St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HC SECND MCHNICL THRMBCTMY ART BYPASS GRAFT (ADD ON)

Facility

$6,253.00

Service Code	CPT 37186 TC
Hospital Charge Code	3613718601
Hospital Revenue Code	361
Min. Negotiated Rate	$1,113.00
Max. Negotiated Rate	$4,689.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,387.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,498.12
Rate for Payer: Aetna Government	$1,498.12
Rate for Payer: Brighton Health Commercial	$4,689.75
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	$3,126.50
Rate for Payer: Group Health Inc Commercial	$3,126.50
Rate for Payer: Group Health Inc Medicare	$2,188.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,126.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3,126.50
Rate for Payer: United Healthcare Commercial	$1,113.00

HC SECND MCHNICL THRMBCTMY ART BYPASS GRAFT (ADD ON)

Facility

$6,253.00

Service Code	CPT 37186 TC
Hospital Charge Code	3613718601
Hospital Revenue Code	361
Min. Negotiated Rate	$3,126.50
Max. Negotiated Rate	$3,126.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,126.50

HC SELECT PICTURE AUDIOMETRY

Facility

$101.00

Service Code	CPT 92583
Hospital Charge Code	4719258301
Hospital Revenue Code	471
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$50.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.50

HC SELECT PICTURE AUDIOMETRY

Facility

$101.00

Service Code	CPT 92583
Hospital Charge Code	4719258301
Hospital Revenue Code	471
Min. Negotiated Rate	$50.81
Max. Negotiated Rate	$158.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.58
Rate for Payer: Aetna Government	$72.58
Rate for Payer: Affinity Essential Plan 1&2	$50.81
Rate for Payer: Affinity Essential Plan 3&4	$50.81
Rate for Payer: Affinity Medicaid/CHP/HARP	$50.81
Rate for Payer: Brighton Health Commercial	$75.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$72.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$80.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$68.68
Rate for Payer: Elderplan Medicare Advantage	$72.58
Rate for Payer: EmblemHealth Commercial	$72.58
Rate for Payer: Fidelis CHP/HARP/Medicaid	$65.32
Rate for Payer: Fidelis Essential Plan Aliesa	$61.69
Rate for Payer: Fidelis Essential Plan QHP	$64.60
Rate for Payer: Fidelis Medicare Advantage	$72.58
Rate for Payer: Fidelis Qualified Health Plan	$64.60
Rate for Payer: Group Health Inc Commercial	$72.58
Rate for Payer: Group Health Inc Medicare	$72.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.58
Rate for Payer: Hamaspik Choice Inc Medicare	$72.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$69.32
Rate for Payer: Healthfirst Medicare Advantage	$61.69
Rate for Payer: Healthfirst QHP	$72.58
Rate for Payer: Humana Medicare	$74.03
Rate for Payer: Senior Whole Health Medicare Advantage	$72.58
Rate for Payer: United Healthcare Commercial	$158.00
Rate for Payer: United Healthcare Medicare Advantage	$72.58
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$72.58
Rate for Payer: Wellcare CHP/FHP/Medicaid	$68.95
Rate for Payer: Wellcare Medicare	$68.95

HC SELF-HELP/PEER SVCS PER 15 MIN

Facility

$27.00

Service Code	CPT H0038
Hospital Charge Code	900H003801
Hospital Revenue Code	900
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$82.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.84
Rate for Payer: Aetna Government	$7.84
Rate for Payer: Affinity Essential Plan 1&2	$82.90
Rate for Payer: Affinity Essential Plan 3&4	$82.90
Rate for Payer: Affinity Medicaid/CHP/HARP	$36.84
Rate for Payer: Amida Care Medicaid	$36.84
Rate for Payer: Brighton Health Commercial	$20.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.36
Rate for Payer: EmblemHealth Commercial	$13.50
Rate for Payer: EmblemHealth Essential Plan 1&2	$82.90
Rate for Payer: EmblemHealth Essential Plan 3&4	$36.84
Rate for Payer: Fidelis CHP/HARP/Medicaid	$36.84
Rate for Payer: Fidelis Essential Plan Aliesa	$82.90
Rate for Payer: Fidelis Essential Plan QHP	$82.90
Rate for Payer: Fidelis Qualified Health Plan	$38.69
Rate for Payer: Group Health Inc Commercial	$13.50
Rate for Payer: Group Health Inc Medicare	$9.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.84
Rate for Payer: Hamaspik Choice Inc Medicare	$36.84
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$36.84
Rate for Payer: Healthfirst Essential Plan	$82.90
Rate for Payer: Healthfirst QHP	$60.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$36.84
Rate for Payer: SOMOS Essential	$82.90
Rate for Payer: United Healthcare Commercial	$13.50
Rate for Payer: United Healthcare Essential Plan 1&2	$82.90
Rate for Payer: United Healthcare Essential Plan 3&4	$40.53
Rate for Payer: United Healthcare Medicaid	$36.84
Rate for Payer: Wellcare CHP/FHP/Medicaid	$36.84

HC SELF-HELP/PEER SVCS PER 15 MIN

Facility

$27.00

Service Code	CPT H0038
Hospital Charge Code	900H003801
Hospital Revenue Code	900
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.50

HC SELF-MGMT EDUC & TRAIN, 1 PT, EA 30 MIN

Facility

$140.00

Service Code	CPT 98960
Hospital Charge Code	9429896001
Hospital Revenue Code	942
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$70.00

HC SELF-MGMT EDUC & TRAIN, 1 PT, EA 30 MIN

Facility

$140.00

Service Code	CPT 98960
Hospital Charge Code	9429896001
Hospital Revenue Code	942
Min. Negotiated Rate	$25.43
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$77.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25.43
Rate for Payer: Aetna Government	$25.43
Rate for Payer: Affinity Essential Plan 1&2	$100.97
Rate for Payer: Affinity Essential Plan 3&4	$100.97
Rate for Payer: Affinity Medicaid/CHP/HARP	$44.87
Rate for Payer: Amida Care Medicaid	$44.87
Rate for Payer: Brighton Health Commercial	$105.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$112.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$95.20
Rate for Payer: EmblemHealth Commercial	$250.00
Rate for Payer: EmblemHealth Essential Plan 1&2	$100.97
Rate for Payer: EmblemHealth Essential Plan 3&4	$44.87
Rate for Payer: Fidelis CHP/HARP/Medicaid	$44.87
Rate for Payer: Fidelis Essential Plan Aliesa	$100.97
Rate for Payer: Fidelis Essential Plan QHP	$100.97
Rate for Payer: Fidelis Qualified Health Plan	$47.12
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	$44.87
Rate for Payer: Hamaspik Choice Inc Medicare	$44.87
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$44.87
Rate for Payer: Healthfirst Essential Plan	$100.97
Rate for Payer: Healthfirst QHP	$73.14
Rate for Payer: SOMOS CHP/HARP/Medicaid	$44.87
Rate for Payer: SOMOS Essential	$100.97
Rate for Payer: United Healthcare Commercial	$70.00
Rate for Payer: United Healthcare Essential Plan 1&2	$100.97
Rate for Payer: United Healthcare Essential Plan 3&4	$49.36
Rate for Payer: United Healthcare Medicaid	$44.87
Rate for Payer: Wellcare CHP/FHP/Medicaid	$44.87

HC SENORINEURAL ACUITY LEVEL TEST

Facility

$101.00

Service Code	CPT 92575
Hospital Charge Code	4719257501
Hospital Revenue Code	471
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$50.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.50

HC SENORINEURAL ACUITY LEVEL TEST

Facility

$101.00

Service Code	CPT 92575
Hospital Charge Code	4719257501
Hospital Revenue Code	471
Min. Negotiated Rate	$33.57
Max. Negotiated Rate	$158.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.96
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$86.63
Rate for Payer: Healthfirst Medicare Advantage	$40.77
Rate for Payer: Healthfirst QHP	$47.96
Rate for Payer: Humana Medicare	$48.92
Rate for Payer: Senior Whole Health Medicare Advantage	$47.96
Rate for Payer: United Healthcare Commercial	$158.00
Rate for Payer: United Healthcare Medicare Advantage	$47.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.96
Rate for Payer: Aetna Government	$47.96
Rate for Payer: Affinity Essential Plan 1&2	$33.57
Rate for Payer: Affinity Essential Plan 3&4	$33.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$33.57
Rate for Payer: Brighton Health Commercial	$75.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$47.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$80.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$68.68
Rate for Payer: Elderplan Medicare Advantage	$47.96
Rate for Payer: EmblemHealth Commercial	$47.96
Rate for Payer: Fidelis CHP/HARP/Medicaid	$43.16
Rate for Payer: Fidelis Essential Plan Aliesa	$40.77
Rate for Payer: Fidelis Essential Plan QHP	$42.68
Rate for Payer: Fidelis Medicare Advantage	$47.96
Rate for Payer: Fidelis Qualified Health Plan	$42.68
Rate for Payer: Group Health Inc Commercial	$47.96
Rate for Payer: Group Health Inc Medicare	$47.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$47.96
Rate for Payer: Wellcare CHP/FHP/Medicaid	$45.56
Rate for Payer: Wellcare Medicare	$45.56

HC SERPINA1 GENE ANALYSIS - ALPHA-1-ANTITRYPSIN DEFICIENCY

Facility

$109.00

Service Code	CPT 81332
Hospital Charge Code	3108133201
Hospital Revenue Code	310
Min. Negotiated Rate	$30.55
Max. Negotiated Rate	$98.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$59.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.65
Rate for Payer: Aetna Government	$43.65
Rate for Payer: Affinity Essential Plan 1&2	$30.55
Rate for Payer: Affinity Essential Plan 3&4	$30.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$30.55
Rate for Payer: Brighton Health Commercial	$43.65
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.12
Rate for Payer: Elderplan Medicare Advantage	$43.65
Rate for Payer: EmblemHealth Commercial	$43.65
Rate for Payer: Fidelis CHP/HARP/Medicaid	$39.28
Rate for Payer: Fidelis Essential Plan Aliesa	$37.10
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Medicare Advantage	$43.65
Rate for Payer: Fidelis Qualified Health Plan	$38.85
Rate for Payer: Group Health Inc Commercial	$43.65
Rate for Payer: Group Health Inc Medicare	$43.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.65
Rate for Payer: Hamaspik Choice Inc Medicare	$43.65
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$43.65
Rate for Payer: Healthfirst Essential Plan	$98.21
Rate for Payer: Healthfirst Medicare Advantage	$43.65
Rate for Payer: Healthfirst QHP	$43.65
Rate for Payer: Humana Medicare	$44.52
Rate for Payer: Senior Whole Health Medicare Advantage	$43.65
Rate for Payer: United Healthcare Medicare Advantage	$43.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$43.65
Rate for Payer: Wellcare Medicare	$39.28

HC SERPINA1 GENE ANALYSIS - ALPHA-1-ANTITRYPSIN DEFICIENCY

Facility

$109.00

Service Code	CPT 81332
Hospital Charge Code	3108133201
Hospital Revenue Code	310
Min. Negotiated Rate	$54.50
Max. Negotiated Rate	$54.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.50

HC SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (COVID-19) VACCINE, MRNA-LNP

Facility

$94.00

Service Code	CPT 91305
Hospital Charge Code	6369130501
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$61.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (COVID-19) VACCINE, MRNA-LNP

Facility

$94.00

Service Code	CPT 91305
Hospital Charge Code	6369130501
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 10 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91319
Hospital Charge Code	6369131901
Hospital Revenue Code	636
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$94.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.00
Rate for Payer: Aetna Government	$47.00
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$94.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 10 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91319
Hospital Charge Code	6369131901
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 25 MCG/0.25 ML DOSAGE

Facility

$94.00

Service Code	CPT 91321
Hospital Charge Code	6369132101
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 25 MCG/0.25 ML DOSAGE

Facility

$94.00

Service Code	CPT 91321
Hospital Charge Code	6369132101
Hospital Revenue Code	636
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$147.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.00
Rate for Payer: Aetna Government	$47.00
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$147.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 30 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91320
Hospital Charge Code	6369132001
Hospital Revenue Code	636
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$168.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.00
Rate for Payer: Aetna Government	$47.00
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$168.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 30 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91320
Hospital Charge Code	6369132001
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 3 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91318
Hospital Charge Code	6369131801
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 3 MCG/0.3 ML DOSAGE

Facility

$94.00

Service Code	CPT 91318
Hospital Charge Code	6369131801
Hospital Revenue Code	636
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$61.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.00
Rate for Payer: Aetna Government	$47.00
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 50 MCG/0.5 ML DOSAGE

Facility

$94.00

Service Code	CPT 91322
Hospital Charge Code	6369132201
Hospital Revenue Code	636
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$47.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 50 MCG/0.5 ML DOSAGE

Facility

$94.00

Service Code	CPT 91322
Hospital Charge Code	6369132201
Hospital Revenue Code	636
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$161.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.00
Rate for Payer: Aetna Government	$47.00
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$161.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

HC SEVERE ACUTE RESPIRATORY SYNDROME SARS-COV-2 5 MCG/0.5 ML DOSAGE

Facility

$94.00

Service Code	CPT 91304
Hospital Charge Code	6369130401
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$191.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$56.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$54.05
Rate for Payer: EmblemHealth Commercial	$47.00
Rate for Payer: Group Health Inc Commercial	$47.00
Rate for Payer: Group Health Inc Medicare	$32.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$47.00
Rate for Payer: Hamaspik Choice Inc Medicare	$47.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$191.92
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$61.10

Know your out-of-pocket cost for care.

All Charges