St. Barnabas Hospital

All Charges

Charge

Type

Price

BONE CEMENT 3

Facility IP

$816.60

Service Code	HCPCS C1713
Hospital Charge Code	40201187
Hospital Revenue Code	278
Min. Negotiated Rate	$408.30
Max. Negotiated Rate	$408.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$408.30
Rate for Payer: Hamaspik Choice Inc Medicare	$408.30

BONE CEMENT RADIOPAQUE

Facility OP

$460.00

Service Code	HCPCS C1713
Hospital Charge Code	40202094
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$483.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$253.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$230.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$264.50
Rate for Payer: Fidelis Medicare Advantage	$483.00
Rate for Payer: Group Health Inc Commercial	$230.00
Rate for Payer: Group Health Inc Medicare	$161.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$230.00
Rate for Payer: Hamaspik Choice Inc Medicare	$230.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$299.00

BONE CEMENT RADIOPAQUE

Facility IP

$460.00

Service Code	HCPCS C1713
Hospital Charge Code	40202094
Hospital Revenue Code	278
Min. Negotiated Rate	$230.00
Max. Negotiated Rate	$230.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$230.00
Rate for Payer: Hamaspik Choice Inc Medicare	$230.00

BONE CUBE CANCELLOUS 5CC

Facility OP

$270.00

Service Code	HCPCS C1713
Hospital Charge Code	40202361
Hospital Revenue Code	278
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$283.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$148.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$135.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$155.25
Rate for Payer: Fidelis Medicare Advantage	$283.50
Rate for Payer: Group Health Inc Commercial	$135.00
Rate for Payer: Group Health Inc Medicare	$94.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.00
Rate for Payer: Hamaspik Choice Inc Medicare	$135.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$175.50

BONE CUBE CANCELLOUS 5CC

Facility IP

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	64901829
Hospital Revenue Code	278
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00

BONE CUBE CANCELLOUS 5CC

Facility IP

$270.00

Service Code	HCPCS C1713
Hospital Charge Code	40202361
Hospital Revenue Code	278
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$135.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.00
Rate for Payer: Hamaspik Choice Inc Medicare	$135.00

BONE CUBE CANCELLOUS 5CC

Facility OP

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	64901829
Hospital Revenue Code	278
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$399.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.50
Rate for Payer: Fidelis Medicare Advantage	$399.00
Rate for Payer: Group Health Inc Commercial	$190.00
Rate for Payer: Group Health Inc Medicare	$133.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$247.00

BONE CURETTE SET

Facility OP

$18.78

Hospital Charge Code	40200640
Hospital Revenue Code	270
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$15.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.39
Rate for Payer: Aetna Government	$9.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.77
Rate for Payer: Group Health Inc Commercial	$9.39
Rate for Payer: Group Health Inc Medicare	$6.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.39
Rate for Payer: Hamaspik Choice Inc Medicare	$9.39

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility IP

$26,590.99

Service Code	MS-DRG 553
Min. Negotiated Rate	$11,589.10
Max. Negotiated Rate	$26,590.99
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19,927.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26,069.60
Rate for Payer: Aetna Government	$26,069.60
Rate for Payer: Brighton Health Commercial	$19,596.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$26,590.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23,339.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$19,260.39
Rate for Payer: Elderplan Medicare Advantage	$24,766.12
Rate for Payer: EmblemHealth Commercial	$11,589.10
Rate for Payer: Fidelis Medicare Advantage	$26,069.60
Rate for Payer: Group Health Inc Commercial	$26,069.60
Rate for Payer: Group Health Inc Medicare	$26,069.60
Rate for Payer: Hamaspik Choice Inc Medicare	$26,069.60
Rate for Payer: Healthfirst Medicare Advantage	$12,122.36
Rate for Payer: Senior Whole Health Medicare Advantage	$26,069.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26,069.60
Rate for Payer: Wellcare Medicare	$24,766.12

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility IP

$19,098.54

Service Code	MS-DRG 554
Min. Negotiated Rate	$7,046.94
Max. Negotiated Rate	$19,098.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12,117.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18,724.06
Rate for Payer: Aetna Government	$18,724.06
Rate for Payer: Brighton Health Commercial	$11,916.10
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$19,098.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14,191.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$11,711.57
Rate for Payer: Elderplan Medicare Advantage	$17,787.86
Rate for Payer: EmblemHealth Commercial	$7,046.94
Rate for Payer: Fidelis Medicare Advantage	$18,724.06
Rate for Payer: Group Health Inc Commercial	$18,724.06
Rate for Payer: Group Health Inc Medicare	$18,724.06
Rate for Payer: Hamaspik Choice Inc Medicare	$18,724.06
Rate for Payer: Healthfirst Medicare Advantage	$8,706.69
Rate for Payer: Senior Whole Health Medicare Advantage	$18,724.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18,724.06
Rate for Payer: Wellcare Medicare	$17,787.86

BONE GRAFT

Facility OP

$4,240.00

Service Code	HCPCS C1713
Hospital Charge Code	40203019
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,452.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,332.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,120.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,438.00
Rate for Payer: Fidelis Medicare Advantage	$4,452.00
Rate for Payer: Group Health Inc Commercial	$2,120.00
Rate for Payer: Group Health Inc Medicare	$1,484.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,120.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,120.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,756.00

BONE GRAFT

Facility IP

$4,240.00

Service Code	HCPCS C1713
Hospital Charge Code	40203019
Hospital Revenue Code	278
Min. Negotiated Rate	$2,120.00
Max. Negotiated Rate	$2,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,120.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,120.00

Bone graft, any donor area; minor or small (eg, dowel or button)

Facility OP

$8,273.12

Service Code	CPT 20900
Hospital Revenue Code	360
Min. Negotiated Rate	$202.36
Max. Negotiated Rate	$8,273.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8,273.12
Rate for Payer: Aetna Government	$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 CHP/HARP/Medicaid	$202.36
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 Medicare	$8,273.12
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$224.85
Rate for Payer: Healthfirst Medicare Advantage	$7,032.15
Rate for Payer: Healthfirst QHP	$8,273.12
Rate for Payer: Senior Whole Health 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

BONE GRAFT ANY DONOR - LARGE

Facility OP

$18,117.83

Service Code	HCPCS 20902
Hospital Charge Code	40089405
Hospital Revenue Code	360
Min. Negotiated Rate	$309.03
Max. Negotiated Rate	$9,058.92
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: 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 CHP/HARP/Medicaid	$309.03
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 CHP/FHP/Medicaid	$343.37
Rate for Payer: Healthfirst Medicare Advantage	$7,032.15
Rate for Payer: Healthfirst QHP	$8,273.12
Rate for Payer: Senior Whole Health 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

BONE GRAFT ANY DONOR - SMALL

Facility OP

$18,117.83

Service Code	HCPCS 20900
Hospital Charge Code	40082790
Hospital Revenue Code	360
Min. Negotiated Rate	$202.36
Max. Negotiated Rate	$9,058.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8,273.12
Rate for Payer: Aetna Government	$8,273.12
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 CHP/HARP/Medicaid	$202.36
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 CHP/FHP/Medicaid	$224.85
Rate for Payer: Healthfirst Medicare Advantage	$7,032.15
Rate for Payer: Healthfirst QHP	$8,273.12
Rate for Payer: Senior Whole Health 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

BONE GRAFT FEMUR

Facility OP

$4,144.04

Service Code	HCPCS 27170
Hospital Charge Code	40023261
Hospital Revenue Code	360
Min. Negotiated Rate	$1,214.68
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,279.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,214.68
Rate for Payer: Aetna Government	$1,214.68
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: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,332.11
Rate for Payer: Group Health Inc Commercial	$2,072.02
Rate for Payer: Group Health Inc Medicare	$1,450.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,072.02
Rate for Payer: Hamaspik Choice Inc Medicare	$2,072.02
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,480.12

BONE GRAFT FOR RIDGE PRESERVATION

Facility OP

$625.00

Service Code	HCPCS D7953
Hospital Charge Code	42300751
Hospital Revenue Code	361
Min. Negotiated Rate	$62.53
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$343.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$62.53
Rate for Payer: Aetna Government	$62.53
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	$312.50
Rate for Payer: Group Health Inc Medicare	$218.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$312.50
Rate for Payer: Hamaspik Choice Inc Medicare	$312.50

BONE GRAFT INJ 2CC

Facility OP

$2,375.00

Service Code	HCPCS C1713
Hospital Charge Code	64901192
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,493.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,306.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,187.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,365.62
Rate for Payer: Fidelis Medicare Advantage	$2,493.75
Rate for Payer: Group Health Inc Commercial	$1,187.50
Rate for Payer: Group Health Inc Medicare	$831.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,187.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,187.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,543.75

BONE GRAFT INJ 2CC

Facility IP

$2,375.00

Service Code	HCPCS C1713
Hospital Charge Code	64901192
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.50
Max. Negotiated Rate	$1,187.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,187.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,187.50

BONE GRAFT INJ 5CC

Facility OP

$3,987.50

Service Code	HCPCS C1713
Hospital Charge Code	64903671
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,186.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,193.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,993.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,292.81
Rate for Payer: Fidelis Medicare Advantage	$4,186.88
Rate for Payer: Group Health Inc Commercial	$1,993.75
Rate for Payer: Group Health Inc Medicare	$1,395.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,993.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,993.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,591.88

BONE GRAFT INJ 5CC

Facility IP

$3,987.50

Service Code	HCPCS C1713
Hospital Charge Code	64903671
Hospital Revenue Code	278
Min. Negotiated Rate	$1,993.75
Max. Negotiated Rate	$1,993.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,993.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,993.75

BONE GRAFT MANDIBLE

Facility OP

$14,691.05

Service Code	HCPCS 21215
Hospital Charge Code	40013263
Hospital Revenue Code	360
Min. Negotiated Rate	$845.85
Max. Negotiated Rate	$7,345.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,772.21
Rate for Payer: Aetna Government	$6,772.21
Rate for Payer: Cash Price	$6,772.21
Rate for Payer: Cash Price	$6,772.21
Rate for Payer: Cash Price	$6,772.21
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6,772.21
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	$6,772.21
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$845.85
Rate for Payer: Fidelis Essential Plan Aliesa	$5,756.38
Rate for Payer: Fidelis Essential Plan QHP	$6,027.27
Rate for Payer: Fidelis Medicare Advantage	$6,772.21
Rate for Payer: Fidelis Qualified Health Plan	$6,027.27
Rate for Payer: Group Health Inc Commercial	$6,772.21
Rate for Payer: Group Health Inc Medicare	$6,772.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,345.52
Rate for Payer: Hamaspik Choice Inc Medicare	$6,772.21
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$939.83
Rate for Payer: Healthfirst Medicare Advantage	$5,756.38
Rate for Payer: Healthfirst QHP	$6,772.21
Rate for Payer: Senior Whole Health Medicare Advantage	$6,772.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,772.21
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5,417.77
Rate for Payer: Wellcare Medicare	$6,433.60

BONE GRAFT REPAIR PERIMPLANT

Facility OP

$500.00

Service Code	HCPCS D6103
Hospital Charge Code	42300997
Hospital Revenue Code	361
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$275.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$272.65
Rate for Payer: Aetna Government	$272.65
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	$250.00
Rate for Payer: Group Health Inc Medicare	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00

BONE GRAFT STRIP 19X26X7

Facility IP

$5,500.00

Service Code	HCPCS C1713
Hospital Charge Code	64903783
Hospital Revenue Code	278
Min. Negotiated Rate	$2,750.00
Max. Negotiated Rate	$2,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,750.00

BONE GRAFT STRIP 19X26X7

Facility OP

$5,500.00

Service Code	HCPCS C1713
Hospital Charge Code	64903783
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,775.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,025.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,162.50
Rate for Payer: Fidelis Medicare Advantage	$5,775.00
Rate for Payer: Group Health Inc Commercial	$2,750.00
Rate for Payer: Group Health Inc Medicare	$1,925.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,575.00

Price Transparency.

All Charges