St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CMF SCR TIT NEU EMER SLFTP 4MM LP

Facility

$616.00

Service Code	HCPCS C1713
Hospital Charge Code	40202353
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$646.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$338.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$369.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$308.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$354.20
Rate for Payer: EmblemHealth Commercial	$308.00
Rate for Payer: Fidelis Medicare Advantage	$646.80
Rate for Payer: Group Health Inc Commercial	$308.00
Rate for Payer: Group Health Inc Medicare	$215.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$308.00
Rate for Payer: Hamaspik Choice Inc Medicare	$308.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$400.40

CMF SCR TIT NEU EMER SLFTP 4MM LP

Facility

$616.00

Service Code	HCPCS C1713
Hospital Charge Code	40202353
Hospital Revenue Code	278
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$308.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$308.00
Rate for Payer: Hamaspik Choice Inc Medicare	$308.00

CMF SCRW 1.5MM TIT CRA STRDRV 4MM

Facility

$590.00

Service Code	HCPCS C1776
Hospital Charge Code	40208136
Hospital Revenue Code	278
Min. Negotiated Rate	$295.00
Max. Negotiated Rate	$295.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00

CMF SCRW 1.5MM TIT CRA STRDRV 4MM

Facility

$590.00

Service Code	HCPCS C1776
Hospital Charge Code	40208136
Hospital Revenue Code	278
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$619.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$324.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$354.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$295.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$339.25
Rate for Payer: EmblemHealth Commercial	$295.00
Rate for Payer: Fidelis Medicare Advantage	$619.50
Rate for Payer: Group Health Inc Commercial	$295.00
Rate for Payer: Group Health Inc Medicare	$206.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$383.50

CMF SCRW 1.5 TIT CRAN W/STARDRIVE

Facility

$590.00

Service Code	HCPCS C1713
Hospital Charge Code	40202327
Hospital Revenue Code	278
Min. Negotiated Rate	$295.00
Max. Negotiated Rate	$295.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00

CMF SCRW 1.5 TIT CRAN W/STARDRIVE

Facility

$590.00

Service Code	HCPCS C1713
Hospital Charge Code	40202327
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$619.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$324.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$354.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$295.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$339.25
Rate for Payer: EmblemHealth Commercial	$295.00
Rate for Payer: Fidelis Medicare Advantage	$619.50
Rate for Payer: Group Health Inc Commercial	$295.00
Rate for Payer: Group Health Inc Medicare	$206.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$383.50

CMF SCRW TIT NEURO SLFDR 3MM LPRO

Facility

$676.00

Service Code	HCPCS C1713
Hospital Charge Code	40202351
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$709.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$371.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$405.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$338.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$388.70
Rate for Payer: EmblemHealth Commercial	$338.00
Rate for Payer: Fidelis Medicare Advantage	$709.80
Rate for Payer: Group Health Inc Commercial	$338.00
Rate for Payer: Group Health Inc Medicare	$236.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$338.00
Rate for Payer: Hamaspik Choice Inc Medicare	$338.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$439.40

CMF SCRW TIT NEURO SLFDR 3MM LPRO

Facility

$676.00

Service Code	HCPCS C1713
Hospital Charge Code	40202351
Hospital Revenue Code	278
Min. Negotiated Rate	$338.00
Max. Negotiated Rate	$338.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$338.00
Rate for Payer: Hamaspik Choice Inc Medicare	$338.00

CMF SCRW TIT NEURO S/T 1.2X L/P

Facility

$160.00

Service Code	HCPCS C1713
Hospital Charge Code	40205928
Hospital Revenue Code	278
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$80.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$80.00
Rate for Payer: Hamaspik Choice Inc Medicare	$80.00

CMF SCRW TIT NEURO S/T 1.2X L/P

Facility

$160.00

Service Code	HCPCS C1713
Hospital Charge Code	40205928
Hospital Revenue Code	278
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$168.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$88.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$96.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$80.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$92.00
Rate for Payer: EmblemHealth Commercial	$80.00
Rate for Payer: Fidelis Medicare Advantage	$168.00
Rate for Payer: Group Health Inc Commercial	$80.00
Rate for Payer: Group Health Inc Medicare	$56.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$80.00
Rate for Payer: Hamaspik Choice Inc Medicare	$80.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$104.00

CMMI ASYNTELEHEALTH 10-20MIN

Professional

Both

$134.02

Service Code	HCPCS G9869
Min. Negotiated Rate	$100.52
Max. Negotiated Rate	$100.52
Rate for Payer: Cash Price	$37.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$100.52
Rate for Payer: SOMOS Essential	$100.52

CMMI ASYNTELEHEALTH <10MIN

Professional

Both

$100.21

Service Code	HCPCS G9868
Min. Negotiated Rate	$75.16
Max. Negotiated Rate	$75.16
Rate for Payer: Cash Price	$27.90
Rate for Payer: SOMOS CHP/HARP/Medicaid	$75.16
Rate for Payer: SOMOS Essential	$75.16

CMMI ASYNTELEHEALTH >20MIN

Professional

Both

$167.83

Service Code	HCPCS G9870
Min. Negotiated Rate	$125.87
Max. Negotiated Rate	$125.87
Rate for Payer: Cash Price	$46.73
Rate for Payer: SOMOS CHP/HARP/Medicaid	$125.87
Rate for Payer: SOMOS Essential	$125.87

CMPLX RPR F/C/C/M/N/AX 2.6-7.5CM

Facility

$1,505.35

Service Code	HCPCS 13132
Hospital Charge Code	30105559
Hospital Revenue Code	450
Rate for Payer: Cash Price	$726.29

CMPLX RPR F/C/C/M/N/AX 2.6-7.5CM

Facility

$1,505.35

Service Code	HCPCS 13132
Hospital Charge Code	30305559
Hospital Revenue Code	450
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$726.29
Rate for Payer: Aetna Government	$726.29
Rate for Payer: Affinity Essential Plan 1&2	$508.40
Rate for Payer: Affinity Essential Plan 3&4	$508.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$508.40
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$726.29
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$726.29
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: Elderplan Medicare Advantage	$726.29
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$617.35
Rate for Payer: Fidelis Essential Plan QHP	$646.40
Rate for Payer: Fidelis Medicare Advantage	$726.29
Rate for Payer: Fidelis Qualified Health Plan	$646.40
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$752.68
Rate for Payer: Hamaspik Choice Inc Medicare	$726.29
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$726.29
Rate for Payer: Humana Medicare	$740.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$726.29
Rate for Payer: Senior Whole Health Medicare Advantage	$726.29
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$726.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$726.29
Rate for Payer: Wellcare CHP/FHP/Medicaid	$581.03
Rate for Payer: Wellcare Medicare	$689.98

CMPLX RPR F/C/C/M/N/AX 2.6-7.5CM

Facility

$1,505.35

Service Code	HCPCS 13132
Hospital Charge Code	30305559
Hospital Revenue Code	450
Rate for Payer: Cash Price	$726.29

CMPLX RPR F/C/C/M/N/AX 2.6-7.5CM

Facility

$1,505.35

Service Code	HCPCS 13132
Hospital Charge Code	30105559
Hospital Revenue Code	450
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$726.29
Rate for Payer: Aetna Government	$726.29
Rate for Payer: Affinity Essential Plan 1&2	$508.40
Rate for Payer: Affinity Essential Plan 3&4	$508.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$508.40
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$726.29
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Cash Price	$726.29
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$726.29
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: Elderplan Medicare Advantage	$726.29
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$617.35
Rate for Payer: Fidelis Essential Plan QHP	$646.40
Rate for Payer: Fidelis Medicare Advantage	$726.29
Rate for Payer: Fidelis Qualified Health Plan	$646.40
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$752.68
Rate for Payer: Hamaspik Choice Inc Medicare	$726.29
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$726.29
Rate for Payer: Humana Medicare	$740.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$726.29
Rate for Payer: Senior Whole Health Medicare Advantage	$726.29
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$726.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$726.29
Rate for Payer: Wellcare CHP/FHP/Medicaid	$581.03
Rate for Payer: Wellcare Medicare	$689.98

CMPTR OPHTH DX IMG ANT SEGMT

Facility

$166.60

Service Code	HCPCS 92132 TC
Hospital Charge Code	30301451
Hospital Revenue Code	510
Rate for Payer: Cash Price	$70.74

CMPTR OPHTH DX IMG ANT SEGMT

Facility

$166.60

Service Code	HCPCS 92132 TC
Hospital Charge Code	30301451
Hospital Revenue Code	510
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.74
Rate for Payer: Aetna Government	$70.74
Rate for Payer: Affinity Essential Plan 1&2	$49.52
Rate for Payer: Affinity Essential Plan 3&4	$49.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.52
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: Fidelis Essential Plan Aliesa	$60.13
Rate for Payer: Fidelis Essential Plan QHP	$62.96
Rate for Payer: Fidelis Medicare Advantage	$70.74
Rate for Payer: Fidelis Qualified Health Plan	$62.96
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
Rate for Payer: Hamaspik Choice Inc Medicare	$70.74
Rate for Payer: Healthfirst Medicare Advantage	$60.13
Rate for Payer: Healthfirst QHP	$70.74
Rate for Payer: Humana Medicare	$72.15
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$70.74
Rate for Payer: Senior Whole Health Medicare Advantage	$70.74
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$70.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.59
Rate for Payer: Wellcare Medicare	$67.20

CMPTR OPHTH IMG OPTIC NERVE

Facility

$166.60

Service Code	HCPCS 92133 TC
Hospital Charge Code	30301453
Hospital Revenue Code	510
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.74
Rate for Payer: Aetna Government	$70.74
Rate for Payer: Affinity Essential Plan 1&2	$49.52
Rate for Payer: Affinity Essential Plan 3&4	$49.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.52
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: Fidelis Essential Plan Aliesa	$60.13
Rate for Payer: Fidelis Essential Plan QHP	$62.96
Rate for Payer: Fidelis Medicare Advantage	$70.74
Rate for Payer: Fidelis Qualified Health Plan	$62.96
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
Rate for Payer: Hamaspik Choice Inc Medicare	$70.74
Rate for Payer: Healthfirst Medicare Advantage	$60.13
Rate for Payer: Healthfirst QHP	$70.74
Rate for Payer: Humana Medicare	$72.15
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$70.74
Rate for Payer: Senior Whole Health Medicare Advantage	$70.74
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$70.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.59
Rate for Payer: Wellcare Medicare	$67.20

CMPTR OPHTH IMG OPTIC NERVE

Facility

$166.60

Service Code	HCPCS 92133 TC
Hospital Charge Code	30301453
Hospital Revenue Code	510
Rate for Payer: Cash Price	$70.74

CMV FEE

Facility

$35.98

Service Code	HCPCS 86644
Hospital Charge Code	40701195
Hospital Revenue Code	300
Rate for Payer: Cash Price	$14.39

CMV FEE

Facility

$35.98

Service Code	HCPCS 86644
Hospital Charge Code	40701195
Hospital Revenue Code	300
Min. Negotiated Rate	$10.07
Max. Negotiated Rate	$26.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.39
Rate for Payer: Aetna Government	$14.39
Rate for Payer: Affinity Essential Plan 1&2	$10.07
Rate for Payer: Affinity Essential Plan 3&4	$10.07
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.07
Rate for Payer: Brighton Health Commercial	$26.98
Rate for Payer: Cash Price	$14.39
Rate for Payer: Cash Price	$14.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$14.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.35
Rate for Payer: Elderplan Medicare Advantage	$14.39
Rate for Payer: EmblemHealth Commercial	$14.39
Rate for Payer: Fidelis Essential Plan Aliesa	$12.23
Rate for Payer: Fidelis Essential Plan QHP	$12.81
Rate for Payer: Fidelis Medicare Advantage	$14.39
Rate for Payer: Fidelis Qualified Health Plan	$12.81
Rate for Payer: Group Health Inc Commercial	$14.39
Rate for Payer: Group Health Inc Medicare	$14.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.99
Rate for Payer: Hamaspik Choice Inc Medicare	$14.39
Rate for Payer: Healthfirst Medicare Advantage	$14.39
Rate for Payer: Healthfirst QHP	$14.39
Rate for Payer: Humana Medicare	$14.68
Rate for Payer: Senior Whole Health Medicare Advantage	$14.39
Rate for Payer: United Healthcare Commercial	$18.22
Rate for Payer: United Healthcare Medicare Advantage	$14.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.51
Rate for Payer: Wellcare Medicare	$12.95

CMV PCR

Facility

$87.73

Service Code	HCPCS 87496
Hospital Charge Code	40619198
Hospital Revenue Code	300
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$65.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.09
Rate for Payer: Aetna Government	$35.09
Rate for Payer: Affinity Essential Plan 1&2	$24.56
Rate for Payer: Affinity Essential Plan 3&4	$24.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$24.56
Rate for Payer: Brighton Health Commercial	$65.80
Rate for Payer: Cash Price	$35.09
Rate for Payer: Cash Price	$35.09
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$35.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.20
Rate for Payer: Elderplan Medicare Advantage	$35.09
Rate for Payer: EmblemHealth Commercial	$35.09
Rate for Payer: Fidelis Essential Plan Aliesa	$29.83
Rate for Payer: Fidelis Essential Plan QHP	$31.23
Rate for Payer: Fidelis Medicare Advantage	$35.09
Rate for Payer: Fidelis Qualified Health Plan	$31.23
Rate for Payer: Group Health Inc Commercial	$35.09
Rate for Payer: Group Health Inc Medicare	$35.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.86
Rate for Payer: Hamaspik Choice Inc Medicare	$35.09
Rate for Payer: Healthfirst Medicare Advantage	$35.09
Rate for Payer: Healthfirst QHP	$35.09
Rate for Payer: Humana Medicare	$35.79
Rate for Payer: Senior Whole Health Medicare Advantage	$35.09
Rate for Payer: United Healthcare Commercial	$44.45
Rate for Payer: United Healthcare Medicare Advantage	$35.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35.09
Rate for Payer: Wellcare CHP/FHP/Medicaid	$28.07
Rate for Payer: Wellcare Medicare	$31.58

CMV PCR

Facility

$87.73

Service Code	HCPCS 87496
Hospital Charge Code	40619198
Hospital Revenue Code	300
Rate for Payer: Cash Price	$35.09

Know your out-of-pocket cost for care.

All Charges