St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

COMP FEM POR CRUC RET SZ F RT

Facility

$10,467.75

Service Code	HCPCS C1713
Hospital Charge Code	64901994
Hospital Revenue Code	278
Min. Negotiated Rate	$5,233.88
Max. Negotiated Rate	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88

COMP FEM POR CRUC RET SZ F RT

Facility

$10,467.75

Service Code	HCPCS C1713
Hospital Charge Code	64901994
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$10,991.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,757.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$6,280.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,233.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,018.96
Rate for Payer: EmblemHealth Commercial	$5,233.88
Rate for Payer: Fidelis Medicare Advantage	$10,991.14
Rate for Payer: Group Health Inc Commercial	$5,233.88
Rate for Payer: Group Health Inc Medicare	$3,663.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,804.04

COMP KNEE ART SURF GRN 10MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64901852
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,402.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,305.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,515.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,096.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,410.76
Rate for Payer: EmblemHealth Commercial	$2,096.32
Rate for Payer: Fidelis Medicare Advantage	$4,402.26
Rate for Payer: Group Health Inc Commercial	$2,096.32
Rate for Payer: Group Health Inc Medicare	$1,467.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,725.21

COMP KNEE ART SURF GRN 10MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64901852
Hospital Revenue Code	278
Min. Negotiated Rate	$2,096.32
Max. Negotiated Rate	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32

COMP KNEE ART SURF GRN 12MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64902206
Hospital Revenue Code	278
Min. Negotiated Rate	$2,096.32
Max. Negotiated Rate	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32

COMP KNEE ART SURF GRN 12MM

Facility

$3,539.40

Service Code	HCPCS C1776
Hospital Charge Code	40205066
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.70
Max. Negotiated Rate	$1,769.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,769.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1,769.70

COMP KNEE ART SURF GRN 12MM

Facility

$3,539.40

Service Code	HCPCS C1776
Hospital Charge Code	40205066
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,716.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,946.67
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,123.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,769.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,035.16
Rate for Payer: EmblemHealth Commercial	$1,769.70
Rate for Payer: Fidelis Medicare Advantage	$3,716.37
Rate for Payer: Group Health Inc Commercial	$1,769.70
Rate for Payer: Group Health Inc Medicare	$1,238.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,769.70
Rate for Payer: Hamaspik Choice Inc Medicare	$1,769.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,300.61

COMP KNEE ART SURF GRN 12MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64902206
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,402.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,305.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,515.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,096.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,410.76
Rate for Payer: EmblemHealth Commercial	$2,096.32
Rate for Payer: Fidelis Medicare Advantage	$4,402.26
Rate for Payer: Group Health Inc Commercial	$2,096.32
Rate for Payer: Group Health Inc Medicare	$1,467.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,725.21

COMP KNEE ART SURF GRN 14MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64901973
Hospital Revenue Code	278
Min. Negotiated Rate	$2,096.32
Max. Negotiated Rate	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32

COMP KNEE ART SURF GRN 14MM

Facility

$4,192.63

Service Code	HCPCS C1776
Hospital Charge Code	64901973
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,402.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,305.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,515.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,096.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,410.76
Rate for Payer: EmblemHealth Commercial	$2,096.32
Rate for Payer: Fidelis Medicare Advantage	$4,402.26
Rate for Payer: Group Health Inc Commercial	$2,096.32
Rate for Payer: Group Health Inc Medicare	$1,467.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,725.21

COMP KNEE FEMORAL POR SZ G LFT

Facility

$8,374.20

Service Code	HCPCS C1776
Hospital Charge Code	40205078
Hospital Revenue Code	278
Min. Negotiated Rate	$4,187.10
Max. Negotiated Rate	$4,187.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,187.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4,187.10

COMP KNEE FEMORAL POR SZ G LFT

Facility

$8,374.20

Service Code	HCPCS C1776
Hospital Charge Code	40205078
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$8,792.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,605.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$5,024.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,187.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,815.16
Rate for Payer: EmblemHealth Commercial	$4,187.10
Rate for Payer: Fidelis Medicare Advantage	$8,792.91
Rate for Payer: Group Health Inc Commercial	$4,187.10
Rate for Payer: Group Health Inc Medicare	$2,930.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,187.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4,187.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,443.23

COMP KNEE FEMRL POR SZ-G RGT

Facility

$10,467.75

Service Code	HCPCS C1776
Hospital Charge Code	64902519
Hospital Revenue Code	278
Min. Negotiated Rate	$5,233.88
Max. Negotiated Rate	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88

COMP KNEE FEMRL POR SZ-G RGT

Facility

$10,467.75

Service Code	HCPCS C1776
Hospital Charge Code	64902519
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$10,991.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,757.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$6,280.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,233.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,018.96
Rate for Payer: EmblemHealth Commercial	$5,233.88
Rate for Payer: Fidelis Medicare Advantage	$10,991.14
Rate for Payer: Group Health Inc Commercial	$5,233.88
Rate for Payer: Group Health Inc Medicare	$3,663.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,804.04

COMPLEMENT C1Q, QUANTITATIVE

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609139
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.00

COMPLEMENT C1Q, QUANTITATIVE

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609139
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$22.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.00
Rate for Payer: Aetna Government	$12.00
Rate for Payer: Affinity Essential Plan 1&2	$8.40
Rate for Payer: Affinity Essential Plan 3&4	$8.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.40
Rate for Payer: Brighton Health Commercial	$22.50
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.15
Rate for Payer: Elderplan Medicare Advantage	$12.00
Rate for Payer: EmblemHealth Commercial	$12.00
Rate for Payer: Fidelis Essential Plan Aliesa	$10.20
Rate for Payer: Fidelis Essential Plan QHP	$10.68
Rate for Payer: Fidelis Medicare Advantage	$12.00
Rate for Payer: Fidelis Qualified Health Plan	$10.68
Rate for Payer: Group Health Inc Commercial	$12.00
Rate for Payer: Group Health Inc Medicare	$12.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12.00
Rate for Payer: Healthfirst Medicare Advantage	$12.00
Rate for Payer: Healthfirst QHP	$12.00
Rate for Payer: Humana Medicare	$12.24
Rate for Payer: Senior Whole Health Medicare Advantage	$12.00
Rate for Payer: United Healthcare Commercial	$15.20
Rate for Payer: United Healthcare Medicare Advantage	$12.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.60
Rate for Payer: Wellcare Medicare	$10.80

COMPLEMENT C3, SERUM

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609136
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$22.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.00
Rate for Payer: Aetna Government	$12.00
Rate for Payer: Affinity Essential Plan 1&2	$8.40
Rate for Payer: Affinity Essential Plan 3&4	$8.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.40
Rate for Payer: Brighton Health Commercial	$22.50
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.15
Rate for Payer: Elderplan Medicare Advantage	$12.00
Rate for Payer: EmblemHealth Commercial	$12.00
Rate for Payer: Fidelis Essential Plan Aliesa	$10.20
Rate for Payer: Fidelis Essential Plan QHP	$10.68
Rate for Payer: Fidelis Medicare Advantage	$12.00
Rate for Payer: Fidelis Qualified Health Plan	$10.68
Rate for Payer: Group Health Inc Commercial	$12.00
Rate for Payer: Group Health Inc Medicare	$12.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12.00
Rate for Payer: Healthfirst Medicare Advantage	$12.00
Rate for Payer: Healthfirst QHP	$12.00
Rate for Payer: Humana Medicare	$12.24
Rate for Payer: Senior Whole Health Medicare Advantage	$12.00
Rate for Payer: United Healthcare Commercial	$15.20
Rate for Payer: United Healthcare Medicare Advantage	$12.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.60
Rate for Payer: Wellcare Medicare	$10.80

COMPLEMENT C3, SERUM

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609136
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.00

COMPLEMENT C4, SERUM

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609137
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.00

COMPLEMENT C4, SERUM

Facility

$30.00

Service Code	HCPCS 86160
Hospital Charge Code	40609137
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$22.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.00
Rate for Payer: Aetna Government	$12.00
Rate for Payer: Affinity Essential Plan 1&2	$8.40
Rate for Payer: Affinity Essential Plan 3&4	$8.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.40
Rate for Payer: Brighton Health Commercial	$22.50
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.15
Rate for Payer: Elderplan Medicare Advantage	$12.00
Rate for Payer: EmblemHealth Commercial	$12.00
Rate for Payer: Fidelis Essential Plan Aliesa	$10.20
Rate for Payer: Fidelis Essential Plan QHP	$10.68
Rate for Payer: Fidelis Medicare Advantage	$12.00
Rate for Payer: Fidelis Qualified Health Plan	$10.68
Rate for Payer: Group Health Inc Commercial	$12.00
Rate for Payer: Group Health Inc Medicare	$12.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12.00
Rate for Payer: Healthfirst Medicare Advantage	$12.00
Rate for Payer: Healthfirst QHP	$12.00
Rate for Payer: Humana Medicare	$12.24
Rate for Payer: Senior Whole Health Medicare Advantage	$12.00
Rate for Payer: United Healthcare Commercial	$15.20
Rate for Payer: United Healthcare Medicare Advantage	$12.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.60
Rate for Payer: Wellcare Medicare	$10.80

COMPLEMENT, TOTAL (CH50)

Facility

$50.80

Service Code	HCPCS 86162
Hospital Charge Code	40609140
Hospital Revenue Code	300
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$38.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$27.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.32
Rate for Payer: Aetna Government	$20.32
Rate for Payer: Affinity Essential Plan 1&2	$14.22
Rate for Payer: Affinity Essential Plan 3&4	$14.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.22
Rate for Payer: Brighton Health Commercial	$38.10
Rate for Payer: Cash Price	$20.32
Rate for Payer: Cash Price	$20.32
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.32
Rate for Payer: Elderplan Medicare Advantage	$20.32
Rate for Payer: EmblemHealth Commercial	$20.32
Rate for Payer: Fidelis Essential Plan Aliesa	$17.27
Rate for Payer: Fidelis Essential Plan QHP	$18.08
Rate for Payer: Fidelis Medicare Advantage	$20.32
Rate for Payer: Fidelis Qualified Health Plan	$18.08
Rate for Payer: Group Health Inc Commercial	$20.32
Rate for Payer: Group Health Inc Medicare	$20.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$25.40
Rate for Payer: Hamaspik Choice Inc Medicare	$20.32
Rate for Payer: Healthfirst Medicare Advantage	$20.32
Rate for Payer: Healthfirst QHP	$20.32
Rate for Payer: Humana Medicare	$20.73
Rate for Payer: Senior Whole Health Medicare Advantage	$20.32
Rate for Payer: United Healthcare Commercial	$25.73
Rate for Payer: United Healthcare Medicare Advantage	$20.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20.32
Rate for Payer: Wellcare CHP/FHP/Medicaid	$16.26
Rate for Payer: Wellcare Medicare	$18.29

COMPLEMENT, TOTAL (CH50)

Facility

$50.80

Service Code	HCPCS 86162
Hospital Charge Code	40609140
Hospital Revenue Code	300
Rate for Payer: Cash Price	$20.32

COMPLETE AUDIO- PTT & SPEECH AUDI

Facility

$419.03

Service Code	HCPCS 92557
Hospital Charge Code	42003115
Hospital Revenue Code	471
Rate for Payer: Cash Price	$180.64

COMPLETE AUDIO- PTT & SPEECH AUDI

Facility

$419.03

Service Code	HCPCS 92557
Hospital Charge Code	42003115
Hospital Revenue Code	471
Min. Negotiated Rate	$126.45
Max. Negotiated Rate	$335.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$230.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$180.64
Rate for Payer: Aetna Government	$180.64
Rate for Payer: Affinity Essential Plan 1&2	$126.45
Rate for Payer: Affinity Essential Plan 3&4	$126.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$126.45
Rate for Payer: Brighton Health Commercial	$314.27
Rate for Payer: Cash Price	$180.64
Rate for Payer: Cash Price	$180.64
Rate for Payer: Cash Price	$180.64
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$180.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$335.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$284.94
Rate for Payer: Elderplan Medicare Advantage	$180.64
Rate for Payer: EmblemHealth Commercial	$180.64
Rate for Payer: Fidelis Essential Plan Aliesa	$153.54
Rate for Payer: Fidelis Essential Plan QHP	$160.77
Rate for Payer: Fidelis Medicare Advantage	$180.64
Rate for Payer: Fidelis Qualified Health Plan	$160.77
Rate for Payer: Group Health Inc Commercial	$180.64
Rate for Payer: Group Health Inc Medicare	$180.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$209.52
Rate for Payer: Hamaspik Choice Inc Medicare	$180.64
Rate for Payer: Healthfirst Medicare Advantage	$153.54
Rate for Payer: Healthfirst QHP	$180.64
Rate for Payer: Humana Medicare	$184.25
Rate for Payer: Senior Whole Health Medicare Advantage	$180.64
Rate for Payer: United Healthcare Commercial	$158.00
Rate for Payer: United Healthcare Medicare Advantage	$180.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$180.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$144.51
Rate for Payer: Wellcare Medicare	$171.61

COMPLETE LOWER DENTURE

Facility

$1,400.00

Service Code	HCPCS D5120
Hospital Charge Code	42300965
Hospital Revenue Code	361
Min. Negotiated Rate	$285.71
Max. Negotiated Rate	$28,571.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$770.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.84
Rate for Payer: Aetna Government	$402.84
Rate for Payer: Affinity Essential Plan 1&2	$642.85
Rate for Payer: Affinity Essential Plan 3&4	$642.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$285.71
Rate for Payer: Amida Care Medicaid	$285.71
Rate for Payer: Brighton Health Commercial	$1,050.00
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: Fidelis CHP/HARP/Medicaid	$28,571.00
Rate for Payer: Fidelis Essential Plan Aliesa	$285.71
Rate for Payer: Fidelis Essential Plan QHP	$285.71
Rate for Payer: Fidelis Qualified Health Plan	$300.00
Rate for Payer: Group Health Inc Commercial	$700.00
Rate for Payer: Group Health Inc Medicare	$490.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$285.71
Rate for Payer: Hamaspik Choice Inc Medicare	$700.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$285.71
Rate for Payer: Healthfirst Essential Plan	$642.85
Rate for Payer: Healthfirst QHP	$285.71
Rate for Payer: SOMOS CHP/HARP/Medicaid	$285.71
Rate for Payer: SOMOS Essential	$642.85
Rate for Payer: United Healthcare Essential Plan 1&2	$642.85
Rate for Payer: United Healthcare Essential Plan 3&4	$314.28
Rate for Payer: United Healthcare Medicaid	$285.71
Rate for Payer: Wellcare CHP/FHP/Medicaid	$285.71

Know your out-of-pocket cost for care.

All Charges