St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CRIZANLIZUMAB-TMCA 100 MG/10ML IV SOLN [170380]

Facility

$294.35

Service Code	HCPCS J0791
Hospital Charge Code	00078088361
Hospital Revenue Code	278
Min. Negotiated Rate	$147.18
Max. Negotiated Rate	$147.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$147.18
Rate for Payer: Hamaspik Choice Inc Medicare	$147.18

CRIZANLIZUMAB-TMCA 100 MG/10ML IV SOLN [170380]

Facility

$294.35

Service Code	HCPCS J0791
Hospital Charge Code	00078088361
Hospital Revenue Code	278
Min. Negotiated Rate	$101.68
Max. Negotiated Rate	$191.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$161.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.10
Rate for Payer: Aetna Government	$127.10
Rate for Payer: Brighton Health Commercial	$176.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$147.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$169.25
Rate for Payer: Elderplan Medicare Advantage	$127.10
Rate for Payer: EmblemHealth Commercial	$147.18
Rate for Payer: Fidelis Medicare Advantage	$127.10
Rate for Payer: Group Health Inc Commercial	$127.10
Rate for Payer: Group Health Inc Medicare	$127.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$147.18
Rate for Payer: Hamaspik Choice Inc Medicare	$147.18
Rate for Payer: Healthfirst Medicare Advantage	$108.04
Rate for Payer: Healthfirst QHP	$127.10
Rate for Payer: Humana Medicare	$129.64
Rate for Payer: Senior Whole Health Medicare Advantage	$127.10
Rate for Payer: United Healthcare Medicare Advantage	$127.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$191.33
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.68

CROCHET VEIN HOOK A

Facility

$237.50

Hospital Charge Code	64903611
Hospital Revenue Code	270
Min. Negotiated Rate	$83.12
Max. Negotiated Rate	$190.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.75
Rate for Payer: Aetna Government	$118.75
Rate for Payer: Brighton Health Commercial	$178.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$161.50
Rate for Payer: Group Health Inc Commercial	$118.75
Rate for Payer: Group Health Inc Medicare	$83.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$118.75
Rate for Payer: Hamaspik Choice Inc Medicare	$118.75

CROCHET VEIN HOOK B

Facility

$237.50

Hospital Charge Code	64903613
Hospital Revenue Code	270
Min. Negotiated Rate	$83.12
Max. Negotiated Rate	$190.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.75
Rate for Payer: Aetna Government	$118.75
Rate for Payer: Brighton Health Commercial	$178.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$161.50
Rate for Payer: Group Health Inc Commercial	$118.75
Rate for Payer: Group Health Inc Medicare	$83.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$118.75
Rate for Payer: Hamaspik Choice Inc Medicare	$118.75

CROCHET VEIN HOOK C

Facility

$237.50

Hospital Charge Code	64903615
Hospital Revenue Code	270
Min. Negotiated Rate	$83.12
Max. Negotiated Rate	$190.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.75
Rate for Payer: Aetna Government	$118.75
Rate for Payer: Brighton Health Commercial	$178.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$161.50
Rate for Payer: Group Health Inc Commercial	$118.75
Rate for Payer: Group Health Inc Medicare	$83.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$118.75
Rate for Payer: Hamaspik Choice Inc Medicare	$118.75

CROMOLYN 4% OPHTHALMIC SOLN 10 ML

Facility

$14.00

Hospital Charge Code	41651269
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

CROMOLYN 4% OPHTHALMIC SOLN 10 ML

Facility

$14.00

Hospital Charge Code	41641269
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

CROSSCONNECTOR SPINAL 30-35MML

Facility

$4,595.88

Service Code	HCPCS C1776
Hospital Charge Code	64904439
Hospital Revenue Code	278
Min. Negotiated Rate	$2,297.94
Max. Negotiated Rate	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicare	$2,297.94

CROSSCONNECTOR SPINAL 30-35MML

Facility

$4,595.88

Service Code	HCPCS C1776
Hospital Charge Code	64904439
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,825.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,527.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,757.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,297.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,642.63
Rate for Payer: EmblemHealth Commercial	$2,297.94
Rate for Payer: Fidelis Medicare Advantage	$4,825.67
Rate for Payer: Group Health Inc Commercial	$2,297.94
Rate for Payer: Group Health Inc Medicare	$1,608.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicare	$2,297.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,987.32

CROSS CT FISSURE CARBIDE

Facility

$17.83

Hospital Charge Code	64905195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$14.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.92
Rate for Payer: Aetna Government	$8.92
Rate for Payer: Brighton Health Commercial	$13.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.12
Rate for Payer: Group Health Inc Commercial	$8.92
Rate for Payer: Group Health Inc Medicare	$6.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.92
Rate for Payer: Hamaspik Choice Inc Medicare	$8.92

CROSSLINK 35-44MM

Facility

$4,595.88

Service Code	HCPCS C1713
Hospital Charge Code	64902332
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,825.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,527.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,757.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,297.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,642.63
Rate for Payer: EmblemHealth Commercial	$2,297.94
Rate for Payer: Fidelis Medicare Advantage	$4,825.67
Rate for Payer: Group Health Inc Commercial	$2,297.94
Rate for Payer: Group Health Inc Medicare	$1,608.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicare	$2,297.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,987.32

CROSSLINK 35-44MM

Facility

$4,595.88

Service Code	HCPCS C1713
Hospital Charge Code	64902332
Hospital Revenue Code	278
Min. Negotiated Rate	$2,297.94
Max. Negotiated Rate	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,297.94
Rate for Payer: Hamaspik Choice Inc Medicare	$2,297.94

CROSSLINK XIA 3 TI M-AX 53X73

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	64906682
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,100.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,100.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,200.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,000.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,150.00
Rate for Payer: EmblemHealth Commercial	$1,000.00
Rate for Payer: Fidelis Medicare Advantage	$2,100.00
Rate for Payer: Group Health Inc Commercial	$1,000.00
Rate for Payer: Group Health Inc Medicare	$700.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,000.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,300.00

CROSSLINK XIA 3 TI M-AX 53X73

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	64906682
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,000.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,000.00

CROSSMATCH

Facility

$434.63

Service Code	HCPCS 86920
Hospital Charge Code	40701192
Hospital Revenue Code	300
Rate for Payer: Cash Price	$197.52

CROSSMATCH

Facility

$434.63

Service Code	HCPCS 86920
Hospital Charge Code	40701192
Hospital Revenue Code	300
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$325.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.52
Rate for Payer: Aetna Government	$197.52
Rate for Payer: Affinity Essential Plan 1&2	$138.26
Rate for Payer: Affinity Essential Plan 3&4	$138.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.26
Rate for Payer: Brighton Health Commercial	$325.97
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cash Price	$197.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.41
Rate for Payer: Elderplan Medicare Advantage	$197.52
Rate for Payer: EmblemHealth Commercial	$197.52
Rate for Payer: Fidelis Essential Plan Aliesa	$167.89
Rate for Payer: Fidelis Essential Plan QHP	$175.79
Rate for Payer: Fidelis Medicare Advantage	$197.52
Rate for Payer: Fidelis Qualified Health Plan	$175.79
Rate for Payer: Group Health Inc Commercial	$197.52
Rate for Payer: Group Health Inc Medicare	$197.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.32
Rate for Payer: Hamaspik Choice Inc Medicare	$197.52
Rate for Payer: Healthfirst Medicare Advantage	$197.52
Rate for Payer: Healthfirst QHP	$197.52
Rate for Payer: Humana Medicare	$201.47
Rate for Payer: Senior Whole Health Medicare Advantage	$197.52
Rate for Payer: United Healthcare Commercial	$13.44
Rate for Payer: United Healthcare Medicare Advantage	$197.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$158.02
Rate for Payer: Wellcare Medicare	$177.77

CROSSMATCH ELECTRONIC

Facility

$434.63

Service Code	HCPCS 86923
Hospital Charge Code	40701183
Hospital Revenue Code	300
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$325.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.52
Rate for Payer: Aetna Government	$197.52
Rate for Payer: Affinity Essential Plan 1&2	$138.26
Rate for Payer: Affinity Essential Plan 3&4	$138.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.26
Rate for Payer: Brighton Health Commercial	$325.97
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cash Price	$197.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.86
Rate for Payer: Elderplan Medicare Advantage	$197.52
Rate for Payer: EmblemHealth Commercial	$197.52
Rate for Payer: Fidelis Essential Plan Aliesa	$167.89
Rate for Payer: Fidelis Essential Plan QHP	$175.79
Rate for Payer: Fidelis Medicare Advantage	$197.52
Rate for Payer: Fidelis Qualified Health Plan	$175.79
Rate for Payer: Group Health Inc Commercial	$197.52
Rate for Payer: Group Health Inc Medicare	$197.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.32
Rate for Payer: Hamaspik Choice Inc Medicare	$197.52
Rate for Payer: Healthfirst Medicare Advantage	$197.52
Rate for Payer: Healthfirst QHP	$197.52
Rate for Payer: Humana Medicare	$201.47
Rate for Payer: Senior Whole Health Medicare Advantage	$197.52
Rate for Payer: United Healthcare Commercial	$13.44
Rate for Payer: United Healthcare Medicare Advantage	$197.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$158.02
Rate for Payer: Wellcare Medicare	$177.77

CROSSMATCH ELECTRONIC

Facility

$434.63

Service Code	HCPCS 86923
Hospital Charge Code	40701183
Hospital Revenue Code	300
Rate for Payer: Cash Price	$197.52

CROSSMATCHING/HUMAN ANTIGLBLIN

Facility

$434.63

Service Code	HCPCS 86922
Hospital Charge Code	40711065
Hospital Revenue Code	300
Rate for Payer: Cash Price	$197.52

CROSSMATCHING/HUMAN ANTIGLBLIN

Facility

$434.63

Service Code	HCPCS 86922
Hospital Charge Code	40711065
Hospital Revenue Code	300
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$325.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.52
Rate for Payer: Aetna Government	$197.52
Rate for Payer: Affinity Essential Plan 1&2	$138.26
Rate for Payer: Affinity Essential Plan 3&4	$138.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.26
Rate for Payer: Brighton Health Commercial	$325.97
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cash Price	$197.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.02
Rate for Payer: Elderplan Medicare Advantage	$197.52
Rate for Payer: EmblemHealth Commercial	$197.52
Rate for Payer: Fidelis Essential Plan Aliesa	$167.89
Rate for Payer: Fidelis Essential Plan QHP	$175.79
Rate for Payer: Fidelis Medicare Advantage	$197.52
Rate for Payer: Fidelis Qualified Health Plan	$175.79
Rate for Payer: Group Health Inc Commercial	$197.52
Rate for Payer: Group Health Inc Medicare	$197.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.32
Rate for Payer: Hamaspik Choice Inc Medicare	$197.52
Rate for Payer: Healthfirst Medicare Advantage	$197.52
Rate for Payer: Healthfirst QHP	$197.52
Rate for Payer: Humana Medicare	$201.47
Rate for Payer: Senior Whole Health Medicare Advantage	$197.52
Rate for Payer: United Healthcare Commercial	$22.57
Rate for Payer: United Healthcare Medicare Advantage	$197.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$158.02
Rate for Payer: Wellcare Medicare	$177.77

CROSS PIN 1.7X10MM

Facility

$113.30

Hospital Charge Code	64906002
Hospital Revenue Code	270
Min. Negotiated Rate	$39.66
Max. Negotiated Rate	$90.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.65
Rate for Payer: Aetna Government	$56.65
Rate for Payer: Brighton Health Commercial	$84.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$77.04
Rate for Payer: Group Health Inc Commercial	$56.65
Rate for Payer: Group Health Inc Medicare	$39.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.65
Rate for Payer: Hamaspik Choice Inc Medicare	$56.65

CROSS PIN 1.7X3MM

Facility

$127.33

Hospital Charge Code	64906003
Hospital Revenue Code	270
Min. Negotiated Rate	$44.57
Max. Negotiated Rate	$101.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$70.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$63.66
Rate for Payer: Aetna Government	$63.66
Rate for Payer: Brighton Health Commercial	$95.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$101.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$86.58
Rate for Payer: Group Health Inc Commercial	$63.66
Rate for Payer: Group Health Inc Medicare	$44.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$63.66
Rate for Payer: Hamaspik Choice Inc Medicare	$63.66

CROTALIDAE ANTIVENOM 10 ML INJ - NF

Facility

$1,172.00

Hospital Charge Code	41642303
Hospital Revenue Code	250
Min. Negotiated Rate	$410.20
Max. Negotiated Rate	$937.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$644.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$586.00
Rate for Payer: Aetna Government	$586.00
Rate for Payer: Brighton Health Commercial	$879.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$937.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$796.96
Rate for Payer: Group Health Inc Commercial	$586.00
Rate for Payer: Group Health Inc Medicare	$410.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$586.00
Rate for Payer: Hamaspik Choice Inc Medicare	$586.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$761.80

CROTALIDAE ANTIVENOM 10 ML INJ - NF

Facility

$1,172.00

Hospital Charge Code	41652303
Hospital Revenue Code	250
Min. Negotiated Rate	$410.20
Max. Negotiated Rate	$937.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$644.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$586.00
Rate for Payer: Aetna Government	$586.00
Rate for Payer: Brighton Health Commercial	$879.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$937.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$796.96
Rate for Payer: Group Health Inc Commercial	$586.00
Rate for Payer: Group Health Inc Medicare	$410.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$586.00
Rate for Payer: Hamaspik Choice Inc Medicare	$586.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$761.80

CROWN 3/4 BASE METAL/BRIDGE

Facility

$1,000.00

Service Code	HCPCS D6781
Hospital Charge Code	42303356
Hospital Revenue Code	361
Min. Negotiated Rate	$310.41
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$310.41
Rate for Payer: Aetna Government	$310.41
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

Know your out-of-pocket cost for care.

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