St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SP ESOPHAGUS DILATION

Facility

$4,716.98

Service Code	HCPCS 43453 TC
Hospital Charge Code	41547677
Hospital Revenue Code	361
Min. Negotiated Rate	$1,409.00
Max. Negotiated Rate	$3,537.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
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	$2,200.46
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 EVASC PRLNG ADMIN RX AGNT ADD

Facility

$1,490.25

Service Code	HCPCS 61651 TC
Hospital Charge Code	41543347
Hospital Revenue Code	361
Min. Negotiated Rate	$261.10
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$819.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$261.10
Rate for Payer: Aetna Government	$261.10
Rate for Payer: Brighton Health Commercial	$1,117.69
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	$745.12
Rate for Payer: Group Health Inc Medicare	$521.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$745.12
Rate for Payer: Hamaspik Choice Inc Medicare	$745.12
Rate for Payer: United Healthcare Commercial	$1,496.00

SP EVASC PRLNG ADMN RX AGNT 1ST

Facility

$3,499.05

Service Code	HCPCS 61650 TC
Hospital Charge Code	41543346
Hospital Revenue Code	361
Min. Negotiated Rate	$614.76
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,924.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$614.76
Rate for Payer: Aetna Government	$614.76
Rate for Payer: Brighton Health Commercial	$2,624.29
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	$1,749.52
Rate for Payer: Group Health Inc Medicare	$1,224.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,749.52
Rate for Payer: Hamaspik Choice Inc Medicare	$1,749.52
Rate for Payer: United Healthcare Commercial	$1,496.00

SP EXCHANGE PREVIOUS DRAIN CATH

Facility

$4,716.98

Service Code	HCPCS 49423 TC
Hospital Charge Code	41561814
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,200.46

SP EXCHANGE PREVIOUS DRAIN CATH

Facility

$4,716.98

Service Code	HCPCS 49423 TC
Hospital Charge Code	41561814
Hospital Revenue Code	361
Min. Negotiated Rate	$1,409.00
Max. Negotiated Rate	$3,537.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
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	$2,200.46
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 EXT. ART. NDL/INTA. BI

Facility

$1,475.15

Service Code	HCPCS 36140 TC
Hospital Charge Code	41542030
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	$475.11
Rate for Payer: Aetna Government	$475.11
Rate for Payer: Brighton Health Commercial	$1,106.36
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	$737.58
Rate for Payer: Group Health Inc Medicare	$516.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$737.58
Rate for Payer: Hamaspik Choice Inc Medicare	$737.58
Rate for Payer: United Healthcare Commercial	$1,113.00

SP EXT. ART. NDL/INTA. UNI

Facility

$1,475.15

Service Code	HCPCS 36140 TC
Hospital Charge Code	41542028
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	$475.11
Rate for Payer: Aetna Government	$475.11
Rate for Payer: Brighton Health Commercial	$1,106.36
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	$737.58
Rate for Payer: Group Health Inc Medicare	$516.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$737.58
Rate for Payer: Hamaspik Choice Inc Medicare	$737.58
Rate for Payer: United Healthcare Commercial	$1,113.00

SP EXTREMITY VEIN UNILATERAL

Facility

$570.55

Service Code	HCPCS 36000 TC
Hospital Charge Code	41547445
Hospital Revenue Code	361
Min. Negotiated Rate	$27.49
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.49
Rate for Payer: Aetna Government	$27.49
Rate for Payer: Brighton Health Commercial	$427.91
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	$285.28
Rate for Payer: Group Health Inc Medicare	$199.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$285.28
Rate for Payer: Hamaspik Choice Inc Medicare	$285.28
Rate for Payer: United Healthcare Commercial	$1,113.00

SP FALLOPIAN DILATION

Facility

$7,566.13

Service Code	HCPCS 58345 TC
Hospital Charge Code	41548584
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,615.39

SP FALLOPIAN DILATION

Facility

$7,566.13

Service Code	HCPCS 58345 TC
Hospital Charge Code	41548584
Hospital Revenue Code	361
Min. Negotiated Rate	$1,468.00
Max. Negotiated Rate	$5,674.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,615.39
Rate for Payer: Aetna Government	$3,615.39
Rate for Payer: Affinity Essential Plan 1&2	$2,530.77
Rate for Payer: Affinity Essential Plan 3&4	$2,530.77
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,530.77
Rate for Payer: Brighton Health Commercial	$5,674.60
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,615.39
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	$3,615.39
Rate for Payer: EmblemHealth Commercial	$3,615.39
Rate for Payer: Fidelis Essential Plan Aliesa	$3,073.08
Rate for Payer: Fidelis Essential Plan QHP	$3,217.70
Rate for Payer: Fidelis Medicare Advantage	$3,615.39
Rate for Payer: Fidelis Qualified Health Plan	$3,217.70
Rate for Payer: Group Health Inc Commercial	$3,615.39
Rate for Payer: Group Health Inc Medicare	$3,615.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,783.06
Rate for Payer: Hamaspik Choice Inc Medicare	$3,615.39
Rate for Payer: Healthfirst Medicare Advantage	$3,073.08
Rate for Payer: Healthfirst QHP	$3,615.39
Rate for Payer: Humana Medicare	$3,687.70
Rate for Payer: Senior Whole Health Medicare Advantage	$3,615.39
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$3,615.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,615.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,892.31
Rate for Payer: Wellcare Medicare	$3,434.62

SP FEM/POPL REVASC W/STENT

Facility

$30,010.30

Service Code	HCPCS 37226
Hospital Charge Code	41101441
Hospital Revenue Code	361
Rate for Payer: Cash Price	$12,721.98

SP FEM/POPL REVASC W/STENT

Facility

$30,010.30

Service Code	HCPCS 37226
Hospital Charge Code	41101441
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$22,507.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12,721.98
Rate for Payer: Aetna Government	$12,721.98
Rate for Payer: Affinity Essential Plan 1&2	$8,905.39
Rate for Payer: Affinity Essential Plan 3&4	$8,905.39
Rate for Payer: Affinity Medicaid/CHP/HARP	$8,905.39
Rate for Payer: Brighton Health Commercial	$22,507.72
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12,721.98
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	$12,721.98
Rate for Payer: EmblemHealth Commercial	$12,721.98
Rate for Payer: Fidelis Essential Plan Aliesa	$10,813.68
Rate for Payer: Fidelis Essential Plan QHP	$11,322.56
Rate for Payer: Fidelis Medicare Advantage	$12,721.98
Rate for Payer: Fidelis Qualified Health Plan	$11,322.56
Rate for Payer: Group Health Inc Commercial	$12,721.98
Rate for Payer: Group Health Inc Medicare	$12,721.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,005.15
Rate for Payer: Hamaspik Choice Inc Medicare	$12,721.98
Rate for Payer: Healthfirst Medicare Advantage	$10,813.68
Rate for Payer: Healthfirst QHP	$12,721.98
Rate for Payer: Humana Medicare	$12,976.42
Rate for Payer: Senior Whole Health Medicare Advantage	$12,721.98
Rate for Payer: United Healthcare Commercial	$3,190.00
Rate for Payer: United Healthcare Medicare Advantage	$12,721.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12,721.98
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10,177.58
Rate for Payer: Wellcare Medicare	$12,085.88

SP FEM/POPL REVAS W/TLA

Facility

$15,004.15

Service Code	HCPCS 37224
Hospital Charge Code	41101440
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,609.72

SP FEM/POPL REVAS W/TLA

Facility

$15,004.15

Service Code	HCPCS 37224
Hospital Charge Code	41101440
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$11,253.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,609.72
Rate for Payer: Aetna Government	$6,609.72
Rate for Payer: Affinity Essential Plan 1&2	$4,626.80
Rate for Payer: Affinity Essential Plan 3&4	$4,626.80
Rate for Payer: Affinity Medicaid/CHP/HARP	$4,626.80
Rate for Payer: Brighton Health Commercial	$11,253.11
Rate for Payer: Cash Price	$6,609.72
Rate for Payer: Cash Price	$6,609.72
Rate for Payer: Cash Price	$6,609.72
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6,609.72
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	$6,609.72
Rate for Payer: EmblemHealth Commercial	$6,609.72
Rate for Payer: Fidelis Essential Plan Aliesa	$5,618.26
Rate for Payer: Fidelis Essential Plan QHP	$5,882.65
Rate for Payer: Fidelis Medicare Advantage	$6,609.72
Rate for Payer: Fidelis Qualified Health Plan	$5,882.65
Rate for Payer: Group Health Inc Commercial	$6,609.72
Rate for Payer: Group Health Inc Medicare	$6,609.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,502.08
Rate for Payer: Hamaspik Choice Inc Medicare	$6,609.72
Rate for Payer: Healthfirst Medicare Advantage	$5,618.26
Rate for Payer: Healthfirst QHP	$6,609.72
Rate for Payer: Humana Medicare	$6,741.91
Rate for Payer: Senior Whole Health Medicare Advantage	$6,609.72
Rate for Payer: United Healthcare Commercial	$2,546.00
Rate for Payer: United Healthcare Medicare Advantage	$6,609.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,609.72
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5,287.78
Rate for Payer: Wellcare Medicare	$6,279.23

SP FEM-POP TRANSLUMBAR

Facility

$30,010.30

Service Code	HCPCS 37225 TC
Hospital Charge Code	41542770
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$22,507.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20,278.00
Rate for Payer: Aetna Government	$20,278.00
Rate for Payer: Affinity Essential Plan 1&2	$14,194.60
Rate for Payer: Affinity Essential Plan 3&4	$14,194.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$14,194.60
Rate for Payer: Brighton Health Commercial	$22,507.72
Rate for Payer: Cash Price	$20,278.00
Rate for Payer: Cash Price	$20,278.00
Rate for Payer: Cash Price	$20,278.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20,278.00
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: Elderplan Medicare Advantage	$20,278.00
Rate for Payer: EmblemHealth Commercial	$20,278.00
Rate for Payer: Fidelis Essential Plan Aliesa	$17,236.30
Rate for Payer: Fidelis Essential Plan QHP	$18,047.42
Rate for Payer: Fidelis Medicare Advantage	$20,278.00
Rate for Payer: Fidelis Qualified Health Plan	$18,047.42
Rate for Payer: Group Health Inc Commercial	$20,278.00
Rate for Payer: Group Health Inc Medicare	$20,278.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,005.15
Rate for Payer: Hamaspik Choice Inc Medicare	$20,278.00
Rate for Payer: Healthfirst Medicare Advantage	$17,236.30
Rate for Payer: Healthfirst QHP	$20,278.00
Rate for Payer: Humana Medicare	$20,683.56
Rate for Payer: Senior Whole Health Medicare Advantage	$20,278.00
Rate for Payer: United Healthcare Commercial	$3,190.00
Rate for Payer: United Healthcare Medicare Advantage	$20,278.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20,278.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$16,222.40
Rate for Payer: Wellcare Medicare	$19,264.10

SP FEM-POP TRANSLUMBAR

Facility

$30,010.30

Service Code	HCPCS 37225 TC
Hospital Charge Code	41542770
Hospital Revenue Code	361
Rate for Payer: Cash Price	$20,278.00

SP FIBROID EMBOLIZATION

Facility

$30,948.00

Service Code	HCPCS 37243 TC
Hospital Charge Code	41549956
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$23,211.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12,721.98
Rate for Payer: Aetna Government	$12,721.98
Rate for Payer: Affinity Essential Plan 1&2	$8,905.39
Rate for Payer: Affinity Essential Plan 3&4	$8,905.39
Rate for Payer: Affinity Medicaid/CHP/HARP	$8,905.39
Rate for Payer: Brighton Health Commercial	$23,211.00
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12,721.98
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	$12,721.98
Rate for Payer: EmblemHealth Commercial	$12,721.98
Rate for Payer: Fidelis Essential Plan Aliesa	$10,813.68
Rate for Payer: Fidelis Essential Plan QHP	$11,322.56
Rate for Payer: Fidelis Medicare Advantage	$12,721.98
Rate for Payer: Fidelis Qualified Health Plan	$11,322.56
Rate for Payer: Group Health Inc Commercial	$12,721.98
Rate for Payer: Group Health Inc Medicare	$12,721.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,474.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12,721.98
Rate for Payer: Healthfirst Medicare Advantage	$10,813.68
Rate for Payer: Healthfirst QHP	$12,721.98
Rate for Payer: Humana Medicare	$12,976.42
Rate for Payer: Senior Whole Health Medicare Advantage	$12,721.98
Rate for Payer: United Healthcare Commercial	$3,190.00
Rate for Payer: United Healthcare Medicare Advantage	$12,721.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12,721.98
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10,177.58
Rate for Payer: Wellcare Medicare	$12,085.88

SP FIBROID EMBOLIZATION

Facility

$30,948.00

Service Code	HCPCS 37243 TC
Hospital Charge Code	41549956
Hospital Revenue Code	361
Rate for Payer: Cash Price	$12,721.98

SP FIBRSHTH STRP SEP VENOUS ACC

Facility

$8,393.53

Service Code	HCPCS 36595 TC
Hospital Charge Code	41549849
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,686.08

SP FIBRSHTH STRP SEP VENOUS ACC

Facility

$8,393.53

Service Code	HCPCS 36595 TC
Hospital Charge Code	41549849
Hospital Revenue Code	361
Min. Negotiated Rate	$1,835.00
Max. Negotiated Rate	$6,295.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,686.08
Rate for Payer: Aetna Government	$3,686.08
Rate for Payer: Affinity Essential Plan 1&2	$2,580.26
Rate for Payer: Affinity Essential Plan 3&4	$2,580.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,580.26
Rate for Payer: Brighton Health Commercial	$6,295.15
Rate for Payer: Cash Price	$3,686.08
Rate for Payer: Cash Price	$3,686.08
Rate for Payer: Cash Price	$3,686.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,686.08
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	$3,686.08
Rate for Payer: EmblemHealth Commercial	$3,686.08
Rate for Payer: Fidelis Essential Plan Aliesa	$3,133.17
Rate for Payer: Fidelis Essential Plan QHP	$3,280.61
Rate for Payer: Fidelis Medicare Advantage	$3,686.08
Rate for Payer: Fidelis Qualified Health Plan	$3,280.61
Rate for Payer: Group Health Inc Commercial	$3,686.08
Rate for Payer: Group Health Inc Medicare	$3,686.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,196.76
Rate for Payer: Hamaspik Choice Inc Medicare	$3,686.08
Rate for Payer: Healthfirst Medicare Advantage	$3,133.17
Rate for Payer: Healthfirst QHP	$3,686.08
Rate for Payer: Humana Medicare	$3,759.80
Rate for Payer: Senior Whole Health Medicare Advantage	$3,686.08
Rate for Payer: United Healthcare Commercial	$1,835.00
Rate for Payer: United Healthcare Medicare Advantage	$3,686.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,686.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,948.86
Rate for Payer: Wellcare Medicare	$3,501.78

SP FISTULA OR SINUS TRACT STUDY

Facility

$4,086.83

Service Code	HCPCS 20501 TC
Hospital Charge Code	41547626
Hospital Revenue Code	361
Min. Negotiated Rate	$118.86
Max. Negotiated Rate	$3,065.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.86
Rate for Payer: Aetna Government	$118.86
Rate for Payer: Brighton Health Commercial	$3,065.12
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: Group Health Inc Commercial	$2,043.42
Rate for Payer: Group Health Inc Medicare	$1,430.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,043.42
Rate for Payer: Hamaspik Choice Inc Medicare	$2,043.42
Rate for Payer: United Healthcare Commercial	$1,113.00

SP FISTULA/SINUS TRACT

Facility

$4,086.83

Service Code	HCPCS 20501 TC
Hospital Charge Code	41542822
Hospital Revenue Code	361
Min. Negotiated Rate	$118.86
Max. Negotiated Rate	$3,065.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.86
Rate for Payer: Aetna Government	$118.86
Rate for Payer: Brighton Health Commercial	$3,065.12
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: Group Health Inc Commercial	$2,043.42
Rate for Payer: Group Health Inc Medicare	$1,430.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,043.42
Rate for Payer: Hamaspik Choice Inc Medicare	$2,043.42
Rate for Payer: United Healthcare Commercial	$1,113.00

SP FNA BX W/CT GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10009
Hospital Charge Code	41546544
Hospital Revenue Code	361
Rate for Payer: Cash Price	$813.63

SP FNA BX W/CT GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10009
Hospital Charge Code	41546544
Hospital Revenue Code	361
Min. Negotiated Rate	$569.54
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$813.63
Rate for Payer: Aetna Government	$813.63
Rate for Payer: Affinity Essential Plan 1&2	$569.54
Rate for Payer: Affinity Essential Plan 3&4	$569.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$569.54
Rate for Payer: Brighton Health Commercial	$1,385.68
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$813.63
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	$813.63
Rate for Payer: EmblemHealth Commercial	$813.63
Rate for Payer: Fidelis Essential Plan Aliesa	$691.59
Rate for Payer: Fidelis Essential Plan QHP	$724.13
Rate for Payer: Fidelis Medicare Advantage	$813.63
Rate for Payer: Fidelis Qualified Health Plan	$724.13
Rate for Payer: Group Health Inc Commercial	$813.63
Rate for Payer: Group Health Inc Medicare	$813.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$813.63
Rate for Payer: Healthfirst Medicare Advantage	$691.59
Rate for Payer: Healthfirst QHP	$813.63
Rate for Payer: Humana Medicare	$829.90
Rate for Payer: Senior Whole Health Medicare Advantage	$813.63
Rate for Payer: United Healthcare Commercial	$1,188.00
Rate for Payer: United Healthcare Medicare Advantage	$813.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$813.63
Rate for Payer: Wellcare CHP/FHP/Medicaid	$650.90
Rate for Payer: Wellcare Medicare	$772.95

SP FNA BX W/CT GDN EA ADDL

Facility

$923.79

Service Code	HCPCS 10010
Hospital Charge Code	41546545
Hospital Revenue Code	361
Min. Negotiated Rate	$70.47
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.47
Rate for Payer: Aetna Government	$70.47
Rate for Payer: Brighton Health Commercial	$692.84
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	$461.90
Rate for Payer: Group Health Inc Medicare	$323.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$461.90
Rate for Payer: Hamaspik Choice Inc Medicare	$461.90
Rate for Payer: United Healthcare Commercial	$1,113.00

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