St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

EQ CHANGE GASTRO TUBE

Facility

$650.40

Service Code	HCPCS 75984 TC
Hospital Charge Code	41102708
Hospital Revenue Code	320
Min. Negotiated Rate	$55.93
Max. Negotiated Rate	$520.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$357.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.93
Rate for Payer: Aetna Government	$55.93
Rate for Payer: Brighton Health Commercial	$487.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$520.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.27
Rate for Payer: Group Health Inc Commercial	$325.20
Rate for Payer: Group Health Inc Medicare	$227.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$325.20
Rate for Payer: Hamaspik Choice Inc Medicare	$325.20

EQ CHANGE URETEROSTOMY CATH

Facility

$650.40

Service Code	HCPCS 75984 TC
Hospital Charge Code	41107640
Hospital Revenue Code	320
Min. Negotiated Rate	$55.93
Max. Negotiated Rate	$520.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$357.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.93
Rate for Payer: Aetna Government	$55.93
Rate for Payer: Brighton Health Commercial	$487.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$520.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.27
Rate for Payer: Group Health Inc Commercial	$325.20
Rate for Payer: Group Health Inc Medicare	$227.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$325.20
Rate for Payer: Hamaspik Choice Inc Medicare	$325.20

EQ CHANGE URTRLSTNT 1/EA/CONDUIT

Facility

$650.40

Service Code	HCPCS 75984 TC
Hospital Charge Code	41108035
Hospital Revenue Code	320
Min. Negotiated Rate	$55.93
Max. Negotiated Rate	$520.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$357.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.93
Rate for Payer: Aetna Government	$55.93
Rate for Payer: Brighton Health Commercial	$487.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$520.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.27
Rate for Payer: Group Health Inc Commercial	$325.20
Rate for Payer: Group Health Inc Medicare	$227.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$325.20
Rate for Payer: Hamaspik Choice Inc Medicare	$325.20

EQ CHOLANGIO ADDL SET INTRAOPT

Facility

$306.05

Service Code	HCPCS 74301 TC
Hospital Charge Code	41107681
Hospital Revenue Code	320
Min. Negotiated Rate	$16.05
Max. Negotiated Rate	$244.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$168.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.05
Rate for Payer: Aetna Government	$16.05
Rate for Payer: Brighton Health Commercial	$229.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$244.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$208.11
Rate for Payer: Group Health Inc Commercial	$153.02
Rate for Payer: Group Health Inc Medicare	$107.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$153.02
Rate for Payer: Hamaspik Choice Inc Medicare	$153.02

EQ CHOLANGIOGRAM O.R.

Facility

$306.05

Service Code	HCPCS 74300 TC
Hospital Charge Code	41102514
Hospital Revenue Code	320
Min. Negotiated Rate	$27.77
Max. Negotiated Rate	$244.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$168.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.77
Rate for Payer: Aetna Government	$27.77
Rate for Payer: Brighton Health Commercial	$229.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$244.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$208.11
Rate for Payer: Group Health Inc Commercial	$153.02
Rate for Payer: Group Health Inc Medicare	$107.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$153.02
Rate for Payer: Hamaspik Choice Inc Medicare	$153.02

EQ CHOLANGIOGRAPHY INTRAOPT

Facility

$306.05

Service Code	HCPCS 74300 TC
Hospital Charge Code	41107680
Hospital Revenue Code	320
Min. Negotiated Rate	$27.77
Max. Negotiated Rate	$244.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$168.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.77
Rate for Payer: Aetna Government	$27.77
Rate for Payer: Brighton Health Commercial	$229.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$244.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$208.11
Rate for Payer: Group Health Inc Commercial	$153.02
Rate for Payer: Group Health Inc Medicare	$107.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$153.02
Rate for Payer: Hamaspik Choice Inc Medicare	$153.02

EQ COAGULATION ACTIVATED ACT

Facility

$10.70

Service Code	HCPCS 85347 TC
Hospital Charge Code	41107470
Hospital Revenue Code	300
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$8.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.28
Rate for Payer: Aetna Government	$4.28
Rate for Payer: Affinity Essential Plan 1&2	$3.00
Rate for Payer: Affinity Essential Plan 3&4	$3.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$3.00
Rate for Payer: Brighton Health Commercial	$8.02
Rate for Payer: Cash Price	$4.28
Rate for Payer: Cash Price	$4.28
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.72
Rate for Payer: Elderplan Medicare Advantage	$4.28
Rate for Payer: EmblemHealth Commercial	$4.28
Rate for Payer: Fidelis Essential Plan Aliesa	$3.64
Rate for Payer: Fidelis Essential Plan QHP	$3.81
Rate for Payer: Fidelis Medicare Advantage	$4.28
Rate for Payer: Fidelis Qualified Health Plan	$3.81
Rate for Payer: Group Health Inc Commercial	$4.28
Rate for Payer: Group Health Inc Medicare	$4.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.35
Rate for Payer: Hamaspik Choice Inc Medicare	$4.28
Rate for Payer: Healthfirst Medicare Advantage	$4.28
Rate for Payer: Healthfirst QHP	$4.28
Rate for Payer: Humana Medicare	$4.37
Rate for Payer: Senior Whole Health Medicare Advantage	$4.28
Rate for Payer: United Healthcare Commercial	$5.39
Rate for Payer: United Healthcare Medicare Advantage	$4.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.28
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3.42
Rate for Payer: Wellcare Medicare	$3.85

EQ COAGULATION ACTIVATED ACT

Facility

$10.70

Service Code	HCPCS 85347 TC
Hospital Charge Code	41107470
Hospital Revenue Code	300
Rate for Payer: Cash Price	$4.28

EQ COLONIC STENT

Facility

$551.90

Service Code	HCPCS 74270 TC
Hospital Charge Code	41107676
Hospital Revenue Code	320
Min. Negotiated Rate	$146.86
Max. Negotiated Rate	$303.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$303.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$212.47
Rate for Payer: Aetna Government	$212.47
Rate for Payer: Affinity Essential Plan 1&2	$148.73
Rate for Payer: Affinity Essential Plan 3&4	$148.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$148.73
Rate for Payer: Brighton Health Commercial	$212.47
Rate for Payer: Cash Price	$212.47
Rate for Payer: Cash Price	$212.47
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$212.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$173.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$146.86
Rate for Payer: Elderplan Medicare Advantage	$212.47
Rate for Payer: EmblemHealth Commercial	$148.73
Rate for Payer: Fidelis CHP/HARP/Medicaid	$180.60
Rate for Payer: Fidelis Essential Plan Aliesa	$180.60
Rate for Payer: Fidelis Essential Plan QHP	$189.10
Rate for Payer: Fidelis Medicare Advantage	$212.47
Rate for Payer: Fidelis Qualified Health Plan	$189.10
Rate for Payer: Group Health Inc Commercial	$191.22
Rate for Payer: Group Health Inc Medicare	$191.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.95
Rate for Payer: Hamaspik Choice Inc Medicare	$212.47
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$191.22
Rate for Payer: Healthfirst Medicare Advantage	$212.47
Rate for Payer: Healthfirst QHP	$212.47
Rate for Payer: Humana Medicare	$216.72
Rate for Payer: Senior Whole Health Medicare Advantage	$212.47
Rate for Payer: United Healthcare Medicare Advantage	$212.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$212.47
Rate for Payer: Wellcare CHP/FHP/Medicaid	$169.98
Rate for Payer: Wellcare Medicare	$201.85

EQ COLONIC STENT

Facility

$551.90

Service Code	HCPCS 74270 TC
Hospital Charge Code	41107676
Hospital Revenue Code	320
Rate for Payer: Cash Price	$212.47

EQ CONVERTION TO G-J TUBE

Facility

$697.79

Service Code	HCPCS 74355 TC
Hospital Charge Code	41107660
Hospital Revenue Code	320
Min. Negotiated Rate	$84.98
Max. Negotiated Rate	$558.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$84.98
Rate for Payer: Aetna Government	$84.98
Rate for Payer: Brighton Health Commercial	$523.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$558.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$474.50
Rate for Payer: Group Health Inc Commercial	$348.90
Rate for Payer: Group Health Inc Medicare	$244.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.90
Rate for Payer: Hamaspik Choice Inc Medicare	$348.90

EQ CONVERT J-TUBE FR EXIST G-TUBE

Facility

$697.79

Service Code	HCPCS 74355 TC
Hospital Charge Code	41107656
Hospital Revenue Code	320
Min. Negotiated Rate	$84.98
Max. Negotiated Rate	$558.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$383.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$84.98
Rate for Payer: Aetna Government	$84.98
Rate for Payer: Brighton Health Commercial	$523.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$558.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$474.50
Rate for Payer: Group Health Inc Commercial	$348.90
Rate for Payer: Group Health Inc Medicare	$244.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$348.90
Rate for Payer: Hamaspik Choice Inc Medicare	$348.90

EQ CV CATHINJCKTIP PERIP VEIN

Facility

$1,909.65

Service Code	HCPCS 75820 TC
Hospital Charge Code	41109858
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,852.05

EQ CV CATHINJCKTIP PERIP VEIN

Facility

$1,909.65

Service Code	HCPCS 75820 TC
Hospital Charge Code	41109858
Hospital Revenue Code	320
Min. Negotiated Rate	$954.82
Max. Negotiated Rate	$1,889.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,050.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,852.05
Rate for Payer: Aetna Government	$1,852.05
Rate for Payer: Affinity Essential Plan 1&2	$1,296.44
Rate for Payer: Affinity Essential Plan 3&4	$1,296.44
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,296.44
Rate for Payer: Brighton Health Commercial	$1,852.05
Rate for Payer: Cash Price	$1,852.05
Rate for Payer: Cash Price	$1,852.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,852.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,438.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,217.14
Rate for Payer: Elderplan Medicare Advantage	$1,852.05
Rate for Payer: EmblemHealth Commercial	$1,296.44
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,574.24
Rate for Payer: Fidelis Essential Plan Aliesa	$1,574.24
Rate for Payer: Fidelis Essential Plan QHP	$1,648.32
Rate for Payer: Fidelis Medicare Advantage	$1,852.05
Rate for Payer: Fidelis Qualified Health Plan	$1,648.32
Rate for Payer: Group Health Inc Commercial	$1,666.84
Rate for Payer: Group Health Inc Medicare	$1,666.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1,852.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,666.84
Rate for Payer: Healthfirst Medicare Advantage	$1,852.05
Rate for Payer: Healthfirst QHP	$1,852.05
Rate for Payer: Humana Medicare	$1,889.09
Rate for Payer: Senior Whole Health Medicare Advantage	$1,852.05
Rate for Payer: United Healthcare Medicare Advantage	$1,852.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,852.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,481.64
Rate for Payer: Wellcare Medicare	$1,759.45

EQ CV CAT INJ/CKTIPRA/SVC

Facility

$1,909.65

Service Code	HCPCS 75827 TC
Hospital Charge Code	41109857
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,852.05

EQ CV CAT INJ/CKTIPRA/SVC

Facility

$1,909.65

Service Code	HCPCS 75827 TC
Hospital Charge Code	41109857
Hospital Revenue Code	320
Min. Negotiated Rate	$954.82
Max. Negotiated Rate	$1,889.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,050.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,852.05
Rate for Payer: Aetna Government	$1,852.05
Rate for Payer: Affinity Essential Plan 1&2	$1,296.44
Rate for Payer: Affinity Essential Plan 3&4	$1,296.44
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,296.44
Rate for Payer: Brighton Health Commercial	$1,852.05
Rate for Payer: Cash Price	$1,852.05
Rate for Payer: Cash Price	$1,852.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,852.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,438.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,217.14
Rate for Payer: Elderplan Medicare Advantage	$1,852.05
Rate for Payer: EmblemHealth Commercial	$1,296.44
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,574.24
Rate for Payer: Fidelis Essential Plan Aliesa	$1,574.24
Rate for Payer: Fidelis Essential Plan QHP	$1,648.32
Rate for Payer: Fidelis Medicare Advantage	$1,852.05
Rate for Payer: Fidelis Qualified Health Plan	$1,648.32
Rate for Payer: Group Health Inc Commercial	$1,666.84
Rate for Payer: Group Health Inc Medicare	$1,666.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1,852.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,666.84
Rate for Payer: Healthfirst Medicare Advantage	$1,852.05
Rate for Payer: Healthfirst QHP	$1,852.05
Rate for Payer: Humana Medicare	$1,889.09
Rate for Payer: Senior Whole Health Medicare Advantage	$1,852.05
Rate for Payer: United Healthcare Medicare Advantage	$1,852.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,852.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,481.64
Rate for Payer: Wellcare Medicare	$1,759.45

EQ CYSTOGRAM

Facility

$1,156.53

Service Code	HCPCS 74430 TC
Hospital Charge Code	41102134
Hospital Revenue Code	320
Rate for Payer: Cash Price	$444.73

EQ CYSTOGRAM

Facility

$1,156.53

Service Code	HCPCS 74430 TC
Hospital Charge Code	41102134
Hospital Revenue Code	320
Min. Negotiated Rate	$298.26
Max. Negotiated Rate	$636.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$636.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$444.73
Rate for Payer: Aetna Government	$444.73
Rate for Payer: Affinity Essential Plan 1&2	$311.31
Rate for Payer: Affinity Essential Plan 3&4	$311.31
Rate for Payer: Affinity Medicaid/CHP/HARP	$311.31
Rate for Payer: Brighton Health Commercial	$444.73
Rate for Payer: Cash Price	$444.73
Rate for Payer: Cash Price	$444.73
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$444.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$352.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$298.26
Rate for Payer: Elderplan Medicare Advantage	$444.73
Rate for Payer: EmblemHealth Commercial	$311.31
Rate for Payer: Fidelis CHP/HARP/Medicaid	$378.02
Rate for Payer: Fidelis Essential Plan Aliesa	$378.02
Rate for Payer: Fidelis Essential Plan QHP	$395.81
Rate for Payer: Fidelis Medicare Advantage	$444.73
Rate for Payer: Fidelis Qualified Health Plan	$395.81
Rate for Payer: Group Health Inc Commercial	$400.26
Rate for Payer: Group Health Inc Medicare	$400.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$578.26
Rate for Payer: Hamaspik Choice Inc Medicare	$444.73
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$400.26
Rate for Payer: Healthfirst Medicare Advantage	$444.73
Rate for Payer: Healthfirst QHP	$444.73
Rate for Payer: Humana Medicare	$453.62
Rate for Payer: Senior Whole Health Medicare Advantage	$444.73
Rate for Payer: United Healthcare Medicare Advantage	$444.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$444.73
Rate for Payer: Wellcare CHP/FHP/Medicaid	$355.78
Rate for Payer: Wellcare Medicare	$422.49

EQ CYSTOGRAM VOID

Facility

$705.83

Service Code	HCPCS 74455 TC
Hospital Charge Code	41102156
Hospital Revenue Code	320
Min. Negotiated Rate	$198.36
Max. Negotiated Rate	$388.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$388.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$283.37
Rate for Payer: Aetna Government	$283.37
Rate for Payer: Affinity Essential Plan 1&2	$198.36
Rate for Payer: Affinity Essential Plan 3&4	$198.36
Rate for Payer: Affinity Medicaid/CHP/HARP	$198.36
Rate for Payer: Brighton Health Commercial	$283.37
Rate for Payer: Cash Price	$283.37
Rate for Payer: Cash Price	$283.37
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$283.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$352.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$298.26
Rate for Payer: Elderplan Medicare Advantage	$283.37
Rate for Payer: EmblemHealth Commercial	$198.36
Rate for Payer: Fidelis CHP/HARP/Medicaid	$240.86
Rate for Payer: Fidelis Essential Plan Aliesa	$240.86
Rate for Payer: Fidelis Essential Plan QHP	$252.20
Rate for Payer: Fidelis Medicare Advantage	$283.37
Rate for Payer: Fidelis Qualified Health Plan	$252.20
Rate for Payer: Group Health Inc Commercial	$255.03
Rate for Payer: Group Health Inc Medicare	$255.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$352.92
Rate for Payer: Hamaspik Choice Inc Medicare	$283.37
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$255.03
Rate for Payer: Healthfirst Medicare Advantage	$283.37
Rate for Payer: Healthfirst QHP	$283.37
Rate for Payer: Humana Medicare	$289.04
Rate for Payer: Senior Whole Health Medicare Advantage	$283.37
Rate for Payer: United Healthcare Medicare Advantage	$283.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$283.37
Rate for Payer: Wellcare CHP/FHP/Medicaid	$226.70
Rate for Payer: Wellcare Medicare	$269.20

EQ CYSTOGRAM VOID

Facility

$705.83

Service Code	HCPCS 74455 TC
Hospital Charge Code	41102156
Hospital Revenue Code	320
Rate for Payer: Cash Price	$283.37

EQ DENVER SHUNT

Facility

$339.45

Service Code	HCPCS 75809 TC
Hospital Charge Code	41107474
Hospital Revenue Code	320
Rate for Payer: Cash Price	$127.14

EQ DENVER SHUNT

Facility

$339.45

Service Code	HCPCS 75809 TC
Hospital Charge Code	41107474
Hospital Revenue Code	320
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$186.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$186.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$151.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$128.48
Rate for Payer: Elderplan Medicare Advantage	$127.14
Rate for Payer: EmblemHealth Commercial	$89.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$108.07
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$114.43
Rate for Payer: Group Health Inc Medicare	$114.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.72
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$114.43
Rate for Payer: Healthfirst Medicare Advantage	$127.14
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

EQ DILATATION OF URTERS

Facility

$5,365.58

Service Code	HCPCS 74485 TC
Hospital Charge Code	41102738
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,355.42

EQ DILATATION OF URTERS

Facility

$5,365.58

Service Code	HCPCS 74485 TC
Hospital Charge Code	41102738
Hospital Revenue Code	320
Min. Negotiated Rate	$1,648.79
Max. Negotiated Rate	$2,951.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,951.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,355.42
Rate for Payer: Aetna Government	$2,355.42
Rate for Payer: Affinity Essential Plan 1&2	$1,648.79
Rate for Payer: Affinity Essential Plan 3&4	$1,648.79
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,648.79
Rate for Payer: Brighton Health Commercial	$2,355.42
Rate for Payer: Cash Price	$2,355.42
Rate for Payer: Cash Price	$2,355.42
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$2,355.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,422.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,049.86
Rate for Payer: Elderplan Medicare Advantage	$2,355.42
Rate for Payer: EmblemHealth Commercial	$1,648.79
Rate for Payer: Fidelis CHP/HARP/Medicaid	$2,002.11
Rate for Payer: Fidelis Essential Plan Aliesa	$2,002.11
Rate for Payer: Fidelis Essential Plan QHP	$2,096.32
Rate for Payer: Fidelis Medicare Advantage	$2,355.42
Rate for Payer: Fidelis Qualified Health Plan	$2,096.32
Rate for Payer: Group Health Inc Commercial	$2,119.88
Rate for Payer: Group Health Inc Medicare	$2,119.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,682.79
Rate for Payer: Hamaspik Choice Inc Medicare	$2,355.42
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2,119.88
Rate for Payer: Healthfirst Medicare Advantage	$2,355.42
Rate for Payer: Healthfirst QHP	$2,355.42
Rate for Payer: Humana Medicare	$2,402.53
Rate for Payer: Senior Whole Health Medicare Advantage	$2,355.42
Rate for Payer: United Healthcare Medicare Advantage	$2,355.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,355.42
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,884.34
Rate for Payer: Wellcare Medicare	$2,237.65

EQ DILATION

Facility

$650.40

Service Code	HCPCS 74360 TC
Hospital Charge Code	41102522
Hospital Revenue Code	320
Min. Negotiated Rate	$72.42
Max. Negotiated Rate	$520.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$357.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.42
Rate for Payer: Aetna Government	$72.42
Rate for Payer: Brighton Health Commercial	$487.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$520.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.27
Rate for Payer: Group Health Inc Commercial	$325.20
Rate for Payer: Group Health Inc Medicare	$227.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$325.20
Rate for Payer: Hamaspik Choice Inc Medicare	$325.20

Know your out-of-pocket cost for care.

All Charges