St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SERRATO POLYAXIAL SCREW 6.0X35MM

Facility

$2,333.00

Service Code	HCPCS C1713
Hospital Charge Code	40208512
Hospital Revenue Code	278
Min. Negotiated Rate	$1,166.50
Max. Negotiated Rate	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,166.50

SERRATO POLYAXIAL SCREW 6.0X35MM

Facility

$2,333.00

Service Code	HCPCS C1713
Hospital Charge Code	40208512
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,449.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,283.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,399.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,166.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,341.48
Rate for Payer: EmblemHealth Commercial	$1,166.50
Rate for Payer: Fidelis Medicare Advantage	$2,449.65
Rate for Payer: Group Health Inc Commercial	$1,166.50
Rate for Payer: Group Health Inc Medicare	$816.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,166.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,516.45

SERRATO POLYAXIAL SCREW 6.0X40MM

Facility

$2,333.00

Service Code	HCPCS C1713
Hospital Charge Code	40208514
Hospital Revenue Code	278
Min. Negotiated Rate	$1,166.50
Max. Negotiated Rate	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,166.50

SERRATO POLYAXIAL SCREW 6.0X40MM

Facility

$2,333.00

Service Code	HCPCS C1713
Hospital Charge Code	40208514
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,449.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,283.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,399.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,166.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,341.48
Rate for Payer: EmblemHealth Commercial	$1,166.50
Rate for Payer: Fidelis Medicare Advantage	$2,449.65
Rate for Payer: Group Health Inc Commercial	$1,166.50
Rate for Payer: Group Health Inc Medicare	$816.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,166.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,166.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,516.45

SERTRALINE 100 MG TAB

Facility

$1.00

Hospital Charge Code	41640819
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

SERTRALINE 100 MG TAB

Facility

$1.00

Hospital Charge Code	41650819
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

SERTRALINE 25 MG TAB

Facility

$0.27

Hospital Charge Code	41642724
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.14
Rate for Payer: Aetna Government	$0.14
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

SERTRALINE 25 MG TAB

Facility

$0.27

Hospital Charge Code	41652724
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.14
Rate for Payer: Aetna Government	$0.14
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

SERTRALINE 50 MG TAB

Facility

$1.00

Hospital Charge Code	41650237
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

SERTRALINE 50 MG TAB

Facility

$1.00

Hospital Charge Code	41640237
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

SERTRALINE HCL 100 MG PO TABS [11350]

Facility

$0.55

Service Code	NDC 00904692661
Hospital Charge Code	00904692661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.36

SERTRALINE HCL 100 MG PO TABS [11350]

Facility

$2.85

Service Code	NDC 65862001330
Hospital Charge Code	65862001330
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.42
Rate for Payer: Aetna Government	$1.42
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SERTRALINE HCL 100 MG PO TABS [11350]

Facility

$2.85

Service Code	NDC 68180035309
Hospital Charge Code	68180035309
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.43
Rate for Payer: Aetna Government	$1.43
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.43
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.43
Rate for Payer: Hamaspik Choice Inc Medicare	$1.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SERTRALINE HCL 100 MG PO TABS [11350]

Facility

$2.85

Service Code	NDC 65862001301
Hospital Charge Code	65862001301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.42
Rate for Payer: Aetna Government	$1.42
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SERTRALINE HCL 25 MG PO TABS [19882]

Facility

$0.40

Service Code	NDC 60687023101
Hospital Charge Code	60687023101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.20
Rate for Payer: Aetna Government	$0.20
Rate for Payer: Brighton Health Commercial	$0.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.26

SERTRALINE HCL 25 MG PO TABS [19882]

Facility

$2.85

Service Code	NDC 65862001130
Hospital Charge Code	65862001130
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.42
Rate for Payer: Aetna Government	$1.42
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SERTRALINE HCL 25 MG PO TABS [19882]

Facility

$0.42

Service Code	NDC 00904692461
Hospital Charge Code	00904692461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.21
Rate for Payer: Aetna Government	$0.21
Rate for Payer: Brighton Health Commercial	$0.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.28
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.27

SERTRALINE HCL 25 MG PO TABS [19882]

Facility

$0.40

Service Code	NDC 60687023111
Hospital Charge Code	60687023111
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.20
Rate for Payer: Aetna Government	$0.20
Rate for Payer: Brighton Health Commercial	$0.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.26

SERTRALINE HCL 25 MG PO TABS [19882]

Facility

$2.71

Service Code	NDC 69097083312
Hospital Charge Code	69097083312
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.36
Rate for Payer: Aetna Government	$1.36
Rate for Payer: Brighton Health Commercial	$2.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.85
Rate for Payer: Group Health Inc Commercial	$1.36
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.36
Rate for Payer: Hamaspik Choice Inc Medicare	$1.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

SERTRALINE HCL 50 MG PO TABS [11351]

Facility

$2.85

Service Code	NDC 65862001205
Hospital Charge Code	65862001205
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.42
Rate for Payer: Aetna Government	$1.42
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SERTRALINE HCL 50 MG PO TABS [11351]

Facility

$0.48

Service Code	NDC 00904692561
Hospital Charge Code	00904692561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
Rate for Payer: Brighton Health Commercial	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.33
Rate for Payer: Group Health Inc Commercial	$0.24
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.24
Rate for Payer: Hamaspik Choice Inc Medicare	$0.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.31

SERTRALINE HCL 50 MG PO TABS [11351]

Facility

$2.71

Service Code	NDC 69097083412
Hospital Charge Code	69097083412
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.36
Rate for Payer: Aetna Government	$1.36
Rate for Payer: Brighton Health Commercial	$2.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.85
Rate for Payer: Group Health Inc Commercial	$1.36
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.36
Rate for Payer: Hamaspik Choice Inc Medicare	$1.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

SERTRALINE HCL 50 MG PO TABS [11351]

Facility

$2.85

Service Code	NDC 65862001230
Hospital Charge Code	65862001230
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.42
Rate for Payer: Aetna Government	$1.42
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

SESAMOIDECTOMY

Facility

$8,291.05

Service Code	HCPCS 28315
Hospital Charge Code	40082740
Hospital Revenue Code	360
Min. Negotiated Rate	$1,468.00
Max. Negotiated Rate	$6,218.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,743.15
Rate for Payer: Aetna Government	$3,743.15
Rate for Payer: Affinity Essential Plan 1&2	$2,620.20
Rate for Payer: Affinity Essential Plan 3&4	$2,620.20
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,620.20
Rate for Payer: Brighton Health Commercial	$6,218.29
Rate for Payer: Cash Price	$3,743.15
Rate for Payer: Cash Price	$3,743.15
Rate for Payer: Cash Price	$3,743.15
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,743.15
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	$3,743.15
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,181.68
Rate for Payer: Fidelis Essential Plan QHP	$3,331.40
Rate for Payer: Fidelis Medicare Advantage	$3,743.15
Rate for Payer: Fidelis Qualified Health Plan	$3,331.40
Rate for Payer: Group Health Inc Commercial	$3,743.15
Rate for Payer: Group Health Inc Medicare	$3,743.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,145.52
Rate for Payer: Hamaspik Choice Inc Medicare	$3,743.15
Rate for Payer: Healthfirst Medicare Advantage	$3,181.68
Rate for Payer: Healthfirst QHP	$3,743.15
Rate for Payer: Humana Medicare	$3,818.01
Rate for Payer: Senior Whole Health Medicare Advantage	$3,743.15
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$3,743.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,743.15
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,994.52
Rate for Payer: Wellcare Medicare	$3,555.99

SESAMOIDECTOMY

Facility

$8,291.05

Service Code	HCPCS 28315
Hospital Charge Code	40082740
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,743.15

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