St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

METHOCARBAMOL 100 MG/ML INJ

Facility

$150.00

Service Code	HCPCS J2800
Hospital Charge Code	41653229
Hospital Revenue Code	636
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$97.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$82.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.95
Rate for Payer: Aetna Government	$6.95
Rate for Payer: Brighton Health Commercial	$90.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$75.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$86.25
Rate for Payer: Group Health Inc Commercial	$75.00
Rate for Payer: Group Health Inc Medicare	$52.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$75.00
Rate for Payer: Hamaspik Choice Inc Medicare	$75.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6.54
Rate for Payer: SOMOS Essential	$6.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$97.50

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.36

Service Code	NDC 50268052015
Hospital Charge Code	50268052015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.30

Service Code	NDC 60687055901
Hospital Charge Code	60687055901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.51

Service Code	NDC 70010075401
Hospital Charge Code	70010075401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.33

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.36

Service Code	NDC 50268052011
Hospital Charge Code	50268052011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.49

Service Code	NDC 69584061150
Hospital Charge Code	69584061150
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
Rate for Payer: Brighton Health Commercial	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.33
Rate for Payer: Group Health Inc Commercial	$0.24
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.24
Rate for Payer: Hamaspik Choice Inc Medicare	$0.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.32

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.51

Service Code	NDC 43547040510
Hospital Charge Code	43547040510
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.33

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.32

Service Code	NDC 00904705761
Hospital Charge Code	00904705761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.16
Rate for Payer: Aetna Government	$0.16
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.16
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16
Rate for Payer: Hamaspik Choice Inc Medicare	$0.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

METHOCARBAMOL 500 MG PO TABS [4971]

Facility

$0.51

Service Code	NDC 69367025501
Hospital Charge Code	69367025501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.33

METHOCARBAMOL 500 MG TAB

Facility

$1.00

Hospital Charge Code	41644232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

METHOCARBAMOL 500 MG TAB

Facility

$1.00

Hospital Charge Code	41654232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

METHOCARBAMOL 750 MG PO TABS [4972]

Facility

$0.34

Service Code	NDC 63739099210
Hospital Charge Code	63739099210
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.22

METHOCARBAMOL 750 MG PO TABS [4972]

Facility

$0.73

Service Code	NDC 76385012401
Hospital Charge Code	76385012401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Brighton Health Commercial	$0.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.49
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	$0.47

METHOCARBAMOL 750 MG PO TABS [4972]

Facility

$0.73

Service Code	NDC 70010077001
Hospital Charge Code	70010077001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Brighton Health Commercial	$0.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.49
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	$0.47

METHOCARBAMOL 750 MG PO TABS [4972]

Facility

$0.39

Service Code	NDC 00904705861
Hospital Charge Code	00904705861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.26
Rate for Payer: Group Health Inc Commercial	$0.19
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19
Rate for Payer: Hamaspik Choice Inc Medicare	$0.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

METHOCARBAMOL 750 MG PO TABS [4972]

Facility

$0.37

Service Code	NDC 60687056801
Hospital Charge Code	60687056801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.19
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19
Rate for Payer: Hamaspik Choice Inc Medicare	$0.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.24

METHOCARBAMOL 750 MG TAB

Facility

$1.00

Hospital Charge Code	41654816
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

METHOCARBAMOL 750 MG TAB

Facility

$1.00

Hospital Charge Code	41644816
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

METHODONE 10MG TABLET

Facility

$0.14

Service Code	HCPCS J1230
Hospital Charge Code	41648423
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

METHODONE 10MG TABLET

Facility

$0.14

Service Code	HCPCS J1230
Hospital Charge Code	41648423
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$21.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.80
Rate for Payer: Aetna Government	$17.80
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21.84
Rate for Payer: SOMOS Essential	$21.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

METHODONE HCL (DETOX) 5MG TAB

Facility

$0.44

Hospital Charge Code	41651352
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.22
Rate for Payer: Aetna Government	$0.22
Rate for Payer: Brighton Health Commercial	$0.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: Group Health Inc Commercial	$0.22
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

METHOTREXATE 25 MG/ML INJ 2 ML PF

Facility

$0.44

Service Code	HCPCS J9250
Hospital Charge Code	41654616
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22

METHOTREXATE 25 MG/ML INJ 2 ML PF

Facility

$0.44

Service Code	HCPCS J9250
Hospital Charge Code	41644616
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.22
Rate for Payer: Aetna Government	$0.22
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.22
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

METHOTREXATE 25 MG/ML INJ 2 ML PF

Facility

$0.44

Service Code	HCPCS J9250
Hospital Charge Code	41644616
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22

METHOTREXATE 25 MG/ML INJ 2 ML PF

Facility

$0.44

Service Code	HCPCS J9250
Hospital Charge Code	41654616
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.22
Rate for Payer: Aetna Government	$0.22
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.22
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

Know your out-of-pocket cost for care.

All Charges