.91
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	$279.87
Rate for Payer: Hamaspik Choice Inc Medicare	$279.87
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE CONSULT COMP HIGH COMPLEX

Facility

$592.71

Hospital Charge Code	30300120
Hospital Revenue Code	510
Min. Negotiated Rate	$173.89
Max. Negotiated Rate	$325.99
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$325.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$296.36
Rate for Payer: Aetna Government	$296.36
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	$296.36
Rate for Payer: Hamaspik Choice Inc Medicare	$296.36
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE CONSULT COMP MOD COMPLEX

Facility

$447.79

Hospital Charge Code	30300119
Hospital Revenue Code	510
Min. Negotiated Rate	$173.89
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$246.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$223.90
Rate for Payer: Aetna Government	$223.90
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	$223.90
Rate for Payer: Hamaspik Choice Inc Medicare	$223.90
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE CONSULT COMP MOD COMPLEX

Facility

$528.33

Service Code	HCPCS 99244
Hospital Charge Code	30300066
Hospital Revenue Code	510
Min. Negotiated Rate	$113.18
Max. Negotiated Rate	$290.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$290.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$113.18
Rate for Payer: Aetna Government	$113.18
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	$264.16
Rate for Payer: Hamaspik Choice Inc Medicare	$264.16
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE CONSULT NEW/EST EXPAND HIS

Facility

$395.39

Service Code	HCPCS 99242
Hospital Charge Code	30300051
Hospital Revenue Code	510
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$50.34
Rate for Payer: Aetna Government	$50.34
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	$197.70
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE/OP CONSULT NEW/EST PT

Facility

$479.51

Service Code	HCPCS 99243
Hospital Charge Code	30300058
Hospital Revenue Code	510
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$263.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$263.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.38
Rate for Payer: Aetna Government	$70.38
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	$239.76
Rate for Payer: Hamaspik Choice Inc Medicare	$239.76
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST HI 40-54 MIN

Facility

$457.71

Service Code	HCPCS 99215
Hospital Charge Code	30400214
Hospital Revenue Code	510
Min. Negotiated Rate	$80.96
Max. Negotiated Rate	$251.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$251.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$80.96
Rate for Payer: Aetna Government	$80.96
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	$228.86
Rate for Payer: Hamaspik Choice Inc Medicare	$228.86
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST HI 40-54 MIN

Facility

$457.71

Service Code	HCPCS 99215
Hospital Charge Code	42500108
Hospital Revenue Code	510
Min. Negotiated Rate	$80.96
Max. Negotiated Rate	$251.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$251.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$80.96
Rate for Payer: Aetna Government	$80.96
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	$228.86
Rate for Payer: Hamaspik Choice Inc Medicare	$228.86
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST HI 40-54MIN

Facility

$457.71

Service Code	HCPCS 99215
Hospital Charge Code	30300118
Hospital Revenue Code	510
Min. Negotiated Rate	$80.96
Max. Negotiated Rate	$251.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$251.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$80.96
Rate for Payer: Aetna Government	$80.96
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	$228.86
Rate for Payer: Hamaspik Choice Inc Medicare	$228.86
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST HI40-54 MIN

Facility

$457.71

Service Code	HCPCS 99215
Hospital Charge Code	30300065
Hospital Revenue Code	510
Min. Negotiated Rate	$80.96
Max. Negotiated Rate	$251.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$251.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$80.96
Rate for Payer: Aetna Government	$80.96
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	$228.86
Rate for Payer: Hamaspik Choice Inc Medicare	$228.86
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST HI 40-54MIN,MOD25

Facility

$479.51

Service Code	HCPCS 99215 25
Hospital Charge Code	42500109
Hospital Revenue Code	510
Min. Negotiated Rate	$106.36
Max. Negotiated Rate	$263.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$263.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$106.36
Rate for Payer: Aetna Government	$106.36
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	$239.76
Rate for Payer: Hamaspik Choice Inc Medicare	$239.76
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW 20-29 MIN

Facility

$415.16

Service Code	HCPCS 99213
Hospital Charge Code	42500124
Hospital Revenue Code	510
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
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	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW 20-29 MIN

Facility

$415.16

Service Code	HCPCS 99213
Hospital Charge Code	30400074
Hospital Revenue Code	510
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
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	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW 20-29MIN

Facility

$415.16

Service Code	HCPCS 99213
Hospital Charge Code	30400212
Hospital Revenue Code	510
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
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	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW20-29 MIN

Facility

$415.16

Service Code	HCPCS 99213
Hospital Charge Code	42500104
Hospital Revenue Code	510
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
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	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW 20-29MIN,MOD25

Facility

$415.16

Service Code	HCPCS 99213 25
Hospital Charge Code	42500101
Hospital Revenue Code	510
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.00
Rate for Payer: Aetna Government	$57.00
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	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST LOW 20-29MIN,TELEM

Facility

$395.39

Service Code	HCPCS 99213 95
Hospital Charge Code	30300992
Hospital Revenue Code	510
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.00
Rate for Payer: Aetna Government	$57.00
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	$197.70
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST MINIMAL PROB

Facility

$395.39

Service Code	HCPCS 99211
Hospital Charge Code	42500152
Hospital Revenue Code	510
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$2,020.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.70
Rate for Payer: Aetna Government	$6.70
Rate for Payer: Affinity Essential Plan 1&2	$45.45
Rate for Payer: Affinity Essential Plan 3&4	$45.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.20
Rate for Payer: Amida Care Medicaid	$20.20
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: Fidelis CHP/HARP/Medicaid	$2,020.00
Rate for Payer: Fidelis Essential Plan Aliesa	$20.20
Rate for Payer: Fidelis Essential Plan QHP	$20.20
Rate for Payer: Fidelis Qualified Health Plan	$21.21
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	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.20
Rate for Payer: Healthfirst Essential Plan	$45.45
Rate for Payer: Healthfirst QHP	$20.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20.20
Rate for Payer: SOMOS Essential	$20.20
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$45.45
Rate for Payer: United Healthcare Essential Plan 3&4	$22.22
Rate for Payer: United Healthcare Medicaid	$20.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20.20

OFFICE O/P EST MINIMAL PROB

Facility

$395.39

Service Code	HCPCS 99211
Hospital Charge Code	30400210
Hospital Revenue Code	510
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$2,020.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.70
Rate for Payer: Aetna Government	$6.70
Rate for Payer: Affinity Essential Plan 1&2	$45.45
Rate for Payer: Affinity Essential Plan 3&4	$45.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.20
Rate for Payer: Amida Care Medicaid	$20.20
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: Fidelis CHP/HARP/Medicaid	$2,020.00
Rate for Payer: Fidelis Essential Plan Aliesa	$20.20
Rate for Payer: Fidelis Essential Plan QHP	$20.20
Rate for Payer: Fidelis Qualified Health Plan	$21.21
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	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.20
Rate for Payer: Healthfirst Essential Plan	$45.45
Rate for Payer: Healthfirst QHP	$20.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20.20
Rate for Payer: SOMOS Essential	$20.20
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$45.45
Rate for Payer: United Healthcare Essential Plan 3&4	$22.22
Rate for Payer: United Healthcare Medicaid	$20.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20.20

OFFICE O/P EST MINIMAL PROBL

Facility

$395.39

Service Code	HCPCS 99211
Hospital Charge Code	30300101
Hospital Revenue Code	510
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$2,020.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.70
Rate for Payer: Aetna Government	$6.70
Rate for Payer: Affinity Essential Plan 1&2	$45.45
Rate for Payer: Affinity Essential Plan 3&4	$45.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.20
Rate for Payer: Amida Care Medicaid	$20.20
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: Fidelis CHP/HARP/Medicaid	$2,020.00
Rate for Payer: Fidelis Essential Plan Aliesa	$20.20
Rate for Payer: Fidelis Essential Plan QHP	$20.20
Rate for Payer: Fidelis Qualified Health Plan	$21.21
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	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.20
Rate for Payer: Healthfirst Essential Plan	$45.45
Rate for Payer: Healthfirst QHP	$20.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20.20
Rate for Payer: SOMOS Essential	$20.20
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$45.45
Rate for Payer: United Healthcare Essential Plan 3&4	$22.22
Rate for Payer: United Healthcare Medicaid	$20.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20.20

OFFICE O/P EST MINIMAL PROB,TELEM

Facility

$395.39

Service Code	HCPCS 99211 95
Hospital Charge Code	30300997
Hospital Revenue Code	510
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$2,020.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.83
Rate for Payer: Aetna Government	$14.83
Rate for Payer: Affinity Essential Plan 1&2	$45.45
Rate for Payer: Affinity Essential Plan 3&4	$45.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.20
Rate for Payer: Amida Care Medicaid	$20.20
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: Fidelis CHP/HARP/Medicaid	$2,020.00
Rate for Payer: Fidelis Essential Plan Aliesa	$20.20
Rate for Payer: Fidelis Essential Plan QHP	$20.20
Rate for Payer: Fidelis Qualified Health Plan	$21.21
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	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.20
Rate for Payer: Healthfirst Essential Plan	$45.45
Rate for Payer: Healthfirst QHP	$20.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20.20
Rate for Payer: SOMOS Essential	$20.20
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$45.45
Rate for Payer: United Healthcare Essential Plan 3&4	$22.22
Rate for Payer: United Healthcare Medicaid	$20.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20.20

OFFICE O/P EST MINMAL PROB

Facility

$395.39

Service Code	HCPCS 99211
Hospital Charge Code	30300001
Hospital Revenue Code	510
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$2,020.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.70
Rate for Payer: Aetna Government	$6.70
Rate for Payer: Affinity Essential Plan 1&2	$45.45
Rate for Payer: Affinity Essential Plan 3&4	$45.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.20
Rate for Payer: Amida Care Medicaid	$20.20
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: Fidelis CHP/HARP/Medicaid	$2,020.00
Rate for Payer: Fidelis Essential Plan Aliesa	$20.20
Rate for Payer: Fidelis Essential Plan QHP	$20.20
Rate for Payer: Fidelis Qualified Health Plan	$21.21
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	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$197.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.20
Rate for Payer: Healthfirst Essential Plan	$45.45
Rate for Payer: Healthfirst QHP	$20.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20.20
Rate for Payer: SOMOS Essential	$20.20
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$45.45
Rate for Payer: United Healthcare Essential Plan 3&4	$22.22
Rate for Payer: United Healthcare Medicaid	$20.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20.20

OFFICE O/P EST MOD 30-39 MIN

Facility

$435.92

Service Code	HCPCS 99214
Hospital Charge Code	30400082
Hospital Revenue Code	510
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$54.00
Rate for Payer: Aetna Government	$54.00
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	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P EST MOD 30-39MIN

Facility

$435.92

Service Code	HCPCS 99214
Hospital Charge Code	30400213
Hospital Revenue Code	510
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$54.00
Rate for Payer: Aetna Government	$54.00
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	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

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