St. Barnabas Hospital

All Charges

Charge

Type

Price

ENDO GIA ROTICUL UNIV 45-2.5

Facility OP

$346.26

Hospital Charge Code	40205110
Hospital Revenue Code	270
Min. Negotiated Rate	$121.19
Max. Negotiated Rate	$277.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$190.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$173.13
Rate for Payer: Aetna Government	$173.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$277.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$235.46
Rate for Payer: Group Health Inc Commercial	$173.13
Rate for Payer: Group Health Inc Medicare	$121.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$173.13
Rate for Payer: Hamaspik Choice Inc Medicare	$173.13

ENDO-GI MED THICK STAPLE

Facility OP

$11,278.40

Hospital Charge Code	40008320
Hospital Revenue Code	279
Min. Negotiated Rate	$3,947.44
Max. Negotiated Rate	$9,022.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,203.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,639.20
Rate for Payer: Aetna Government	$5,639.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9,022.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,669.31
Rate for Payer: Group Health Inc Commercial	$5,639.20
Rate for Payer: Group Health Inc Medicare	$3,947.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,639.20
Rate for Payer: Hamaspik Choice Inc Medicare	$5,639.20

ENDO GRASPERS 5MM

Facility OP

$883.92

Hospital Charge Code	40200434
Hospital Revenue Code	270
Min. Negotiated Rate	$309.37
Max. Negotiated Rate	$707.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$486.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$441.96
Rate for Payer: Aetna Government	$441.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$707.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$601.07
Rate for Payer: Group Health Inc Commercial	$441.96
Rate for Payer: Group Health Inc Medicare	$309.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$441.96
Rate for Payer: Hamaspik Choice Inc Medicare	$441.96

ENDOLOGIX AFX/A28-28/C75

Facility IP

$6,990.00

Service Code	HCPCS C1768
Hospital Charge Code	40205779
Hospital Revenue Code	278
Min. Negotiated Rate	$3,495.00
Max. Negotiated Rate	$3,495.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,495.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,495.00

ENDOLOGIX AFX/A28-28/C75

Facility OP

$6,990.00

Service Code	HCPCS C1768
Hospital Charge Code	40205779
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$7,339.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,844.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,495.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,019.25
Rate for Payer: Fidelis Medicare Advantage	$7,339.50
Rate for Payer: Group Health Inc Commercial	$3,495.00
Rate for Payer: Group Health Inc Medicare	$2,446.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,495.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,495.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,543.50

ENDOLOGIX AORTIC GRAFT 25-25-95RL

Facility IP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40206031
Hospital Revenue Code	278
Min. Negotiated Rate	$2,795.00
Max. Negotiated Rate	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00

ENDOLOGIX AORTIC GRAFT 25-25-95RL

Facility OP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40206031
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$5,869.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,074.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,795.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,214.25
Rate for Payer: Fidelis Medicare Advantage	$5,869.50
Rate for Payer: Group Health Inc Commercial	$2,795.00
Rate for Payer: Group Health Inc Medicare	$1,956.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,633.50

ENDOLOGIX AORTIC GRAFT 28-28-95RL

Facility IP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40202218
Hospital Revenue Code	278
Min. Negotiated Rate	$2,795.00
Max. Negotiated Rate	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00

ENDOLOGIX AORTIC GRAFT 28-28-95RL

Facility OP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40202218
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$5,869.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,074.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,795.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,214.25
Rate for Payer: Fidelis Medicare Advantage	$5,869.50
Rate for Payer: Group Health Inc Commercial	$2,795.00
Rate for Payer: Group Health Inc Medicare	$1,956.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,633.50

ENDOLOGIX AORTIC GRFT 25-16-140BL

Facility OP

$20,990.00

Service Code	HCPCS C1768
Hospital Charge Code	40206029
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$22,039.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11,544.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10,495.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,069.25
Rate for Payer: Fidelis Medicare Advantage	$22,039.50
Rate for Payer: Group Health Inc Commercial	$10,495.00
Rate for Payer: Group Health Inc Medicare	$7,346.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,495.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10,495.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13,643.50

ENDOLOGIX AORTIC GRFT 25-16-140BL

Facility IP

$20,990.00

Service Code	HCPCS C1768
Hospital Charge Code	40206029
Hospital Revenue Code	278
Min. Negotiated Rate	$10,495.00
Max. Negotiated Rate	$10,495.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,495.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10,495.00

ENDOLOGIX AORTIC GRFT 25-25-75RL

Facility IP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40205780
Hospital Revenue Code	278
Min. Negotiated Rate	$2,795.00
Max. Negotiated Rate	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00

ENDOLOGIX AORTIC GRFT 25-25-75RL

Facility OP

$5,590.00

Service Code	HCPCS C1768
Hospital Charge Code	40205780
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$5,869.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,074.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,795.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,214.25
Rate for Payer: Fidelis Medicare Advantage	$5,869.50
Rate for Payer: Group Health Inc Commercial	$2,795.00
Rate for Payer: Group Health Inc Medicare	$1,956.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,795.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,633.50

ENDOLOGIX POWER LINK

Facility OP

$21,590.00

Hospital Charge Code	40205662
Hospital Revenue Code	279
Min. Negotiated Rate	$7,556.50
Max. Negotiated Rate	$17,272.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11,874.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10,795.00
Rate for Payer: Aetna Government	$10,795.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17,272.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$14,681.20
Rate for Payer: Group Health Inc Commercial	$10,795.00
Rate for Payer: Group Health Inc Medicare	$7,556.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,795.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10,795.00

ENDOLOGIX POWER LINK SYSTEM

Facility OP

$6,790.00

Hospital Charge Code	40205649
Hospital Revenue Code	279
Min. Negotiated Rate	$2,376.50
Max. Negotiated Rate	$5,432.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,734.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,395.00
Rate for Payer: Aetna Government	$3,395.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,432.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,617.20
Rate for Payer: Group Health Inc Commercial	$3,395.00
Rate for Payer: Group Health Inc Medicare	$2,376.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,395.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,395.00

ENDOLOGIX P/S W/D/S 55M

Facility OP

$4,690.00

Service Code	HCPCS C1768
Hospital Charge Code	40205652
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$4,924.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,579.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,345.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,696.75
Rate for Payer: Fidelis Medicare Advantage	$4,924.50
Rate for Payer: Group Health Inc Commercial	$2,345.00
Rate for Payer: Group Health Inc Medicare	$1,641.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,345.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,345.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,048.50

ENDOLOGIX P/S W/D/S 55M

Facility IP

$4,690.00

Service Code	HCPCS C1768
Hospital Charge Code	40205652
Hospital Revenue Code	278
Min. Negotiated Rate	$2,345.00
Max. Negotiated Rate	$2,345.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,345.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,345.00

ENDOLOGIX SHEATH AFX S17-45

Facility OP

$650.00

Hospital Charge Code	40205785
Hospital Revenue Code	270
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$520.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$357.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$325.00
Rate for Payer: Aetna Government	$325.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$520.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.00
Rate for Payer: Group Health Inc Commercial	$325.00
Rate for Payer: Group Health Inc Medicare	$227.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$325.00
Rate for Payer: Hamaspik Choice Inc Medicare	$325.00

ENDOLOOP SUTURE #EJ10G

Facility OP

$280.14

Hospital Charge Code	40206057
Hospital Revenue Code	270
Min. Negotiated Rate	$98.05
Max. Negotiated Rate	$224.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$140.07
Rate for Payer: Aetna Government	$140.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$190.50
Rate for Payer: Group Health Inc Commercial	$140.07
Rate for Payer: Group Health Inc Medicare	$98.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.07
Rate for Payer: Hamaspik Choice Inc Medicare	$140.07

ENDOLOOP SUTURE VICRYL 18

Facility OP

$101.93

Hospital Charge Code	64902993
Hospital Revenue Code	270
Min. Negotiated Rate	$35.68
Max. Negotiated Rate	$81.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$56.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$50.96
Rate for Payer: Aetna Government	$50.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$81.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$69.31
Rate for Payer: Group Health Inc Commercial	$50.96
Rate for Payer: Group Health Inc Medicare	$35.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.96
Rate for Payer: Hamaspik Choice Inc Medicare	$50.96

Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure)

Facility OP

$6,937.00

Service Code	CPT 92978
Hospital Revenue Code	481
Min. Negotiated Rate	$256.73
Max. Negotiated Rate	$6,937.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$256.73
Rate for Payer: Aetna Government	$256.73
Rate for Payer: Brighton Health Commercial	$6,937.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,959.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,215.78

ENDOMETR ABLATE THERMAL

Facility OP

$12,937.43

Service Code	HCPCS 58353
Hospital Charge Code	40059672
Hospital Revenue Code	360
Min. Negotiated Rate	$259.85
Max. Negotiated Rate	$6,468.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,751.94
Rate for Payer: Aetna Government	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$5,751.94
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	$5,751.94
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$259.85
Rate for Payer: Fidelis Essential Plan Aliesa	$4,889.15
Rate for Payer: Fidelis Essential Plan QHP	$5,119.23
Rate for Payer: Fidelis Medicare Advantage	$5,751.94
Rate for Payer: Fidelis Qualified Health Plan	$5,119.23
Rate for Payer: Group Health Inc Commercial	$5,751.94
Rate for Payer: Group Health Inc Medicare	$5,751.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,468.72
Rate for Payer: Hamaspik Choice Inc Medicare	$5,751.94
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$288.72
Rate for Payer: Healthfirst Medicare Advantage	$4,889.15
Rate for Payer: Healthfirst QHP	$5,751.94
Rate for Payer: Senior Whole Health Medicare Advantage	$5,751.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,751.94
Rate for Payer: Wellcare CHP/FHP/Medicaid	$4,601.55
Rate for Payer: Wellcare Medicare	$5,464.34

ENDOMETRIAL BIOPSY

Facility OP

$502.93

Service Code	HCPCS 58100
Hospital Charge Code	40129539
Hospital Revenue Code	360
Min. Negotiated Rate	$70.08
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$230.44
Rate for Payer: Aetna Government	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$230.44
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	$230.44
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$70.08
Rate for Payer: Fidelis Essential Plan Aliesa	$195.87
Rate for Payer: Fidelis Essential Plan QHP	$205.09
Rate for Payer: Fidelis Medicare Advantage	$230.44
Rate for Payer: Fidelis Qualified Health Plan	$205.09
Rate for Payer: Group Health Inc Commercial	$230.44
Rate for Payer: Group Health Inc Medicare	$230.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.46
Rate for Payer: Hamaspik Choice Inc Medicare	$230.44
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$77.87
Rate for Payer: Healthfirst Medicare Advantage	$195.87
Rate for Payer: Healthfirst QHP	$230.44
Rate for Payer: Senior Whole Health Medicare Advantage	$230.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$230.44
Rate for Payer: Wellcare CHP/FHP/Medicaid	$184.35
Rate for Payer: Wellcare Medicare	$218.92

ENDOMETRIAL CURRETAGE

Facility OP

$12,937.43

Service Code	HCPCS 58356
Hospital Charge Code	40129538
Hospital Revenue Code	360
Min. Negotiated Rate	$397.46
Max. Negotiated Rate	$6,468.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,751.94
Rate for Payer: Aetna Government	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Cash Price	$5,751.94
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$5,751.94
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	$5,751.94
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$397.46
Rate for Payer: Fidelis Essential Plan Aliesa	$4,889.15
Rate for Payer: Fidelis Essential Plan QHP	$5,119.23
Rate for Payer: Fidelis Medicare Advantage	$5,751.94
Rate for Payer: Fidelis Qualified Health Plan	$5,119.23
Rate for Payer: Group Health Inc Commercial	$5,751.94
Rate for Payer: Group Health Inc Medicare	$5,751.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,468.72
Rate for Payer: Hamaspik Choice Inc Medicare	$5,751.94
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$441.62
Rate for Payer: Healthfirst Medicare Advantage	$4,889.15
Rate for Payer: Healthfirst QHP	$5,751.94
Rate for Payer: Senior Whole Health Medicare Advantage	$5,751.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,751.94
Rate for Payer: Wellcare CHP/FHP/Medicaid	$4,601.55
Rate for Payer: Wellcare Medicare	$5,464.34

ENDOMYSIAL ANTIBODY IGA

Facility OP

$30.13

Service Code	HCPCS 86255
Hospital Charge Code	40729337
Hospital Revenue Code	300
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$19.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.05
Rate for Payer: Aetna Government	$12.05
Rate for Payer: Cash Price	$12.05
Rate for Payer: Cash Price	$12.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.20
Rate for Payer: Elderplan Medicare Advantage	$12.05
Rate for Payer: EmblemHealth Commercial	$12.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$10.84
Rate for Payer: Fidelis Essential Plan Aliesa	$10.24
Rate for Payer: Fidelis Essential Plan QHP	$10.72
Rate for Payer: Fidelis Medicare Advantage	$12.05
Rate for Payer: Fidelis Qualified Health Plan	$10.72
Rate for Payer: Group Health Inc Commercial	$12.05
Rate for Payer: Group Health Inc Medicare	$12.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.06
Rate for Payer: Hamaspik Choice Inc Medicare	$12.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$12.05
Rate for Payer: Healthfirst Medicare Advantage	$12.05
Rate for Payer: Healthfirst QHP	$12.05
Rate for Payer: Senior Whole Health Medicare Advantage	$12.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.64
Rate for Payer: Wellcare Medicare	$10.84

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