St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PAD EYE OVAL STERILE

Facility

$0.19

Hospital Charge Code	64901136
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10

PAD FOREHEAD COMFORT

Facility

$24.73

Hospital Charge Code	64904033
Hospital Revenue Code	270
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$19.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.36
Rate for Payer: Aetna Government	$12.36
Rate for Payer: Brighton Health Commercial	$18.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.82
Rate for Payer: Group Health Inc Commercial	$12.36
Rate for Payer: Group Health Inc Medicare	$8.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.36
Rate for Payer: Hamaspik Choice Inc Medicare	$12.36

PAD GROUNDING TOPRAK PEDI RF-DGPL

Facility

$15.00

Hospital Charge Code	64906511
Hospital Revenue Code	270
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$12.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.50
Rate for Payer: Aetna Government	$7.50
Rate for Payer: Brighton Health Commercial	$11.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.20
Rate for Payer: Group Health Inc Commercial	$7.50
Rate for Payer: Group Health Inc Medicare	$5.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.50
Rate for Payer: Hamaspik Choice Inc Medicare	$7.50

PAD HI SPD

Facility

$13.58

Hospital Charge Code	64907360
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$10.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.79
Rate for Payer: Aetna Government	$6.79
Rate for Payer: Brighton Health Commercial	$10.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.23
Rate for Payer: Group Health Inc Commercial	$6.79
Rate for Payer: Group Health Inc Medicare	$4.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.79
Rate for Payer: Hamaspik Choice Inc Medicare	$6.79

PAD,MATERNITY,CURITY

Facility

$0.16

Hospital Charge Code	64901825
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08

PAD MATERNITY PERI WINGED

Facility

$36.83

Hospital Charge Code	64901552
Hospital Revenue Code	270
Min. Negotiated Rate	$12.89
Max. Negotiated Rate	$29.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.42
Rate for Payer: Aetna Government	$18.42
Rate for Payer: Brighton Health Commercial	$27.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.04
Rate for Payer: Group Health Inc Commercial	$18.42
Rate for Payer: Group Health Inc Medicare	$12.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.42
Rate for Payer: Hamaspik Choice Inc Medicare	$18.42

PAD,NON-ADHERENT,3X4,STER,LF

Facility

$0.13

Hospital Charge Code	64901549
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.07
Rate for Payer: Aetna Government	$0.07
Rate for Payer: Brighton Health Commercial	$0.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.09
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

PAD NURSING

Facility

$0.17

Hospital Charge Code	64901940
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09

PAD OB 11 STERILE

Facility

$0.34

Hospital Charge Code	64901911
Hospital Revenue Code	270
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17

PAD ONLY VAC SENSA T.R.A.C.

Facility

$46.48

Hospital Charge Code	64901134
Hospital Revenue Code	270
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$37.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.56
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.24
Rate for Payer: Aetna Government	$23.24
Rate for Payer: Brighton Health Commercial	$34.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$31.61
Rate for Payer: Group Health Inc Commercial	$23.24
Rate for Payer: Group Health Inc Medicare	$16.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.24
Rate for Payer: Hamaspik Choice Inc Medicare	$23.24

PAD,PREP,ALCOHOL,STERILE MED

Facility

$0.03

Hospital Charge Code	64901165
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02

PAD QWIK CONNECT SPRIAL

Facility

$2.29

Hospital Charge Code	64901577
Hospital Revenue Code	270
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.14
Rate for Payer: Aetna Government	$1.14
Rate for Payer: Brighton Health Commercial	$1.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.56
Rate for Payer: Group Health Inc Commercial	$1.14
Rate for Payer: Group Health Inc Medicare	$0.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.14
Rate for Payer: Hamaspik Choice Inc Medicare	$1.14

PADS STRIPPING 20 BLACK 3M

Facility

$275.00

Hospital Charge Code	64902800
Hospital Revenue Code	270
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$220.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$151.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$137.50
Rate for Payer: Aetna Government	$137.50
Rate for Payer: Brighton Health Commercial	$206.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$220.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$187.00
Rate for Payer: Group Health Inc Commercial	$137.50
Rate for Payer: Group Health Inc Medicare	$96.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$137.50
Rate for Payer: Hamaspik Choice Inc Medicare	$137.50

PAD SURF PREP

Facility

$39.98

Hospital Charge Code	64907361
Hospital Revenue Code	270
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$31.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.99
Rate for Payer: Aetna Government	$19.99
Rate for Payer: Brighton Health Commercial	$29.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.19
Rate for Payer: Group Health Inc Commercial	$19.99
Rate for Payer: Group Health Inc Medicare	$13.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.99
Rate for Payer: Hamaspik Choice Inc Medicare	$19.99

PAD UNDER 23X36 DISPOSABLE

Facility

$0.29

Hospital Charge Code	64902009
Hospital Revenue Code	270
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15

PAIRING AND CURETTEMENT 1 LE

Facility

$502.69

Service Code	HCPCS 11055
Hospital Charge Code	42201330
Hospital Revenue Code	361
Min. Negotiated Rate	$162.06
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$231.52
Rate for Payer: Aetna Government	$231.52
Rate for Payer: Affinity Essential Plan 1&2	$162.06
Rate for Payer: Affinity Essential Plan 3&4	$162.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$162.06
Rate for Payer: Brighton Health Commercial	$377.02
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$231.52
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	$231.52
Rate for Payer: EmblemHealth Commercial	$231.52
Rate for Payer: Fidelis Essential Plan Aliesa	$196.79
Rate for Payer: Fidelis Essential Plan QHP	$206.05
Rate for Payer: Fidelis Medicare Advantage	$231.52
Rate for Payer: Fidelis Qualified Health Plan	$206.05
Rate for Payer: Group Health Inc Commercial	$231.52
Rate for Payer: Group Health Inc Medicare	$231.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.34
Rate for Payer: Hamaspik Choice Inc Medicare	$231.52
Rate for Payer: Healthfirst Medicare Advantage	$196.79
Rate for Payer: Healthfirst QHP	$231.52
Rate for Payer: Humana Medicare	$236.15
Rate for Payer: Senior Whole Health Medicare Advantage	$231.52
Rate for Payer: United Healthcare Commercial	$1,113.00
Rate for Payer: United Healthcare Medicare Advantage	$231.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$231.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$185.22
Rate for Payer: Wellcare Medicare	$219.94

PAIRING AND CURETTEMENT 1 LE

Facility

$502.69

Service Code	HCPCS 11055
Hospital Charge Code	42201330
Hospital Revenue Code	361
Rate for Payer: Cash Price	$231.52

PAIRING & CURETTEMENT 2-4 LESI

Facility

$529.23

Service Code	HCPCS 11056
Hospital Charge Code	42201335
Hospital Revenue Code	361
Rate for Payer: Cash Price	$231.52

PAIRING & CURETTEMENT 2-4 LESI

Facility

$529.23

Service Code	HCPCS 11056
Hospital Charge Code	42201335
Hospital Revenue Code	361
Min. Negotiated Rate	$162.06
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$231.52
Rate for Payer: Aetna Government	$231.52
Rate for Payer: Affinity Essential Plan 1&2	$162.06
Rate for Payer: Affinity Essential Plan 3&4	$162.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$162.06
Rate for Payer: Brighton Health Commercial	$396.92
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$231.52
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	$231.52
Rate for Payer: EmblemHealth Commercial	$231.52
Rate for Payer: Fidelis Essential Plan Aliesa	$196.79
Rate for Payer: Fidelis Essential Plan QHP	$206.05
Rate for Payer: Fidelis Medicare Advantage	$231.52
Rate for Payer: Fidelis Qualified Health Plan	$206.05
Rate for Payer: Group Health Inc Commercial	$231.52
Rate for Payer: Group Health Inc Medicare	$231.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$264.62
Rate for Payer: Hamaspik Choice Inc Medicare	$231.52
Rate for Payer: Healthfirst Medicare Advantage	$196.79
Rate for Payer: Healthfirst QHP	$231.52
Rate for Payer: Humana Medicare	$236.15
Rate for Payer: Senior Whole Health Medicare Advantage	$231.52
Rate for Payer: United Healthcare Commercial	$1,113.00
Rate for Payer: United Healthcare Medicare Advantage	$231.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$231.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$185.22
Rate for Payer: Wellcare Medicare	$219.94

PAIRING & CURETTEMENT >4 LESIO

Facility

$529.23

Service Code	HCPCS 11057
Hospital Charge Code	42201340
Hospital Revenue Code	361
Min. Negotiated Rate	$162.06
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$231.52
Rate for Payer: Aetna Government	$231.52
Rate for Payer: Affinity Essential Plan 1&2	$162.06
Rate for Payer: Affinity Essential Plan 3&4	$162.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$162.06
Rate for Payer: Brighton Health Commercial	$396.92
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$231.52
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	$231.52
Rate for Payer: EmblemHealth Commercial	$231.52
Rate for Payer: Fidelis Essential Plan Aliesa	$196.79
Rate for Payer: Fidelis Essential Plan QHP	$206.05
Rate for Payer: Fidelis Medicare Advantage	$231.52
Rate for Payer: Fidelis Qualified Health Plan	$206.05
Rate for Payer: Group Health Inc Commercial	$231.52
Rate for Payer: Group Health Inc Medicare	$231.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$264.62
Rate for Payer: Hamaspik Choice Inc Medicare	$231.52
Rate for Payer: Healthfirst Medicare Advantage	$196.79
Rate for Payer: Healthfirst QHP	$231.52
Rate for Payer: Humana Medicare	$236.15
Rate for Payer: Senior Whole Health Medicare Advantage	$231.52
Rate for Payer: United Healthcare Commercial	$1,113.00
Rate for Payer: United Healthcare Medicare Advantage	$231.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$231.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$185.22
Rate for Payer: Wellcare Medicare	$219.94

PAIRING & CURETTEMENT >4 LESIO

Facility

$529.23

Service Code	HCPCS 11057
Hospital Charge Code	42201340
Hospital Revenue Code	361
Rate for Payer: Cash Price	$231.52

PAIR OR CUT OF BENIGHN HYPERKERAT

Facility

$502.69

Service Code	HCPCS 11055
Hospital Charge Code	30106421
Hospital Revenue Code	450
Rate for Payer: Cash Price	$231.52

PAIR OR CUT OF BENIGHN HYPERKERAT

Facility

$502.69

Service Code	HCPCS 11055
Hospital Charge Code	30106421
Hospital Revenue Code	450
Min. Negotiated Rate	$162.06
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$231.52
Rate for Payer: Aetna Government	$231.52
Rate for Payer: Affinity Essential Plan 1&2	$162.06
Rate for Payer: Affinity Essential Plan 3&4	$162.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$162.06
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$231.52
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$231.52
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	$231.52
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$196.79
Rate for Payer: Fidelis Essential Plan QHP	$206.05
Rate for Payer: Fidelis Medicare Advantage	$231.52
Rate for Payer: Fidelis Qualified Health Plan	$206.05
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	$251.34
Rate for Payer: Hamaspik Choice Inc Medicare	$231.52
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$231.52
Rate for Payer: Humana Medicare	$236.15
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$231.52
Rate for Payer: Senior Whole Health Medicare Advantage	$231.52
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$231.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$231.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$185.22
Rate for Payer: Wellcare Medicare	$219.94

PALATAL AUGMENTATION PROSTHESIS

Facility

$1,816.00

Service Code	HCPCS D5954
Hospital Charge Code	42301340
Hospital Revenue Code	361
Min. Negotiated Rate	$635.60
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$998.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,800.60
Rate for Payer: Aetna Government	$1,800.60
Rate for Payer: Brighton Health Commercial	$1,362.00
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	$908.00
Rate for Payer: Group Health Inc Medicare	$635.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$908.00
Rate for Payer: Hamaspik Choice Inc Medicare	$908.00

PALATAL LIFT PROSTHESIS, DEFINITI

Facility

$2,320.00

Service Code	HCPCS D5955
Hospital Charge Code	42301345
Hospital Revenue Code	361
Min. Negotiated Rate	$812.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,276.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,665.33
Rate for Payer: Aetna Government	$1,665.33
Rate for Payer: Brighton Health Commercial	$1,740.00
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	$1,160.00
Rate for Payer: Group Health Inc Medicare	$812.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,160.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,160.00

Know your out-of-pocket cost for care.

All Charges