St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HC OASIS BURN MATRIX PER SQ CM

Facility

$20.00

Service Code	CPT Q4103
Hospital Charge Code	636Q410301
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$13.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.28
Rate for Payer: Aetna Government	$1.28
Rate for Payer: Brighton Health Commercial	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.50
Rate for Payer: EmblemHealth Commercial	$10.00
Rate for Payer: Group Health Inc Commercial	$10.00
Rate for Payer: Group Health Inc Medicare	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$12.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.00

HC OASIS BURN MATRIX PER SQ CM

Facility

$20.00

Service Code	CPT Q4103
Hospital Charge Code	636Q410301
Hospital Revenue Code	636
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$10.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00

HC OASIS ULTRA TRILAYER WOUND MATRIX, PER SQ CM

Facility

$28.00

Service Code	CPT Q4124
Hospital Charge Code	636Q412401
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$18.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.35
Rate for Payer: Aetna Government	$10.35
Rate for Payer: Brighton Health Commercial	$16.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.10
Rate for Payer: EmblemHealth Commercial	$14.00
Rate for Payer: Group Health Inc Commercial	$14.00
Rate for Payer: Group Health Inc Medicare	$9.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.20

HC OASIS ULTRA TRILAYER WOUND MATRIX, PER SQ CM

Facility

$28.00

Service Code	CPT Q4124
Hospital Charge Code	636Q412401
Hospital Revenue Code	636
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$14.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00

HC OASIS WOUND MATRIX PER 1 SQ CM

Facility

$48.00

Service Code	CPT Q4102
Hospital Charge Code	636Q410201
Hospital Revenue Code	636
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$24.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00

HC OASIS WOUND MATRIX PER 1 SQ CM

Facility

$48.00

Service Code	CPT Q4102
Hospital Charge Code	636Q410201
Hospital Revenue Code	636
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$31.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.05
Rate for Payer: Aetna Government	$11.05
Rate for Payer: Brighton Health Commercial	$28.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.60
Rate for Payer: EmblemHealth Commercial	$24.00
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$11.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

HC OBSTETRICAL CARE,VAG DELIV ONLY

Facility

$7,566.00

Service Code	CPT 59409
Hospital Charge Code	7205940901
Hospital Revenue Code	720
Min. Negotiated Rate	$3,783.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,783.00

HC OBSTETRICAL CARE,VAG DELIV ONLY

Facility

$7,566.00

Service Code	CPT 59409
Hospital Charge Code	3615940901
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 OBSTETRICAL CARE,VAG DELIV ONLY

Facility

$7,566.00

Service Code	CPT 59409
Hospital Charge Code	3615940901
Hospital Revenue Code	361
Min. Negotiated Rate	$957.21
Max. Negotiated Rate	$5,674.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
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	$3,884.81
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$957.21
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 OBSTETRICAL CARE,VAG DELIV ONLY

Facility

$7,566.00

Service Code	CPT 59409
Hospital Charge Code	7205940901
Hospital Revenue Code	720
Min. Negotiated Rate	$957.21
Max. Negotiated Rate	$8,223.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
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	$6,052.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,144.88
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	$3,884.81
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$957.21
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	$8,223.00
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 OBSTETRIC PANEL - BUNDLED CHARGE

Facility

$119.00

Service Code	CPT 80055
Hospital Charge Code	3018005501
Hospital Revenue Code	301
Min. Negotiated Rate	$33.47
Max. Negotiated Rate	$89.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$65.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.81
Rate for Payer: Aetna Government	$47.81
Rate for Payer: Affinity Essential Plan 1&2	$33.47
Rate for Payer: Affinity Essential Plan 3&4	$33.47
Rate for Payer: Affinity Medicaid/CHP/HARP	$33.47
Rate for Payer: Brighton Health Commercial	$89.25
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$47.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$71.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$60.11
Rate for Payer: Elderplan Medicare Advantage	$47.81
Rate for Payer: EmblemHealth Commercial	$47.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$43.03
Rate for Payer: Fidelis Essential Plan Aliesa	$40.64
Rate for Payer: Fidelis Essential Plan QHP	$42.55
Rate for Payer: Fidelis Medicare Advantage	$47.81
Rate for Payer: Fidelis Qualified Health Plan	$42.55
Rate for Payer: Group Health Inc Commercial	$47.81
Rate for Payer: Group Health Inc Medicare	$47.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.81
Rate for Payer: Hamaspik Choice Inc Medicare	$47.81
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$47.81
Rate for Payer: Healthfirst Medicare Advantage	$47.81
Rate for Payer: Healthfirst QHP	$47.81
Rate for Payer: Humana Medicare	$48.77
Rate for Payer: Senior Whole Health Medicare Advantage	$47.81
Rate for Payer: United Healthcare Commercial	$53.21
Rate for Payer: United Healthcare Medicare Advantage	$47.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$47.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$45.42
Rate for Payer: Wellcare Medicare	$43.03

HC OBSTETRIC PANEL - BUNDLED CHARGE

Facility

$119.00

Service Code	CPT 80055
Hospital Charge Code	3018005501
Hospital Revenue Code	301
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$59.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$59.50

HC OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE

Facility

$2,380.00

Service Code	CPT 49460 TC
Hospital Charge Code	3614946001
Hospital Revenue Code	361
Min. Negotiated Rate	$503.39
Max. Negotiated Rate	$3,092.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$845.07
Rate for Payer: Aetna Government	$845.07
Rate for Payer: Brighton Health Commercial	$1,785.00
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	$1,190.00
Rate for Payer: Group Health Inc Commercial	$1,190.00
Rate for Payer: Group Health Inc Medicare	$833.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$503.39
Rate for Payer: United Healthcare Commercial	$1,409.00

HC OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE

Facility

$2,380.00

Service Code	CPT 49460 TC
Hospital Charge Code	3614946001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,190.00
Max. Negotiated Rate	$1,190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,190.00

HC OBTAINING SCREEN PAP SMEAR

Facility

$69.00

Service Code	CPT Q0091
Hospital Charge Code	923Q009101
Hospital Revenue Code	923
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$55.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$37.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.92
Rate for Payer: Aetna Government	$29.92
Rate for Payer: Affinity Essential Plan 1&2	$20.94
Rate for Payer: Affinity Essential Plan 3&4	$20.94
Rate for Payer: Affinity Medicaid/CHP/HARP	$20.94
Rate for Payer: Brighton Health Commercial	$51.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$46.92
Rate for Payer: Elderplan Medicare Advantage	$29.92
Rate for Payer: EmblemHealth Commercial	$29.92
Rate for Payer: Fidelis CHP/HARP/Medicaid	$26.93
Rate for Payer: Fidelis Essential Plan Aliesa	$25.43
Rate for Payer: Fidelis Essential Plan QHP	$26.63
Rate for Payer: Fidelis Medicare Advantage	$29.92
Rate for Payer: Fidelis Qualified Health Plan	$26.63
Rate for Payer: Group Health Inc Commercial	$29.92
Rate for Payer: Group Health Inc Medicare	$29.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.92
Rate for Payer: Hamaspik Choice Inc Medicare	$29.92
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$19.80
Rate for Payer: Healthfirst Medicare Advantage	$25.43
Rate for Payer: Healthfirst QHP	$29.92
Rate for Payer: Humana Medicare	$30.52
Rate for Payer: Senior Whole Health Medicare Advantage	$29.92
Rate for Payer: United Healthcare Commercial	$8.96
Rate for Payer: United Healthcare Medicare Advantage	$29.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$28.42
Rate for Payer: Wellcare Medicare	$28.42

HC OBTAINING SCREEN PAP SMEAR

Facility

$69.00

Service Code	CPT Q0091
Hospital Charge Code	923Q009101
Hospital Revenue Code	923
Min. Negotiated Rate	$34.50
Max. Negotiated Rate	$34.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$34.50

HC OB US < 14 WKS ADDL FETUS - US OB < 14 WEEKS EACH ADDITIONAL GEST

Facility

$169.00

Service Code	CPT 76802 TC
Hospital Charge Code	4027680201
Hospital Revenue Code	402
Min. Negotiated Rate	$84.50
Max. Negotiated Rate	$84.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$84.50

HC OB US < 14 WKS ADDL FETUS - US OB < 14 WEEKS EACH ADDITIONAL GEST

Facility

$169.00

Service Code	CPT 76802 TC
Hospital Charge Code	4027680201
Hospital Revenue Code	402
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$185.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$92.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.57
Rate for Payer: Aetna Government	$17.57
Rate for Payer: Brighton Health Commercial	$126.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$133.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$112.12
Rate for Payer: EmblemHealth Commercial	$21.66
Rate for Payer: Group Health Inc Commercial	$84.50
Rate for Payer: Group Health Inc Medicare	$59.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$84.50
Rate for Payer: Hamaspik Choice Inc Medicare	$84.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21.66
Rate for Payer: Healthfirst Essential Plan	$185.83
Rate for Payer: United Healthcare Commercial	$49.80
Rate for Payer: Wellcare CHP/FHP/Medicaid	$82.59

HC OB US >/= 14 WKS ADDL FETUS - US OB 14+ WEEKS EACH ADDITIONAL GEST

Facility

$169.00

Service Code	CPT 76810 TC
Hospital Charge Code	4027681001
Hospital Revenue Code	402
Min. Negotiated Rate	$34.03
Max. Negotiated Rate	$239.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$92.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$34.03
Rate for Payer: Aetna Government	$34.03
Rate for Payer: Brighton Health Commercial	$126.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$206.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.43
Rate for Payer: EmblemHealth Commercial	$42.48
Rate for Payer: Group Health Inc Commercial	$84.50
Rate for Payer: Group Health Inc Medicare	$59.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$84.50
Rate for Payer: Hamaspik Choice Inc Medicare	$84.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$42.48
Rate for Payer: Healthfirst Essential Plan	$239.29
Rate for Payer: United Healthcare Commercial	$77.02
Rate for Payer: Wellcare CHP/FHP/Medicaid	$106.35

HC OB US >/= 14 WKS ADDL FETUS - US OB 14+ WEEKS EACH ADDITIONAL GEST

Facility

$169.00

Service Code	CPT 76810 TC
Hospital Charge Code	4027681001
Hospital Revenue Code	402
Min. Negotiated Rate	$84.50
Max. Negotiated Rate	$84.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$84.50

HC OB US < 14 WKS SINGLE FETUS - US OB < 14 WEEKS SINGLE OR FIRST GEST

Facility

$339.00

Service Code	CPT 76801 TC
Hospital Charge Code	4027680101
Hospital Revenue Code	402
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$318.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$186.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.60
Rate for Payer: Aetna Government	$57.60
Rate for Payer: Brighton Health Commercial	$254.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$206.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.43
Rate for Payer: EmblemHealth Commercial	$73.22
Rate for Payer: Group Health Inc Commercial	$169.50
Rate for Payer: Group Health Inc Medicare	$118.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.50
Rate for Payer: Hamaspik Choice Inc Medicare	$169.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$73.22
Rate for Payer: Healthfirst Essential Plan	$318.35
Rate for Payer: United Healthcare Commercial	$77.02
Rate for Payer: Wellcare CHP/FHP/Medicaid	$141.49

HC OB US < 14 WKS SINGLE FETUS - US OB < 14 WEEKS SINGLE OR FIRST GEST

Facility

$339.00

Service Code	CPT 76801 TC
Hospital Charge Code	4027680101
Hospital Revenue Code	402
Min. Negotiated Rate	$169.50
Max. Negotiated Rate	$169.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.50

HC OB US >/= 14 WKS SNGL FETUS - US OB 14+ WEEKS SINGLE OR FIRST GEST

Facility

$339.00

Service Code	CPT 76805 TC
Hospital Charge Code	4027680501
Hospital Revenue Code	402
Min. Negotiated Rate	$169.50
Max. Negotiated Rate	$169.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.50

HC OB US >/= 14 WKS SNGL FETUS - US OB 14+ WEEKS SINGLE OR FIRST GEST

Facility

$339.00

Service Code	CPT 76805 TC
Hospital Charge Code	4027680501
Hospital Revenue Code	402
Min. Negotiated Rate	$72.39
Max. Negotiated Rate	$343.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$186.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.39
Rate for Payer: Aetna Government	$72.39
Rate for Payer: Brighton Health Commercial	$254.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$206.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.43
Rate for Payer: EmblemHealth Commercial	$91.59
Rate for Payer: Group Health Inc Commercial	$169.50
Rate for Payer: Group Health Inc Medicare	$118.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.50
Rate for Payer: Hamaspik Choice Inc Medicare	$169.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$91.59
Rate for Payer: Healthfirst Essential Plan	$343.51
Rate for Payer: United Healthcare Commercial	$77.02
Rate for Payer: Wellcare CHP/FHP/Medicaid	$152.67

HC OB US DETAILED ADDL FETUS - US OB DETAIL FETAL ANAT EA ADDL GEST

Facility

$595.00

Service Code	CPT 76812 TC
Hospital Charge Code	4027681201
Hospital Revenue Code	402
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$297.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$297.50

Know your out-of-pocket cost for care.

All Charges