St. Barnabas Hospital

All Charges

Charge

Type

Price

SP LYMPHANGIOGRAM PEL-ABD UNI

Facility OP

$238.14

Service Code	HCPCS 38790 TC
Hospital Charge Code	41547461
Hospital Revenue Code	361
Min. Negotiated Rate	$83.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$119.07
Rate for Payer: Aetna Government	$119.07
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	$119.07
Rate for Payer: Group Health Inc Medicare	$83.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$119.07
Rate for Payer: Hamaspik Choice Inc Medicare	$119.07

SP LYMPHANG,PELVIC/ABD,BIL

Facility OP

$238.14

Service Code	HCPCS 38790 TC
Hospital Charge Code	41547636
Hospital Revenue Code	361
Min. Negotiated Rate	$83.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$119.07
Rate for Payer: Aetna Government	$119.07
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	$119.07
Rate for Payer: Group Health Inc Medicare	$83.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$119.07
Rate for Payer: Hamaspik Choice Inc Medicare	$119.07

SP LYMPHANG,PELVIC/ABD UNI

Facility OP

$238.14

Service Code	HCPCS 38790 TC
Hospital Charge Code	41547634
Hospital Revenue Code	361
Min. Negotiated Rate	$83.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$119.07
Rate for Payer: Aetna Government	$119.07
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	$119.07
Rate for Payer: Group Health Inc Medicare	$83.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$119.07
Rate for Payer: Hamaspik Choice Inc Medicare	$119.07

SP LYMPHATIC LIGATION

Facility OP

$9,175.75

Service Code	HCPCS 38308 TC
Hospital Charge Code	41561890
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$5,046.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,046.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,587.88
Rate for Payer: Aetna Government	$4,587.88
Rate for Payer: Cash Price	$4,407.98
Rate for Payer: Cash Price	$4,407.98
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	$4,587.88
Rate for Payer: Group Health Inc Medicare	$3,211.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,587.88
Rate for Payer: Hamaspik Choice Inc Medicare	$4,587.88

SP LYMPH NODES. INT.MAM

Facility OP

$9,175.75

Service Code	HCPCS 38530 TC
Hospital Charge Code	41547648
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$5,046.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,046.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,587.88
Rate for Payer: Aetna Government	$4,587.88
Rate for Payer: Cash Price	$4,407.98
Rate for Payer: Cash Price	$4,407.98
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	$4,587.88
Rate for Payer: Group Health Inc Medicare	$3,211.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,587.88
Rate for Payer: Hamaspik Choice Inc Medicare	$4,587.88

SP LYMPH NODES.SUP. PERCUTANEOUS

Facility OP

$4,157.25

Service Code	HCPCS 38505 TC
Hospital Charge Code	41547647
Hospital Revenue Code	361
Min. Negotiated Rate	$1,455.04
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,286.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,078.62
Rate for Payer: Aetna Government	$2,078.62
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
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	$2,078.62
Rate for Payer: Group Health Inc Medicare	$1,455.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,078.62
Rate for Payer: Hamaspik Choice Inc Medicare	$2,078.62

SP LYSE CHEST FIBRIN INIT DAY

Facility OP

$1,909.65

Service Code	HCPCS 32561 TC
Hospital Charge Code	41561920
Hospital Revenue Code	361
Min. Negotiated Rate	$668.38
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,050.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$954.82
Rate for Payer: Aetna Government	$954.82
Rate for Payer: Cash Price	$726.47
Rate for Payer: Cash Price	$726.47
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	$954.82
Rate for Payer: Group Health Inc Medicare	$668.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.82
Rate for Payer: Hamaspik Choice Inc Medicare	$954.82

SP LYSE CHEST FIBRIN SUBQ DAY

Facility OP

$1,909.65

Service Code	HCPCS 32562 TC
Hospital Charge Code	41561921
Hospital Revenue Code	361
Min. Negotiated Rate	$668.38
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,050.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$954.82
Rate for Payer: Aetna Government	$954.82
Rate for Payer: Cash Price	$726.47
Rate for Payer: Cash Price	$726.47
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	$954.82
Rate for Payer: Group Health Inc Medicare	$668.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.82
Rate for Payer: Hamaspik Choice Inc Medicare	$954.82

SP MA GUIDED 1ST LOCAL

Facility OP

$1,847.58

Service Code	HCPCS 19281 TC
Hospital Charge Code	41104035
Hospital Revenue Code	361
Min. Negotiated Rate	$646.65
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,016.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$923.79
Rate for Payer: Aetna Government	$923.79
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
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	$923.79
Rate for Payer: Group Health Inc Medicare	$646.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$923.79

SP MA GUIDED EACH ADD

Facility OP

$389.75

Service Code	HCPCS 19282 TC
Hospital Charge Code	41104037
Hospital Revenue Code	361
Min. Negotiated Rate	$136.41
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$214.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$194.88
Rate for Payer: Aetna Government	$194.88
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	$194.88
Rate for Payer: Group Health Inc Medicare	$136.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$194.88
Rate for Payer: Hamaspik Choice Inc Medicare	$194.88

SP MCHNCL THRMBCTMY W/BALLN ANGIO

Facility OP

$30,010.30

Service Code	HCPCS 36905 TC
Hospital Charge Code	41542861
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$16,505.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16,505.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15,005.15
Rate for Payer: Aetna Government	$15,005.15
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
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	$15,005.15
Rate for Payer: Group Health Inc Medicare	$10,503.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,005.15
Rate for Payer: Hamaspik Choice Inc Medicare	$15,005.15

SP MCHNCL THRMBCTMY W/STNT PLCMNT

Facility OP

$48,278.18

Service Code	HCPCS 36906 TC
Hospital Charge Code	41542863
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$26,553.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26,553.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24,139.09
Rate for Payer: Aetna Government	$24,139.09
Rate for Payer: Cash Price	$20,278.00
Rate for Payer: Cash Price	$20,278.00
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	$24,139.09
Rate for Payer: Group Health Inc Medicare	$16,897.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,139.09
Rate for Payer: Hamaspik Choice Inc Medicare	$24,139.09

SP MCHNICL THRMBCTMY

Facility OP

$15,004.15

Service Code	HCPCS 36904 TC
Hospital Charge Code	41542859
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$8,252.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,252.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7,502.08
Rate for Payer: Aetna Government	$7,502.08
Rate for Payer: Cash Price	$6,609.72
Rate for Payer: Cash Price	$6,609.72
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	$7,502.08
Rate for Payer: Group Health Inc Medicare	$5,251.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,502.08
Rate for Payer: Hamaspik Choice Inc Medicare	$7,502.08

SP MCHNICL THRMBCTMY ART/BYPASS

Facility OP

$30,010.30

Service Code	HCPCS 37184 TC
Hospital Charge Code	41548024
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$16,505.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16,505.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15,005.15
Rate for Payer: Aetna Government	$15,005.15
Rate for Payer: Cash Price	$20,278.00
Rate for Payer: Cash Price	$20,278.00
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	$15,005.15
Rate for Payer: Group Health Inc Medicare	$10,503.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,005.15
Rate for Payer: Hamaspik Choice Inc Medicare	$15,005.15

SP MCHNICL THRMBCTMY ART/COMFIX

Facility OP

$6,253.68

Service Code	HCPCS 37186 TC
Hospital Charge Code	41548026
Hospital Revenue Code	361
Min. Negotiated Rate	$2,188.79
Max. Negotiated Rate	$3,439.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,439.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,126.84
Rate for Payer: Aetna Government	$3,126.84
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	$3,126.84
Rate for Payer: Group Health Inc Medicare	$2,188.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,126.84
Rate for Payer: Hamaspik Choice Inc Medicare	$3,126.84

SP MCHNICL THRMBCTMY ART/SUB VES

Facility OP

$2,552.23

Service Code	HCPCS 37185 TC
Hospital Charge Code	41548025
Hospital Revenue Code	361
Min. Negotiated Rate	$893.28
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,403.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,276.12
Rate for Payer: Aetna Government	$1,276.12
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	$1,276.12
Rate for Payer: Group Health Inc Medicare	$893.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,276.12
Rate for Payer: Hamaspik Choice Inc Medicare	$1,276.12

SP MCHNICL THRMBCTMY VEIN/1ST

Facility OP

$15,004.15

Service Code	HCPCS 37187 TC
Hospital Charge Code	41548027
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$8,252.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,252.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7,502.08
Rate for Payer: Aetna Government	$7,502.08
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
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	$7,502.08
Rate for Payer: Group Health Inc Medicare	$5,251.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,502.08
Rate for Payer: Hamaspik Choice Inc Medicare	$7,502.08

SP MCHNICL THRMBCTMY VEIN F/U

Facility OP

$8,393.53

Service Code	HCPCS 37188 TC
Hospital Charge Code	41548028
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$4,616.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,616.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,196.76
Rate for Payer: Aetna Government	$4,196.76
Rate for Payer: Cash Price	$3,686.08
Rate for Payer: Cash Price	$3,686.08
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	$4,196.76
Rate for Payer: Group Health Inc Medicare	$2,937.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,196.76
Rate for Payer: Hamaspik Choice Inc Medicare	$4,196.76

SP MECH REMOVAL INSTRALUMINAL

Facility OP

$4,940.28

Service Code	HCPCS 36596 TC
Hospital Charge Code	41561836
Hospital Revenue Code	361
Min. Negotiated Rate	$1,729.10
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,717.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,470.14
Rate for Payer: Aetna Government	$2,470.14
Rate for Payer: Cash Price	$1,852.05
Rate for Payer: Cash Price	$1,852.05
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	$2,470.14
Rate for Payer: Group Health Inc Medicare	$1,729.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,470.14
Rate for Payer: Hamaspik Choice Inc Medicare	$2,470.14

SP MR GUIDED 1ST LOCAL

Facility OP

$1,847.58

Service Code	HCPCS 19287 TC
Hospital Charge Code	41104027
Hospital Revenue Code	361
Min. Negotiated Rate	$646.65
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,016.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$923.79
Rate for Payer: Aetna Government	$923.79
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
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	$923.79
Rate for Payer: Group Health Inc Medicare	$646.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$923.79

SP MR GUIDED BREAST ADD

Facility OP

$30,948.00

Service Code	HCPCS 19086 TC
Hospital Charge Code	41004045
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$17,021.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17,021.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15,474.00
Rate for Payer: Aetna Government	$15,474.00
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	$15,474.00
Rate for Payer: Group Health Inc Medicare	$10,831.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,474.00
Rate for Payer: Hamaspik Choice Inc Medicare	$15,474.00

SP MR GUIDED BREAST ADD

Facility OP

$1,042.00

Service Code	HCPCS 19086
Hospital Charge Code	41104055
Hospital Revenue Code	610
Min. Negotiated Rate	$78.64
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$78.64
Rate for Payer: Aetna Government	$78.64
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: Fidelis CHP/HARP/Medicaid	$94.98
Rate for Payer: Group Health Inc Commercial	$521.00
Rate for Payer: Group Health Inc Medicare	$364.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$521.00
Rate for Payer: Hamaspik Choice Inc Medicare	$521.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$105.53

SP MR GUIDED EACH ADD

Facility OP

$146.00

Service Code	HCPCS 19288 TC
Hospital Charge Code	41104029
Hospital Revenue Code	361
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$80.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$73.00
Rate for Payer: Aetna Government	$73.00
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	$73.00
Rate for Payer: Group Health Inc Medicare	$51.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.00
Rate for Payer: Hamaspik Choice Inc Medicare	$73.00

SP MRI GUIDANCE NEEDLE PLACEMENT

Facility OP

$2,176.65

Service Code	HCPCS 77021 TC
Hospital Charge Code	41568805
Hospital Revenue Code	610
Min. Negotiated Rate	$398.77
Max. Negotiated Rate	$1,741.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,197.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,088.32
Rate for Payer: Aetna Government	$1,088.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,741.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,480.12
Rate for Payer: Fidelis CHP/HARP/Medicaid	$398.77
Rate for Payer: Group Health Inc Commercial	$1,088.32
Rate for Payer: Group Health Inc Medicare	$761.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,088.32
Rate for Payer: Hamaspik Choice Inc Medicare	$1,088.32
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$443.08

SP MRI GUIDED BREAST BX

Facility OP

$4,157.25

Service Code	HCPCS 19085
Hospital Charge Code	41104023
Hospital Revenue Code	610
Min. Negotiated Rate	$187.84
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,874.89
Rate for Payer: Aetna Government	$1,874.89
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,874.89
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	$1,874.89
Rate for Payer: EmblemHealth Commercial	$1,312.42
Rate for Payer: Fidelis CHP/HARP/Medicaid	$187.84
Rate for Payer: Fidelis Essential Plan Aliesa	$1,593.66
Rate for Payer: Fidelis Essential Plan QHP	$1,668.65
Rate for Payer: Fidelis Medicare Advantage	$1,874.89
Rate for Payer: Fidelis Qualified Health Plan	$1,668.65
Rate for Payer: Group Health Inc Commercial	$1,687.40
Rate for Payer: Group Health Inc Medicare	$1,687.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,078.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1,874.89
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$208.71
Rate for Payer: Healthfirst Medicare Advantage	$1,593.66
Rate for Payer: Healthfirst QHP	$1,874.89
Rate for Payer: Senior Whole Health Medicare Advantage	$1,874.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,874.89
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,499.91
Rate for Payer: Wellcare Medicare	$1,781.15

Price Transparency.

All Charges