St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SP CONTRAST INJ CK VEN ACCESS

Facility

$556.50

Service Code	HCPCS 36598 TC
Hospital Charge Code	41548029
Hospital Revenue Code	361
Rate for Payer: Cash Price	$247.87

SP CONTRAST VENOGRAM

Facility

$1,032.38

Service Code	HCPCS 36005 TC
Hospital Charge Code	41542690
Hospital Revenue Code	361
Min. Negotiated Rate	$342.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$350.58
Rate for Payer: Aetna Government	$350.58
Rate for Payer: Brighton Health Commercial	$774.28
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	$516.19
Rate for Payer: Group Health Inc Medicare	$361.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$516.19
Rate for Payer: Hamaspik Choice Inc Medicare	$516.19
Rate for Payer: United Healthcare Commercial	$1,113.00

SP CONVERTION TO G-J TUBE

Facility

$4,716.98

Service Code	HCPCS 44373 TC
Hospital Charge Code	41547659
Hospital Revenue Code	361
Min. Negotiated Rate	$745.00
Max. Negotiated Rate	$3,537.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,200.46
Rate for Payer: Aetna Government	$2,200.46
Rate for Payer: Affinity Essential Plan 1&2	$1,540.32
Rate for Payer: Affinity Essential Plan 3&4	$1,540.32
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,540.32
Rate for Payer: Brighton Health Commercial	$3,537.74
Rate for Payer: Cash Price	$2,200.46
Rate for Payer: Cash Price	$2,200.46
Rate for Payer: Cash Price	$2,200.46
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$2,200.46
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	$2,200.46
Rate for Payer: EmblemHealth Commercial	$745.00
Rate for Payer: Fidelis Essential Plan Aliesa	$1,870.39
Rate for Payer: Fidelis Essential Plan QHP	$1,958.41
Rate for Payer: Fidelis Medicare Advantage	$2,200.46
Rate for Payer: Fidelis Qualified Health Plan	$1,958.41
Rate for Payer: Group Health Inc Commercial	$2,200.46
Rate for Payer: Group Health Inc Medicare	$2,200.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,358.49
Rate for Payer: Hamaspik Choice Inc Medicare	$2,200.46
Rate for Payer: Healthfirst Medicare Advantage	$1,870.39
Rate for Payer: Healthfirst QHP	$2,200.46
Rate for Payer: Humana Medicare	$2,244.47
Rate for Payer: Senior Whole Health Medicare Advantage	$2,200.46
Rate for Payer: United Healthcare Commercial	$1,409.00
Rate for Payer: United Healthcare Medicare Advantage	$2,200.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,200.46
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,760.37
Rate for Payer: Wellcare Medicare	$2,090.44

SP CONVERTION TO G-J TUBE

Facility

$4,716.98

Service Code	HCPCS 44373 TC
Hospital Charge Code	41547659
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,200.46

SP CONVERT J-TUBE FR EXIST G-TUBE

Facility

$711.45

Service Code	HCPCS 43761 TC
Hospital Charge Code	41547655
Hospital Revenue Code	361
Rate for Payer: Cash Price	$285.81

SP CONVERT J-TUBE FR EXIST G-TUBE

Facility

$711.45

Service Code	HCPCS 43761 TC
Hospital Charge Code	41547655
Hospital Revenue Code	361
Min. Negotiated Rate	$200.07
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$285.81
Rate for Payer: Aetna Government	$285.81
Rate for Payer: Affinity Essential Plan 1&2	$200.07
Rate for Payer: Affinity Essential Plan 3&4	$200.07
Rate for Payer: Affinity Medicaid/CHP/HARP	$200.07
Rate for Payer: Brighton Health Commercial	$533.59
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$285.81
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	$285.81
Rate for Payer: EmblemHealth Commercial	$285.81
Rate for Payer: Fidelis Essential Plan Aliesa	$242.94
Rate for Payer: Fidelis Essential Plan QHP	$254.37
Rate for Payer: Fidelis Medicare Advantage	$285.81
Rate for Payer: Fidelis Qualified Health Plan	$254.37
Rate for Payer: Group Health Inc Commercial	$285.81
Rate for Payer: Group Health Inc Medicare	$285.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$355.72
Rate for Payer: Hamaspik Choice Inc Medicare	$285.81
Rate for Payer: Healthfirst Medicare Advantage	$242.94
Rate for Payer: Healthfirst QHP	$285.81
Rate for Payer: Humana Medicare	$291.53
Rate for Payer: Senior Whole Health Medicare Advantage	$285.81
Rate for Payer: United Healthcare Commercial	$1,113.00
Rate for Payer: United Healthcare Medicare Advantage	$285.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$285.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$228.65
Rate for Payer: Wellcare Medicare	$271.52

SP CRYOABLATION KIDNEY

Facility

$25,481.20

Service Code	HCPCS 50593 TC
Hospital Charge Code	41561826
Hospital Revenue Code	361
Rate for Payer: Cash Price	$11,903.87

SP CRYOABLATION KIDNEY

Facility

$25,481.20

Service Code	HCPCS 50593 TC
Hospital Charge Code	41561826
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$19,110.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11,903.87
Rate for Payer: Aetna Government	$11,903.87
Rate for Payer: Affinity Essential Plan 1&2	$8,332.71
Rate for Payer: Affinity Essential Plan 3&4	$8,332.71
Rate for Payer: Affinity Medicaid/CHP/HARP	$8,332.71
Rate for Payer: Brighton Health Commercial	$19,110.90
Rate for Payer: Cash Price	$11,903.87
Rate for Payer: Cash Price	$11,903.87
Rate for Payer: Cash Price	$11,903.87
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$11,903.87
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	$11,903.87
Rate for Payer: EmblemHealth Commercial	$11,903.87
Rate for Payer: Fidelis Essential Plan Aliesa	$10,118.29
Rate for Payer: Fidelis Essential Plan QHP	$10,594.44
Rate for Payer: Fidelis Medicare Advantage	$11,903.87
Rate for Payer: Fidelis Qualified Health Plan	$10,594.44
Rate for Payer: Group Health Inc Commercial	$11,903.87
Rate for Payer: Group Health Inc Medicare	$11,903.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$12,740.60
Rate for Payer: Hamaspik Choice Inc Medicare	$11,903.87
Rate for Payer: Healthfirst Medicare Advantage	$10,118.29
Rate for Payer: Healthfirst QHP	$11,903.87
Rate for Payer: Humana Medicare	$12,141.95
Rate for Payer: Senior Whole Health Medicare Advantage	$11,903.87
Rate for Payer: United Healthcare Commercial	$2,546.00
Rate for Payer: United Healthcare Medicare Advantage	$11,903.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,903.87
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9,523.10
Rate for Payer: Wellcare Medicare	$11,308.68

SP CYSTOGRAM

Facility

$605.55

Service Code	HCPCS 51600 TC
Hospital Charge Code	41542727
Hospital Revenue Code	361
Min. Negotiated Rate	$211.94
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$224.79
Rate for Payer: Aetna Government	$224.79
Rate for Payer: Brighton Health Commercial	$454.16
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	$302.78
Rate for Payer: Group Health Inc Medicare	$211.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$302.78
Rate for Payer: Hamaspik Choice Inc Medicare	$302.78
Rate for Payer: United Healthcare Commercial	$1,113.00

SP DENVER SHUNT

Facility

$2,425.06

Service Code	HCPCS 49427 TC
Hospital Charge Code	41547447
Hospital Revenue Code	361
Min. Negotiated Rate	$53.15
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$53.15
Rate for Payer: Aetna Government	$53.15
Rate for Payer: Brighton Health Commercial	$1,818.80
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	$1,212.53
Rate for Payer: Group Health Inc Medicare	$848.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,212.53
Rate for Payer: Hamaspik Choice Inc Medicare	$1,212.53
Rate for Payer: United Healthcare Commercial	$1,113.00

SP DESCENDING THORACIC AORTA GRAF

Facility

$6,768.48

Service Code	HCPCS 33875 TC
Hospital Charge Code	41547702
Hospital Revenue Code	361
Min. Negotiated Rate	$1,496.00
Max. Negotiated Rate	$5,076.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,722.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,085.67
Rate for Payer: Aetna Government	$3,085.67
Rate for Payer: Brighton Health Commercial	$5,076.36
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	$3,384.24
Rate for Payer: Group Health Inc Medicare	$2,368.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,384.24
Rate for Payer: Hamaspik Choice Inc Medicare	$3,384.24
Rate for Payer: United Healthcare Commercial	$1,496.00

SP DILATION URETERS

Facility

$9,142.40

Service Code	HCPCS 52351 TC
Hospital Charge Code	41542737
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,031.47

SP DILATION URETERS

Facility

$9,142.40

Service Code	HCPCS 52351 TC
Hospital Charge Code	41542737
Hospital Revenue Code	361
Min. Negotiated Rate	$745.00
Max. Negotiated Rate	$6,856.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,031.47
Rate for Payer: Aetna Government	$4,031.47
Rate for Payer: Affinity Essential Plan 1&2	$2,822.03
Rate for Payer: Affinity Essential Plan 3&4	$2,822.03
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,822.03
Rate for Payer: Brighton Health Commercial	$6,856.80
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,031.47
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	$4,031.47
Rate for Payer: EmblemHealth Commercial	$745.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,426.75
Rate for Payer: Fidelis Essential Plan QHP	$3,588.01
Rate for Payer: Fidelis Medicare Advantage	$4,031.47
Rate for Payer: Fidelis Qualified Health Plan	$3,588.01
Rate for Payer: Group Health Inc Commercial	$4,031.47
Rate for Payer: Group Health Inc Medicare	$4,031.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,571.20
Rate for Payer: Hamaspik Choice Inc Medicare	$4,031.47
Rate for Payer: Healthfirst Medicare Advantage	$3,426.75
Rate for Payer: Healthfirst QHP	$4,031.47
Rate for Payer: Humana Medicare	$4,112.10
Rate for Payer: Senior Whole Health Medicare Advantage	$4,031.47
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$4,031.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,031.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,225.18
Rate for Payer: Wellcare Medicare	$3,829.90

SP DILN EXISTING NEPHROSTOMY

Facility

$5,365.58

Service Code	HCPCS 50436
Hospital Charge Code	41546548
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,031.47

SP DILN EXISTING NEPHROSTOMY

Facility

$5,365.58

Service Code	HCPCS 50436
Hospital Charge Code	41546548
Hospital Revenue Code	361
Min. Negotiated Rate	$1,412.00
Max. Negotiated Rate	$4,112.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,031.47
Rate for Payer: Aetna Government	$4,031.47
Rate for Payer: Affinity Essential Plan 1&2	$2,822.03
Rate for Payer: Affinity Essential Plan 3&4	$2,822.03
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,822.03
Rate for Payer: Brighton Health Commercial	$4,024.18
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,031.47
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	$4,031.47
Rate for Payer: EmblemHealth Commercial	$4,031.47
Rate for Payer: Fidelis Essential Plan Aliesa	$3,426.75
Rate for Payer: Fidelis Essential Plan QHP	$3,588.01
Rate for Payer: Fidelis Medicare Advantage	$4,031.47
Rate for Payer: Fidelis Qualified Health Plan	$3,588.01
Rate for Payer: Group Health Inc Commercial	$4,031.47
Rate for Payer: Group Health Inc Medicare	$4,031.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,682.79
Rate for Payer: Hamaspik Choice Inc Medicare	$4,031.47
Rate for Payer: Healthfirst Medicare Advantage	$3,426.75
Rate for Payer: Healthfirst QHP	$4,031.47
Rate for Payer: Humana Medicare	$4,112.10
Rate for Payer: Senior Whole Health Medicare Advantage	$4,031.47
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$4,031.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,031.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,225.18
Rate for Payer: Wellcare Medicare	$3,829.90

SP DILN NEPHROSTOMY NEW ACCESS

Facility

$9,142.40

Service Code	HCPCS 50437
Hospital Charge Code	41546549
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,031.47

SP DILN NEPHROSTOMY NEW ACCESS

Facility

$9,142.40

Service Code	HCPCS 50437
Hospital Charge Code	41546549
Hospital Revenue Code	361
Min. Negotiated Rate	$1,412.00
Max. Negotiated Rate	$6,856.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,031.47
Rate for Payer: Aetna Government	$4,031.47
Rate for Payer: Affinity Essential Plan 1&2	$2,822.03
Rate for Payer: Affinity Essential Plan 3&4	$2,822.03
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,822.03
Rate for Payer: Brighton Health Commercial	$6,856.80
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Cash Price	$4,031.47
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,031.47
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	$4,031.47
Rate for Payer: EmblemHealth Commercial	$4,031.47
Rate for Payer: Fidelis Essential Plan Aliesa	$3,426.75
Rate for Payer: Fidelis Essential Plan QHP	$3,588.01
Rate for Payer: Fidelis Medicare Advantage	$4,031.47
Rate for Payer: Fidelis Qualified Health Plan	$3,588.01
Rate for Payer: Group Health Inc Commercial	$4,031.47
Rate for Payer: Group Health Inc Medicare	$4,031.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,571.20
Rate for Payer: Hamaspik Choice Inc Medicare	$4,031.47
Rate for Payer: Healthfirst Medicare Advantage	$3,426.75
Rate for Payer: Healthfirst QHP	$4,031.47
Rate for Payer: Humana Medicare	$4,112.10
Rate for Payer: Senior Whole Health Medicare Advantage	$4,031.47
Rate for Payer: United Healthcare Commercial	$1,835.00
Rate for Payer: United Healthcare Medicare Advantage	$4,031.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,031.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,225.18
Rate for Payer: Wellcare Medicare	$3,829.90

SP DISCECTOMY, PERCUTANEOUS

Facility

$5,207.48

Service Code	HCPCS 62287 TC
Hospital Charge Code	41549864
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,232.80

SP DISCECTOMY, PERCUTANEOUS

Facility

$5,207.48

Service Code	HCPCS 62287 TC
Hospital Charge Code	41549864
Hospital Revenue Code	361
Min. Negotiated Rate	$1,562.96
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,232.80
Rate for Payer: Aetna Government	$2,232.80
Rate for Payer: Affinity Essential Plan 1&2	$1,562.96
Rate for Payer: Affinity Essential Plan 3&4	$1,562.96
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,562.96
Rate for Payer: Brighton Health Commercial	$3,905.61
Rate for Payer: Cash Price	$2,232.80
Rate for Payer: Cash Price	$2,232.80
Rate for Payer: Cash Price	$2,232.80
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$2,232.80
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	$2,232.80
Rate for Payer: EmblemHealth Commercial	$2,232.80
Rate for Payer: Fidelis Essential Plan Aliesa	$1,897.88
Rate for Payer: Fidelis Essential Plan QHP	$1,987.19
Rate for Payer: Fidelis Medicare Advantage	$2,232.80
Rate for Payer: Fidelis Qualified Health Plan	$1,987.19
Rate for Payer: Group Health Inc Commercial	$2,232.80
Rate for Payer: Group Health Inc Medicare	$2,232.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,603.74
Rate for Payer: Hamaspik Choice Inc Medicare	$2,232.80
Rate for Payer: Healthfirst Medicare Advantage	$1,897.88
Rate for Payer: Healthfirst QHP	$2,232.80
Rate for Payer: Humana Medicare	$2,277.46
Rate for Payer: Senior Whole Health Medicare Advantage	$2,232.80
Rate for Payer: United Healthcare Commercial	$1,835.00
Rate for Payer: United Healthcare Medicare Advantage	$2,232.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,232.80
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,786.24
Rate for Payer: Wellcare Medicare	$2,121.16

SP DRAINAGE BLADDER

Facility

$2,752.98

Service Code	HCPCS 51101 TC
Hospital Charge Code	41547643
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,209.08

SP DRAINAGE BLADDER

Facility

$2,752.98

Service Code	HCPCS 51101 TC
Hospital Charge Code	41547643
Hospital Revenue Code	361
Min. Negotiated Rate	$342.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,209.08
Rate for Payer: Aetna Government	$1,209.08
Rate for Payer: Affinity Essential Plan 1&2	$846.36
Rate for Payer: Affinity Essential Plan 3&4	$846.36
Rate for Payer: Affinity Medicaid/CHP/HARP	$846.36
Rate for Payer: Brighton Health Commercial	$2,064.74
Rate for Payer: Cash Price	$1,209.08
Rate for Payer: Cash Price	$1,209.08
Rate for Payer: Cash Price	$1,209.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,209.08
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	$1,209.08
Rate for Payer: EmblemHealth Commercial	$1,209.08
Rate for Payer: Fidelis Essential Plan Aliesa	$1,027.72
Rate for Payer: Fidelis Essential Plan QHP	$1,076.08
Rate for Payer: Fidelis Medicare Advantage	$1,209.08
Rate for Payer: Fidelis Qualified Health Plan	$1,076.08
Rate for Payer: Group Health Inc Commercial	$1,209.08
Rate for Payer: Group Health Inc Medicare	$1,209.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.49
Rate for Payer: Hamaspik Choice Inc Medicare	$1,209.08
Rate for Payer: Healthfirst Medicare Advantage	$1,027.72
Rate for Payer: Healthfirst QHP	$1,209.08
Rate for Payer: Humana Medicare	$1,233.26
Rate for Payer: Senior Whole Health Medicare Advantage	$1,209.08
Rate for Payer: United Healthcare Commercial	$1,409.00
Rate for Payer: United Healthcare Medicare Advantage	$1,209.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,209.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$967.26
Rate for Payer: Wellcare Medicare	$1,148.63

SP DUP-SCAN HEMO COMPL BI STD

Facility

$692.43

Service Code	HCPCS 93986
Hospital Charge Code	41561888
Hospital Revenue Code	921
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$553.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$519.32
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$553.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$470.85
Rate for Payer: Elderplan Medicare Advantage	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$346.22
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Commercial	$346.22
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

SP DUP-SCAN HEMO COMPL BI STD

Facility

$692.43

Service Code	HCPCS 93986
Hospital Charge Code	41561888
Hospital Revenue Code	921
Rate for Payer: Cash Price	$127.14

SP DUP-SCAN HEMO COMPL STD UNILAT

Facility

$477.10

Service Code	HCPCS 93985
Hospital Charge Code	41201179
Hospital Revenue Code	921
Min. Negotiated Rate	$198.36
Max. Negotiated Rate	$381.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$283.37
Rate for Payer: Aetna Government	$283.37
Rate for Payer: Affinity Essential Plan 1&2	$198.36
Rate for Payer: Affinity Essential Plan 3&4	$198.36
Rate for Payer: Affinity Medicaid/CHP/HARP	$198.36
Rate for Payer: Brighton Health Commercial	$357.82
Rate for Payer: Cash Price	$283.37
Rate for Payer: Cash Price	$283.37
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$283.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$381.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$324.43
Rate for Payer: Elderplan Medicare Advantage	$283.37
Rate for Payer: EmblemHealth Commercial	$283.37
Rate for Payer: Fidelis Essential Plan Aliesa	$240.86
Rate for Payer: Fidelis Essential Plan QHP	$252.20
Rate for Payer: Fidelis Medicare Advantage	$283.37
Rate for Payer: Fidelis Qualified Health Plan	$252.20
Rate for Payer: Group Health Inc Commercial	$283.37
Rate for Payer: Group Health Inc Medicare	$283.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$238.55
Rate for Payer: Hamaspik Choice Inc Medicare	$283.37
Rate for Payer: Healthfirst Medicare Advantage	$240.86
Rate for Payer: Healthfirst QHP	$283.37
Rate for Payer: Humana Medicare	$289.04
Rate for Payer: Senior Whole Health Medicare Advantage	$283.37
Rate for Payer: United Healthcare Commercial	$238.55
Rate for Payer: United Healthcare Medicare Advantage	$283.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$283.37
Rate for Payer: Wellcare CHP/FHP/Medicaid	$226.70
Rate for Payer: Wellcare Medicare	$269.20

SP DUP-SCAN HEMO COMPL STD UNILAT

Facility

$477.10

Service Code	HCPCS 93985
Hospital Charge Code	41201179
Hospital Revenue Code	921
Rate for Payer: Cash Price	$283.37

Know your out-of-pocket cost for care.

All Charges