St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HC MANDIBLE FRACTURE-CLOSED REDUCTIO

Facility

$1,450.00

Service Code	CPT D7740
Hospital Charge Code	361D774001
Hospital Revenue Code	361
Min. Negotiated Rate	$507.50
Max. Negotiated Rate	$1,160.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$797.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,011.89
Rate for Payer: Aetna Government	$1,011.89
Rate for Payer: Brighton Health Commercial	$1,087.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,160.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$986.00
Rate for Payer: EmblemHealth Commercial	$725.00
Rate for Payer: Group Health Inc Commercial	$725.00
Rate for Payer: Group Health Inc Medicare	$507.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$725.00
Rate for Payer: Hamaspik Choice Inc Medicare	$725.00

HC MANDIBLE FRACTURE-CLOSED REDUCTIO

Facility

$1,450.00

Service Code	CPT D7740
Hospital Charge Code	361D774001
Hospital Revenue Code	361
Min. Negotiated Rate	$725.00
Max. Negotiated Rate	$725.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$725.00

HC MANDIBLE FRACTURE-OPEN REDUCTION,

Facility

$7,796.00

Service Code	CPT D7730
Hospital Charge Code	361D773001
Hospital Revenue Code	361
Min. Negotiated Rate	$2,045.04
Max. Negotiated Rate	$6,236.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,287.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,045.04
Rate for Payer: Aetna Government	$2,045.04
Rate for Payer: Brighton Health Commercial	$5,847.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6,236.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,301.28
Rate for Payer: EmblemHealth Commercial	$3,898.00
Rate for Payer: Group Health Inc Commercial	$3,898.00
Rate for Payer: Group Health Inc Medicare	$2,728.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,898.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,898.00

HC MANDIBLE FRACTURE-OPEN REDUCTION,

Facility

$7,796.00

Service Code	CPT D7730
Hospital Charge Code	361D773001
Hospital Revenue Code	361
Min. Negotiated Rate	$3,898.00
Max. Negotiated Rate	$3,898.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,898.00

HC MANDIBLE FX-CLOSED REDUCT (TEETH

Facility

$1,087.00

Service Code	CPT D7640
Hospital Charge Code	361D764001
Hospital Revenue Code	361
Min. Negotiated Rate	$380.45
Max. Negotiated Rate	$992.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$597.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$992.43
Rate for Payer: Aetna Government	$992.43
Rate for Payer: Brighton Health Commercial	$815.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$869.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$739.16
Rate for Payer: EmblemHealth Commercial	$543.50
Rate for Payer: Group Health Inc Commercial	$543.50
Rate for Payer: Group Health Inc Medicare	$380.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$543.50
Rate for Payer: Hamaspik Choice Inc Medicare	$543.50

HC MANDIBLE FX-CLOSED REDUCT (TEETH

Facility

$1,087.00

Service Code	CPT D7640
Hospital Charge Code	361D764001
Hospital Revenue Code	361
Min. Negotiated Rate	$543.50
Max. Negotiated Rate	$543.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$543.50

HC MANDIBLE FX-OPEN REDUCT (TEETH IM

Facility

$3,262.00

Service Code	CPT D7630
Hospital Charge Code	361D763001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,141.70
Max. Negotiated Rate	$2,609.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,794.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,564.25
Rate for Payer: Aetna Government	$1,564.25
Rate for Payer: Brighton Health Commercial	$2,446.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,609.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,218.16
Rate for Payer: EmblemHealth Commercial	$1,631.00
Rate for Payer: Group Health Inc Commercial	$1,631.00
Rate for Payer: Group Health Inc Medicare	$1,141.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,631.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,631.00

HC MANDIBLE FX-OPEN REDUCT (TEETH IM

Facility

$3,262.00

Service Code	CPT D7630
Hospital Charge Code	361D763001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,631.00
Max. Negotiated Rate	$1,631.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,631.00

HC MANIP, ELBOW W/ANESTHESIA

Facility

$4,105.00

Service Code	CPT 24300
Hospital Charge Code	3612430001
Hospital Revenue Code	361
Min. Negotiated Rate	$533.48
Max. Negotiated Rate	$3,092.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,955.41
Rate for Payer: Aetna Government	$1,955.41
Rate for Payer: Affinity Essential Plan 1&2	$1,368.79
Rate for Payer: Affinity Essential Plan 3&4	$1,368.79
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,368.79
Rate for Payer: Brighton Health Commercial	$3,078.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,955.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,092.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,628.64
Rate for Payer: Elderplan Medicare Advantage	$1,955.41
Rate for Payer: EmblemHealth Commercial	$1,955.41
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,759.87
Rate for Payer: Fidelis Essential Plan Aliesa	$1,662.10
Rate for Payer: Fidelis Essential Plan QHP	$1,740.31
Rate for Payer: Fidelis Medicare Advantage	$1,955.41
Rate for Payer: Fidelis Qualified Health Plan	$1,740.31
Rate for Payer: Group Health Inc Commercial	$1,955.41
Rate for Payer: Group Health Inc Medicare	$1,955.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,955.41
Rate for Payer: Hamaspik Choice Inc Medicare	$838.29
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$533.48
Rate for Payer: Healthfirst Medicare Advantage	$1,662.10
Rate for Payer: Healthfirst QHP	$1,955.41
Rate for Payer: Humana Medicare	$1,994.52
Rate for Payer: Senior Whole Health Medicare Advantage	$1,955.41
Rate for Payer: United Healthcare Commercial	$1,409.00
Rate for Payer: United Healthcare Medicare Advantage	$1,955.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,955.41
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,857.64
Rate for Payer: Wellcare Medicare	$1,857.64

HC MANIP, ELBOW W/ANESTHESIA

Facility

$4,105.00

Service Code	CPT 24300
Hospital Charge Code	3612430001
Hospital Revenue Code	361
Min. Negotiated Rate	$2,052.50
Max. Negotiated Rate	$2,052.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,052.50

HC MANOMETRIC STUD-NEPHRO/PYELO TUBE OR INDWELL CATH

Facility

$1,685.00

Service Code	CPT 50396 TC
Hospital Charge Code	3615039601
Hospital Revenue Code	361
Min. Negotiated Rate	$842.50
Max. Negotiated Rate	$842.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$842.50

HC MANOMETRIC STUD-NEPHRO/PYELO TUBE OR INDWELL CATH

Facility

$1,685.00

Service Code	CPT 50396 TC
Hospital Charge Code	3615039601
Hospital Revenue Code	361
Min. Negotiated Rate	$143.28
Max. Negotiated Rate	$3,092.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$143.28
Rate for Payer: Aetna Government	$143.28
Rate for Payer: Brighton Health Commercial	$1,263.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,092.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,628.64
Rate for Payer: EmblemHealth Commercial	$842.50
Rate for Payer: Group Health Inc Commercial	$842.50
Rate for Payer: Group Health Inc Medicare	$589.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$842.50
Rate for Payer: Hamaspik Choice Inc Medicare	$315.93
Rate for Payer: United Healthcare Commercial	$1,188.00

HC MARSUP BARTHOLIN GLAND CYST

Facility

$7,566.00

Service Code	CPT 56440
Hospital Charge Code	3615644001
Hospital Revenue Code	361
Min. Negotiated Rate	$3,783.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,783.00

HC MARSUP BARTHOLIN GLAND CYST

Facility

$7,566.00

Service Code	CPT 56440
Hospital Charge Code	3615644001
Hospital Revenue Code	361
Min. Negotiated Rate	$212.37
Max. Negotiated Rate	$5,674.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,884.81
Rate for Payer: Aetna Government	$3,884.81
Rate for Payer: Affinity Essential Plan 1&2	$2,719.37
Rate for Payer: Affinity Essential Plan 3&4	$2,719.37
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,719.37
Rate for Payer: Brighton Health Commercial	$5,674.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,884.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,092.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,628.64
Rate for Payer: Elderplan Medicare Advantage	$3,884.81
Rate for Payer: EmblemHealth Commercial	$3,884.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,496.33
Rate for Payer: Fidelis Essential Plan Aliesa	$3,302.09
Rate for Payer: Fidelis Essential Plan QHP	$3,457.48
Rate for Payer: Fidelis Medicare Advantage	$3,884.81
Rate for Payer: Fidelis Qualified Health Plan	$3,457.48
Rate for Payer: Group Health Inc Commercial	$3,884.81
Rate for Payer: Group Health Inc Medicare	$3,884.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,884.81
Rate for Payer: Hamaspik Choice Inc Medicare	$1,674.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$212.37
Rate for Payer: Healthfirst Medicare Advantage	$3,302.09
Rate for Payer: Healthfirst QHP	$3,884.81
Rate for Payer: Humana Medicare	$3,962.51
Rate for Payer: Senior Whole Health Medicare Advantage	$3,884.81
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$3,884.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,884.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,690.57
Rate for Payer: Wellcare Medicare	$3,690.57

HC MASS SPECTROMETRY, IODINE, RANDOM URINE

Facility

$60.00

Service Code	CPT 83789
Hospital Charge Code	3018378901
Hospital Revenue Code	301
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00

HC MASS SPECTROMETRY, IODINE, RANDOM URINE

Facility

$60.00

Service Code	CPT 83789
Hospital Charge Code	3018378901
Hospital Revenue Code	301
Min. Negotiated Rate	$16.88
Max. Negotiated Rate	$45.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.11
Rate for Payer: Aetna Government	$24.11
Rate for Payer: Affinity Essential Plan 1&2	$16.88
Rate for Payer: Affinity Essential Plan 3&4	$16.88
Rate for Payer: Affinity Medicaid/CHP/HARP	$16.88
Rate for Payer: Brighton Health Commercial	$45.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$24.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.83
Rate for Payer: Elderplan Medicare Advantage	$24.11
Rate for Payer: EmblemHealth Commercial	$24.11
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21.70
Rate for Payer: Fidelis Essential Plan Aliesa	$20.49
Rate for Payer: Fidelis Essential Plan QHP	$21.46
Rate for Payer: Fidelis Medicare Advantage	$24.11
Rate for Payer: Fidelis Qualified Health Plan	$21.46
Rate for Payer: Group Health Inc Commercial	$24.11
Rate for Payer: Group Health Inc Medicare	$24.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.11
Rate for Payer: Hamaspik Choice Inc Medicare	$24.11
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24.11
Rate for Payer: Healthfirst Medicare Advantage	$24.11
Rate for Payer: Healthfirst QHP	$24.11
Rate for Payer: Humana Medicare	$24.59
Rate for Payer: Senior Whole Health Medicare Advantage	$24.11
Rate for Payer: United Healthcare Commercial	$22.87
Rate for Payer: United Healthcare Medicare Advantage	$24.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$24.11
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22.90
Rate for Payer: Wellcare Medicare	$21.70

HC MASS SPECTROMETRY, IODINE, SERUM OR PLASMA

Facility

$60.00

Service Code	CPT 83789
Hospital Charge Code	3018378902
Hospital Revenue Code	301
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00

HC MASS SPECTROMETRY, IODINE, SERUM OR PLASMA

Facility

$60.00

Service Code	CPT 83789
Hospital Charge Code	3018378902
Hospital Revenue Code	301
Min. Negotiated Rate	$16.88
Max. Negotiated Rate	$45.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.11
Rate for Payer: Aetna Government	$24.11
Rate for Payer: Affinity Essential Plan 1&2	$16.88
Rate for Payer: Affinity Essential Plan 3&4	$16.88
Rate for Payer: Affinity Medicaid/CHP/HARP	$16.88
Rate for Payer: Brighton Health Commercial	$45.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$24.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.83
Rate for Payer: Elderplan Medicare Advantage	$24.11
Rate for Payer: EmblemHealth Commercial	$24.11
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21.70
Rate for Payer: Fidelis Essential Plan Aliesa	$20.49
Rate for Payer: Fidelis Essential Plan QHP	$21.46
Rate for Payer: Fidelis Medicare Advantage	$24.11
Rate for Payer: Fidelis Qualified Health Plan	$21.46
Rate for Payer: Group Health Inc Commercial	$24.11
Rate for Payer: Group Health Inc Medicare	$24.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.11
Rate for Payer: Hamaspik Choice Inc Medicare	$24.11
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24.11
Rate for Payer: Healthfirst Medicare Advantage	$24.11
Rate for Payer: Healthfirst QHP	$24.11
Rate for Payer: Humana Medicare	$24.59
Rate for Payer: Senior Whole Health Medicare Advantage	$24.11
Rate for Payer: United Healthcare Commercial	$22.87
Rate for Payer: United Healthcare Medicare Advantage	$24.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$24.11
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22.90
Rate for Payer: Wellcare Medicare	$21.70

HC MASTOTOMY W/ ABSCESS EXPLORATN/DRAINAGE, DEEP

Facility

$4,157.00

Service Code	CPT 19020
Hospital Charge Code	3611902001
Hospital Revenue Code	361
Min. Negotiated Rate	$2,078.50
Max. Negotiated Rate	$2,078.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,078.50

HC MASTOTOMY W/ ABSCESS EXPLORATN/DRAINAGE, DEEP

Facility

$4,157.00

Service Code	CPT 19020
Hospital Charge Code	3611902001
Hospital Revenue Code	361
Min. Negotiated Rate	$374.43
Max. Negotiated Rate	$3,117.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,979.64
Rate for Payer: Aetna Government	$1,979.64
Rate for Payer: Affinity Essential Plan 1&2	$1,385.75
Rate for Payer: Affinity Essential Plan 3&4	$1,385.75
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,385.75
Rate for Payer: Brighton Health Commercial	$3,117.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,979.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,092.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,628.64
Rate for Payer: Elderplan Medicare Advantage	$1,979.64
Rate for Payer: EmblemHealth Commercial	$1,979.64
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,781.68
Rate for Payer: Fidelis Essential Plan Aliesa	$1,682.69
Rate for Payer: Fidelis Essential Plan QHP	$1,761.88
Rate for Payer: Fidelis Medicare Advantage	$1,979.64
Rate for Payer: Fidelis Qualified Health Plan	$1,761.88
Rate for Payer: Group Health Inc Commercial	$1,979.64
Rate for Payer: Group Health Inc Medicare	$1,979.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,979.64
Rate for Payer: Hamaspik Choice Inc Medicare	$708.28
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$374.43
Rate for Payer: Healthfirst Medicare Advantage	$1,682.69
Rate for Payer: Healthfirst QHP	$1,979.64
Rate for Payer: Humana Medicare	$2,019.23
Rate for Payer: Senior Whole Health Medicare Advantage	$1,979.64
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$1,979.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,979.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,880.66
Rate for Payer: Wellcare Medicare	$1,880.66

HC MASTRISTEM MICROMETRIX, 1 MG

Facility

$9.00

Service Code	CPT Q4118
Hospital Charge Code	636Q411801
Hospital Revenue Code	636
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$5.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.65
Rate for Payer: Aetna Government	$2.65
Rate for Payer: Brighton Health Commercial	$5.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.17
Rate for Payer: EmblemHealth Commercial	$4.50
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

HC MASTRISTEM MICROMETRIX, 1 MG

Facility

$9.00

Service Code	CPT Q4118
Hospital Charge Code	636Q411801
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50

HC MAXILLA FRACTURE-OPEN REDUCTION,

Facility

$7,088.00

Service Code	CPT D7710
Hospital Charge Code	361D771001
Hospital Revenue Code	361
Min. Negotiated Rate	$3,544.00
Max. Negotiated Rate	$3,544.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,544.00

HC MAXILLA FRACTURE-OPEN REDUCTION,

Facility

$7,088.00

Service Code	CPT D7710
Hospital Charge Code	361D771001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,414.03
Max. Negotiated Rate	$5,670.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,898.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,414.03
Rate for Payer: Aetna Government	$1,414.03
Rate for Payer: Brighton Health Commercial	$5,316.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,670.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,819.84
Rate for Payer: EmblemHealth Commercial	$3,544.00
Rate for Payer: Group Health Inc Commercial	$3,544.00
Rate for Payer: Group Health Inc Medicare	$2,480.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,544.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,544.00

HC MAXILLA FX-CLOSED REDUCT (TEETH I

Facility

$1,087.00

Service Code	CPT D7620
Hospital Charge Code	361D762001
Hospital Revenue Code	361
Min. Negotiated Rate	$543.50
Max. Negotiated Rate	$543.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$543.50

Know your out-of-pocket cost for care.

All Charges