St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

FLUZONE QUAD IM MDV-3YRS+

Facility

$32.00

Service Code	HCPCS 90688
Hospital Charge Code	41645969
Hospital Revenue Code	636
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$16.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.00
Rate for Payer: Hamaspik Choice Inc Medicare	$16.00

FLUZONE QUAD PED 0.25ML SYR

Facility

$24.90

Service Code	HCPCS 90686
Hospital Charge Code	41655729
Hospital Revenue Code	636
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$23.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.53
Rate for Payer: Aetna Government	$20.53
Rate for Payer: Brighton Health Commercial	$14.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.32
Rate for Payer: Group Health Inc Commercial	$12.45
Rate for Payer: Group Health Inc Medicare	$8.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.45
Rate for Payer: Hamaspik Choice Inc Medicare	$12.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23.69
Rate for Payer: SOMOS Essential	$23.69
Rate for Payer: United Healthcare Commercial	$21.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.18

FLUZONE QUAD PED 0.25ML SYR

Facility

$24.90

Service Code	HCPCS 90686
Hospital Charge Code	41655729
Hospital Revenue Code	636
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$12.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.45
Rate for Payer: Hamaspik Choice Inc Medicare	$12.45

FLUZONE QUAD (VFC)0.5ML PFS 3+YRS

Facility

$0.01

Service Code	HCPCS 90686
Hospital Charge Code	41655961
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

FLUZONE QUAD (VFC)0.5ML PFS 3+YRS

Facility

$0.01

Service Code	HCPCS 90686
Hospital Charge Code	41645961
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

FLUZONE QUAD (VFC)0.5ML PFS 3+YRS

Facility

$0.01

Service Code	HCPCS 90686
Hospital Charge Code	41655961
Hospital Revenue Code	636
Max. Negotiated Rate	$23.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.53
Rate for Payer: Aetna Government	$20.53
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: 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: SOMOS CHP/HARP/Medicaid	$23.69
Rate for Payer: SOMOS Essential	$23.69
Rate for Payer: United Healthcare Commercial	$21.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

FLUZONE QUAD (VFC)0.5ML PFS 3+YRS

Facility

$0.01

Service Code	HCPCS 90686
Hospital Charge Code	41645961
Hospital Revenue Code	636
Max. Negotiated Rate	$23.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.53
Rate for Payer: Aetna Government	$20.53
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: 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: SOMOS CHP/HARP/Medicaid	$23.69
Rate for Payer: SOMOS Essential	$23.69
Rate for Payer: United Healthcare Commercial	$21.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

FL VIDEO ESOPHAGUS

Facility

$551.90

Service Code	HCPCS 74230 TC
Hospital Charge Code	41102500
Hospital Revenue Code	320
Rate for Payer: Cash Price	$212.47

FL VIDEO ESOPHAGUS

Facility

$551.90

Service Code	HCPCS 74230 TC
Hospital Charge Code	41102500
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

FLYCOPYRROLATE 2MG 1ML INJ

Facility

$2.00

Hospital Charge Code	41657182
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.15
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

FLYCOPYRROLATE 2MG 1ML INJ

Facility

$2.00

Hospital Charge Code	41657182
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00

FMR CMNTD PSN PS CMT CCR STD SZ7L

Facility

$6,600.00

Service Code	HCPCS C1776
Hospital Charge Code	40204597
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$6,930.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,630.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$3,960.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,300.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,795.00
Rate for Payer: EmblemHealth Commercial	$3,300.00
Rate for Payer: Fidelis Medicare Advantage	$6,930.00
Rate for Payer: Group Health Inc Commercial	$3,300.00
Rate for Payer: Group Health Inc Medicare	$2,310.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,290.00

FMR CMNTD PSN PS CMT CCR STD SZ7L

Facility

$6,600.00

Service Code	HCPCS C1776
Hospital Charge Code	40204597
Hospital Revenue Code	278
Min. Negotiated Rate	$3,300.00
Max. Negotiated Rate	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,300.00

FMS INTERFACE CABLE

Facility

$3,500.00

Hospital Charge Code	64905792
Hospital Revenue Code	270
Min. Negotiated Rate	$1,225.00
Max. Negotiated Rate	$2,800.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,925.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,750.00
Rate for Payer: Aetna Government	$1,750.00
Rate for Payer: Brighton Health Commercial	$2,625.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,800.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,380.00
Rate for Payer: Group Health Inc Commercial	$1,750.00
Rate for Payer: Group Health Inc Medicare	$1,225.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00

FMUR PSN PS CMT CCR NRW SZ3 L

Facility

$6,600.00

Service Code	HCPCS C1776
Hospital Charge Code	40204656
Hospital Revenue Code	278
Min. Negotiated Rate	$3,300.00
Max. Negotiated Rate	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,300.00

FMUR PSN PS CMT CCR NRW SZ3 L

Facility

$6,600.00

Service Code	HCPCS C1776
Hospital Charge Code	40204656
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$6,930.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,630.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$3,960.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,300.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,795.00
Rate for Payer: EmblemHealth Commercial	$3,300.00
Rate for Payer: Fidelis Medicare Advantage	$6,930.00
Rate for Payer: Group Health Inc Commercial	$3,300.00
Rate for Payer: Group Health Inc Medicare	$2,310.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,290.00

FNA BX W/CT GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10009
Hospital Charge Code	30307909
Hospital Revenue Code	510
Rate for Payer: Cash Price	$813.63

FNA BX W/CT GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10009
Hospital Charge Code	30307909
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$813.63
Rate for Payer: Aetna Government	$813.63
Rate for Payer: Affinity Essential Plan 1&2	$569.54
Rate for Payer: Affinity Essential Plan 3&4	$569.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$569.54
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$813.63
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	$813.63
Rate for Payer: Fidelis Essential Plan Aliesa	$691.59
Rate for Payer: Fidelis Essential Plan QHP	$724.13
Rate for Payer: Fidelis Medicare Advantage	$813.63
Rate for Payer: Fidelis Qualified Health Plan	$724.13
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	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$813.63
Rate for Payer: Healthfirst Medicare Advantage	$691.59
Rate for Payer: Healthfirst QHP	$813.63
Rate for Payer: Humana Medicare	$829.90
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$813.63
Rate for Payer: Senior Whole Health Medicare Advantage	$813.63
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$813.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$813.63
Rate for Payer: Wellcare CHP/FHP/Medicaid	$650.90
Rate for Payer: Wellcare Medicare	$772.95

FNA BX W/CT GDN EA ADDL

Facility

$923.79

Service Code	HCPCS 10010
Hospital Charge Code	30307910
Hospital Revenue Code	510
Min. Negotiated Rate	$70.47
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.47
Rate for Payer: Aetna Government	$70.47
Rate for Payer: Brighton Health Commercial	$233.00
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	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$461.90
Rate for Payer: Hamaspik Choice Inc Medicare	$461.90
Rate for Payer: United Healthcare Commercial	$222.00

FNA BX W/FLUOR GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10007
Hospital Charge Code	30307935
Hospital Revenue Code	510
Rate for Payer: Cash Price	$813.63

FNA BX W/FLUOR GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10007
Hospital Charge Code	30307935
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$813.63
Rate for Payer: Aetna Government	$813.63
Rate for Payer: Affinity Essential Plan 1&2	$569.54
Rate for Payer: Affinity Essential Plan 3&4	$569.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$569.54
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$813.63
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	$813.63
Rate for Payer: Fidelis Essential Plan Aliesa	$691.59
Rate for Payer: Fidelis Essential Plan QHP	$724.13
Rate for Payer: Fidelis Medicare Advantage	$813.63
Rate for Payer: Fidelis Qualified Health Plan	$724.13
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	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$813.63
Rate for Payer: Healthfirst Medicare Advantage	$691.59
Rate for Payer: Healthfirst QHP	$813.63
Rate for Payer: Humana Medicare	$829.90
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$813.63
Rate for Payer: Senior Whole Health Medicare Advantage	$813.63
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$813.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$813.63
Rate for Payer: Wellcare CHP/FHP/Medicaid	$650.90
Rate for Payer: Wellcare Medicare	$772.95

FNA BX W/FLUOR GDN EA ADDL

Facility

$923.79

Service Code	HCPCS 10008
Hospital Charge Code	30307936
Hospital Revenue Code	510
Min. Negotiated Rate	$52.04
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.04
Rate for Payer: Aetna Government	$52.04
Rate for Payer: Brighton Health Commercial	$233.00
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	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$461.90
Rate for Payer: Hamaspik Choice Inc Medicare	$461.90
Rate for Payer: United Healthcare Commercial	$222.00

FNA BX W/MR GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10011
Hospital Charge Code	30307911
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$813.63
Rate for Payer: Aetna Government	$813.63
Rate for Payer: Affinity Essential Plan 1&2	$569.54
Rate for Payer: Affinity Essential Plan 3&4	$569.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$569.54
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Cash Price	$813.63
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$813.63
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	$813.63
Rate for Payer: Fidelis Essential Plan Aliesa	$691.59
Rate for Payer: Fidelis Essential Plan QHP	$724.13
Rate for Payer: Fidelis Medicare Advantage	$813.63
Rate for Payer: Fidelis Qualified Health Plan	$724.13
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	$923.79
Rate for Payer: Hamaspik Choice Inc Medicare	$813.63
Rate for Payer: Healthfirst Medicare Advantage	$691.59
Rate for Payer: Healthfirst QHP	$813.63
Rate for Payer: Humana Medicare	$829.90
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$813.63
Rate for Payer: Senior Whole Health Medicare Advantage	$813.63
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$813.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$813.63
Rate for Payer: Wellcare CHP/FHP/Medicaid	$650.90
Rate for Payer: Wellcare Medicare	$772.95

FNA BX W/MR GDN 1ST LES

Facility

$1,847.58

Service Code	HCPCS 10011
Hospital Charge Code	30307911
Hospital Revenue Code	510
Rate for Payer: Cash Price	$813.63

FNA BX W/MR GDN EA ADDL

Facility

$923.79

Service Code	HCPCS 10012
Hospital Charge Code	30307912
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$234.84
Rate for Payer: Aetna Government	$234.84
Rate for Payer: Brighton Health Commercial	$233.00
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	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$461.90
Rate for Payer: Hamaspik Choice Inc Medicare	$461.90
Rate for Payer: United Healthcare Commercial	$222.00

Know your out-of-pocket cost for care.

All Charges