St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HYDROMORPHONE HCL 2 MG/ML IJ SOLN [3758]

Facility

$2.30

Service Code	HCPCS J1170
Hospital Charge Code	00409336510
Hospital Revenue Code	250
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$1.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.56
Rate for Payer: Group Health Inc Commercial	$1.15
Rate for Payer: Group Health Inc Medicare	$0.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.15
Rate for Payer: Hamaspik Choice Inc Medicare	$1.15
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.49

HYDROMORPHONE HCL 2 MG PO TABS [3760]

Facility

$0.20

Service Code	NDC 42858030125
Hospital Charge Code	42858030125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

HYDROMORPHONE HCL 2 MG PO TABS [3760]

Facility

$0.71

Service Code	NDC 60687057911
Hospital Charge Code	60687057911
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

HYDROMORPHONE HCL 2 MG PO TABS [3760]

Facility

$0.71

Service Code	NDC 60687057901
Hospital Charge Code	60687057901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

HYDROMORPHONE HCL 4 MG PO TABS [3761]

Facility

$0.69

Service Code	NDC 00406324401
Hospital Charge Code	00406324401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Brighton Health Commercial	$0.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.47
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.45

HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN [116809]

Facility

$5.14

Service Code	HCPCS J1170
Hospital Charge Code	00409263401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$3.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.50
Rate for Payer: Group Health Inc Commercial	$2.57
Rate for Payer: Group Health Inc Medicare	$1.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.57
Rate for Payer: Hamaspik Choice Inc Medicare	$2.57
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.34

HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN [116809]

Facility

$4.19

Service Code	HCPCS J1170
Hospital Charge Code	00703011001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN [93106]

Facility

$2.94

Service Code	HCPCS J1170
Hospital Charge Code	00409263450
Hospital Revenue Code	250
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$2.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.00
Rate for Payer: Group Health Inc Commercial	$1.47
Rate for Payer: Group Health Inc Medicare	$1.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.47
Rate for Payer: Hamaspik Choice Inc Medicare	$1.47
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.91

HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN [93106]

Facility

$2.61

Service Code	HCPCS J1170
Hospital Charge Code	00409263405
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$1.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.78
Rate for Payer: Group Health Inc Commercial	$1.31
Rate for Payer: Group Health Inc Medicare	$0.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.31
Rate for Payer: Hamaspik Choice Inc Medicare	$1.31
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.70

HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN [93106]

Facility

$4.08

Service Code	HCPCS J1170
Hospital Charge Code	63323085150
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$3.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.78
Rate for Payer: Group Health Inc Commercial	$2.04
Rate for Payer: Group Health Inc Medicare	$1.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.04
Rate for Payer: Hamaspik Choice Inc Medicare	$2.04
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.65

HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN [93106]

Facility

$4.19

Service Code	HCPCS J1170
Hospital Charge Code	00703011001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN [93106]

Facility

$2.61

Service Code	HCPCS J1170
Hospital Charge Code	00409263425
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.30
Rate for Payer: Aetna Government	$3.30
Rate for Payer: Brighton Health Commercial	$1.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.78
Rate for Payer: Group Health Inc Commercial	$1.31
Rate for Payer: Group Health Inc Medicare	$0.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.31
Rate for Payer: Hamaspik Choice Inc Medicare	$1.31
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$4.76
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$5.04
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$5.04
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$5.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.70

HYDROSET 15CC STRYKER

Facility

$11,160.00

Service Code	HCPCS C1713
Hospital Charge Code	64904492
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$11,718.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,138.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$6,696.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,580.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,417.00
Rate for Payer: EmblemHealth Commercial	$5,580.00
Rate for Payer: Fidelis Medicare Advantage	$11,718.00
Rate for Payer: Group Health Inc Commercial	$5,580.00
Rate for Payer: Group Health Inc Medicare	$3,906.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,580.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,580.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,254.00

HYDROSET 15CC STRYKER

Facility

$11,160.00

Service Code	HCPCS C1713
Hospital Charge Code	64904492
Hospital Revenue Code	278
Min. Negotiated Rate	$5,580.00
Max. Negotiated Rate	$5,580.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,580.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,580.00

HYDROSET 5CC STRYKER

Facility

$3,775.00

Service Code	HCPCS C1713
Hospital Charge Code	64904580
Hospital Revenue Code	278
Min. Negotiated Rate	$1,887.50
Max. Negotiated Rate	$1,887.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,887.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,887.50

HYDROSET 5CC STRYKER

Facility

$3,775.00

Service Code	HCPCS C1713
Hospital Charge Code	64904580
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,963.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,076.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,265.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,887.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,170.62
Rate for Payer: EmblemHealth Commercial	$1,887.50
Rate for Payer: Fidelis Medicare Advantage	$3,963.75
Rate for Payer: Group Health Inc Commercial	$1,887.50
Rate for Payer: Group Health Inc Medicare	$1,321.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,887.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,887.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,453.75

HYDROSET INJCT BONE CEMENT 15CC

Facility

$14,236.00

Hospital Charge Code	64906751
Hospital Revenue Code	279
Min. Negotiated Rate	$4,982.60
Max. Negotiated Rate	$11,388.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7,829.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7,118.00
Rate for Payer: Aetna Government	$7,118.00
Rate for Payer: Brighton Health Commercial	$10,677.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11,388.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$9,680.48
Rate for Payer: Group Health Inc Commercial	$7,118.00
Rate for Payer: Group Health Inc Medicare	$4,982.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,118.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,118.00

HYDROSET INJECTABLE BNE SUB 03 CC

Facility

$1,966.00

Service Code	HCPCS C1713
Hospital Charge Code	40201355
Hospital Revenue Code	278
Min. Negotiated Rate	$983.00
Max. Negotiated Rate	$983.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$983.00
Rate for Payer: Hamaspik Choice Inc Medicare	$983.00

HYDROSET INJECTABLE BNE SUB 03 CC

Facility

$1,966.00

Service Code	HCPCS C1713
Hospital Charge Code	40201355
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,064.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,081.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,179.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$983.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,130.45
Rate for Payer: EmblemHealth Commercial	$983.00
Rate for Payer: Fidelis Medicare Advantage	$2,064.30
Rate for Payer: Group Health Inc Commercial	$983.00
Rate for Payer: Group Health Inc Medicare	$688.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$983.00
Rate for Payer: Hamaspik Choice Inc Medicare	$983.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,277.90

HYDROSET INJECTABLE BNE SUB 05 CC

Facility

$1,966.00

Service Code	HCPCS C1713
Hospital Charge Code	40201356
Hospital Revenue Code	278
Min. Negotiated Rate	$983.00
Max. Negotiated Rate	$983.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$983.00
Rate for Payer: Hamaspik Choice Inc Medicare	$983.00

HYDROSET INJECTABLE BNE SUB 05 CC

Facility

$1,966.00

Service Code	HCPCS C1713
Hospital Charge Code	40201356
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,064.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,081.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,179.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$983.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,130.45
Rate for Payer: EmblemHealth Commercial	$983.00
Rate for Payer: Fidelis Medicare Advantage	$2,064.30
Rate for Payer: Group Health Inc Commercial	$983.00
Rate for Payer: Group Health Inc Medicare	$688.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$983.00
Rate for Payer: Hamaspik Choice Inc Medicare	$983.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,277.90

HYDROSET INJECTABLE BNE SUB 10 CC

Facility

$3,980.00

Service Code	HCPCS C1713
Hospital Charge Code	40201357
Hospital Revenue Code	278
Min. Negotiated Rate	$1,990.00
Max. Negotiated Rate	$1,990.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,990.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,990.00

HYDROSET INJECTABLE BNE SUB 10 CC

Facility

$3,980.00

Service Code	HCPCS C1713
Hospital Charge Code	40201357
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,179.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,189.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,388.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,990.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,288.50
Rate for Payer: EmblemHealth Commercial	$1,990.00
Rate for Payer: Fidelis Medicare Advantage	$4,179.00
Rate for Payer: Group Health Inc Commercial	$1,990.00
Rate for Payer: Group Health Inc Medicare	$1,393.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,990.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,990.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,587.00

HYDROSET INJECTABLE BNE SUB 15CC

Facility

$5,999.00

Service Code	HCPCS C1713
Hospital Charge Code	40201358
Hospital Revenue Code	278
Min. Negotiated Rate	$2,999.50
Max. Negotiated Rate	$2,999.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,999.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,999.50

HYDROSET INJECTABLE BNE SUB 15CC

Facility

$5,999.00

Service Code	HCPCS C1713
Hospital Charge Code	40201358
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$6,298.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,299.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,599.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,999.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,449.42
Rate for Payer: EmblemHealth Commercial	$2,999.50
Rate for Payer: Fidelis Medicare Advantage	$6,298.95
Rate for Payer: Group Health Inc Commercial	$2,999.50
Rate for Payer: Group Health Inc Medicare	$2,099.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,999.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,999.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,899.35

Know your out-of-pocket cost for care.

All Charges