St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

BRA SURGICAL X-LRG BREAST SUPPORT

Facility

$36.60

Hospital Charge Code	64903994
Hospital Revenue Code	270
Min. Negotiated Rate	$12.81
Max. Negotiated Rate	$29.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.30
Rate for Payer: Aetna Government	$18.30
Rate for Payer: Brighton Health Commercial	$27.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.89
Rate for Payer: Group Health Inc Commercial	$18.30
Rate for Payer: Group Health Inc Medicare	$12.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.30
Rate for Payer: Hamaspik Choice Inc Medicare	$18.30

BRA SURGICAL XXLRG BREAST SUPPORT

Facility

$39.83

Hospital Charge Code	64903996
Hospital Revenue Code	270
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$31.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.92
Rate for Payer: Aetna Government	$19.92
Rate for Payer: Brighton Health Commercial	$29.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.08
Rate for Payer: Group Health Inc Commercial	$19.92
Rate for Payer: Group Health Inc Medicare	$13.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.92
Rate for Payer: Hamaspik Choice Inc Medicare	$19.92

BRCA1&2 GENE FULL SEQ ALYS

Facility

$0.01

Service Code	HCPCS 81163
Hospital Charge Code	40608840
Hospital Revenue Code	310
Rate for Payer: Cash Price	$468.00

BRCA1&2 GENE FULL SEQ ALYS

Facility

$0.01

Service Code	HCPCS 81163
Hospital Charge Code	40608840
Hospital Revenue Code	310
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$477.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$468.00
Rate for Payer: Aetna Government	$468.00
Rate for Payer: Affinity Essential Plan 1&2	$327.60
Rate for Payer: Affinity Essential Plan 3&4	$327.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$327.60
Rate for Payer: Brighton Health Commercial	$468.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$468.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Elderplan Medicare Advantage	$468.00
Rate for Payer: EmblemHealth Commercial	$468.00
Rate for Payer: Fidelis Essential Plan Aliesa	$397.80
Rate for Payer: Fidelis Essential Plan QHP	$416.52
Rate for Payer: Fidelis Medicare Advantage	$468.00
Rate for Payer: Fidelis Qualified Health Plan	$416.52
Rate for Payer: Group Health Inc Commercial	$468.00
Rate for Payer: Group Health Inc Medicare	$468.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$468.00
Rate for Payer: Healthfirst Medicare Advantage	$468.00
Rate for Payer: Healthfirst QHP	$468.00
Rate for Payer: Humana Medicare	$477.36
Rate for Payer: Senior Whole Health Medicare Advantage	$468.00
Rate for Payer: United Healthcare Medicare Advantage	$468.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$468.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$374.40
Rate for Payer: Wellcare Medicare	$421.20

BRCA1&2 GEN FUL DUP/DEL ALYS

Facility

$0.01

Service Code	HCPCS 81164
Hospital Charge Code	40608839
Hospital Revenue Code	310
Rate for Payer: Cash Price	$584.23

BRCA1&2 GEN FUL DUP/DEL ALYS

Facility

$0.01

Service Code	HCPCS 81164
Hospital Charge Code	40608839
Hospital Revenue Code	310
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$595.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$584.23
Rate for Payer: Aetna Government	$584.23
Rate for Payer: Affinity Essential Plan 1&2	$408.96
Rate for Payer: Affinity Essential Plan 3&4	$408.96
Rate for Payer: Affinity Medicaid/CHP/HARP	$408.96
Rate for Payer: Brighton Health Commercial	$584.23
Rate for Payer: Cash Price	$584.23
Rate for Payer: Cash Price	$584.23
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$584.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Elderplan Medicare Advantage	$584.23
Rate for Payer: EmblemHealth Commercial	$584.23
Rate for Payer: Fidelis Essential Plan Aliesa	$496.60
Rate for Payer: Fidelis Essential Plan QHP	$519.96
Rate for Payer: Fidelis Medicare Advantage	$584.23
Rate for Payer: Fidelis Qualified Health Plan	$519.96
Rate for Payer: Group Health Inc Commercial	$584.23
Rate for Payer: Group Health Inc Medicare	$584.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$584.23
Rate for Payer: Healthfirst Medicare Advantage	$584.23
Rate for Payer: Healthfirst QHP	$584.23
Rate for Payer: Humana Medicare	$595.91
Rate for Payer: Senior Whole Health Medicare Advantage	$584.23
Rate for Payer: United Healthcare Medicare Advantage	$584.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$584.23
Rate for Payer: Wellcare CHP/FHP/Medicaid	$467.38
Rate for Payer: Wellcare Medicare	$525.81

BRCA1&2 GEN FULL SEQ DUP/DEL

Facility

$0.01

Service Code	HCPCS 81162
Hospital Charge Code	40608841
Hospital Revenue Code	310
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1,861.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,824.88
Rate for Payer: Aetna Government	$1,824.88
Rate for Payer: Affinity Essential Plan 1&2	$1,277.42
Rate for Payer: Affinity Essential Plan 3&4	$1,277.42
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,277.42
Rate for Payer: Brighton Health Commercial	$1,824.88
Rate for Payer: Cash Price	$1,824.88
Rate for Payer: Cash Price	$1,824.88
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,824.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Elderplan Medicare Advantage	$1,824.88
Rate for Payer: EmblemHealth Commercial	$1,824.88
Rate for Payer: Fidelis Essential Plan Aliesa	$1,551.15
Rate for Payer: Fidelis Essential Plan QHP	$1,624.14
Rate for Payer: Fidelis Medicare Advantage	$1,824.88
Rate for Payer: Fidelis Qualified Health Plan	$1,624.14
Rate for Payer: Group Health Inc Commercial	$1,824.88
Rate for Payer: Group Health Inc Medicare	$1,824.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$1,824.88
Rate for Payer: Healthfirst Medicare Advantage	$1,824.88
Rate for Payer: Healthfirst QHP	$1,824.88
Rate for Payer: Humana Medicare	$1,861.38
Rate for Payer: Senior Whole Health Medicare Advantage	$1,824.88
Rate for Payer: United Healthcare Medicare Advantage	$1,824.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,824.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,459.90
Rate for Payer: Wellcare Medicare	$1,642.39

BRCA1&2 GEN FULL SEQ DUP/DEL

Facility

$0.01

Service Code	HCPCS 81162
Hospital Charge Code	40608841
Hospital Revenue Code	310
Rate for Payer: Cash Price	$1,824.88

BRCASSURE COMPREHENSIVE TEST

Facility

$4,824.00

Service Code	HCPCS 81211
Hospital Charge Code	40609026
Hospital Revenue Code	300
Min. Negotiated Rate	$1,688.40
Max. Negotiated Rate	$3,859.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,653.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,412.00
Rate for Payer: Aetna Government	$2,412.00
Rate for Payer: Brighton Health Commercial	$3,618.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,859.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,280.32
Rate for Payer: Group Health Inc Commercial	$2,412.00
Rate for Payer: Group Health Inc Medicare	$1,688.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,412.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,412.00

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$47,421.69

Service Code	MSDRG 584
Min. Negotiated Rate	$16,037.15
Max. Negotiated Rate	$47,421.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28,879.56
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34,488.50
Rate for Payer: Aetna Government	$34,488.50
Rate for Payer: Brighton Health Commercial	$28,399.70
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$35,178.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33,823.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$27,912.24
Rate for Payer: Elderplan Medicare Advantage	$32,764.08
Rate for Payer: EmblemHealth Commercial	$16,795.00
Rate for Payer: Fidelis Medicare Advantage	$34,488.50
Rate for Payer: Group Health Inc Commercial	$34,488.50
Rate for Payer: Group Health Inc Medicare	$34,488.50
Rate for Payer: Hamaspik Choice Inc Medicare	$34,488.50
Rate for Payer: Healthfirst Medicare Advantage	$16,037.15
Rate for Payer: Humana Medicare	$47,421.69
Rate for Payer: Senior Whole Health Medicare Advantage	$34,488.50
Rate for Payer: United Healthcare Commercial	$38,950.68
Rate for Payer: United Healthcare Medicare Advantage	$34,488.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34,488.50
Rate for Payer: Wellcare Medicare	$32,764.08

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$42,185.70

Service Code	MSDRG 585
Min. Negotiated Rate	$14,266.44
Max. Negotiated Rate	$42,185.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24,830.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30,680.51
Rate for Payer: Aetna Government	$30,680.51
Rate for Payer: Brighton Health Commercial	$24,418.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$31,294.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29,081.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$23,998.89
Rate for Payer: Elderplan Medicare Advantage	$29,146.48
Rate for Payer: EmblemHealth Commercial	$14,440.30
Rate for Payer: Fidelis Medicare Advantage	$30,680.51
Rate for Payer: Group Health Inc Commercial	$30,680.51
Rate for Payer: Group Health Inc Medicare	$30,680.51
Rate for Payer: Hamaspik Choice Inc Medicare	$30,680.51
Rate for Payer: Healthfirst Medicare Advantage	$14,266.44
Rate for Payer: Humana Medicare	$42,185.70
Rate for Payer: Senior Whole Health Medicare Advantage	$30,680.51
Rate for Payer: United Healthcare Commercial	$33,489.71
Rate for Payer: United Healthcare Medicare Advantage	$30,680.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30,680.51
Rate for Payer: Wellcare Medicare	$29,146.48

BREAST EXPANDER A

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902951
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$3,845.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,014.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Brighton Health Commercial	$2,197.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,831.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,105.94
Rate for Payer: EmblemHealth Commercial	$1,831.25
Rate for Payer: Fidelis Medicare Advantage	$3,845.62
Rate for Payer: Group Health Inc Commercial	$1,831.25
Rate for Payer: Group Health Inc Medicare	$1,281.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,380.62

BREAST EXPANDER A

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902951
Hospital Revenue Code	278
Min. Negotiated Rate	$1,831.25
Max. Negotiated Rate	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25

BREAST EXPANDER B

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902953
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$3,845.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,014.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Brighton Health Commercial	$2,197.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,831.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,105.94
Rate for Payer: EmblemHealth Commercial	$1,831.25
Rate for Payer: Fidelis Medicare Advantage	$3,845.62
Rate for Payer: Group Health Inc Commercial	$1,831.25
Rate for Payer: Group Health Inc Medicare	$1,281.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,380.62

BREAST EXPANDER B

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902953
Hospital Revenue Code	278
Min. Negotiated Rate	$1,831.25
Max. Negotiated Rate	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25

BREAST EXPANDER C

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902955
Hospital Revenue Code	278
Min. Negotiated Rate	$1,831.25
Max. Negotiated Rate	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25

BREAST EXPANDER C

Facility

$3,662.50

Service Code	HCPCS C1789
Hospital Charge Code	64902955
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$3,845.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,014.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Brighton Health Commercial	$2,197.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,831.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,105.94
Rate for Payer: EmblemHealth Commercial	$1,831.25
Rate for Payer: Fidelis Medicare Advantage	$3,845.62
Rate for Payer: Group Health Inc Commercial	$1,831.25
Rate for Payer: Group Health Inc Medicare	$1,281.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,831.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,831.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,380.62

BREAST IMP HSC+ SMTH RD MOD + PRO

Facility

$895.00

Hospital Charge Code	40006230
Hospital Revenue Code	270
Min. Negotiated Rate	$313.25
Max. Negotiated Rate	$716.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$492.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$447.50
Rate for Payer: Aetna Government	$447.50
Rate for Payer: Brighton Health Commercial	$671.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$716.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$608.60
Rate for Payer: Group Health Inc Commercial	$447.50
Rate for Payer: Group Health Inc Medicare	$313.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$447.50
Rate for Payer: Hamaspik Choice Inc Medicare	$447.50

BREAST IMP HSC+ S RND MOD + PROJE

Facility

$895.00

Hospital Charge Code	40006231
Hospital Revenue Code	270
Min. Negotiated Rate	$313.25
Max. Negotiated Rate	$716.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$492.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$447.50
Rate for Payer: Aetna Government	$447.50
Rate for Payer: Brighton Health Commercial	$671.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$716.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$608.60
Rate for Payer: Group Health Inc Commercial	$447.50
Rate for Payer: Group Health Inc Medicare	$313.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$447.50
Rate for Payer: Hamaspik Choice Inc Medicare	$447.50

BREAST IMPLANT

Facility

$1,900.00

Service Code	HCPCS L8600
Hospital Charge Code	40203021
Hospital Revenue Code	278
Min. Negotiated Rate	$326.16
Max. Negotiated Rate	$1,995.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,045.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$326.16
Rate for Payer: Aetna Government	$326.16
Rate for Payer: Brighton Health Commercial	$1,140.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$950.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,092.50
Rate for Payer: EmblemHealth Commercial	$950.00
Rate for Payer: Fidelis Medicare Advantage	$1,995.00
Rate for Payer: Group Health Inc Commercial	$950.00
Rate for Payer: Group Health Inc Medicare	$665.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,235.00

BREAST IMPLANT

Facility

$1,900.00

Service Code	HCPCS L8600
Hospital Charge Code	40203021
Hospital Revenue Code	278
Min. Negotiated Rate	$950.00
Max. Negotiated Rate	$950.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00

BREAST IMPLANT 250CC

Facility

$1,300.00

Service Code	HCPCS L8600
Hospital Charge Code	40203152
Hospital Revenue Code	278
Min. Negotiated Rate	$650.00
Max. Negotiated Rate	$650.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$650.00
Rate for Payer: Hamaspik Choice Inc Medicare	$650.00

BREAST IMPLANT 250CC

Facility

$1,300.00

Service Code	HCPCS L8600
Hospital Charge Code	40203152
Hospital Revenue Code	278
Min. Negotiated Rate	$326.16
Max. Negotiated Rate	$1,365.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$715.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$326.16
Rate for Payer: Aetna Government	$326.16
Rate for Payer: Brighton Health Commercial	$780.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$650.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$747.50
Rate for Payer: EmblemHealth Commercial	$650.00
Rate for Payer: Fidelis Medicare Advantage	$1,365.00
Rate for Payer: Group Health Inc Commercial	$650.00
Rate for Payer: Group Health Inc Medicare	$455.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$650.00
Rate for Payer: Hamaspik Choice Inc Medicare	$650.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$845.00

BREAST IMPLANT 350CC

Facility

$1,900.00

Service Code	HCPCS L8600
Hospital Charge Code	40203153
Hospital Revenue Code	278
Min. Negotiated Rate	$950.00
Max. Negotiated Rate	$950.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00

BREAST IMPLANT 350CC

Facility

$1,900.00

Service Code	HCPCS L8600
Hospital Charge Code	40203153
Hospital Revenue Code	278
Min. Negotiated Rate	$326.16
Max. Negotiated Rate	$1,995.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,045.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$326.16
Rate for Payer: Aetna Government	$326.16
Rate for Payer: Brighton Health Commercial	$1,140.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$950.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,092.50
Rate for Payer: EmblemHealth Commercial	$950.00
Rate for Payer: Fidelis Medicare Advantage	$1,995.00
Rate for Payer: Group Health Inc Commercial	$950.00
Rate for Payer: Group Health Inc Medicare	$665.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,235.00

Know your out-of-pocket cost for care.

All Charges