St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SINGLE ONLAY MET 4 OR MORE SURF.

Facility

$1,169.44

Service Code	HCPCS D2544
Hospital Charge Code	42303285
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY MET THREE SURFACES

Facility

$1,169.44

Service Code	HCPCS D2543
Hospital Charge Code	42303284
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY MET THREE SURFACES

Facility

$1,169.44

Service Code	HCPCS D2543
Hospital Charge Code	42303284
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY MET TWO SURFACES

Facility

$1,169.44

Service Code	HCPCS D2542
Hospital Charge Code	42303283
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY MET TWO SURFACES

Facility

$1,169.44

Service Code	HCPCS D2542
Hospital Charge Code	42303283
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY PORC/CERAM 2 SURF.

Facility

$1,169.44

Service Code	HCPCS D2642
Hospital Charge Code	42303286
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY PORC/CERAM 2 SURF.

Facility

$1,169.44

Service Code	HCPCS D2642
Hospital Charge Code	42303286
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY PORC/CERAM 3 SURF.

Facility

$1,169.44

Service Code	HCPCS D2643
Hospital Charge Code	42303287
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY PORC/CERAM 3 SURF.

Facility

$1,169.44

Service Code	HCPCS D2643
Hospital Charge Code	42303287
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY PORC/CERAM 4 + SURF.

Facility

$1,353.71

Service Code	HCPCS D2644
Hospital Charge Code	42303288
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY PORC/CERAM 4 + SURF.

Facility

$1,353.71

Service Code	HCPCS D2644
Hospital Charge Code	42303288
Hospital Revenue Code	361
Min. Negotiated Rate	$676.86
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$744.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$1,015.28
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$676.86
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY RES-BASE COMP 4+SURF

Facility

$1,169.44

Service Code	HCPCS D2664
Hospital Charge Code	42303291
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY RES-BASE COMP 4+SURF

Facility

$1,169.44

Service Code	HCPCS D2664
Hospital Charge Code	42303291
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY RES-BASED COMP 2SURF

Facility

$1,169.44

Service Code	HCPCS D2662
Hospital Charge Code	42303289
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE ONLAY RES-BASED COMP 2SURF

Facility

$1,169.44

Service Code	HCPCS D2662
Hospital Charge Code	42303289
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY RES-BASED COMP 3SURF

Facility

$1,169.44

Service Code	HCPCS D2663
Hospital Charge Code	42303290
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

SINGLE ONLAY RES-BASED COMP 3SURF

Facility

$1,169.44

Service Code	HCPCS D2663
Hospital Charge Code	42303290
Hospital Revenue Code	361
Min. Negotiated Rate	$584.72
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Brighton Health Commercial	$877.08
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$584.72
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

SINGLE STINGING INSECT,MLT DOSE V

Facility

$115.43

Service Code	HCPCS 95145
Hospital Charge Code	30301418
Hospital Revenue Code	510
Rate for Payer: Cash Price	$54.93

SINGLE STINGING INSECT,MLT DOSE V

Facility

$115.43

Service Code	HCPCS 95145
Hospital Charge Code	30301418
Hospital Revenue Code	510
Min. Negotiated Rate	$43.94
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$63.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$54.93
Rate for Payer: Aetna Government	$54.93
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$54.93
Rate for Payer: Cash Price	$54.93
Rate for Payer: Cash Price	$54.93
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$54.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$54.93
Rate for Payer: Fidelis Essential Plan Aliesa	$46.69
Rate for Payer: Fidelis Essential Plan QHP	$48.89
Rate for Payer: Fidelis Medicare Advantage	$54.93
Rate for Payer: Fidelis Qualified Health Plan	$48.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$57.72
Rate for Payer: Hamaspik Choice Inc Medicare	$54.93
Rate for Payer: Healthfirst Medicare Advantage	$46.69
Rate for Payer: Healthfirst QHP	$54.93
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$54.93
Rate for Payer: Senior Whole Health Medicare Advantage	$54.93
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$54.93
Rate for Payer: Wellcare CHP/FHP/Medicaid	$43.94
Rate for Payer: Wellcare Medicare	$52.18

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$45,799.11

Service Code	MSDRG 135
Min. Negotiated Rate	$20,509.07
Max. Negotiated Rate	$45,799.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$39,105.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44,105.53
Rate for Payer: Aetna Government	$44,105.53
Rate for Payer: Brighton Health Commercial	$38,455.45
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$44,987.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$45,799.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$37,795.40
Rate for Payer: Elderplan Medicare Advantage	$41,900.25
Rate for Payer: EmblemHealth Commercial	$22,741.80
Rate for Payer: Fidelis Medicare Advantage	$44,105.53
Rate for Payer: Group Health Inc Commercial	$44,105.53
Rate for Payer: Group Health Inc Medicare	$44,105.53
Rate for Payer: Hamaspik Choice Inc Medicare	$44,105.53
Rate for Payer: Healthfirst Medicare Advantage	$20,509.07
Rate for Payer: Senior Whole Health Medicare Advantage	$44,105.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$44,105.53
Rate for Payer: Wellcare Medicare	$41,900.25

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$22,245.75

Service Code	MSDRG 136
Min. Negotiated Rate	$8,052.78
Max. Negotiated Rate	$22,245.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13,847.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21,809.56
Rate for Payer: Aetna Government	$21,809.56
Rate for Payer: Brighton Health Commercial	$13,616.95
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$22,245.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18,034.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$14,882.44
Rate for Payer: Elderplan Medicare Advantage	$20,719.08
Rate for Payer: EmblemHealth Commercial	$8,052.78
Rate for Payer: Fidelis Medicare Advantage	$21,809.56
Rate for Payer: Group Health Inc Commercial	$21,809.56
Rate for Payer: Group Health Inc Medicare	$21,809.56
Rate for Payer: Hamaspik Choice Inc Medicare	$21,809.56
Rate for Payer: Healthfirst Medicare Advantage	$10,141.45
Rate for Payer: Senior Whole Health Medicare Advantage	$21,809.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$21,809.56
Rate for Payer: Wellcare Medicare	$20,719.08

SINUS AUG VIA A VERTICAL APPROACH

Facility

$2,000.00

Service Code	HCPCS D7952
Hospital Charge Code	42300749
Hospital Revenue Code	361
Min. Negotiated Rate	$476.08
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,100.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$476.08
Rate for Payer: Aetna Government	$476.08
Rate for Payer: Brighton Health Commercial	$1,500.00
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	$1,000.00
Rate for Payer: Group Health Inc Medicare	$700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,000.00

SINUS AUG W BONE/BONE SUP

Facility

$2,000.00

Service Code	HCPCS D7951
Hospital Charge Code	42303429
Hospital Revenue Code	361
Min. Negotiated Rate	$700.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,100.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$837.26
Rate for Payer: Aetna Government	$837.26
Rate for Payer: Brighton Health Commercial	$1,500.00
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	$1,000.00
Rate for Payer: Group Health Inc Medicare	$700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,000.00

SINUS IMPLANT

Facility

$3,160.00

Hospital Charge Code	40203105
Hospital Revenue Code	272
Min. Negotiated Rate	$1,106.00
Max. Negotiated Rate	$2,528.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,738.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,580.00
Rate for Payer: Aetna Government	$1,580.00
Rate for Payer: Brighton Health Commercial	$2,370.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,528.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,148.80
Rate for Payer: Group Health Inc Commercial	$1,580.00
Rate for Payer: Group Health Inc Medicare	$1,106.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,580.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,580.00

SINUS IRRIGATION

Facility

$616.78

Service Code	HCPCS 31000
Hospital Charge Code	30304092
Hospital Revenue Code	510
Rate for Payer: Cash Price	$282.47

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