St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TBA_CENTRAL_DIALYSIS_SEG_ADDON

Facility

$345.23

Service Code	HCPCS 36907
Hospital Charge Code	66574710
Hospital Revenue Code	361
Min. Negotiated Rate	$120.83
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$135.44
Rate for Payer: Aetna Government	$135.44
Rate for Payer: Brighton Health Commercial	$258.92
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	$172.62
Rate for Payer: Group Health Inc Medicare	$120.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$172.62
Rate for Payer: Hamaspik Choice Inc Medicare	$172.62

TBA EA ADD ARTERY (NOT LE)

Facility

$487.45

Service Code	HCPCS 37247
Hospital Charge Code	40034511
Hospital Revenue Code	361
Min. Negotiated Rate	$170.61
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$191.71
Rate for Payer: Aetna Government	$191.71
Rate for Payer: Brighton Health Commercial	$365.59
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	$243.72
Rate for Payer: Group Health Inc Medicare	$170.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$243.72
Rate for Payer: Hamaspik Choice Inc Medicare	$243.72

TBA EA ADD ARTERY (NOT LE)

Facility

$487.45

Service Code	HCPCS 37247
Hospital Charge Code	66524705
Hospital Revenue Code	361
Min. Negotiated Rate	$170.61
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$191.71
Rate for Payer: Aetna Government	$191.71
Rate for Payer: Brighton Health Commercial	$365.59
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	$243.72
Rate for Payer: Group Health Inc Medicare	$170.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$243.72
Rate for Payer: Hamaspik Choice Inc Medicare	$243.72

TBA_EA_ADD_ARTERY_(NOT LE)

Facility

$487.45

Service Code	HCPCS 37247
Hospital Charge Code	66574712
Hospital Revenue Code	361
Min. Negotiated Rate	$170.61
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$191.71
Rate for Payer: Aetna Government	$191.71
Rate for Payer: Brighton Health Commercial	$365.59
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	$243.72
Rate for Payer: Group Health Inc Medicare	$170.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$243.72
Rate for Payer: Hamaspik Choice Inc Medicare	$243.72

TBA EA ADD ART (NOT DIALYSIS)

Facility

$414.93

Service Code	HCPCS 37249
Hospital Charge Code	40034513
Hospital Revenue Code	361
Min. Negotiated Rate	$145.23
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$163.16
Rate for Payer: Aetna Government	$163.16
Rate for Payer: Brighton Health Commercial	$311.20
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	$207.46
Rate for Payer: Group Health Inc Medicare	$145.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.46
Rate for Payer: Hamaspik Choice Inc Medicare	$207.46

TBA EA ADD ART (NOT DIALYSIS)

Facility

$414.93

Service Code	HCPCS 37249
Hospital Charge Code	66524707
Hospital Revenue Code	361
Min. Negotiated Rate	$145.23
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$163.16
Rate for Payer: Aetna Government	$163.16
Rate for Payer: Brighton Health Commercial	$311.20
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	$207.46
Rate for Payer: Group Health Inc Medicare	$145.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.46
Rate for Payer: Hamaspik Choice Inc Medicare	$207.46

TBA_EA_ADD_ART_(NOT DIALYSIS)

Facility

$414.93

Service Code	HCPCS 37249
Hospital Charge Code	66574714
Hospital Revenue Code	361
Min. Negotiated Rate	$145.23
Max. Negotiated Rate	$5,593.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$163.16
Rate for Payer: Aetna Government	$163.16
Rate for Payer: Brighton Health Commercial	$311.20
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	$207.46
Rate for Payer: Group Health Inc Medicare	$145.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.46
Rate for Payer: Hamaspik Choice Inc Medicare	$207.46

TBA PERIPH DIALYSIS SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	40034517
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,609.72

TBA PERIPH DIALYSIS SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	66524701
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,609.72

TBA PERIPH DIALYSIS SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	66524701
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$11,253.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,609.72
Rate for Payer: Aetna Government	$6,609.72
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: Senior Whole Health 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

TBA PERIPH DIALYSIS SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	40034517
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$11,253.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,609.72
Rate for Payer: Aetna Government	$6,609.72
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: Senior Whole Health 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

TBA_PERIPH_DIALYSIS_SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	66574708
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,609.72

TBA_PERIPH_DIALYSIS_SEGMENT

Facility

$15,004.15

Service Code	HCPCS 36902
Hospital Charge Code	66574708
Hospital Revenue Code	361
Min. Negotiated Rate	$2,477.75
Max. Negotiated Rate	$11,253.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,593.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6,609.72
Rate for Payer: Aetna Government	$6,609.72
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: Senior Whole Health 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

T-BINDERS

Facility

$2.48

Hospital Charge Code	40000375
Hospital Revenue Code	272
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.24
Rate for Payer: Aetna Government	$1.24
Rate for Payer: Brighton Health Commercial	$1.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.69
Rate for Payer: Group Health Inc Commercial	$1.24
Rate for Payer: Group Health Inc Medicare	$0.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.24
Rate for Payer: Hamaspik Choice Inc Medicare	$1.24

TB INTRADERMAL TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	40618196
Hospital Revenue Code	300
Rate for Payer: Cash Price	$34.43

TB INTRADERMAL TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	30305685
Hospital Revenue Code	300
Rate for Payer: Cash Price	$34.43

TB INTRADERMAL TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	40618196
Hospital Revenue Code	300
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$505.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34.43
Rate for Payer: Aetna Government	$34.43
Rate for Payer: Amida Care Medicaid	$5.05
Rate for Payer: Brighton Health Commercial	$52.22
Rate for Payer: Cash Price	$34.43
Rate for Payer: Cash Price	$34.43
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$34.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.14
Rate for Payer: Elderplan Medicare Advantage	$34.43
Rate for Payer: EmblemHealth Commercial	$34.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$5.05
Rate for Payer: Fidelis Essential Plan QHP	$5.05
Rate for Payer: Fidelis Medicare Advantage	$34.43
Rate for Payer: Fidelis Qualified Health Plan	$5.30
Rate for Payer: Group Health Inc Commercial	$34.43
Rate for Payer: Group Health Inc Medicare	$34.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.05
Rate for Payer: Hamaspik Choice Inc Medicare	$34.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: Healthfirst Medicare Advantage	$34.43
Rate for Payer: Healthfirst QHP	$5.05
Rate for Payer: Senior Whole Health Medicare Advantage	$34.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.05
Rate for Payer: SOMOS Essential	$5.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$27.54
Rate for Payer: Wellcare Medicare	$30.99

TB INTRADERMAL TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	30305685
Hospital Revenue Code	300
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$505.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34.43
Rate for Payer: Aetna Government	$34.43
Rate for Payer: Amida Care Medicaid	$5.05
Rate for Payer: Brighton Health Commercial	$52.22
Rate for Payer: Cash Price	$34.43
Rate for Payer: Cash Price	$34.43
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$34.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.14
Rate for Payer: Elderplan Medicare Advantage	$34.43
Rate for Payer: EmblemHealth Commercial	$34.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$5.05
Rate for Payer: Fidelis Essential Plan QHP	$5.05
Rate for Payer: Fidelis Medicare Advantage	$34.43
Rate for Payer: Fidelis Qualified Health Plan	$5.30
Rate for Payer: Group Health Inc Commercial	$34.43
Rate for Payer: Group Health Inc Medicare	$34.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.05
Rate for Payer: Hamaspik Choice Inc Medicare	$34.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: Healthfirst Medicare Advantage	$34.43
Rate for Payer: Healthfirst QHP	$5.05
Rate for Payer: Senior Whole Health Medicare Advantage	$34.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.05
Rate for Payer: SOMOS Essential	$5.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$27.54
Rate for Payer: Wellcare Medicare	$30.99

TB TINE TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	40618197
Hospital Revenue Code	300
Rate for Payer: Cash Price	$34.43

TB TINE TEST

Facility

$69.63

Service Code	HCPCS 86580
Hospital Charge Code	40618197
Hospital Revenue Code	300
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$505.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34.43
Rate for Payer: Aetna Government	$34.43
Rate for Payer: Amida Care Medicaid	$5.05
Rate for Payer: Brighton Health Commercial	$52.22
Rate for Payer: Cash Price	$34.43
Rate for Payer: Cash Price	$34.43
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$34.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.14
Rate for Payer: Elderplan Medicare Advantage	$34.43
Rate for Payer: EmblemHealth Commercial	$34.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$5.05
Rate for Payer: Fidelis Essential Plan QHP	$5.05
Rate for Payer: Fidelis Medicare Advantage	$34.43
Rate for Payer: Fidelis Qualified Health Plan	$5.30
Rate for Payer: Group Health Inc Commercial	$34.43
Rate for Payer: Group Health Inc Medicare	$34.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.05
Rate for Payer: Hamaspik Choice Inc Medicare	$34.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: Healthfirst Medicare Advantage	$34.43
Rate for Payer: Healthfirst QHP	$5.05
Rate for Payer: Senior Whole Health Medicare Advantage	$34.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.05
Rate for Payer: SOMOS Essential	$5.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$27.54
Rate for Payer: Wellcare Medicare	$30.99

TC-99M DMSA

Facility

$1,279.35

Service Code	HCPCS A9551
Hospital Charge Code	41646583
Hospital Revenue Code	343
Min. Negotiated Rate	$447.77
Max. Negotiated Rate	$1,023.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$703.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$496.32
Rate for Payer: Aetna Government	$496.32
Rate for Payer: Brighton Health Commercial	$959.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,023.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$869.96
Rate for Payer: Group Health Inc Commercial	$639.68
Rate for Payer: Group Health Inc Medicare	$447.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$639.68
Rate for Payer: Hamaspik Choice Inc Medicare	$639.68

TC-99M DMSA

Facility

$1,279.35

Service Code	HCPCS A9551
Hospital Charge Code	41656583
Hospital Revenue Code	343
Min. Negotiated Rate	$447.77
Max. Negotiated Rate	$1,023.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$703.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$496.32
Rate for Payer: Aetna Government	$496.32
Rate for Payer: Brighton Health Commercial	$959.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,023.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$869.96
Rate for Payer: Group Health Inc Commercial	$639.68
Rate for Payer: Group Health Inc Medicare	$447.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$639.68
Rate for Payer: Hamaspik Choice Inc Medicare	$639.68

TC-99M MAA

Facility

$54.57

Service Code	HCPCS A9540
Hospital Charge Code	41656578
Hospital Revenue Code	343
Min. Negotiated Rate	$19.10
Max. Negotiated Rate	$43.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.84
Rate for Payer: Aetna Government	$24.84
Rate for Payer: Brighton Health Commercial	$40.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.11
Rate for Payer: Group Health Inc Commercial	$27.28
Rate for Payer: Group Health Inc Medicare	$19.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.28
Rate for Payer: Hamaspik Choice Inc Medicare	$27.28

TC-99M MAA

Facility

$54.57

Service Code	HCPCS A9540
Hospital Charge Code	41646578
Hospital Revenue Code	343
Min. Negotiated Rate	$19.10
Max. Negotiated Rate	$43.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.84
Rate for Payer: Aetna Government	$24.84
Rate for Payer: Brighton Health Commercial	$40.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.11
Rate for Payer: Group Health Inc Commercial	$27.28
Rate for Payer: Group Health Inc Medicare	$19.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.28
Rate for Payer: Hamaspik Choice Inc Medicare	$27.28

TC-99M PENTETATE

Facility

$7.35

Service Code	HCPCS A9539
Hospital Charge Code	41646576
Hospital Revenue Code	343
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$25.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25.94
Rate for Payer: Aetna Government	$25.94
Rate for Payer: Brighton Health Commercial	$5.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.00
Rate for Payer: Group Health Inc Commercial	$3.68
Rate for Payer: Group Health Inc Medicare	$2.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.68
Rate for Payer: Hamaspik Choice Inc Medicare	$3.68

Know your out-of-pocket cost for care.

All Charges