St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TIMOLOL 0.25% OPHTHALMIC SOLN

Facility

$3.00

Hospital Charge Code	41653526
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

TIMOLOL 0.25% OPHTHALMIC SOLN

Facility

$3.00

Hospital Charge Code	41643526
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

TIMOLOL 0.5% OPHTHALMIC SOLN

Facility

$2.12

Hospital Charge Code	41654902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.44
Rate for Payer: Group Health Inc Commercial	$1.06
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.38

TIMOLOL 0.5% OPHTHALMIC SOLN

Facility

$2.12

Hospital Charge Code	41644902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.44
Rate for Payer: Group Health Inc Commercial	$1.06
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.38

TIMOLOL HEMIHYDRATE 0.25 % OP SOLN [15114]

Facility

$33.12

Service Code	NDC 76478000105
Hospital Charge Code	76478000105
Hospital Revenue Code	250
Min. Negotiated Rate	$11.59
Max. Negotiated Rate	$26.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.56
Rate for Payer: Aetna Government	$16.56
Rate for Payer: Brighton Health Commercial	$24.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.52
Rate for Payer: Group Health Inc Commercial	$16.56
Rate for Payer: Group Health Inc Medicare	$11.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.56
Rate for Payer: Hamaspik Choice Inc Medicare	$16.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$21.53

TIMOLOL MALEATE 0.25 % OP SOLN [11561]

Facility

$3.00

Service Code	NDC 61314022605
Hospital Charge Code	61314022605
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

TIMOLOL MALEATE 0.5 % OP SOLN [11562]

Facility

$3.40

Service Code	NDC 61314022705
Hospital Charge Code	61314022705
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$2.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.70
Rate for Payer: Aetna Government	$1.70
Rate for Payer: Brighton Health Commercial	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.31
Rate for Payer: Group Health Inc Commercial	$1.70
Rate for Payer: Group Health Inc Medicare	$1.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.21

TIMOLOL MALEATE 0.5 % OP SOLN [11562]

Facility

$3.40

Service Code	NDC 17478028810
Hospital Charge Code	17478028810
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$2.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.70
Rate for Payer: Aetna Government	$1.70
Rate for Payer: Brighton Health Commercial	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.31
Rate for Payer: Group Health Inc Commercial	$1.70
Rate for Payer: Group Health Inc Medicare	$1.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.21

TIMOLOL MALEATE 0.5 % OP SOLN (WRAPPED) [401999]

Facility

$1.31

Service Code	NDC 60758080105
Hospital Charge Code	60758080105
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$1.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.66
Rate for Payer: Aetna Government	$0.66
Rate for Payer: Brighton Health Commercial	$0.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.89
Rate for Payer: Group Health Inc Commercial	$0.66
Rate for Payer: Group Health Inc Medicare	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.66
Rate for Payer: Hamaspik Choice Inc Medicare	$0.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.85

TIMOLOL MALEATE 0.5 % OP SOLN (WRAPPED) [401999]

Facility

$3.40

Service Code	NDC 64980051405
Hospital Charge Code	64980051405
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$2.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.70
Rate for Payer: Aetna Government	$1.70
Rate for Payer: Brighton Health Commercial	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.31
Rate for Payer: Group Health Inc Commercial	$1.70
Rate for Payer: Group Health Inc Medicare	$1.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.21

TIMOLOL MALEATE 0.5 % OP SOLN (WRAPPED) [401999]

Facility

$3.40

Service Code	NDC 61314022705
Hospital Charge Code	61314022705
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$2.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.87
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.70
Rate for Payer: Aetna Government	$1.70
Rate for Payer: Brighton Health Commercial	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.31
Rate for Payer: Group Health Inc Commercial	$1.70
Rate for Payer: Group Health Inc Medicare	$1.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.21

TIMOLOL MALEATE 0.5 % OP SOLN (WRAPPED) [401999]

Facility

$3.25

Service Code	NDC 64980051415
Hospital Charge Code	64980051415
Hospital Revenue Code	250
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.62
Rate for Payer: Aetna Government	$1.62
Rate for Payer: Brighton Health Commercial	$2.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.21
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.11

TIOTROPIUM BROMIDE 2.5MCG RSPMT

Facility

$97.05

Hospital Charge Code	41657851
Hospital Revenue Code	250
Min. Negotiated Rate	$33.97
Max. Negotiated Rate	$77.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$48.52
Rate for Payer: Aetna Government	$48.52
Rate for Payer: Brighton Health Commercial	$72.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$65.99
Rate for Payer: Group Health Inc Commercial	$48.52
Rate for Payer: Group Health Inc Medicare	$33.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.52
Rate for Payer: Hamaspik Choice Inc Medicare	$48.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63.08

TIOTROPIUM BROMIDE 2.5MCG RSPMT

Facility

$97.05

Hospital Charge Code	41647851
Hospital Revenue Code	250
Min. Negotiated Rate	$33.97
Max. Negotiated Rate	$77.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$48.52
Rate for Payer: Aetna Government	$48.52
Rate for Payer: Brighton Health Commercial	$72.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$65.99
Rate for Payer: Group Health Inc Commercial	$48.52
Rate for Payer: Group Health Inc Medicare	$33.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.52
Rate for Payer: Hamaspik Choice Inc Medicare	$48.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63.08

TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS [127331]

Facility

$158.22

Service Code	NDC 00597010061
Hospital Charge Code	00597010061
Hospital Revenue Code	250
Min. Negotiated Rate	$55.38
Max. Negotiated Rate	$126.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$87.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$79.11
Rate for Payer: Aetna Government	$79.11
Rate for Payer: Brighton Health Commercial	$118.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$126.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$107.59
Rate for Payer: Group Health Inc Commercial	$79.11
Rate for Payer: Group Health Inc Medicare	$55.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$79.11
Rate for Payer: Hamaspik Choice Inc Medicare	$79.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$102.84

TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS [127331]

Facility

$22.50

Service Code	NDC 00597010051
Hospital Charge Code	00597010051
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$18.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.25
Rate for Payer: Aetna Government	$11.25
Rate for Payer: Brighton Health Commercial	$16.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.30
Rate for Payer: Group Health Inc Commercial	$11.25
Rate for Payer: Group Health Inc Medicare	$7.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.25
Rate for Payer: Hamaspik Choice Inc Medicare	$11.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.62

TIOTROPIUM INHALER (18 MCG/PUFF)

Facility

$133.64

Hospital Charge Code	41654002
Hospital Revenue Code	250
Min. Negotiated Rate	$46.77
Max. Negotiated Rate	$106.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$73.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$66.82
Rate for Payer: Aetna Government	$66.82
Rate for Payer: Brighton Health Commercial	$100.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$106.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$90.88
Rate for Payer: Group Health Inc Commercial	$66.82
Rate for Payer: Group Health Inc Medicare	$46.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$66.82
Rate for Payer: Hamaspik Choice Inc Medicare	$66.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$86.87

TIOTROPIUM INHALER (18 MCG/PUFF)

Facility

$133.64

Hospital Charge Code	41644002
Hospital Revenue Code	250
Min. Negotiated Rate	$46.77
Max. Negotiated Rate	$106.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$73.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$66.82
Rate for Payer: Aetna Government	$66.82
Rate for Payer: Brighton Health Commercial	$100.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$106.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$90.88
Rate for Payer: Group Health Inc Commercial	$66.82
Rate for Payer: Group Health Inc Medicare	$46.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$66.82
Rate for Payer: Hamaspik Choice Inc Medicare	$66.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$86.87

TIP DRILL

Facility

$337.75

Hospital Charge Code	64907310
Hospital Revenue Code	270
Min. Negotiated Rate	$118.21
Max. Negotiated Rate	$270.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$168.88
Rate for Payer: Aetna Government	$168.88
Rate for Payer: Brighton Health Commercial	$253.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$270.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$229.67
Rate for Payer: Group Health Inc Commercial	$168.88
Rate for Payer: Group Health Inc Medicare	$118.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$168.88
Rate for Payer: Hamaspik Choice Inc Medicare	$168.88

TIP EAR INFANT RED-BROWN 4.5MM

Facility

$2.30

Hospital Charge Code	64903476
Hospital Revenue Code	270
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.15
Rate for Payer: Aetna Government	$1.15
Rate for Payer: Brighton Health Commercial	$1.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.56
Rate for Payer: Group Health Inc Commercial	$1.15
Rate for Payer: Group Health Inc Medicare	$0.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.15
Rate for Payer: Hamaspik Choice Inc Medicare	$1.15

TIP EAR INFANT TREE YELLOW

Facility

$2.52

Hospital Charge Code	64903402
Hospital Revenue Code	270
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$2.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.26
Rate for Payer: Aetna Government	$1.26
Rate for Payer: Brighton Health Commercial	$1.89
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.71
Rate for Payer: Group Health Inc Commercial	$1.26
Rate for Payer: Group Health Inc Medicare	$0.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.26
Rate for Payer: Hamaspik Choice Inc Medicare	$1.26

TIP EXTENDER BASE

Facility

$5,707.50

Service Code	HCPCS L8699
Hospital Charge Code	64907150
Hospital Revenue Code	278
Min. Negotiated Rate	$1,997.62
Max. Negotiated Rate	$5,992.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,139.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,853.75
Rate for Payer: Aetna Government	$2,853.75
Rate for Payer: Brighton Health Commercial	$3,424.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,853.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,281.81
Rate for Payer: EmblemHealth Commercial	$2,853.75
Rate for Payer: Fidelis Medicare Advantage	$5,992.88
Rate for Payer: Group Health Inc Commercial	$2,853.75
Rate for Payer: Group Health Inc Medicare	$1,997.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,853.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,853.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,709.88

TIP EXTENDER BASE

Facility

$5,707.50

Service Code	HCPCS L8699
Hospital Charge Code	64907150
Hospital Revenue Code	278
Min. Negotiated Rate	$2,853.75
Max. Negotiated Rate	$2,853.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,853.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,853.75

TI PL 15 HOLES LEFT RIB 3

Facility

$2,500.00

Service Code	HCPCS C1713
Hospital Charge Code	40209490
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,625.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,375.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,500.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,437.50
Rate for Payer: EmblemHealth Commercial	$1,250.00
Rate for Payer: Fidelis Medicare Advantage	$2,625.00
Rate for Payer: Group Health Inc Commercial	$1,250.00
Rate for Payer: Group Health Inc Medicare	$875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,250.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,625.00

TI PL 15 HOLES LEFT RIB 3

Facility

$2,500.00

Service Code	HCPCS C1713
Hospital Charge Code	40209490
Hospital Revenue Code	278
Min. Negotiated Rate	$1,250.00
Max. Negotiated Rate	$1,250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,250.00

Know your out-of-pocket cost for care.

All Charges