St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HC POCT PREGNANCY URINE

Facility

$30.00

Service Code	CPT 81025
Hospital Charge Code	3008202501
Hospital Revenue Code	300
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$322.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.61
Rate for Payer: Aetna Government	$8.61
Rate for Payer: Affinity Essential Plan 1&2	$7.25
Rate for Payer: Affinity Essential Plan 3&4	$7.25
Rate for Payer: Affinity Medicaid/CHP/HARP	$3.22
Rate for Payer: Amida Care Medicaid	$3.22
Rate for Payer: Brighton Health Commercial	$22.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$8.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.06
Rate for Payer: Elderplan Medicare Advantage	$8.61
Rate for Payer: EmblemHealth Commercial	$8.61
Rate for Payer: EmblemHealth Essential Plan 1&2	$7.25
Rate for Payer: EmblemHealth Essential Plan 3&4	$3.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3.22
Rate for Payer: Fidelis Essential Plan Aliesa	$7.25
Rate for Payer: Fidelis Essential Plan QHP	$7.25
Rate for Payer: Fidelis Medicare Advantage	$8.61
Rate for Payer: Fidelis Qualified Health Plan	$3.38
Rate for Payer: Group Health Inc Commercial	$8.61
Rate for Payer: Group Health Inc Medicare	$8.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.22
Rate for Payer: Hamaspik Choice Inc Medicare	$8.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$322.00
Rate for Payer: Healthfirst Essential Plan	$7.25
Rate for Payer: Healthfirst Medicare Advantage	$8.61
Rate for Payer: Healthfirst QHP	$5.25
Rate for Payer: Humana Medicare	$8.78
Rate for Payer: Senior Whole Health Medicare Advantage	$8.61
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3.22
Rate for Payer: SOMOS Essential	$7.25
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Essential Plan 1&2	$7.25
Rate for Payer: United Healthcare Essential Plan 3&4	$3.54
Rate for Payer: United Healthcare Medicaid	$3.22
Rate for Payer: United Healthcare Medicare Advantage	$8.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3.22
Rate for Payer: Wellcare Medicare	$7.75

HC POCT PREGNANCY URINE

Facility

$30.00

Service Code	CPT 81025
Hospital Charge Code	3008202501
Hospital Revenue Code	300
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$15.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.00

HC POCT RAPID COVID 19 ANTIGEN

Facility

$12.00

Service Code	CPT 87811 QW
Hospital Charge Code	3068781101
Hospital Revenue Code	306
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$55.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$41.38
Rate for Payer: Aetna Government	$41.38
Rate for Payer: Affinity Essential Plan 1&2	$28.97
Rate for Payer: Affinity Essential Plan 3&4	$28.97
Rate for Payer: Affinity Medicaid/CHP/HARP	$28.97
Rate for Payer: Brighton Health Commercial	$9.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$41.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.16
Rate for Payer: Elderplan Medicare Advantage	$41.38
Rate for Payer: EmblemHealth Commercial	$41.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$37.24
Rate for Payer: Fidelis Essential Plan Aliesa	$35.17
Rate for Payer: Fidelis Essential Plan QHP	$36.83
Rate for Payer: Fidelis Medicare Advantage	$41.38
Rate for Payer: Fidelis Qualified Health Plan	$36.83
Rate for Payer: Group Health Inc Commercial	$41.38
Rate for Payer: Group Health Inc Medicare	$41.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$41.38
Rate for Payer: Hamaspik Choice Inc Medicare	$41.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24.83
Rate for Payer: Healthfirst Essential Plan	$55.87
Rate for Payer: Healthfirst Medicare Advantage	$41.38
Rate for Payer: Healthfirst QHP	$41.38
Rate for Payer: Humana Medicare	$42.21
Rate for Payer: Senior Whole Health Medicare Advantage	$41.38
Rate for Payer: United Healthcare Commercial	$37.33
Rate for Payer: United Healthcare Medicare Advantage	$41.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$41.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24.83
Rate for Payer: Wellcare Medicare	$37.24

HC POCT RAPID COVID 19 ANTIGEN

Facility

$12.00

Service Code	CPT 87811 QW
Hospital Charge Code	3068781101
Hospital Revenue Code	306
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00

HC POCT SARS-COV-2/FLLU/RSV XPERT XP

Facility

$170.00

Service Code	CPT 0241U QW
Hospital Charge Code	3100241U01
Hospital Revenue Code	310
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$142.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$93.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$142.63
Rate for Payer: Aetna Government	$142.63
Rate for Payer: Brighton Health Commercial	$127.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$136.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.60
Rate for Payer: EmblemHealth Commercial	$85.00
Rate for Payer: Group Health Inc Commercial	$85.00
Rate for Payer: Group Health Inc Medicare	$59.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$85.00
Rate for Payer: Hamaspik Choice Inc Medicare	$85.00

HC POCT SARS-COV-2/FLLU/RSV XPERT XP

Facility

$170.00

Service Code	CPT 0241U QW
Hospital Charge Code	3100241U01
Hospital Revenue Code	310
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$85.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$85.00

HC POCT SARS-COV-2 XPERT XPRESS CEPHID

Facility

$130.00

Service Code	CPT 87635 QW
Hospital Charge Code	3068763502
Hospital Revenue Code	306
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$65.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$65.00

HC POCT SARS-COV-2 XPERT XPRESS CEPHID

Facility

$130.00

Service Code	CPT 87635 QW
Hospital Charge Code	3068763502
Hospital Revenue Code	306
Min. Negotiated Rate	$30.79
Max. Negotiated Rate	$104.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$71.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$51.31
Rate for Payer: Aetna Government	$51.31
Rate for Payer: Affinity Essential Plan 1&2	$35.92
Rate for Payer: Affinity Essential Plan 3&4	$35.92
Rate for Payer: Affinity Medicaid/CHP/HARP	$35.92
Rate for Payer: Brighton Health Commercial	$97.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$51.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$104.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$88.40
Rate for Payer: Elderplan Medicare Advantage	$51.31
Rate for Payer: EmblemHealth Commercial	$51.31
Rate for Payer: Fidelis CHP/HARP/Medicaid	$46.18
Rate for Payer: Fidelis Essential Plan Aliesa	$43.61
Rate for Payer: Fidelis Essential Plan QHP	$45.67
Rate for Payer: Fidelis Medicare Advantage	$51.31
Rate for Payer: Fidelis Qualified Health Plan	$45.67
Rate for Payer: Group Health Inc Commercial	$51.31
Rate for Payer: Group Health Inc Medicare	$51.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.31
Rate for Payer: Hamaspik Choice Inc Medicare	$51.31
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$30.79
Rate for Payer: Healthfirst Essential Plan	$69.28
Rate for Payer: Healthfirst Medicare Advantage	$51.31
Rate for Payer: Healthfirst QHP	$51.31
Rate for Payer: Humana Medicare	$52.34
Rate for Payer: Senior Whole Health Medicare Advantage	$51.31
Rate for Payer: United Healthcare Commercial	$46.18
Rate for Payer: United Healthcare Medicare Advantage	$51.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$51.31
Rate for Payer: Wellcare CHP/FHP/Medicaid	$30.79
Rate for Payer: Wellcare Medicare	$46.18

HC POLIOMYELITIS IMMUNIZATN,INACTV,SUB-Q

Facility

$289.00

Service Code	CPT 90713
Hospital Charge Code	6369071301
Hospital Revenue Code	636
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$144.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$144.50
Rate for Payer: Hamaspik Choice Inc Medicare	$144.50

HC POLIOMYELITIS IMMUNIZATN,INACTV,SUB-Q

Facility

$289.00

Service Code	CPT 90713
Hospital Charge Code	6369071301
Hospital Revenue Code	636
Min. Negotiated Rate	$37.49
Max. Negotiated Rate	$187.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$158.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.49
Rate for Payer: Aetna Government	$37.49
Rate for Payer: Brighton Health Commercial	$173.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$144.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$166.18
Rate for Payer: EmblemHealth Commercial	$144.50
Rate for Payer: Group Health Inc Commercial	$144.50
Rate for Payer: Group Health Inc Medicare	$101.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$144.50
Rate for Payer: Hamaspik Choice Inc Medicare	$144.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$187.85

HC POLYSOM <6 YRS 4/> PARAMTRS

Facility

$2,752.00

Service Code	CPT 95782
Hospital Charge Code	7409578201
Hospital Revenue Code	740
Min. Negotiated Rate	$822.00
Max. Negotiated Rate	$2,342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,243.07
Rate for Payer: Aetna Government	$1,243.07
Rate for Payer: Affinity Essential Plan 1&2	$870.15
Rate for Payer: Affinity Essential Plan 3&4	$870.15
Rate for Payer: Affinity Medicaid/CHP/HARP	$870.15
Rate for Payer: Brighton Health Commercial	$2,342.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,243.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,201.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.36
Rate for Payer: Elderplan Medicare Advantage	$1,243.07
Rate for Payer: EmblemHealth Commercial	$1,243.07
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,118.76
Rate for Payer: Fidelis Essential Plan Aliesa	$1,056.61
Rate for Payer: Fidelis Essential Plan QHP	$1,106.33
Rate for Payer: Fidelis Medicare Advantage	$1,243.07
Rate for Payer: Fidelis Qualified Health Plan	$1,106.33
Rate for Payer: Group Health Inc Commercial	$1,243.07
Rate for Payer: Group Health Inc Medicare	$1,243.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,243.07
Rate for Payer: Hamaspik Choice Inc Medicare	$1,243.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,128.18
Rate for Payer: Healthfirst Medicare Advantage	$1,056.61
Rate for Payer: Healthfirst QHP	$1,243.07
Rate for Payer: Humana Medicare	$1,267.93
Rate for Payer: Senior Whole Health Medicare Advantage	$1,243.07
Rate for Payer: United Healthcare Commercial	$822.00
Rate for Payer: United Healthcare Medicare Advantage	$1,243.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,243.07
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,180.92
Rate for Payer: Wellcare Medicare	$1,180.92

HC POLYSOM <6 YRS 4/> PARAMTRS

Facility

$2,752.00

Service Code	CPT 95782
Hospital Charge Code	7409578201
Hospital Revenue Code	740
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOM < 6 YRS CPAP/BILVL

Facility

$2,752.00

Service Code	CPT 95783
Hospital Charge Code	7409578301
Hospital Revenue Code	740
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOM < 6 YRS CPAP/BILVL

Facility

$2,752.00

Service Code	CPT 95783
Hospital Charge Code	7409578301
Hospital Revenue Code	740
Min. Negotiated Rate	$822.00
Max. Negotiated Rate	$2,342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,243.07
Rate for Payer: Aetna Government	$1,243.07
Rate for Payer: Affinity Essential Plan 1&2	$870.15
Rate for Payer: Affinity Essential Plan 3&4	$870.15
Rate for Payer: Affinity Medicaid/CHP/HARP	$870.15
Rate for Payer: Brighton Health Commercial	$2,342.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,243.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,201.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.36
Rate for Payer: Elderplan Medicare Advantage	$1,243.07
Rate for Payer: EmblemHealth Commercial	$1,243.07
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,118.76
Rate for Payer: Fidelis Essential Plan Aliesa	$1,056.61
Rate for Payer: Fidelis Essential Plan QHP	$1,106.33
Rate for Payer: Fidelis Medicare Advantage	$1,243.07
Rate for Payer: Fidelis Qualified Health Plan	$1,106.33
Rate for Payer: Group Health Inc Commercial	$1,243.07
Rate for Payer: Group Health Inc Medicare	$1,243.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,243.07
Rate for Payer: Hamaspik Choice Inc Medicare	$1,243.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,195.17
Rate for Payer: Healthfirst Medicare Advantage	$1,056.61
Rate for Payer: Healthfirst QHP	$1,243.07
Rate for Payer: Humana Medicare	$1,267.93
Rate for Payer: Senior Whole Health Medicare Advantage	$1,243.07
Rate for Payer: United Healthcare Commercial	$822.00
Rate for Payer: United Healthcare Medicare Advantage	$1,243.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,243.07
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,180.92
Rate for Payer: Wellcare Medicare	$1,180.92

HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95810 TC
Hospital Charge Code	9209581001
Hospital Revenue Code	920
Min. Negotiated Rate	$451.82
Max. Negotiated Rate	$2,342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$451.82
Rate for Payer: Aetna Government	$451.82
Rate for Payer: Brighton Health Commercial	$2,342.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,201.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.36
Rate for Payer: EmblemHealth Commercial	$1,376.00
Rate for Payer: Group Health Inc Commercial	$1,376.00
Rate for Payer: Group Health Inc Medicare	$963.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,376.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$599.11
Rate for Payer: United Healthcare Commercial	$822.00

HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95810 TC
Hospital Charge Code	5109581001
Hospital Revenue Code	510
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95810 TC
Hospital Charge Code	5109581001
Hospital Revenue Code	510
Min. Negotiated Rate	$184.48
Max. Negotiated Rate	$1,513.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$451.82
Rate for Payer: Aetna Government	$451.82
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$217.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$184.48
Rate for Payer: EmblemHealth Commercial	$250.00
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,376.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$599.11
Rate for Payer: United Healthcare Commercial	$222.00

HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95810 TC
Hospital Charge Code	9209581001
Hospital Revenue Code	920
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95811 TC
Hospital Charge Code	5109581101
Hospital Revenue Code	510
Min. Negotiated Rate	$184.48
Max. Negotiated Rate	$1,513.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$476.14
Rate for Payer: Aetna Government	$476.14
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$217.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$184.48
Rate for Payer: EmblemHealth Commercial	$250.00
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,376.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$627.84
Rate for Payer: United Healthcare Commercial	$222.00

HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95811 TC
Hospital Charge Code	7409581101
Hospital Revenue Code	740
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95811 TC
Hospital Charge Code	7409581101
Hospital Revenue Code	740
Min. Negotiated Rate	$476.14
Max. Negotiated Rate	$2,342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$476.14
Rate for Payer: Aetna Government	$476.14
Rate for Payer: Brighton Health Commercial	$2,342.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,201.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.36
Rate for Payer: EmblemHealth Commercial	$1,376.00
Rate for Payer: Group Health Inc Commercial	$1,376.00
Rate for Payer: Group Health Inc Medicare	$963.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,376.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$627.84
Rate for Payer: United Healthcare Commercial	$822.00

HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

Facility

$2,752.00

Service Code	CPT 95811 TC
Hospital Charge Code	5109581101
Hospital Revenue Code	510
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POLYSOMNOGRAPHY, W/ 1-3 PARAMETERS, ATTENDED

Facility

$2,752.00

Service Code	CPT 95808 TC
Hospital Charge Code	9209580801
Hospital Revenue Code	920
Min. Negotiated Rate	$481.27
Max. Negotiated Rate	$2,201.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,513.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$488.84
Rate for Payer: Aetna Government	$488.84
Rate for Payer: Brighton Health Commercial	$2,064.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,201.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.36
Rate for Payer: EmblemHealth Commercial	$1,376.00
Rate for Payer: Group Health Inc Commercial	$1,376.00
Rate for Payer: Group Health Inc Medicare	$963.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,376.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$481.27
Rate for Payer: United Healthcare Commercial	$822.00

HC POLYSOMNOGRAPHY, W/ 1-3 PARAMETERS, ATTENDED

Facility

$2,752.00

Service Code	CPT 95808 TC
Hospital Charge Code	9209580801
Hospital Revenue Code	920
Min. Negotiated Rate	$1,376.00
Max. Negotiated Rate	$1,376.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,376.00

HC POOLING OF PLATELETS/OTHER BLOOD PRODUCTS

Facility

$434.00

Service Code	CPT 86965
Hospital Charge Code	3008696501
Hospital Revenue Code	300
Min. Negotiated Rate	$217.00
Max. Negotiated Rate	$217.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.00

Know your out-of-pocket cost for care.

All Charges