St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CONCUSSION WITH MCC

Facility

$39,321.74

Service Code	MSDRG 088
Min. Negotiated Rate	$13,152.30
Max. Negotiated Rate	$39,321.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22,615.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28,597.63
Rate for Payer: Aetna Government	$28,597.63
Rate for Payer: Brighton Health Commercial	$22,240.10
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29,169.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26,487.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$21,858.37
Rate for Payer: Elderplan Medicare Advantage	$27,167.75
Rate for Payer: EmblemHealth Commercial	$13,152.30
Rate for Payer: Fidelis Medicare Advantage	$28,597.63
Rate for Payer: Group Health Inc Commercial	$28,597.63
Rate for Payer: Group Health Inc Medicare	$28,597.63
Rate for Payer: Hamaspik Choice Inc Medicare	$28,597.63
Rate for Payer: Healthfirst Medicare Advantage	$13,297.90
Rate for Payer: Humana Medicare	$39,321.74
Rate for Payer: Senior Whole Health Medicare Advantage	$28,597.63
Rate for Payer: United Healthcare Commercial	$30,502.68
Rate for Payer: United Healthcare Medicare Advantage	$28,597.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28,597.63
Rate for Payer: Wellcare Medicare	$27,167.75

CONCUSSION WITHOUT CC/MCC

Facility

$27,900.22

Service Code	MSDRG 090
Min. Negotiated Rate	$8,015.91
Max. Negotiated Rate	$27,900.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13,783.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20,291.07
Rate for Payer: Aetna Government	$20,291.07
Rate for Payer: Brighton Health Commercial	$13,554.60
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20,696.89
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16,143.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$13,321.95
Rate for Payer: Elderplan Medicare Advantage	$19,276.52
Rate for Payer: EmblemHealth Commercial	$8,015.91
Rate for Payer: Fidelis Medicare Advantage	$20,291.07
Rate for Payer: Group Health Inc Commercial	$20,291.07
Rate for Payer: Group Health Inc Medicare	$20,291.07
Rate for Payer: Hamaspik Choice Inc Medicare	$20,291.07
Rate for Payer: Healthfirst Medicare Advantage	$9,435.35
Rate for Payer: Humana Medicare	$27,900.22
Rate for Payer: Senior Whole Health Medicare Advantage	$20,291.07
Rate for Payer: United Healthcare Commercial	$18,590.37
Rate for Payer: United Healthcare Medicare Advantage	$20,291.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20,291.07
Rate for Payer: Wellcare Medicare	$19,276.52

CONDITIONING PLAY AUDIOMETRY

Facility

$419.03

Service Code	HCPCS 92582
Hospital Charge Code	42004513
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

CONDITIONING PLAY AUDIOMETRY

Facility

$419.03

Service Code	HCPCS 92582
Hospital Charge Code	42004513
Hospital Revenue Code	471
Rate for Payer: Cash Price	$180.64

CONDUIT NERVE REPAIR 2.5MM ID

Facility

$3,275.93

Hospital Charge Code	64904073
Hospital Revenue Code	279
Min. Negotiated Rate	$1,146.58
Max. Negotiated Rate	$2,620.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,801.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,637.96
Rate for Payer: Aetna Government	$1,637.96
Rate for Payer: Brighton Health Commercial	$2,456.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,620.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,227.63
Rate for Payer: Group Health Inc Commercial	$1,637.96
Rate for Payer: Group Health Inc Medicare	$1,146.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,637.96
Rate for Payer: Hamaspik Choice Inc Medicare	$1,637.96

CONDUIT NERVE REPAIR 3MM ID 2

Facility

$3,845.55

Hospital Charge Code	64904372
Hospital Revenue Code	279
Min. Negotiated Rate	$1,345.94
Max. Negotiated Rate	$3,076.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,115.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,922.78
Rate for Payer: Aetna Government	$1,922.78
Rate for Payer: Brighton Health Commercial	$2,884.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,076.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,614.97
Rate for Payer: Group Health Inc Commercial	$1,922.78
Rate for Payer: Group Health Inc Medicare	$1,345.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,922.78
Rate for Payer: Hamaspik Choice Inc Medicare	$1,922.78

CONDUIT NERVE REPAIR 4MM ID 2

Facility

$3,845.55

Hospital Charge Code	64904080
Hospital Revenue Code	279
Min. Negotiated Rate	$1,345.94
Max. Negotiated Rate	$3,076.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,115.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,922.78
Rate for Payer: Aetna Government	$1,922.78
Rate for Payer: Brighton Health Commercial	$2,884.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,076.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,614.97
Rate for Payer: Group Health Inc Commercial	$1,922.78
Rate for Payer: Group Health Inc Medicare	$1,345.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,922.78
Rate for Payer: Hamaspik Choice Inc Medicare	$1,922.78

CONDYLAR MARX TEMPORARY

Facility

$2,155.30

Hospital Charge Code	64904448
Hospital Revenue Code	270
Min. Negotiated Rate	$754.36
Max. Negotiated Rate	$1,724.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,185.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,077.65
Rate for Payer: Aetna Government	$1,077.65
Rate for Payer: Brighton Health Commercial	$1,616.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,724.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,465.60
Rate for Payer: Group Health Inc Commercial	$1,077.65
Rate for Payer: Group Health Inc Medicare	$754.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,077.65
Rate for Payer: Hamaspik Choice Inc Medicare	$1,077.65

CONDYLECTOMY

Facility

$4,350.00

Service Code	HCPCS D7840
Hospital Charge Code	42301955
Hospital Revenue Code	361
Min. Negotiated Rate	$1,522.50
Max. Negotiated Rate	$3,262.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,392.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,803.34
Rate for Payer: Aetna Government	$1,803.34
Rate for Payer: Brighton Health Commercial	$3,262.50
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: Group Health Inc Commercial	$2,175.00
Rate for Payer: Group Health Inc Medicare	$1,522.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,175.00

CONDYLE FASTENING SCREW

Facility

$200.00

Service Code	HCPCS C1713
Hospital Charge Code	40200532
Hospital Revenue Code	278
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$120.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: EmblemHealth Commercial	$100.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CONDYLE FASTENING SCREW

Facility

$200.00

Service Code	HCPCS C1713
Hospital Charge Code	40200532
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CONE ASYM TRI AUG

Facility

$16,132.50

Service Code	HCPCS C1776
Hospital Charge Code	64907220
Hospital Revenue Code	278
Min. Negotiated Rate	$8,066.25
Max. Negotiated Rate	$8,066.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,066.25
Rate for Payer: Hamaspik Choice Inc Medicare	$8,066.25

CONE ASYM TRI AUG

Facility

$16,132.50

Service Code	HCPCS C1776
Hospital Charge Code	64907220
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$16,939.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,872.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$9,679.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,066.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$9,276.19
Rate for Payer: EmblemHealth Commercial	$8,066.25
Rate for Payer: Fidelis Medicare Advantage	$16,939.12
Rate for Payer: Group Health Inc Commercial	$8,066.25
Rate for Payer: Group Health Inc Medicare	$5,646.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$8,066.25
Rate for Payer: Hamaspik Choice Inc Medicare	$8,066.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10,486.12

CONE BEAM CT CAP & INTE LTD VIEWS

Facility

$697.50

Service Code	HCPCS D0364
Hospital Charge Code	42300703
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT CAP & INTE LTD VIEWS

Facility

$697.50

Service Code	HCPCS D0364
Hospital Charge Code	42300703
Hospital Revenue Code	361
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$523.12
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.75
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

CONE BEAM CT CAP&INTR JAW W/CRANI

Facility

$697.50

Service Code	HCPCS D0367
Hospital Charge Code	42300702
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT CAP&INTR JAW W/CRANI

Facility

$697.50

Service Code	HCPCS D0367
Hospital Charge Code	42300702
Hospital Revenue Code	361
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$523.12
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.75
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

CONE BEAM CT CAPTURE & INTRP FULL

Facility

$697.50

Service Code	HCPCS D0365
Hospital Charge Code	42300709
Hospital Revenue Code	361
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$523.12
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.75
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

CONE BEAM CT CAPTURE & INTRP FULL

Facility

$697.50

Service Code	HCPCS D0365
Hospital Charge Code	42300709
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT IMAGE LTD VIEW

Facility

$150.00

Service Code	HCPCS D0380
Hospital Charge Code	42300701
Hospital Revenue Code	361
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$82.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$112.50
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$75.00
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

CONE BEAM CT IMAGE LTD VIEW

Facility

$150.00

Service Code	HCPCS D0380
Hospital Charge Code	42300701
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT MAXILLA AND CRANIUM

Facility

$697.50

Service Code	HCPCS D0366
Hospital Charge Code	42300711
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT MAXILLA AND CRANIUM

Facility

$697.50

Service Code	HCPCS D0366
Hospital Charge Code	42300711
Hospital Revenue Code	361
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$523.12
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.75
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

CONE BEAM CT TMJ SERIES ICLD 2+

Facility

$697.50

Service Code	HCPCS D0368
Hospital Charge Code	42300712
Hospital Revenue Code	361
Rate for Payer: Cash Price	$127.14

CONE BEAM CT TMJ SERIES ICLD 2+

Facility

$697.50

Service Code	HCPCS D0368
Hospital Charge Code	42300712
Hospital Revenue Code	361
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$523.12
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
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	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.75
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

Know your out-of-pocket cost for care.

All Charges