St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SINUS IRRIGATION

Facility

$616.78

Service Code	HCPCS 31000
Hospital Charge Code	30304092
Hospital Revenue Code	510
Min. Negotiated Rate	$225.98
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$282.47
Rate for Payer: Aetna Government	$282.47
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$282.47
Rate for Payer: Cash Price	$282.47
Rate for Payer: Cash Price	$282.47
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$282.47
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: Elderplan Medicare Advantage	$282.47
Rate for Payer: Fidelis Essential Plan Aliesa	$240.10
Rate for Payer: Fidelis Essential Plan QHP	$251.40
Rate for Payer: Fidelis Medicare Advantage	$282.47
Rate for Payer: Fidelis Qualified Health Plan	$251.40
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	$308.39
Rate for Payer: Hamaspik Choice Inc Medicare	$282.47
Rate for Payer: Healthfirst Medicare Advantage	$240.10
Rate for Payer: Healthfirst QHP	$282.47
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$282.47
Rate for Payer: Senior Whole Health Medicare Advantage	$282.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$282.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$225.98
Rate for Payer: Wellcare Medicare	$268.35

SINUS LIFT WITH BONE GRAFT

Facility

$2,126.00

Service Code	HCPCS D7950
Hospital Charge Code	42303385
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,772.21

SINUS LIFT WITH BONE GRAFT

Facility

$2,126.00

Service Code	HCPCS D7950
Hospital Charge Code	42303385
Hospital Revenue Code	361
Min. Negotiated Rate	$1,063.00
Max. Negotiated Rate	$6,772.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,169.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,772.21
Rate for Payer: Aetna Government	$6,772.21
Rate for Payer: Brighton Health Commercial	$1,594.50
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	$6,772.21
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	$1,063.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6,772.21
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

SITAGLIPTIN 100 MG TAB - NF

Facility

$14.05

Hospital Charge Code	41644866
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.02
Rate for Payer: Aetna Government	$7.02
Rate for Payer: Brighton Health Commercial	$10.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.55
Rate for Payer: Group Health Inc Commercial	$7.02
Rate for Payer: Group Health Inc Medicare	$4.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.02
Rate for Payer: Hamaspik Choice Inc Medicare	$7.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.13

SITAGLIPTIN 100 MG TAB - NF

Facility

$14.05

Hospital Charge Code	41654866
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.02
Rate for Payer: Aetna Government	$7.02
Rate for Payer: Brighton Health Commercial	$10.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.55
Rate for Payer: Group Health Inc Commercial	$7.02
Rate for Payer: Group Health Inc Medicare	$4.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.02
Rate for Payer: Hamaspik Choice Inc Medicare	$7.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.13

SITAGLIPTIN 25 MG TAB - NF

Facility

$13.00

Hospital Charge Code	41654864
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$10.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Brighton Health Commercial	$9.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.84
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$4.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.45

SITAGLIPTIN 25 MG TAB - NF

Facility

$13.00

Hospital Charge Code	41644864
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$10.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Brighton Health Commercial	$9.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.84
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$4.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.45

SITAGLIPTIN 50 MG TAB - NF

Facility

$14.07

Hospital Charge Code	41644865
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.04
Rate for Payer: Aetna Government	$7.04
Rate for Payer: Brighton Health Commercial	$10.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.57
Rate for Payer: Group Health Inc Commercial	$7.04
Rate for Payer: Group Health Inc Medicare	$4.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.04
Rate for Payer: Hamaspik Choice Inc Medicare	$7.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.15

SITAGLIPTIN 50 MG TAB - NF

Facility

$14.07

Hospital Charge Code	41654865
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.04
Rate for Payer: Aetna Government	$7.04
Rate for Payer: Brighton Health Commercial	$10.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.57
Rate for Payer: Group Health Inc Commercial	$7.04
Rate for Payer: Group Health Inc Medicare	$4.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.04
Rate for Payer: Hamaspik Choice Inc Medicare	$7.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.15

SITAGLIPTIN PHOSPHATE 100 MG PO TABS [77617]

Facility

$22.92

Service Code	NDC 00006027731
Hospital Charge Code	00006027731
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 100 MG PO TABS [77617]

Facility

$22.92

Service Code	NDC 00006027701
Hospital Charge Code	00006027701
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 100 MG PO TABS [77617]

Facility

$22.92

Service Code	NDC 00006027728
Hospital Charge Code	00006027728
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 25 MG PO TABS [77615]

Facility

$22.92

Service Code	NDC 00006022128
Hospital Charge Code	00006022128
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 25 MG PO TABS [77615]

Facility

$22.92

Service Code	NDC 00006022101
Hospital Charge Code	00006022101
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 25 MG PO TABS [77615]

Facility

$22.92

Service Code	NDC 00006022131
Hospital Charge Code	00006022131
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 50 MG PO TABS [77616]

Facility

$22.92

Service Code	NDC 00006011231
Hospital Charge Code	00006011231
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 50 MG PO TABS [77616]

Facility

$22.92

Service Code	NDC 00006011228
Hospital Charge Code	00006011228
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 50 MG PO TABS [77616]

Facility

$22.92

Service Code	NDC 00006011201
Hospital Charge Code	00006011201
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITZ BATH

Facility

$7.80

Hospital Charge Code	40207626
Hospital Revenue Code	270
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$6.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.90
Rate for Payer: Aetna Government	$3.90
Rate for Payer: Brighton Health Commercial	$5.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.30
Rate for Payer: Group Health Inc Commercial	$3.90
Rate for Payer: Group Health Inc Medicare	$2.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.90
Rate for Payer: Hamaspik Choice Inc Medicare	$3.90

SIZE 3-4 21MM CONSTRAINED INSERT

Facility

$4,700.00

Service Code	HCPCS C1776
Hospital Charge Code	64904173
Hospital Revenue Code	278
Min. Negotiated Rate	$2,350.00
Max. Negotiated Rate	$2,350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,350.00

SIZE 3-4 21MM CONSTRAINED INSERT

Facility

$4,700.00

Service Code	HCPCS C1776
Hospital Charge Code	64904173
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,935.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,585.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,820.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,350.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,702.50
Rate for Payer: EmblemHealth Commercial	$2,350.00
Rate for Payer: Fidelis Medicare Advantage	$4,935.00
Rate for Payer: Group Health Inc Commercial	$2,350.00
Rate for Payer: Group Health Inc Medicare	$1,645.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,350.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,055.00

SIZE 3 RIGHT REVISION TIB

Facility

$97,187.50

Service Code	HCPCS C1713
Hospital Charge Code	64904175
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$102,046.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53,453.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$58,312.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$48,593.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$55,882.81
Rate for Payer: EmblemHealth Commercial	$48,593.75
Rate for Payer: Fidelis Medicare Advantage	$102,046.88
Rate for Payer: Group Health Inc Commercial	$48,593.75
Rate for Payer: Group Health Inc Medicare	$34,015.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$48,593.75
Rate for Payer: Hamaspik Choice Inc Medicare	$48,593.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63,171.88

SIZE 3 RIGHT REVISION TIB

Facility

$97,187.50

Service Code	HCPCS C1713
Hospital Charge Code	64904175
Hospital Revenue Code	278
Min. Negotiated Rate	$48,593.75
Max. Negotiated Rate	$48,593.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$48,593.75
Rate for Payer: Hamaspik Choice Inc Medicare	$48,593.75

SIZE 4 RIGHT OX REV FEMUR

Facility

$24,211.25

Service Code	HCPCS C1713
Hospital Charge Code	64904170
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$25,421.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13,316.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$14,526.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12,105.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$13,921.47
Rate for Payer: EmblemHealth Commercial	$12,105.62
Rate for Payer: Fidelis Medicare Advantage	$25,421.81
Rate for Payer: Group Health Inc Commercial	$12,105.62
Rate for Payer: Group Health Inc Medicare	$8,473.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$12,105.62
Rate for Payer: Hamaspik Choice Inc Medicare	$12,105.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15,737.31

SIZE 4 RIGHT OX REV FEMUR

Facility

$24,211.25

Service Code	HCPCS C1713
Hospital Charge Code	64904170
Hospital Revenue Code	278
Min. Negotiated Rate	$12,105.62
Max. Negotiated Rate	$12,105.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$12,105.62
Rate for Payer: Hamaspik Choice Inc Medicare	$12,105.62

Know your out-of-pocket cost for care.

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