St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OSTOMY BELT

Facility

$8.86

Service Code	HCPCS A4367
Hospital Charge Code	40207905
Hospital Revenue Code	272
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.16
Rate for Payer: Aetna Government	$4.16
Rate for Payer: Brighton Health Commercial	$6.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.02
Rate for Payer: Group Health Inc Commercial	$4.43
Rate for Payer: Group Health Inc Medicare	$3.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.43
Rate for Payer: Hamaspik Choice Inc Medicare	$4.43

OSTOMY FACE PLATE

Facility

$5.67

Service Code	HCPCS A4361
Hospital Charge Code	40207901
Hospital Revenue Code	272
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$9.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.49
Rate for Payer: Aetna Government	$9.49
Rate for Payer: Brighton Health Commercial	$4.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.86
Rate for Payer: Group Health Inc Commercial	$2.84
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.84
Rate for Payer: Hamaspik Choice Inc Medicare	$2.84

OSTOMY LIQUID BARRIER

Facility

$11.34

Service Code	HCPCS A4364
Hospital Charge Code	40207903
Hospital Revenue Code	272
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$9.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.79
Rate for Payer: Aetna Government	$1.79
Rate for Payer: Brighton Health Commercial	$8.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.71
Rate for Payer: Group Health Inc Commercial	$5.67
Rate for Payer: Group Health Inc Medicare	$3.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.67
Rate for Payer: Hamaspik Choice Inc Medicare	$5.67

OSTOMY LUBRICANT

Facility

$5.67

Service Code	HCPCS A4402
Hospital Charge Code	40207908
Hospital Revenue Code	272
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$4.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.97
Rate for Payer: Aetna Government	$0.97
Rate for Payer: Brighton Health Commercial	$4.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.86
Rate for Payer: Group Health Inc Commercial	$2.84
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.84
Rate for Payer: Hamaspik Choice Inc Medicare	$2.84

OSTOMY RINGS

Facility

$4.25

Service Code	HCPCS A4404
Hospital Charge Code	40207909
Hospital Revenue Code	272
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$3.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.02
Rate for Payer: Aetna Government	$1.02
Rate for Payer: Brighton Health Commercial	$3.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.89
Rate for Payer: Group Health Inc Commercial	$2.12
Rate for Payer: Group Health Inc Medicare	$1.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.12
Rate for Payer: Hamaspik Choice Inc Medicare	$2.12

OSTOMY SKIN BARRIER

Facility

$11.34

Service Code	HCPCS A4362
Hospital Charge Code	40207902
Hospital Revenue Code	272
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$9.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.11
Rate for Payer: Aetna Government	$2.11
Rate for Payer: Brighton Health Commercial	$8.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.71
Rate for Payer: Group Health Inc Commercial	$5.67
Rate for Payer: Group Health Inc Medicare	$3.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.67
Rate for Payer: Hamaspik Choice Inc Medicare	$5.67

OSTOMY SKIN BOND OR CEMENT,REM

Facility

$8.15

Service Code	HCPCS A4406
Hospital Charge Code	40207906
Hospital Revenue Code	272
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$6.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.48
Rate for Payer: Aetna Government	$3.48
Rate for Payer: Brighton Health Commercial	$6.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.54
Rate for Payer: Group Health Inc Commercial	$4.08
Rate for Payer: Group Health Inc Medicare	$2.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.08
Rate for Payer: Hamaspik Choice Inc Medicare	$4.08

OT ADL TRAINING 15 MTS

Facility

$99.85

Service Code	HCPCS 97535 GO
Hospital Charge Code	41809499
Hospital Revenue Code	430
Min. Negotiated Rate	$21.18
Max. Negotiated Rate	$5,078.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$54.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.18
Rate for Payer: Aetna Government	$21.18
Rate for Payer: Affinity Essential Plan 1&2	$114.26
Rate for Payer: Affinity Essential Plan 3&4	$114.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$50.78
Rate for Payer: Amida Care Medicaid	$50.78
Rate for Payer: Brighton Health Commercial	$182.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$147.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$124.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$5,078.00
Rate for Payer: Fidelis Essential Plan Aliesa	$50.78
Rate for Payer: Fidelis Essential Plan QHP	$50.78
Rate for Payer: Fidelis Qualified Health Plan	$53.32
Rate for Payer: Group Health Inc Commercial	$49.92
Rate for Payer: Group Health Inc Medicare	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.78
Rate for Payer: Hamaspik Choice Inc Medicare	$49.92
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$50.78
Rate for Payer: Healthfirst Essential Plan	$114.26
Rate for Payer: Healthfirst QHP	$50.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$50.78
Rate for Payer: SOMOS Essential	$114.26
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$114.26
Rate for Payer: United Healthcare Essential Plan 3&4	$55.86
Rate for Payer: United Healthcare Medicaid	$50.78
Rate for Payer: Wellcare CHP/FHP/Medicaid	$50.78
Rate for Payer: Wellcare Medicare	$55.00

OT ALGINATE,WOUND CVR PADSZ<16 SQ

Facility

$15.44

Service Code	HCPCS A6197
Hospital Charge Code	41809564
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$12.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.99
Rate for Payer: Aetna Government	$9.99
Rate for Payer: Brighton Health Commercial	$11.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.50
Rate for Payer: Group Health Inc Commercial	$7.72
Rate for Payer: Group Health Inc Medicare	$5.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.72
Rate for Payer: Hamaspik Choice Inc Medicare	$7.72

OT ALIGIN WOUND CVR PAD SZ16SQ.IN

Facility

$15.44

Service Code	HCPCS A6197
Hospital Charge Code	41809565
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$12.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.99
Rate for Payer: Aetna Government	$9.99
Rate for Payer: Brighton Health Commercial	$11.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.50
Rate for Payer: Group Health Inc Commercial	$7.72
Rate for Payer: Group Health Inc Medicare	$5.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.72
Rate for Payer: Hamaspik Choice Inc Medicare	$7.72

OT ANGLED FORK/SPOON

Facility

$34.02

Service Code	HCPCS A9270
Hospital Charge Code	41809526
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$27.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$25.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.13
Rate for Payer: Group Health Inc Commercial	$17.01
Rate for Payer: Group Health Inc Medicare	$11.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.01
Rate for Payer: Hamaspik Choice Inc Medicare	$17.01

OT ANGLED KNIFE

Facility

$20.56

Service Code	HCPCS A9270
Hospital Charge Code	41809527
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$16.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$15.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.98
Rate for Payer: Group Health Inc Commercial	$10.28
Rate for Payer: Group Health Inc Medicare	$7.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.28
Rate for Payer: Hamaspik Choice Inc Medicare	$10.28

OT APPLICATION UNNA BOOT

Facility

$405.08

Service Code	HCPCS 29580
Hospital Charge Code	41801135
Hospital Revenue Code	430
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$182.22
Rate for Payer: Aetna Government	$182.22
Rate for Payer: Affinity Essential Plan 1&2	$127.55
Rate for Payer: Affinity Essential Plan 3&4	$127.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$127.55
Rate for Payer: Brighton Health Commercial	$182.00
Rate for Payer: Cash Price	$182.22
Rate for Payer: Cash Price	$182.22
Rate for Payer: Cash Price	$182.22
Rate for Payer: Cash Price	$182.22
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$182.22
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	$182.22
Rate for Payer: EmblemHealth Commercial	$182.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$182.22
Rate for Payer: Fidelis Essential Plan Aliesa	$154.89
Rate for Payer: Fidelis Essential Plan QHP	$162.18
Rate for Payer: Fidelis Medicare Advantage	$182.22
Rate for Payer: Fidelis Qualified Health Plan	$162.18
Rate for Payer: Group Health Inc Commercial	$182.22
Rate for Payer: Group Health Inc Medicare	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$202.54
Rate for Payer: Hamaspik Choice Inc Medicare	$182.22
Rate for Payer: Healthfirst Medicare Advantage	$154.89
Rate for Payer: Healthfirst QHP	$182.22
Rate for Payer: Humana Medicare	$185.86
Rate for Payer: Senior Whole Health Medicare Advantage	$182.22
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$182.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$182.22
Rate for Payer: Wellcare CHP/FHP/Medicaid	$145.78
Rate for Payer: Wellcare Medicare	$55.00

OT APPLICATION UNNA BOOT

Facility

$405.08

Service Code	HCPCS 29580
Hospital Charge Code	41801135
Hospital Revenue Code	430
Rate for Payer: Cash Price	$182.22

OT BIOFEEDBACK TRG BY ANY MODALIT

Facility

$57.33

Service Code	HCPCS 90901 GP
Hospital Charge Code	41809514
Hospital Revenue Code	420
Min. Negotiated Rate	$28.66
Max. Negotiated Rate	$222.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$96.30
Rate for Payer: Aetna Government	$96.30
Rate for Payer: Brighton Health Commercial	$182.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$147.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$124.95
Rate for Payer: Group Health Inc Commercial	$28.66
Rate for Payer: Group Health Inc Medicare	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.66
Rate for Payer: Hamaspik Choice Inc Medicare	$28.66
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: Wellcare Medicare	$55.00

OT BOUTONNIERE DEFORM STATIC SPLI

Facility

$122.26

Service Code	HCPCS Q4049
Hospital Charge Code	41806350
Hospital Revenue Code	270
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$97.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$67.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.84
Rate for Payer: Aetna Government	$1.84
Rate for Payer: Brighton Health Commercial	$91.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$97.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$83.14
Rate for Payer: Group Health Inc Commercial	$61.13
Rate for Payer: Group Health Inc Medicare	$42.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$61.13
Rate for Payer: Hamaspik Choice Inc Medicare	$61.13

OT BUDDY STRAP

Facility

$101.25

Service Code	HCPCS 29280
Hospital Charge Code	41809402
Hospital Revenue Code	430
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.74
Rate for Payer: Aetna Government	$70.74
Rate for Payer: Affinity Essential Plan 1&2	$49.52
Rate for Payer: Affinity Essential Plan 3&4	$49.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.52
Rate for Payer: Brighton Health Commercial	$182.00
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.74
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	$70.74
Rate for Payer: EmblemHealth Commercial	$70.74
Rate for Payer: Fidelis CHP/HARP/Medicaid	$70.74
Rate for Payer: Fidelis Essential Plan Aliesa	$60.13
Rate for Payer: Fidelis Essential Plan QHP	$62.96
Rate for Payer: Fidelis Medicare Advantage	$70.74
Rate for Payer: Fidelis Qualified Health Plan	$62.96
Rate for Payer: Group Health Inc Commercial	$70.74
Rate for Payer: Group Health Inc Medicare	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.62
Rate for Payer: Hamaspik Choice Inc Medicare	$70.74
Rate for Payer: Healthfirst Medicare Advantage	$60.13
Rate for Payer: Healthfirst QHP	$70.74
Rate for Payer: Humana Medicare	$72.15
Rate for Payer: Senior Whole Health Medicare Advantage	$70.74
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$70.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.59
Rate for Payer: Wellcare Medicare	$55.00

OT BUDDY STRAP

Facility

$101.25

Service Code	HCPCS 29280
Hospital Charge Code	41809402
Hospital Revenue Code	430
Rate for Payer: Cash Price	$70.74

OT COCK UP SPLINT

Facility

$244.52

Service Code	HCPCS L3906
Hospital Charge Code	41806150
Hospital Revenue Code	274
Min. Negotiated Rate	$85.58
Max. Negotiated Rate	$256.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$134.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$195.89
Rate for Payer: Aetna Government	$195.89
Rate for Payer: Brighton Health Commercial	$146.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$122.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$140.60
Rate for Payer: EmblemHealth Commercial	$122.26
Rate for Payer: Fidelis Medicare Advantage	$256.75
Rate for Payer: Group Health Inc Commercial	$122.26
Rate for Payer: Group Health Inc Medicare	$85.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$122.26
Rate for Payer: Hamaspik Choice Inc Medicare	$122.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$158.94

OT CONTRAST BATH 15 MTS

Facility

$44.20

Service Code	HCPCS 97034 GO
Hospital Charge Code	41809480
Hospital Revenue Code	430
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$2,902.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.95
Rate for Payer: Aetna Government	$10.95
Rate for Payer: Affinity Essential Plan 1&2	$65.30
Rate for Payer: Affinity Essential Plan 3&4	$65.30
Rate for Payer: Affinity Medicaid/CHP/HARP	$29.02
Rate for Payer: Amida Care Medicaid	$29.02
Rate for Payer: Brighton Health Commercial	$182.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$147.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$124.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$2,902.00
Rate for Payer: Fidelis Essential Plan Aliesa	$29.02
Rate for Payer: Fidelis Essential Plan QHP	$29.02
Rate for Payer: Fidelis Qualified Health Plan	$30.47
Rate for Payer: Group Health Inc Commercial	$22.10
Rate for Payer: Group Health Inc Medicare	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.02
Rate for Payer: Hamaspik Choice Inc Medicare	$22.10
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$29.02
Rate for Payer: Healthfirst Essential Plan	$65.30
Rate for Payer: Healthfirst QHP	$29.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$29.02
Rate for Payer: SOMOS Essential	$65.30
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Essential Plan 1&2	$65.30
Rate for Payer: United Healthcare Essential Plan 3&4	$31.92
Rate for Payer: United Healthcare Medicaid	$29.02
Rate for Payer: Wellcare CHP/FHP/Medicaid	$29.02
Rate for Payer: Wellcare Medicare	$55.00

OT DORSAL HOOD-DYNAMIC TRACT.SPLI

Facility

$244.52

Service Code	HCPCS E1805
Hospital Charge Code	41806700
Hospital Revenue Code	270
Min. Negotiated Rate	$85.58
Max. Negotiated Rate	$955.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$134.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$955.30
Rate for Payer: Aetna Government	$955.30
Rate for Payer: Brighton Health Commercial	$183.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$195.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$166.27
Rate for Payer: Group Health Inc Commercial	$122.26
Rate for Payer: Group Health Inc Medicare	$85.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$122.26
Rate for Payer: Hamaspik Choice Inc Medicare	$122.26

OT DORSAL HOOD - ELBOW BASED

Facility

$489.04

Service Code	HCPCS L3906
Hospital Charge Code	41806800
Hospital Revenue Code	274
Min. Negotiated Rate	$171.16
Max. Negotiated Rate	$513.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$268.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$195.89
Rate for Payer: Aetna Government	$195.89
Rate for Payer: Brighton Health Commercial	$293.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$244.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$281.20
Rate for Payer: EmblemHealth Commercial	$244.52
Rate for Payer: Fidelis Medicare Advantage	$513.49
Rate for Payer: Group Health Inc Commercial	$244.52
Rate for Payer: Group Health Inc Medicare	$171.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$244.52
Rate for Payer: Hamaspik Choice Inc Medicare	$244.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$317.88

OT DORSAL HOOD -FOREARM

Facility

$326.03

Service Code	HCPCS L3906
Hospital Charge Code	41806750
Hospital Revenue Code	274
Min. Negotiated Rate	$114.11
Max. Negotiated Rate	$342.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$179.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$195.89
Rate for Payer: Aetna Government	$195.89
Rate for Payer: Brighton Health Commercial	$195.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$163.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$187.47
Rate for Payer: EmblemHealth Commercial	$163.02
Rate for Payer: Fidelis Medicare Advantage	$342.33
Rate for Payer: Group Health Inc Commercial	$163.02
Rate for Payer: Group Health Inc Medicare	$114.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$163.02
Rate for Payer: Hamaspik Choice Inc Medicare	$163.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$211.92

OT DORSAL WRIST & OUTRIGGER

Facility

$326.03

Service Code	HCPCS L3931
Hospital Charge Code	41808091
Hospital Revenue Code	274
Min. Negotiated Rate	$91.61
Max. Negotiated Rate	$342.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$179.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$91.61
Rate for Payer: Aetna Government	$91.61
Rate for Payer: Brighton Health Commercial	$195.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$163.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$187.47
Rate for Payer: EmblemHealth Commercial	$163.02
Rate for Payer: Fidelis Medicare Advantage	$342.33
Rate for Payer: Group Health Inc Commercial	$163.02
Rate for Payer: Group Health Inc Medicare	$114.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$163.02
Rate for Payer: Hamaspik Choice Inc Medicare	$163.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$211.92

OT DRESSING STICK

Facility

$8.51

Service Code	HCPCS A9270
Hospital Charge Code	41809531
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$6.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$6.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.79
Rate for Payer: Group Health Inc Commercial	$4.26
Rate for Payer: Group Health Inc Medicare	$2.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.26
Rate for Payer: Hamaspik Choice Inc Medicare	$4.26

Know your out-of-pocket cost for care.

All Charges