St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HIV PEP STARTER PACK

Facility

$0.01

Service Code	NDC 9999123476
Hospital Charge Code	9999123476
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: EmblemHealth Commercial	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

HIV w major HIV related condition

Facility

$55,047.44

Service Code	APR-DRG 8923
Min. Negotiated Rate	$13,971.00
Max. Negotiated Rate	$55,047.44
Rate for Payer: Affinity Essential Plan 1&2	$55,047.44
Rate for Payer: Affinity Essential Plan 3&4	$55,047.44
Rate for Payer: Affinity Medicaid/CHP/HARP	$24,465.53
Rate for Payer: Amida Care Medicaid	$24,465.53
Rate for Payer: EmblemHealth Essential Plan 1&2	$55,047.44
Rate for Payer: EmblemHealth Essential Plan 3&4	$24,465.53
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24,465.53
Rate for Payer: Fidelis Qualified Health Plan	$29,358.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,465.53
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24,465.53
Rate for Payer: Healthfirst Commercial	$22,082.00
Rate for Payer: Healthfirst Essential Plan	$55,047.44
Rate for Payer: Healthfirst QHP	$13,971.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$24,465.53
Rate for Payer: SOMOS Essential	$55,047.44
Rate for Payer: United Healthcare Essential Plan 1&2	$55,047.44
Rate for Payer: United Healthcare Essential Plan 3&4	$55,047.44
Rate for Payer: United Healthcare Medicaid	$24,465.53
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24,465.53

HIV w major HIV related condition

Facility

$44,681.40

Service Code	APR-DRG 8921
Min. Negotiated Rate	$10,237.00
Max. Negotiated Rate	$44,681.40
Rate for Payer: Affinity Essential Plan 1&2	$44,681.40
Rate for Payer: Affinity Essential Plan 3&4	$44,681.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$19,858.40
Rate for Payer: Amida Care Medicaid	$19,858.40
Rate for Payer: EmblemHealth Essential Plan 1&2	$44,681.40
Rate for Payer: EmblemHealth Essential Plan 3&4	$19,858.40
Rate for Payer: Fidelis CHP/HARP/Medicaid	$19,858.40
Rate for Payer: Fidelis Qualified Health Plan	$23,830.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$19,858.40
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$19,858.40
Rate for Payer: Healthfirst Commercial	$15,754.00
Rate for Payer: Healthfirst Essential Plan	$44,681.40
Rate for Payer: Healthfirst QHP	$10,237.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$19,858.40
Rate for Payer: SOMOS Essential	$44,681.40
Rate for Payer: United Healthcare Essential Plan 1&2	$44,681.40
Rate for Payer: United Healthcare Essential Plan 3&4	$44,681.40
Rate for Payer: United Healthcare Medicaid	$19,858.40
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19,858.40

HIV w major HIV related condition

Facility

$48,427.54

Service Code	APR-DRG 8922
Min. Negotiated Rate	$10,943.00
Max. Negotiated Rate	$48,427.54
Rate for Payer: Affinity Essential Plan 1&2	$48,427.54
Rate for Payer: Affinity Essential Plan 3&4	$48,427.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,523.35
Rate for Payer: Amida Care Medicaid	$21,523.35
Rate for Payer: EmblemHealth Essential Plan 1&2	$48,427.54
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,523.35
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,523.35
Rate for Payer: Fidelis Qualified Health Plan	$25,828.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,523.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,523.35
Rate for Payer: Healthfirst Commercial	$15,754.00
Rate for Payer: Healthfirst Essential Plan	$48,427.54
Rate for Payer: Healthfirst QHP	$10,943.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,523.35
Rate for Payer: SOMOS Essential	$48,427.54
Rate for Payer: United Healthcare Essential Plan 1&2	$48,427.54
Rate for Payer: United Healthcare Essential Plan 3&4	$48,427.54
Rate for Payer: United Healthcare Medicaid	$21,523.35
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,523.35

HIV w major HIV related condition

Facility

$73,074.60

Service Code	APR-DRG 8924
Min. Negotiated Rate	$26,169.00
Max. Negotiated Rate	$73,074.60
Rate for Payer: Affinity Essential Plan 1&2	$73,074.60
Rate for Payer: Affinity Essential Plan 3&4	$73,074.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$32,477.60
Rate for Payer: Amida Care Medicaid	$32,477.60
Rate for Payer: EmblemHealth Essential Plan 1&2	$73,074.60
Rate for Payer: EmblemHealth Essential Plan 3&4	$32,477.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$32,477.60
Rate for Payer: Fidelis Qualified Health Plan	$38,973.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$32,477.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$32,477.60
Rate for Payer: Healthfirst Commercial	$42,925.00
Rate for Payer: Healthfirst Essential Plan	$73,074.60
Rate for Payer: Healthfirst QHP	$26,169.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$32,477.60
Rate for Payer: SOMOS Essential	$73,074.60
Rate for Payer: United Healthcare Essential Plan 1&2	$73,074.60
Rate for Payer: United Healthcare Essential Plan 3&4	$73,074.60
Rate for Payer: United Healthcare Medicaid	$32,477.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$32,477.60

HIV w multiple major HIV related conditions

Facility

$51,600.31

Service Code	APR-DRG 8901
Min. Negotiated Rate	$14,298.00
Max. Negotiated Rate	$51,600.31
Rate for Payer: Affinity Essential Plan 1&2	$51,600.31
Rate for Payer: Affinity Essential Plan 3&4	$51,600.31
Rate for Payer: Affinity Medicaid/CHP/HARP	$22,933.47
Rate for Payer: Amida Care Medicaid	$22,933.47
Rate for Payer: EmblemHealth Essential Plan 1&2	$51,600.31
Rate for Payer: EmblemHealth Essential Plan 3&4	$22,933.47
Rate for Payer: Fidelis CHP/HARP/Medicaid	$22,933.47
Rate for Payer: Fidelis Qualified Health Plan	$27,520.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$22,933.47
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$22,933.47
Rate for Payer: Healthfirst Commercial	$20,987.00
Rate for Payer: Healthfirst Essential Plan	$51,600.31
Rate for Payer: Healthfirst QHP	$14,298.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$22,933.47
Rate for Payer: SOMOS Essential	$51,600.31
Rate for Payer: United Healthcare Essential Plan 1&2	$51,600.31
Rate for Payer: United Healthcare Essential Plan 3&4	$51,600.31
Rate for Payer: United Healthcare Medicaid	$22,933.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22,933.47

HIV w multiple major HIV related conditions

Facility

$98,611.60

Service Code	APR-DRG 8904
Min. Negotiated Rate	$40,051.00
Max. Negotiated Rate	$98,611.60
Rate for Payer: Affinity Essential Plan 1&2	$98,611.60
Rate for Payer: Affinity Essential Plan 3&4	$98,611.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$43,827.38
Rate for Payer: Amida Care Medicaid	$43,827.38
Rate for Payer: EmblemHealth Essential Plan 1&2	$98,611.60
Rate for Payer: EmblemHealth Essential Plan 3&4	$43,827.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$43,827.38
Rate for Payer: Fidelis Qualified Health Plan	$52,592.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$43,827.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$43,827.38
Rate for Payer: Healthfirst Commercial	$63,688.00
Rate for Payer: Healthfirst Essential Plan	$98,611.60
Rate for Payer: Healthfirst QHP	$40,051.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$43,827.38
Rate for Payer: SOMOS Essential	$98,611.60
Rate for Payer: United Healthcare Essential Plan 1&2	$98,611.60
Rate for Payer: United Healthcare Essential Plan 3&4	$98,611.60
Rate for Payer: United Healthcare Medicaid	$43,827.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$43,827.38

HIV w multiple major HIV related conditions

Facility

$51,628.46

Service Code	APR-DRG 8902
Min. Negotiated Rate	$14,298.00
Max. Negotiated Rate	$51,628.46
Rate for Payer: Affinity Essential Plan 1&2	$51,628.46
Rate for Payer: Affinity Essential Plan 3&4	$51,628.46
Rate for Payer: Affinity Medicaid/CHP/HARP	$22,945.98
Rate for Payer: Amida Care Medicaid	$22,945.98
Rate for Payer: EmblemHealth Essential Plan 1&2	$51,628.46
Rate for Payer: EmblemHealth Essential Plan 3&4	$22,945.98
Rate for Payer: Fidelis CHP/HARP/Medicaid	$22,945.98
Rate for Payer: Fidelis Qualified Health Plan	$27,535.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$22,945.98
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$22,945.98
Rate for Payer: Healthfirst Commercial	$21,044.00
Rate for Payer: Healthfirst Essential Plan	$51,628.46
Rate for Payer: Healthfirst QHP	$14,298.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$22,945.98
Rate for Payer: SOMOS Essential	$51,628.46
Rate for Payer: United Healthcare Essential Plan 1&2	$51,628.46
Rate for Payer: United Healthcare Essential Plan 3&4	$51,628.46
Rate for Payer: United Healthcare Medicaid	$22,945.98
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22,945.98

HIV w multiple major HIV related conditions

Facility

$65,890.12

Service Code	APR-DRG 8903
Min. Negotiated Rate	$20,766.00
Max. Negotiated Rate	$65,890.12
Rate for Payer: Affinity Essential Plan 1&2	$65,890.12
Rate for Payer: Affinity Essential Plan 3&4	$65,890.12
Rate for Payer: Affinity Medicaid/CHP/HARP	$29,284.50
Rate for Payer: Amida Care Medicaid	$29,284.50
Rate for Payer: EmblemHealth Essential Plan 1&2	$65,890.12
Rate for Payer: EmblemHealth Essential Plan 3&4	$29,284.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$29,284.50
Rate for Payer: Fidelis Qualified Health Plan	$35,141.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$29,284.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$29,284.50
Rate for Payer: Healthfirst Commercial	$31,328.00
Rate for Payer: Healthfirst Essential Plan	$65,890.12
Rate for Payer: Healthfirst QHP	$20,766.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$29,284.50
Rate for Payer: SOMOS Essential	$65,890.12
Rate for Payer: United Healthcare Essential Plan 1&2	$65,890.12
Rate for Payer: United Healthcare Essential Plan 3&4	$65,890.12
Rate for Payer: United Healthcare Medicaid	$29,284.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$29,284.50

HIV w multiple significant HIV related conditions

Facility

$57,560.69

Service Code	APR-DRG 8933
Min. Negotiated Rate	$14,487.00
Max. Negotiated Rate	$57,560.69
Rate for Payer: Affinity Essential Plan 1&2	$57,560.69
Rate for Payer: Affinity Essential Plan 3&4	$57,560.69
Rate for Payer: Affinity Medicaid/CHP/HARP	$25,582.53
Rate for Payer: Amida Care Medicaid	$25,582.53
Rate for Payer: EmblemHealth Essential Plan 1&2	$57,560.69
Rate for Payer: EmblemHealth Essential Plan 3&4	$25,582.53
Rate for Payer: Fidelis CHP/HARP/Medicaid	$25,582.53
Rate for Payer: Fidelis Qualified Health Plan	$30,699.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,582.53
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$25,582.53
Rate for Payer: Healthfirst Commercial	$22,988.00
Rate for Payer: Healthfirst Essential Plan	$57,560.69
Rate for Payer: Healthfirst QHP	$14,487.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$25,582.53
Rate for Payer: SOMOS Essential	$57,560.69
Rate for Payer: United Healthcare Essential Plan 1&2	$57,560.69
Rate for Payer: United Healthcare Essential Plan 3&4	$57,560.69
Rate for Payer: United Healthcare Medicaid	$25,582.53
Rate for Payer: Wellcare CHP/FHP/Medicaid	$25,582.53

HIV w multiple significant HIV related conditions

Facility

$45,775.35

Service Code	APR-DRG 8931
Min. Negotiated Rate	$9,539.00
Max. Negotiated Rate	$45,775.35
Rate for Payer: Affinity Essential Plan 1&2	$45,775.35
Rate for Payer: Affinity Essential Plan 3&4	$45,775.35
Rate for Payer: Affinity Medicaid/CHP/HARP	$20,344.60
Rate for Payer: Amida Care Medicaid	$20,344.60
Rate for Payer: EmblemHealth Essential Plan 1&2	$45,775.35
Rate for Payer: EmblemHealth Essential Plan 3&4	$20,344.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20,344.60
Rate for Payer: Fidelis Qualified Health Plan	$24,413.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$20,344.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20,344.60
Rate for Payer: Healthfirst Commercial	$12,913.00
Rate for Payer: Healthfirst Essential Plan	$45,775.35
Rate for Payer: Healthfirst QHP	$9,539.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20,344.60
Rate for Payer: SOMOS Essential	$45,775.35
Rate for Payer: United Healthcare Essential Plan 1&2	$45,775.35
Rate for Payer: United Healthcare Essential Plan 3&4	$45,775.35
Rate for Payer: United Healthcare Medicaid	$20,344.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20,344.60

HIV w multiple significant HIV related conditions

Facility

$58,070.75

Service Code	APR-DRG 8934
Min. Negotiated Rate	$14,808.00
Max. Negotiated Rate	$58,070.75
Rate for Payer: Affinity Essential Plan 1&2	$58,070.75
Rate for Payer: Affinity Essential Plan 3&4	$58,070.75
Rate for Payer: Affinity Medicaid/CHP/HARP	$25,809.22
Rate for Payer: Amida Care Medicaid	$25,809.22
Rate for Payer: EmblemHealth Essential Plan 1&2	$58,070.75
Rate for Payer: EmblemHealth Essential Plan 3&4	$25,809.22
Rate for Payer: Fidelis CHP/HARP/Medicaid	$25,809.22
Rate for Payer: Fidelis Qualified Health Plan	$30,971.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,809.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$25,809.22
Rate for Payer: Healthfirst Commercial	$23,761.00
Rate for Payer: Healthfirst Essential Plan	$58,070.75
Rate for Payer: Healthfirst QHP	$14,808.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$25,809.22
Rate for Payer: SOMOS Essential	$58,070.75
Rate for Payer: United Healthcare Essential Plan 1&2	$58,070.75
Rate for Payer: United Healthcare Essential Plan 3&4	$58,070.75
Rate for Payer: United Healthcare Medicaid	$25,809.22
Rate for Payer: Wellcare CHP/FHP/Medicaid	$25,809.22

HIV w multiple significant HIV related conditions

Facility

$48,276.27

Service Code	APR-DRG 8932
Min. Negotiated Rate	$10,728.00
Max. Negotiated Rate	$48,276.27
Rate for Payer: Affinity Essential Plan 1&2	$48,276.27
Rate for Payer: Affinity Essential Plan 3&4	$48,276.27
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,456.12
Rate for Payer: Amida Care Medicaid	$21,456.12
Rate for Payer: EmblemHealth Essential Plan 1&2	$48,276.27
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,456.12
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,456.12
Rate for Payer: Fidelis Qualified Health Plan	$25,747.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,456.12
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,456.12
Rate for Payer: Healthfirst Commercial	$16,543.00
Rate for Payer: Healthfirst Essential Plan	$48,276.27
Rate for Payer: Healthfirst QHP	$10,728.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,456.12
Rate for Payer: SOMOS Essential	$48,276.27
Rate for Payer: United Healthcare Essential Plan 1&2	$48,276.27
Rate for Payer: United Healthcare Essential Plan 3&4	$48,276.27
Rate for Payer: United Healthcare Medicaid	$21,456.12
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,456.12

HIV w one signif HIV cond or w/o signif related cond

Facility

$52,404.05

Service Code	APR-DRG 8943
Min. Negotiated Rate	$11,297.00
Max. Negotiated Rate	$52,404.05
Rate for Payer: Affinity Essential Plan 1&2	$52,404.05
Rate for Payer: Affinity Essential Plan 3&4	$52,404.05
Rate for Payer: Affinity Medicaid/CHP/HARP	$23,290.69
Rate for Payer: Amida Care Medicaid	$23,290.69
Rate for Payer: EmblemHealth Essential Plan 1&2	$52,404.05
Rate for Payer: EmblemHealth Essential Plan 3&4	$23,290.69
Rate for Payer: Fidelis CHP/HARP/Medicaid	$23,290.69
Rate for Payer: Fidelis Qualified Health Plan	$27,948.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$23,290.69
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23,290.69
Rate for Payer: Healthfirst Commercial	$18,899.00
Rate for Payer: Healthfirst Essential Plan	$52,404.05
Rate for Payer: Healthfirst QHP	$11,297.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23,290.69
Rate for Payer: SOMOS Essential	$52,404.05
Rate for Payer: United Healthcare Essential Plan 1&2	$52,404.05
Rate for Payer: United Healthcare Essential Plan 3&4	$52,404.05
Rate for Payer: United Healthcare Medicaid	$23,290.69
Rate for Payer: Wellcare CHP/FHP/Medicaid	$23,290.69

HIV w one signif HIV cond or w/o signif related cond

Facility

$52,404.05

Service Code	APR-DRG 8944
Min. Negotiated Rate	$11,405.00
Max. Negotiated Rate	$52,404.05
Rate for Payer: Affinity Essential Plan 1&2	$52,404.05
Rate for Payer: Affinity Essential Plan 3&4	$52,404.05
Rate for Payer: Affinity Medicaid/CHP/HARP	$23,290.69
Rate for Payer: Amida Care Medicaid	$23,290.69
Rate for Payer: EmblemHealth Essential Plan 1&2	$52,404.05
Rate for Payer: EmblemHealth Essential Plan 3&4	$23,290.69
Rate for Payer: Fidelis CHP/HARP/Medicaid	$23,290.69
Rate for Payer: Fidelis Qualified Health Plan	$27,948.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$23,290.69
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23,290.69
Rate for Payer: Healthfirst Commercial	$19,000.00
Rate for Payer: Healthfirst Essential Plan	$52,404.05
Rate for Payer: Healthfirst QHP	$11,405.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23,290.69
Rate for Payer: SOMOS Essential	$52,404.05
Rate for Payer: United Healthcare Essential Plan 1&2	$52,404.05
Rate for Payer: United Healthcare Essential Plan 3&4	$52,404.05
Rate for Payer: United Healthcare Medicaid	$23,290.69
Rate for Payer: Wellcare CHP/FHP/Medicaid	$23,290.69

HIV w one signif HIV cond or w/o signif related cond

Facility

$42,811.85

Service Code	APR-DRG 8941
Min. Negotiated Rate	$6,645.00
Max. Negotiated Rate	$42,811.85
Rate for Payer: Affinity Essential Plan 1&2	$42,811.85
Rate for Payer: Affinity Essential Plan 3&4	$42,811.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$19,027.49
Rate for Payer: Amida Care Medicaid	$19,027.49
Rate for Payer: EmblemHealth Essential Plan 1&2	$42,811.85
Rate for Payer: EmblemHealth Essential Plan 3&4	$19,027.49
Rate for Payer: Fidelis CHP/HARP/Medicaid	$19,027.49
Rate for Payer: Fidelis Qualified Health Plan	$22,832.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$19,027.49
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$19,027.49
Rate for Payer: Healthfirst Commercial	$11,213.00
Rate for Payer: Healthfirst Essential Plan	$42,811.85
Rate for Payer: Healthfirst QHP	$6,645.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$19,027.49
Rate for Payer: SOMOS Essential	$42,811.85
Rate for Payer: United Healthcare Essential Plan 1&2	$42,811.85
Rate for Payer: United Healthcare Essential Plan 3&4	$42,811.85
Rate for Payer: United Healthcare Medicaid	$19,027.49
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19,027.49

HIV w one signif HIV cond or w/o signif related cond

Facility

$45,418.32

Service Code	APR-DRG 8942
Min. Negotiated Rate	$8,022.00
Max. Negotiated Rate	$45,418.32
Rate for Payer: Affinity Essential Plan 1&2	$45,418.32
Rate for Payer: Affinity Essential Plan 3&4	$45,418.32
Rate for Payer: Affinity Medicaid/CHP/HARP	$20,185.92
Rate for Payer: Amida Care Medicaid	$20,185.92
Rate for Payer: EmblemHealth Essential Plan 1&2	$45,418.32
Rate for Payer: EmblemHealth Essential Plan 3&4	$20,185.92
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20,185.92
Rate for Payer: Fidelis Qualified Health Plan	$24,223.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$20,185.92
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20,185.92
Rate for Payer: Healthfirst Commercial	$13,170.00
Rate for Payer: Healthfirst Essential Plan	$45,418.32
Rate for Payer: Healthfirst QHP	$8,022.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20,185.92
Rate for Payer: SOMOS Essential	$45,418.32
Rate for Payer: United Healthcare Essential Plan 1&2	$45,418.32
Rate for Payer: United Healthcare Essential Plan 3&4	$45,418.32
Rate for Payer: United Healthcare Medicaid	$20,185.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20,185.92

HPV 9-VALENT RECOMB VACCINE IM SUSY

Facility

$689.78

Service Code	NDC 0006412102
Hospital Charge Code	0006412102
Hospital Revenue Code	250
Min. Negotiated Rate	$344.89
Max. Negotiated Rate	$344.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$344.89

HPV 9-VALENT RECOMB VACCINE IM SUSY

Facility

$689.78

Service Code	NDC 0006412102
Hospital Charge Code	0006412102
Hospital Revenue Code	250
Min. Negotiated Rate	$241.42
Max. Negotiated Rate	$551.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$379.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$344.89
Rate for Payer: Aetna Government	$344.89
Rate for Payer: Brighton Health Commercial	$517.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$551.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$469.05
Rate for Payer: EmblemHealth Commercial	$344.89
Rate for Payer: Group Health Inc Commercial	$344.89
Rate for Payer: Group Health Inc Medicare	$241.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$344.89
Rate for Payer: Hamaspik Choice Inc Medicare	$344.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$448.36

H. PYLORI INFECTION

Facility

$172.26

Service Code	EAPG 00810
Min. Negotiated Rate	$124.97
Max. Negotiated Rate	$172.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$124.97
Rate for Payer: Healthfirst Commercial	$172.26

HSPC PRO COMPREHENSIVE, 35 MIN, UNSTABLE, NEW PROBLEM

Facility

$429.00

Service Code	CPT 99310
Hospital Charge Code	6579931001
Hospital Revenue Code	657
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$214.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$214.50

HSPC PRO COMPREHENSIVE, 35 MIN, UNSTABLE, NEW PROBLEM

Facility

$429.00

Service Code	CPT 99310
Hospital Charge Code	6579931001
Hospital Revenue Code	657
Min. Negotiated Rate	$101.40
Max. Negotiated Rate	$343.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$235.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$101.40
Rate for Payer: Aetna Government	$101.40
Rate for Payer: Brighton Health Commercial	$321.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$343.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$291.72
Rate for Payer: EmblemHealth Commercial	$214.50
Rate for Payer: Group Health Inc Commercial	$214.50
Rate for Payer: Group Health Inc Medicare	$150.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$214.50
Rate for Payer: Hamaspik Choice Inc Medicare	$214.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$170.54

HSPC PRO COMPREHENSIVE (MOD-HIGH) 40 MIN

Facility

$358.00

Service Code	CPT 99350
Hospital Charge Code	6579935001
Hospital Revenue Code	657
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$286.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$196.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$132.73
Rate for Payer: Aetna Government	$132.73
Rate for Payer: Brighton Health Commercial	$268.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$286.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$243.44
Rate for Payer: EmblemHealth Commercial	$179.00
Rate for Payer: Group Health Inc Commercial	$179.00
Rate for Payer: Group Health Inc Medicare	$125.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.00
Rate for Payer: Hamaspik Choice Inc Medicare	$179.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$203.06

HSPC PRO COMPREHENSIVE (MOD-HIGH) 40 MIN

Facility

$358.00

Service Code	CPT 99350
Hospital Charge Code	6579935001
Hospital Revenue Code	657
Min. Negotiated Rate	$179.00
Max. Negotiated Rate	$179.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.00

HSPC PRO DETAILED HX & EXAM (MOD-HIGH) 40 MIN

Facility

$248.00

Service Code	CPT 99349
Hospital Charge Code	6579934901
Hospital Revenue Code	657
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$124.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$124.00

Know your out-of-pocket cost for care.

All Charges