St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TUBING IRRIG STRGHT SHOT XPS

Facility

$74.00

Hospital Charge Code	64906926
Hospital Revenue Code	270
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$59.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.00
Rate for Payer: Aetna Government	$37.00
Rate for Payer: Brighton Health Commercial	$55.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$59.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$50.32
Rate for Payer: Group Health Inc Commercial	$37.00
Rate for Payer: Group Health Inc Medicare	$25.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00

TUBING OUTFLOW CASSETTE

Facility

$155.40

Hospital Charge Code	64907376
Hospital Revenue Code	270
Min. Negotiated Rate	$54.39
Max. Negotiated Rate	$124.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$85.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$77.70
Rate for Payer: Aetna Government	$77.70
Rate for Payer: Brighton Health Commercial	$116.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$124.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$105.67
Rate for Payer: Group Health Inc Commercial	$77.70
Rate for Payer: Group Health Inc Medicare	$54.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.70
Rate for Payer: Hamaspik Choice Inc Medicare	$77.70

TUBING SUCTION 3/16 X 12

Facility

$2.48

Hospital Charge Code	64906822
Hospital Revenue Code	270
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

TUBING,SUCTION/IRRIGATION,4

Facility

$186.26

Hospital Charge Code	64905912
Hospital Revenue Code	270
Min. Negotiated Rate	$65.19
Max. Negotiated Rate	$149.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$102.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$93.13
Rate for Payer: Aetna Government	$93.13
Rate for Payer: Brighton Health Commercial	$139.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$149.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$126.66
Rate for Payer: Group Health Inc Commercial	$93.13
Rate for Payer: Group Health Inc Medicare	$65.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.13
Rate for Payer: Hamaspik Choice Inc Medicare	$93.13

TUBNG FLUD SAFE INTGRA0502200000A

Facility

$850.00

Hospital Charge Code	64906446
Hospital Revenue Code	279
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$680.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$467.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$425.00
Rate for Payer: Aetna Government	$425.00
Rate for Payer: Brighton Health Commercial	$637.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$680.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$578.00
Rate for Payer: Group Health Inc Commercial	$425.00
Rate for Payer: Group Health Inc Medicare	$297.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$425.00

TULANT IMPLANT 9 MM

Facility

$1,500.00

Hospital Charge Code	40200335
Hospital Revenue Code	272
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$825.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$750.00
Rate for Payer: Aetna Government	$750.00
Rate for Payer: Brighton Health Commercial	$1,125.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,200.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,020.00
Rate for Payer: Group Health Inc Commercial	$750.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$750.00

TULIP, RELINE MOD

Facility

$2,990.63

Hospital Charge Code	64906130
Hospital Revenue Code	270
Min. Negotiated Rate	$1,046.72
Max. Negotiated Rate	$2,392.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,644.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,495.32
Rate for Payer: Aetna Government	$1,495.32
Rate for Payer: Brighton Health Commercial	$2,242.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,392.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,033.63
Rate for Payer: Group Health Inc Commercial	$1,495.32
Rate for Payer: Group Health Inc Medicare	$1,046.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,495.32
Rate for Payer: Hamaspik Choice Inc Medicare	$1,495.32

TUMOR FINGER

Facility

$4,157.25

Service Code	HCPCS 26115
Hospital Charge Code	40021745
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,874.89

TUMOR FINGER

Facility

$4,157.25

Service Code	HCPCS 26115
Hospital Charge Code	40021745
Hospital Revenue Code	360
Min. Negotiated Rate	$1,499.91
Max. Negotiated Rate	$3,117.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,874.89
Rate for Payer: Aetna Government	$1,874.89
Rate for Payer: Brighton Health Commercial	$3,117.94
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Cash Price	$1,874.89
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,874.89
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	$1,874.89
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$1,593.66
Rate for Payer: Fidelis Essential Plan QHP	$1,668.65
Rate for Payer: Fidelis Medicare Advantage	$1,874.89
Rate for Payer: Fidelis Qualified Health Plan	$1,668.65
Rate for Payer: Group Health Inc Commercial	$1,874.89
Rate for Payer: Group Health Inc Medicare	$1,874.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,078.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1,874.89
Rate for Payer: Healthfirst Medicare Advantage	$1,593.66
Rate for Payer: Healthfirst QHP	$1,874.89
Rate for Payer: Senior Whole Health Medicare Advantage	$1,874.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,874.89
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,499.91
Rate for Payer: Wellcare Medicare	$1,781.15

TUMOR IMMUNOHISTOCHEM/MANUAL

Facility

$434.63

Service Code	HCPCS 88360 TC
Hospital Charge Code	30305429
Hospital Revenue Code	310
Min. Negotiated Rate	$152.12
Max. Negotiated Rate	$347.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$217.32
Rate for Payer: Aetna Government	$217.32
Rate for Payer: Brighton Health Commercial	$325.97
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$347.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$295.55
Rate for Payer: Group Health Inc Commercial	$217.32
Rate for Payer: Group Health Inc Medicare	$152.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.32
Rate for Payer: Hamaspik Choice Inc Medicare	$217.32

TUMOR IMMUNOHISTOCHEM/MANUAL

Facility

$434.63

Service Code	HCPCS 88360 TC
Hospital Charge Code	30305429
Hospital Revenue Code	310
Rate for Payer: Cash Price	$197.52

TUNNELERS,A/V ACCESS 12/30.5CM

Facility

$1,295.00

Hospital Charge Code	64905734
Hospital Revenue Code	270
Min. Negotiated Rate	$453.25
Max. Negotiated Rate	$1,036.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$712.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$647.50
Rate for Payer: Aetna Government	$647.50
Rate for Payer: Brighton Health Commercial	$971.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,036.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$880.60
Rate for Payer: Group Health Inc Commercial	$647.50
Rate for Payer: Group Health Inc Medicare	$453.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$647.50
Rate for Payer: Hamaspik Choice Inc Medicare	$647.50

TURB BLADDER TUMOR

Facility

$12,816.53

Service Code	HCPCS 52240
Hospital Charge Code	40123045
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,983.74

TURB BLADDER TUMOR

Facility

$12,816.53

Service Code	HCPCS 52240
Hospital Charge Code	40123045
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$9,612.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,983.74
Rate for Payer: Aetna Government	$5,983.74
Rate for Payer: Brighton Health Commercial	$9,612.40
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$5,983.74
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	$5,983.74
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$5,086.18
Rate for Payer: Fidelis Essential Plan QHP	$5,325.53
Rate for Payer: Fidelis Medicare Advantage	$5,983.74
Rate for Payer: Fidelis Qualified Health Plan	$5,325.53
Rate for Payer: Group Health Inc Commercial	$5,983.74
Rate for Payer: Group Health Inc Medicare	$5,983.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,408.26
Rate for Payer: Hamaspik Choice Inc Medicare	$5,983.74
Rate for Payer: Healthfirst Medicare Advantage	$5,086.18
Rate for Payer: Healthfirst QHP	$5,983.74
Rate for Payer: Senior Whole Health Medicare Advantage	$5,983.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,983.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$4,786.99
Rate for Payer: Wellcare Medicare	$5,684.55

TURB MEDIUM TUMOR 0.5-2.0 CM

Facility

$9,142.40

Service Code	HCPCS 52234
Hospital Charge Code	40129679
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,031.47

TURB MEDIUM TUMOR 0.5-2.0 CM

Facility

$9,142.40

Service Code	HCPCS 52234
Hospital Charge Code	40129679
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$6,856.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,031.47
Rate for Payer: Aetna Government	$4,031.47
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	$1,505.00
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: Senior Whole Health 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

TURB MEDIUM TUMOR 2.0-5.0CM

Facility

$9,142.40

Service Code	HCPCS 52235
Hospital Charge Code	40129813
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
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: 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	$1,505.00
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: Senior Whole Health 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

TURB MEDIUM TUMOR 2.0-5.0CM

Facility

$9,142.40

Service Code	HCPCS 52235
Hospital Charge Code	40129813
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,031.47

TURBOVAC SUPER

Facility

$412.50

Hospital Charge Code	64904554
Hospital Revenue Code	270
Min. Negotiated Rate	$144.38
Max. Negotiated Rate	$330.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$226.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$206.25
Rate for Payer: Aetna Government	$206.25
Rate for Payer: Brighton Health Commercial	$309.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$330.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$280.50
Rate for Payer: Group Health Inc Commercial	$206.25
Rate for Payer: Group Health Inc Medicare	$144.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$206.25
Rate for Payer: Hamaspik Choice Inc Medicare	$206.25

TUR PROSTATE

Facility

$12,816.53

Service Code	HCPCS 52601
Hospital Charge Code	40123050
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$9,612.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,983.74
Rate for Payer: Aetna Government	$5,983.74
Rate for Payer: Brighton Health Commercial	$9,612.40
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Cash Price	$5,983.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$5,983.74
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	$5,983.74
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$5,086.18
Rate for Payer: Fidelis Essential Plan QHP	$5,325.53
Rate for Payer: Fidelis Medicare Advantage	$5,983.74
Rate for Payer: Fidelis Qualified Health Plan	$5,325.53
Rate for Payer: Group Health Inc Commercial	$5,983.74
Rate for Payer: Group Health Inc Medicare	$5,983.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,408.26
Rate for Payer: Hamaspik Choice Inc Medicare	$5,983.74
Rate for Payer: Healthfirst Medicare Advantage	$5,086.18
Rate for Payer: Healthfirst QHP	$5,983.74
Rate for Payer: Senior Whole Health Medicare Advantage	$5,983.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,983.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$4,786.99
Rate for Payer: Wellcare Medicare	$5,684.55

TUR PROSTATE

Facility

$12,816.53

Service Code	HCPCS 52601
Hospital Charge Code	40123050
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,983.74

TUR SET

Facility

$12.05

Hospital Charge Code	40206050
Hospital Revenue Code	270
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$9.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.02
Rate for Payer: Aetna Government	$6.02
Rate for Payer: Brighton Health Commercial	$9.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.19
Rate for Payer: Group Health Inc Commercial	$6.02
Rate for Payer: Group Health Inc Medicare	$4.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.02
Rate for Payer: Hamaspik Choice Inc Medicare	$6.02

TUR SET-2C4002

Facility

$7.80

Hospital Charge Code	40000410
Hospital Revenue Code	272
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

TW DL/1.6X29MM 18MM

Facility

$750.00

Service Code	HCPCS C1713
Hospital Charge Code	64903680
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$787.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$412.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$450.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$375.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$431.25
Rate for Payer: EmblemHealth Commercial	$375.00
Rate for Payer: Fidelis Medicare Advantage	$787.50
Rate for Payer: Group Health Inc Commercial	$375.00
Rate for Payer: Group Health Inc Medicare	$262.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$375.00
Rate for Payer: Hamaspik Choice Inc Medicare	$375.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$487.50

TW DL/1.6X29MM 18MM

Facility

$750.00

Service Code	HCPCS C1713
Hospital Charge Code	64903680
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$375.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$375.00
Rate for Payer: Hamaspik Choice Inc Medicare	$375.00

Know your out-of-pocket cost for care.

All Charges