St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MIDAZOLAM HCL 50 MG/10ML IJ SOLN [93523]

Facility

$0.83

Service Code	HCPCS J2250
Hospital Charge Code	00641606001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

MIDAZOLAM HCL 50 MG/10ML IJ SOLN [93523]

Facility

$0.83

Service Code	HCPCS J2250
Hospital Charge Code	00641606010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

MIDAZOLAM HCL 50 MG/10ML IJ SOLN [93523]

Facility

$0.71

Service Code	HCPCS J2250
Hospital Charge Code	72611074910
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
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	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

MIDAZOLAM HCL 5 MG/ML IJ SOLN [10608]

Facility

$1.44

Service Code	HCPCS J2250
Hospital Charge Code	00641606125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$1.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.98
Rate for Payer: Group Health Inc Commercial	$0.72
Rate for Payer: Group Health Inc Medicare	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.72
Rate for Payer: Hamaspik Choice Inc Medicare	$0.72
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.94

MIDAZOLAM HCL 5 MG/ML IJ SOLN [10608]

Facility

$3.91

Service Code	HCPCS J2250
Hospital Charge Code	63323041225
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$3.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$2.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.66
Rate for Payer: Group Health Inc Commercial	$1.96
Rate for Payer: Group Health Inc Medicare	$1.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.96
Rate for Payer: Hamaspik Choice Inc Medicare	$1.96
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.54

MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN [168903]

Facility

$0.64

Service Code	HCPCS J2250
Hospital Charge Code	00409230516
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: Group Health Inc Commercial	$0.32
Rate for Payer: Group Health Inc Medicare	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.32
Rate for Payer: Hamaspik Choice Inc Medicare	$0.32
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

MIDAZOLAM HCL (PF) 5 MG/5ML IJ SOLN [168904]

Facility

$0.27

Service Code	HCPCS J2250
Hospital Charge Code	00409230505
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.19
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN [168902]

Facility

$1.39

Service Code	HCPCS J2250
Hospital Charge Code	00409230821
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$1.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.95
Rate for Payer: Group Health Inc Commercial	$0.70
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.90

MIDAZOLAM INJ 10MG/2ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41645915
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

MIDAZOLAM INJ 10MG/2ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41645915
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

MIDAZOLAM INJ 10MG/2ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41655915
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

MIDAZOLAM INJ 10MG/2ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41655915
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

MIDAZOLAM INTRANASAL 5MG/ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41655913
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

MIDAZOLAM INTRANASAL 5MG/ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41655913
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

MIDAZOLAM INTRANASAL 5MG/ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41645913
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

MIDAZOLAM INTRANASAL 5MG/ML-1MG

Facility

$1.00

Service Code	HCPCS J2250
Hospital Charge Code	41645913
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN [177599]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	44567061110
Hospital Revenue Code	278
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.28
Rate for Payer: Aetna Government	$0.28
Rate for Payer: Brighton Health Commercial	$0.22
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.21
Rate for Payer: Elderplan Medicare Advantage	$0.28
Rate for Payer: EmblemHealth Commercial	$0.18
Rate for Payer: Fidelis Medicare Advantage	$0.28
Rate for Payer: Group Health Inc Commercial	$0.28
Rate for Payer: Group Health Inc Medicare	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: Healthfirst Medicare Advantage	$0.24
Rate for Payer: Healthfirst QHP	$0.28
Rate for Payer: Humana Medicare	$0.29
Rate for Payer: Senior Whole Health Medicare Advantage	$0.28
Rate for Payer: United Healthcare Medicare Advantage	$0.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23
Rate for Payer: Wellcare CHP/FHP/Medicaid	$0.23

MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN [177599]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	44567061101
Hospital Revenue Code	278
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.28
Rate for Payer: Aetna Government	$0.28
Rate for Payer: Brighton Health Commercial	$0.22
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.21
Rate for Payer: Elderplan Medicare Advantage	$0.28
Rate for Payer: EmblemHealth Commercial	$0.18
Rate for Payer: Fidelis Medicare Advantage	$0.28
Rate for Payer: Group Health Inc Commercial	$0.28
Rate for Payer: Group Health Inc Medicare	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: Healthfirst Medicare Advantage	$0.24
Rate for Payer: Healthfirst QHP	$0.28
Rate for Payer: Humana Medicare	$0.29
Rate for Payer: Senior Whole Health Medicare Advantage	$0.28
Rate for Payer: United Healthcare Medicare Advantage	$0.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23
Rate for Payer: Wellcare CHP/FHP/Medicaid	$0.23

MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN [177599]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	44567061110
Hospital Revenue Code	278
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18

MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN [177599]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	44567061101
Hospital Revenue Code	278
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18

MIDFACE INFLAY MOD MESH HALF SIZE

Facility

$332.00

Service Code	HCPCS C1781
Hospital Charge Code	40201239
Hospital Revenue Code	278
Min. Negotiated Rate	$166.00
Max. Negotiated Rate	$166.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$166.00
Rate for Payer: Hamaspik Choice Inc Medicare	$166.00

MIDFACE INFLAY MOD MESH HALF SIZE

Facility

$332.00

Service Code	HCPCS C1781
Hospital Charge Code	40201239
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$348.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$182.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Brighton Health Commercial	$199.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$166.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$190.90
Rate for Payer: EmblemHealth Commercial	$166.00
Rate for Payer: Fidelis Medicare Advantage	$348.60
Rate for Payer: Group Health Inc Commercial	$166.00
Rate for Payer: Group Health Inc Medicare	$116.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$166.00
Rate for Payer: Hamaspik Choice Inc Medicare	$166.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$215.80

MIDFACE INFLAY MOD,STD FULL SIZE

Facility

$760.00

Service Code	HCPCS C1713
Hospital Charge Code	40201241
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$798.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$418.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$456.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$380.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$437.00
Rate for Payer: EmblemHealth Commercial	$380.00
Rate for Payer: Fidelis Medicare Advantage	$798.00
Rate for Payer: Group Health Inc Commercial	$380.00
Rate for Payer: Group Health Inc Medicare	$266.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$380.00
Rate for Payer: Hamaspik Choice Inc Medicare	$380.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$494.00

MIDFACE INFLAY MOD,STD FULL SIZE

Facility

$760.00

Service Code	HCPCS C1713
Hospital Charge Code	40201241
Hospital Revenue Code	278
Min. Negotiated Rate	$380.00
Max. Negotiated Rate	$380.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$380.00
Rate for Payer: Hamaspik Choice Inc Medicare	$380.00

MIDFACE INFLAY MOD,STD HALF SIZE

Facility

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	40201242
Hospital Revenue Code	278
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$399.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$228.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.50
Rate for Payer: EmblemHealth Commercial	$190.00
Rate for Payer: Fidelis Medicare Advantage	$399.00
Rate for Payer: Group Health Inc Commercial	$190.00
Rate for Payer: Group Health Inc Medicare	$133.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$247.00

Know your out-of-pocket cost for care.

All Charges