St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

EXTRACTION 1 CORONAL REMNANTS

Facility

$87.50

Service Code	HCPCS D7111
Hospital Charge Code	42303434
Hospital Revenue Code	361
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$65.62
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
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	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

EXTRACTION 1 CORONAL REMNANTS

Facility

$87.50

Service Code	HCPCS D7111
Hospital Charge Code	42303434
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

EXTRACTOR CORTEX .60MMX16MM

Facility

$18.18

Hospital Charge Code	64904243
Hospital Revenue Code	270
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$14.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.09
Rate for Payer: Aetna Government	$9.09
Rate for Payer: Brighton Health Commercial	$13.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.36
Rate for Payer: Group Health Inc Commercial	$9.09
Rate for Payer: Group Health Inc Medicare	$6.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.09
Rate for Payer: Hamaspik Choice Inc Medicare	$9.09

EXTRACTOR PRO BALLOON RX 12-15MM

Facility

$550.20

Hospital Charge Code	64904280
Hospital Revenue Code	270
Min. Negotiated Rate	$192.57
Max. Negotiated Rate	$440.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.10
Rate for Payer: Aetna Government	$275.10
Rate for Payer: Brighton Health Commercial	$412.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$440.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$374.14
Rate for Payer: Group Health Inc Commercial	$275.10
Rate for Payer: Group Health Inc Medicare	$192.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.10
Rate for Payer: Hamaspik Choice Inc Medicare	$275.10

EXTRACTOR PRO BALLOON RX 15-18MM

Facility

$550.20

Hospital Charge Code	64904282
Hospital Revenue Code	270
Min. Negotiated Rate	$192.57
Max. Negotiated Rate	$440.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.10
Rate for Payer: Aetna Government	$275.10
Rate for Payer: Brighton Health Commercial	$412.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$440.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$374.14
Rate for Payer: Group Health Inc Commercial	$275.10
Rate for Payer: Group Health Inc Medicare	$192.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.10
Rate for Payer: Hamaspik Choice Inc Medicare	$275.10

EXTRACTOR PRO BALLOON RX 9-12MM

Facility

$550.20

Hospital Charge Code	64904278
Hospital Revenue Code	270
Min. Negotiated Rate	$192.57
Max. Negotiated Rate	$440.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.10
Rate for Payer: Aetna Government	$275.10
Rate for Payer: Brighton Health Commercial	$412.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$440.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$374.14
Rate for Payer: Group Health Inc Commercial	$275.10
Rate for Payer: Group Health Inc Medicare	$192.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.10
Rate for Payer: Hamaspik Choice Inc Medicare	$275.10

EXTRACTOR,STAPLE PSX PROXIMATE

Facility

$5.00

Hospital Charge Code	64901615
Hospital Revenue Code	270
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.50
Rate for Payer: Aetna Government	$2.50
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$39,905.22

Service Code	MSDRG 115
Min. Negotiated Rate	$13,414.70
Max. Negotiated Rate	$39,905.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23,067.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29,021.98
Rate for Payer: Aetna Government	$29,021.98
Rate for Payer: Brighton Health Commercial	$22,683.80
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29,602.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27,015.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$22,294.45
Rate for Payer: Elderplan Medicare Advantage	$27,570.88
Rate for Payer: EmblemHealth Commercial	$13,414.70
Rate for Payer: Fidelis Medicare Advantage	$29,021.98
Rate for Payer: Group Health Inc Commercial	$29,021.98
Rate for Payer: Group Health Inc Medicare	$29,021.98
Rate for Payer: Hamaspik Choice Inc Medicare	$29,021.98
Rate for Payer: Healthfirst Medicare Advantage	$13,495.22
Rate for Payer: Humana Medicare	$39,905.22
Rate for Payer: Senior Whole Health Medicare Advantage	$29,021.98
Rate for Payer: United Healthcare Commercial	$31,111.22
Rate for Payer: United Healthcare Medicare Advantage	$29,021.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29,021.98
Rate for Payer: Wellcare Medicare	$27,570.88

EXTRAORAL- EACH ADDITIONAL FILM

Facility

$31.19

Service Code	HCPCS D0260
Hospital Charge Code	42300704
Hospital Revenue Code	361
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.60
Rate for Payer: Aetna Government	$15.60
Rate for Payer: Brighton Health Commercial	$23.39
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: Group Health Inc Commercial	$15.60
Rate for Payer: Group Health Inc Medicare	$10.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.60
Rate for Payer: Hamaspik Choice Inc Medicare	$15.60

EXTRAORAL-FIRST FILM

Facility

$62.50

Service Code	HCPCS D0250
Hospital Charge Code	42300130
Hospital Revenue Code	361
Min. Negotiated Rate	$31.25
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$34.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$105.08
Rate for Payer: Aetna Government	$105.08
Rate for Payer: Affinity Essential Plan 1&2	$73.56
Rate for Payer: Affinity Essential Plan 3&4	$73.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.56
Rate for Payer: Brighton Health Commercial	$46.88
Rate for Payer: Cash Price	$105.08
Rate for Payer: Cash Price	$105.08
Rate for Payer: Cash Price	$105.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$105.08
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	$105.08
Rate for Payer: EmblemHealth Commercial	$105.08
Rate for Payer: Fidelis Essential Plan Aliesa	$89.32
Rate for Payer: Fidelis Essential Plan QHP	$93.52
Rate for Payer: Fidelis Medicare Advantage	$105.08
Rate for Payer: Fidelis Qualified Health Plan	$93.52
Rate for Payer: Group Health Inc Commercial	$105.08
Rate for Payer: Group Health Inc Medicare	$105.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.25
Rate for Payer: Hamaspik Choice Inc Medicare	$105.08
Rate for Payer: Healthfirst Medicare Advantage	$89.32
Rate for Payer: Healthfirst QHP	$105.08
Rate for Payer: Humana Medicare	$107.18
Rate for Payer: Senior Whole Health Medicare Advantage	$105.08
Rate for Payer: United Healthcare Medicare Advantage	$105.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$105.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$84.06
Rate for Payer: Wellcare Medicare	$99.83

EXTRAORAL-FIRST FILM

Facility

$62.50

Service Code	HCPCS D0250
Hospital Charge Code	42300130
Hospital Revenue Code	361
Rate for Payer: Cash Price	$105.08

EXTRAORAL POSTERIOR IMAGE

Facility

$75.00

Service Code	HCPCS D0251
Hospital Charge Code	42303460
Hospital Revenue Code	361
Rate for Payer: Cash Price	$105.08

EXTRAORAL POSTERIOR IMAGE

Facility

$75.00

Service Code	HCPCS D0251
Hospital Charge Code	42303460
Hospital Revenue Code	361
Min. Negotiated Rate	$37.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$41.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$105.08
Rate for Payer: Aetna Government	$105.08
Rate for Payer: Affinity Essential Plan 1&2	$73.56
Rate for Payer: Affinity Essential Plan 3&4	$73.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.56
Rate for Payer: Brighton Health Commercial	$56.25
Rate for Payer: Cash Price	$105.08
Rate for Payer: Cash Price	$105.08
Rate for Payer: Cash Price	$105.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$105.08
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	$105.08
Rate for Payer: EmblemHealth Commercial	$105.08
Rate for Payer: Fidelis Essential Plan Aliesa	$89.32
Rate for Payer: Fidelis Essential Plan QHP	$93.52
Rate for Payer: Fidelis Medicare Advantage	$105.08
Rate for Payer: Fidelis Qualified Health Plan	$93.52
Rate for Payer: Group Health Inc Commercial	$105.08
Rate for Payer: Group Health Inc Medicare	$105.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.50
Rate for Payer: Hamaspik Choice Inc Medicare	$105.08
Rate for Payer: Healthfirst Medicare Advantage	$89.32
Rate for Payer: Healthfirst QHP	$105.08
Rate for Payer: Humana Medicare	$107.18
Rate for Payer: Senior Whole Health Medicare Advantage	$105.08
Rate for Payer: United Healthcare Medicare Advantage	$105.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$105.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$84.06
Rate for Payer: Wellcare Medicare	$99.83

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$124,483.62

Service Code	MSDRG 790
Min. Negotiated Rate	$3,163.00
Max. Negotiated Rate	$124,483.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$88,471.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$90,533.54
Rate for Payer: Aetna Government	$90,533.54
Rate for Payer: Brighton Health Commercial	$87,001.45
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$92,344.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$103,615.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$85,508.15
Rate for Payer: Elderplan Medicare Advantage	$86,006.86
Rate for Payer: EmblemHealth Commercial	$51,450.90
Rate for Payer: Fidelis Medicare Advantage	$90,533.54
Rate for Payer: Group Health Inc Commercial	$90,533.54
Rate for Payer: Group Health Inc Medicare	$90,533.54
Rate for Payer: Hamaspik Choice Inc Medicare	$90,533.54
Rate for Payer: Healthfirst Medicare Advantage	$42,098.10
Rate for Payer: Humana Medicare	$124,483.62
Rate for Payer: Senior Whole Health Medicare Advantage	$90,533.54
Rate for Payer: United Healthcare Commercial	$3,163.00
Rate for Payer: United Healthcare Medicare Advantage	$90,533.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$90,533.54
Rate for Payer: Wellcare Medicare	$86,006.86

EXTREMITY STUDY

Facility

$330.23

Service Code	HCPCS 93922 TC
Hospital Charge Code	30303129
Hospital Revenue Code	920
Rate for Payer: Cash Price	$147.72

EXTREMITY STUDY

Facility

$330.23

Service Code	HCPCS 93922 TC
Hospital Charge Code	30303129
Hospital Revenue Code	920
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$264.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$181.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$147.72
Rate for Payer: Aetna Government	$147.72
Rate for Payer: Affinity Essential Plan 1&2	$103.40
Rate for Payer: Affinity Essential Plan 3&4	$103.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$103.40
Rate for Payer: Brighton Health Commercial	$247.67
Rate for Payer: Cash Price	$147.72
Rate for Payer: Cash Price	$147.72
Rate for Payer: Cash Price	$147.72
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$147.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$264.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.56
Rate for Payer: Elderplan Medicare Advantage	$147.72
Rate for Payer: EmblemHealth Commercial	$147.72
Rate for Payer: Fidelis Essential Plan Aliesa	$125.56
Rate for Payer: Fidelis Essential Plan QHP	$131.47
Rate for Payer: Fidelis Medicare Advantage	$147.72
Rate for Payer: Fidelis Qualified Health Plan	$131.47
Rate for Payer: Group Health Inc Commercial	$147.72
Rate for Payer: Group Health Inc Medicare	$147.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$165.12
Rate for Payer: Hamaspik Choice Inc Medicare	$147.72
Rate for Payer: Healthfirst Medicare Advantage	$125.56
Rate for Payer: Healthfirst QHP	$147.72
Rate for Payer: Humana Medicare	$150.67
Rate for Payer: Senior Whole Health Medicare Advantage	$147.72
Rate for Payer: United Healthcare Commercial	$94.00
Rate for Payer: United Healthcare Medicare Advantage	$147.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$147.72
Rate for Payer: Wellcare CHP/FHP/Medicaid	$118.18
Rate for Payer: Wellcare Medicare	$140.33

EXT RX RETRI BALLN 12.0-15.0MM D

Facility

$418.00

Hospital Charge Code	40200544
Hospital Revenue Code	270
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$334.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$229.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$209.00
Rate for Payer: Aetna Government	$209.00
Rate for Payer: Brighton Health Commercial	$313.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$334.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$284.24
Rate for Payer: Group Health Inc Commercial	$209.00
Rate for Payer: Group Health Inc Medicare	$146.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$209.00
Rate for Payer: Hamaspik Choice Inc Medicare	$209.00

EXT RX RETRI BALLN12.0-15.0MMPROX

Facility

$418.00

Hospital Charge Code	40200545
Hospital Revenue Code	270
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$334.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$229.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$209.00
Rate for Payer: Aetna Government	$209.00
Rate for Payer: Brighton Health Commercial	$313.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$334.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$284.24
Rate for Payer: Group Health Inc Commercial	$209.00
Rate for Payer: Group Health Inc Medicare	$146.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$209.00
Rate for Payer: Hamaspik Choice Inc Medicare	$209.00

EXT RX RETRI BALLN 15.0-18.0DIST

Facility

$398.00

Hospital Charge Code	40200546
Hospital Revenue Code	270
Min. Negotiated Rate	$139.30
Max. Negotiated Rate	$318.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$218.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$199.00
Rate for Payer: Aetna Government	$199.00
Rate for Payer: Brighton Health Commercial	$298.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$318.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$270.64
Rate for Payer: Group Health Inc Commercial	$199.00
Rate for Payer: Group Health Inc Medicare	$139.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.00
Rate for Payer: Hamaspik Choice Inc Medicare	$199.00

EXT RX RETRI BALLN 15.0-18.0 PROX

Facility

$398.00

Hospital Charge Code	40200547
Hospital Revenue Code	270
Min. Negotiated Rate	$139.30
Max. Negotiated Rate	$318.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$218.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$199.00
Rate for Payer: Aetna Government	$199.00
Rate for Payer: Brighton Health Commercial	$298.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$318.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$270.64
Rate for Payer: Group Health Inc Commercial	$199.00
Rate for Payer: Group Health Inc Medicare	$139.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.00
Rate for Payer: Hamaspik Choice Inc Medicare	$199.00

EXT RX RETRI BALLN 9.0-12.0MM DIS

Facility

$398.00

Hospital Charge Code	40200548
Hospital Revenue Code	270
Min. Negotiated Rate	$139.30
Max. Negotiated Rate	$318.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$218.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$199.00
Rate for Payer: Aetna Government	$199.00
Rate for Payer: Brighton Health Commercial	$298.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$318.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$270.64
Rate for Payer: Group Health Inc Commercial	$199.00
Rate for Payer: Group Health Inc Medicare	$139.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.00
Rate for Payer: Hamaspik Choice Inc Medicare	$199.00

EXT RX RETRI BALLN 9.0-12.0MMPROX

Facility

$398.00

Hospital Charge Code	40200549
Hospital Revenue Code	270
Min. Negotiated Rate	$139.30
Max. Negotiated Rate	$318.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$218.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$199.00
Rate for Payer: Aetna Government	$199.00
Rate for Payer: Brighton Health Commercial	$298.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$318.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$270.64
Rate for Payer: Group Health Inc Commercial	$199.00
Rate for Payer: Group Health Inc Medicare	$139.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.00
Rate for Payer: Hamaspik Choice Inc Medicare	$199.00

EXTUBATION/TUBE REPOSITION

Facility

$711.45

Service Code	HCPCS 43761
Hospital Charge Code	40302400
Hospital Revenue Code	360
Min. Negotiated Rate	$200.07
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$285.81
Rate for Payer: Aetna Government	$285.81
Rate for Payer: Affinity Essential Plan 1&2	$200.07
Rate for Payer: Affinity Essential Plan 3&4	$200.07
Rate for Payer: Affinity Medicaid/CHP/HARP	$200.07
Rate for Payer: Brighton Health Commercial	$533.59
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$285.81
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	$285.81
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$242.94
Rate for Payer: Fidelis Essential Plan QHP	$254.37
Rate for Payer: Fidelis Medicare Advantage	$285.81
Rate for Payer: Fidelis Qualified Health Plan	$254.37
Rate for Payer: Group Health Inc Commercial	$285.81
Rate for Payer: Group Health Inc Medicare	$285.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$355.72
Rate for Payer: Hamaspik Choice Inc Medicare	$285.81
Rate for Payer: Healthfirst Medicare Advantage	$242.94
Rate for Payer: Healthfirst QHP	$285.81
Rate for Payer: Humana Medicare	$291.53
Rate for Payer: Senior Whole Health Medicare Advantage	$285.81
Rate for Payer: United Healthcare Commercial	$1,113.00
Rate for Payer: United Healthcare Medicare Advantage	$285.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$285.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$228.65
Rate for Payer: Wellcare Medicare	$271.52

EXTUBATION/TUBE REPOSITION

Facility

$711.45

Service Code	HCPCS 43761
Hospital Charge Code	40302400
Hospital Revenue Code	360
Rate for Payer: Cash Price	$285.81

EYE EXAM 12MONTHS BEFORE SURGERY

Facility

$0.01

Service Code	HCPCS 2020F
Hospital Charge Code	30300361
Hospital Revenue Code	969
Max. Negotiated Rate	$2,915.00
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	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
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

Know your out-of-pocket cost for care.

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