St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ROTAVIRUS MENOVALENT (VFC) 1ML OR

Facility

$0.01

Service Code	HCPCS 90681
Hospital Charge Code	41659565
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

ROTAVIRUS MENOVALENT (VFC) 1ML OR

Facility

$0.01

Service Code	HCPCS 90681
Hospital Charge Code	41659565
Hospital Revenue Code	636
Max. Negotiated Rate	$129.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$129.45
Rate for Payer: Aetna Government	$129.45
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

ROTAVIRUS MENOVALENT (VFC) 1ML OR

Facility

$0.01

Service Code	HCPCS 90681
Hospital Charge Code	41649565
Hospital Revenue Code	636
Max. Negotiated Rate	$129.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$129.45
Rate for Payer: Aetna Government	$129.45
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

ROTAVIRUS MENOVALENT (VFC) 1ML OR

Facility

$0.01

Service Code	HCPCS 90681
Hospital Charge Code	41649565
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

ROTAVIRUS PENTAVALENT ORAL (ROTATEQ) VAC

Facility

$130.00

Hospital Charge Code	41654835
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$104.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$71.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$65.00
Rate for Payer: Aetna Government	$65.00
Rate for Payer: Brighton Health Commercial	$97.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$104.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$88.40
Rate for Payer: Group Health Inc Commercial	$65.00
Rate for Payer: Group Health Inc Medicare	$45.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$65.00
Rate for Payer: Hamaspik Choice Inc Medicare	$65.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$84.50

ROTAVIRUS PENTAVALENT ORAL (ROTATEQ) VAC

Facility

$130.00

Hospital Charge Code	41644835
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$104.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$71.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$65.00
Rate for Payer: Aetna Government	$65.00
Rate for Payer: Brighton Health Commercial	$97.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$104.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$88.40
Rate for Payer: Group Health Inc Commercial	$65.00
Rate for Payer: Group Health Inc Medicare	$45.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$65.00
Rate for Payer: Hamaspik Choice Inc Medicare	$65.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$84.50

ROTAVIRUS PENTAVALENT (VFC)2ML OR

Facility

$0.01

Service Code	HCPCS 90680
Hospital Charge Code	41659567
Hospital Revenue Code	636
Max. Negotiated Rate	$92.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$92.18
Rate for Payer: Aetna Government	$92.18
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

ROTAVIRUS PENTAVALENT (VFC)2ML OR

Facility

$0.01

Service Code	HCPCS 90680
Hospital Charge Code	41649567
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

ROTAVIRUS PENTAVALENT (VFC)2ML OR

Facility

$0.01

Service Code	HCPCS 90680
Hospital Charge Code	41649567
Hospital Revenue Code	636
Max. Negotiated Rate	$92.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$92.18
Rate for Payer: Aetna Government	$92.18
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

ROTAVIRUS PENTAVALENT (VFC)2ML OR

Facility

$0.01

Service Code	HCPCS 90680
Hospital Charge Code	41659567
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

ROTAVIRUS VAC LIVE PENTAVALENT PO SOLN [122171]

Facility

$57.50

Service Code	NDC 00006404741
Hospital Charge Code	00006404741
Hospital Revenue Code	250
Min. Negotiated Rate	$20.13
Max. Negotiated Rate	$46.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28.75
Rate for Payer: Aetna Government	$28.75
Rate for Payer: Brighton Health Commercial	$43.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$46.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$39.10
Rate for Payer: Group Health Inc Commercial	$28.75
Rate for Payer: Group Health Inc Medicare	$20.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.75
Rate for Payer: Hamaspik Choice Inc Medicare	$28.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37.38

ROTICULAT ENDO GIA UNIV 45-4.8

Facility

$364.00

Hospital Charge Code	40206017
Hospital Revenue Code	270
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$291.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$200.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$182.00
Rate for Payer: Aetna Government	$182.00
Rate for Payer: Brighton Health Commercial	$273.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$291.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$247.52
Rate for Payer: Group Health Inc Commercial	$182.00
Rate for Payer: Group Health Inc Medicare	$127.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$182.00
Rate for Payer: Hamaspik Choice Inc Medicare	$182.00

ROTICULATOR ENDO GIA 45 2.5

Facility

$2,018.00

Hospital Charge Code	40201026
Hospital Revenue Code	270
Min. Negotiated Rate	$706.30
Max. Negotiated Rate	$1,614.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,109.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,009.00
Rate for Payer: Aetna Government	$1,009.00
Rate for Payer: Brighton Health Commercial	$1,513.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,614.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,372.24
Rate for Payer: Group Health Inc Commercial	$1,009.00
Rate for Payer: Group Health Inc Medicare	$706.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,009.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,009.00

ROTICUL ENDO GIA UNIV 30-2.5SULU

Facility

$303.00

Hospital Charge Code	40206016
Hospital Revenue Code	270
Min. Negotiated Rate	$106.05
Max. Negotiated Rate	$242.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$166.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$151.50
Rate for Payer: Aetna Government	$151.50
Rate for Payer: Brighton Health Commercial	$227.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$242.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.04
Rate for Payer: Group Health Inc Commercial	$151.50
Rate for Payer: Group Health Inc Medicare	$106.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$151.50
Rate for Payer: Hamaspik Choice Inc Medicare	$151.50

ROTICUL ENDO GIA UNIV 60-4.8SULU

Facility

$511.28

Hospital Charge Code	40206019
Hospital Revenue Code	270
Min. Negotiated Rate	$178.95
Max. Negotiated Rate	$409.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$281.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$255.64
Rate for Payer: Aetna Government	$255.64
Rate for Payer: Brighton Health Commercial	$383.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$409.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$347.67
Rate for Payer: Group Health Inc Commercial	$255.64
Rate for Payer: Group Health Inc Medicare	$178.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$255.64
Rate for Payer: Hamaspik Choice Inc Medicare	$255.64

ROUND BURR

Facility

$24.00

Hospital Charge Code	40202162
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.00
Rate for Payer: Aetna Government	$12.00
Rate for Payer: Brighton Health Commercial	$18.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.32
Rate for Payer: Group Health Inc Commercial	$12.00
Rate for Payer: Group Health Inc Medicare	$8.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12.00

ROUND FILTERS W/INDICATOR

Facility

$116.88

Hospital Charge Code	64905114
Hospital Revenue Code	270
Min. Negotiated Rate	$40.91
Max. Negotiated Rate	$93.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$64.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$58.44
Rate for Payer: Aetna Government	$58.44
Rate for Payer: Brighton Health Commercial	$87.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$93.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$79.48
Rate for Payer: Group Health Inc Commercial	$58.44
Rate for Payer: Group Health Inc Medicare	$40.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$58.44
Rate for Payer: Hamaspik Choice Inc Medicare	$58.44

ROUTINE ELECTROCARDIOGRAM

Facility

$166.60

Service Code	HCPCS 93005
Hospital Charge Code	30305900
Hospital Revenue Code	730
Rate for Payer: Cash Price	$70.74

ROUTINE ELECTROCARDIOGRAM

Facility

$166.60

Service Code	HCPCS 93005
Hospital Charge Code	30305900
Hospital Revenue Code	730
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$133.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
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	$124.95
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	$133.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$113.29
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: EmblemHealth Commercial	$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	$70.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
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	$101.00
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	$67.20

ROUTINE ELECTROCARDIOGRAM

Facility

$166.60

Service Code	HCPCS 93005
Hospital Charge Code	40801000
Hospital Revenue Code	730
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$133.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
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	$124.95
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	$133.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$113.29
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: EmblemHealth Commercial	$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	$70.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
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	$101.00
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	$67.20

ROUTINE ELECTROCARDIOGRAM

Facility

$166.60

Service Code	HCPCS 93005
Hospital Charge Code	40801000
Hospital Revenue Code	730
Rate for Payer: Cash Price	$70.74

ROUTINE VENIPUNCTURE

Facility

$9.71

Service Code	HCPCS 36415
Hospital Charge Code	30300034
Hospital Revenue Code	300
Rate for Payer: Cash Price	$8.83

ROUTINE VENIPUNCTURE

Facility

$9.71

Service Code	HCPCS 36415
Hospital Charge Code	30300034
Hospital Revenue Code	300
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$926.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.57
Rate for Payer: Aetna Government	$8.57
Rate for Payer: Affinity Essential Plan 1&2	$20.84
Rate for Payer: Affinity Essential Plan 3&4	$20.84
Rate for Payer: Affinity Medicaid/CHP/HARP	$9.26
Rate for Payer: Amida Care Medicaid	$9.26
Rate for Payer: Brighton Health Commercial	$7.28
Rate for Payer: Cash Price	$8.83
Rate for Payer: Cash Price	$8.83
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$8.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.87
Rate for Payer: Elderplan Medicare Advantage	$8.57
Rate for Payer: EmblemHealth Commercial	$8.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$926.00
Rate for Payer: Fidelis Essential Plan Aliesa	$9.26
Rate for Payer: Fidelis Essential Plan QHP	$9.26
Rate for Payer: Fidelis Medicare Advantage	$8.57
Rate for Payer: Fidelis Qualified Health Plan	$9.72
Rate for Payer: Group Health Inc Commercial	$8.57
Rate for Payer: Group Health Inc Medicare	$8.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.26
Rate for Payer: Hamaspik Choice Inc Medicare	$8.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$9.26
Rate for Payer: Healthfirst Essential Plan	$20.84
Rate for Payer: Healthfirst Medicare Advantage	$7.28
Rate for Payer: Healthfirst QHP	$9.26
Rate for Payer: Humana Medicare	$8.74
Rate for Payer: Senior Whole Health Medicare Advantage	$8.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.26
Rate for Payer: SOMOS Essential	$20.84
Rate for Payer: United Healthcare Commercial	$2.70
Rate for Payer: United Healthcare Essential Plan 1&2	$20.84
Rate for Payer: United Healthcare Essential Plan 3&4	$10.19
Rate for Payer: United Healthcare Medicaid	$9.26
Rate for Payer: United Healthcare Medicare Advantage	$8.57
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$6.86
Rate for Payer: Wellcare Medicare	$7.71

RPAIR/GRAFT RADIUS OR ULNA

Facility

$18,117.83

Service Code	HCPCS 25405
Hospital Charge Code	40029824
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$13,588.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8,273.12
Rate for Payer: Aetna Government	$8,273.12
Rate for Payer: Affinity Essential Plan 1&2	$5,791.18
Rate for Payer: Affinity Essential Plan 3&4	$5,791.18
Rate for Payer: Affinity Medicaid/CHP/HARP	$5,791.18
Rate for Payer: Brighton Health Commercial	$13,588.37
Rate for Payer: Cash Price	$8,273.12
Rate for Payer: Cash Price	$8,273.12
Rate for Payer: Cash Price	$8,273.12
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$8,273.12
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: Elderplan Medicare Advantage	$8,273.12
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$7,032.15
Rate for Payer: Fidelis Essential Plan QHP	$7,363.08
Rate for Payer: Fidelis Medicare Advantage	$8,273.12
Rate for Payer: Fidelis Qualified Health Plan	$7,363.08
Rate for Payer: Group Health Inc Commercial	$8,273.12
Rate for Payer: Group Health Inc Medicare	$8,273.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$9,058.92
Rate for Payer: Hamaspik Choice Inc Medicare	$8,273.12
Rate for Payer: Healthfirst Medicare Advantage	$7,032.15
Rate for Payer: Healthfirst QHP	$8,273.12
Rate for Payer: Humana Medicare	$8,438.58
Rate for Payer: Senior Whole Health Medicare Advantage	$8,273.12
Rate for Payer: United Healthcare Commercial	$2,546.00
Rate for Payer: United Healthcare Medicare Advantage	$8,273.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8,273.12
Rate for Payer: Wellcare CHP/FHP/Medicaid	$6,618.50
Rate for Payer: Wellcare Medicare	$7,859.46

RPAIR/GRAFT RADIUS OR ULNA

Facility

$18,117.83

Service Code	HCPCS 25405
Hospital Charge Code	40029824
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,273.12

Know your out-of-pocket cost for care.

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