St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MINOR SKIN DISORDERS WITH MCC

Facility

$40,313.25

Service Code	MSDRG 606
Min. Negotiated Rate	$13,598.20
Max. Negotiated Rate	$40,313.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23,382.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29,318.73
Rate for Payer: Aetna Government	$29,318.73
Rate for Payer: Brighton Health Commercial	$22,994.10
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29,905.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27,385.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$22,599.43
Rate for Payer: Elderplan Medicare Advantage	$27,852.79
Rate for Payer: EmblemHealth Commercial	$13,598.20
Rate for Payer: Fidelis Medicare Advantage	$29,318.73
Rate for Payer: Group Health Inc Commercial	$29,318.73
Rate for Payer: Group Health Inc Medicare	$29,318.73
Rate for Payer: Hamaspik Choice Inc Medicare	$29,318.73
Rate for Payer: Healthfirst Medicare Advantage	$13,633.21
Rate for Payer: Humana Medicare	$40,313.25
Rate for Payer: Senior Whole Health Medicare Advantage	$29,318.73
Rate for Payer: United Healthcare Commercial	$31,536.80
Rate for Payer: United Healthcare Medicare Advantage	$29,318.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29,318.73
Rate for Payer: Wellcare Medicare	$27,852.79

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$27,112.72

Service Code	MSDRG 607
Min. Negotiated Rate	$7,661.76
Max. Negotiated Rate	$27,112.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13,174.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19,718.34
Rate for Payer: Aetna Government	$19,718.34
Rate for Payer: Brighton Health Commercial	$12,955.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20,112.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15,429.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,733.38
Rate for Payer: Elderplan Medicare Advantage	$18,732.42
Rate for Payer: EmblemHealth Commercial	$7,661.76
Rate for Payer: Fidelis Medicare Advantage	$19,718.34
Rate for Payer: Group Health Inc Commercial	$19,718.34
Rate for Payer: Group Health Inc Medicare	$19,718.34
Rate for Payer: Hamaspik Choice Inc Medicare	$19,718.34
Rate for Payer: Healthfirst Medicare Advantage	$9,169.03
Rate for Payer: Humana Medicare	$27,112.72
Rate for Payer: Senior Whole Health Medicare Advantage	$19,718.34
Rate for Payer: United Healthcare Commercial	$17,769.03
Rate for Payer: United Healthcare Medicare Advantage	$19,718.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$19,718.34
Rate for Payer: Wellcare Medicare	$18,732.42

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$39,451.40

Service Code	MSDRG 345
Min. Negotiated Rate	$13,210.60
Max. Negotiated Rate	$39,451.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22,716.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28,691.93
Rate for Payer: Aetna Government	$28,691.93
Rate for Payer: Brighton Health Commercial	$22,338.70
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$29,265.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26,604.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$21,955.28
Rate for Payer: Elderplan Medicare Advantage	$27,257.33
Rate for Payer: EmblemHealth Commercial	$13,210.60
Rate for Payer: Fidelis Medicare Advantage	$28,691.93
Rate for Payer: Group Health Inc Commercial	$28,691.93
Rate for Payer: Group Health Inc Medicare	$28,691.93
Rate for Payer: Hamaspik Choice Inc Medicare	$28,691.93
Rate for Payer: Healthfirst Medicare Advantage	$13,341.75
Rate for Payer: Humana Medicare	$39,451.40
Rate for Payer: Senior Whole Health Medicare Advantage	$28,691.93
Rate for Payer: United Healthcare Commercial	$30,637.91
Rate for Payer: United Healthcare Medicare Advantage	$28,691.93
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28,691.93
Rate for Payer: Wellcare Medicare	$27,257.33

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$62,328.76

Service Code	MSDRG 344
Min. Negotiated Rate	$21,078.45
Max. Negotiated Rate	$62,328.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40,407.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45,330.01
Rate for Payer: Aetna Government	$45,330.01
Rate for Payer: Brighton Health Commercial	$39,735.80
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$46,236.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47,323.97
Rate for Payer: Cigna LocalPlus Benefit Plan	$39,053.77
Rate for Payer: Elderplan Medicare Advantage	$43,063.51
Rate for Payer: EmblemHealth Commercial	$23,498.90
Rate for Payer: Fidelis Medicare Advantage	$45,330.01
Rate for Payer: Group Health Inc Commercial	$45,330.01
Rate for Payer: Group Health Inc Medicare	$45,330.01
Rate for Payer: Hamaspik Choice Inc Medicare	$45,330.01
Rate for Payer: Healthfirst Medicare Advantage	$21,078.45
Rate for Payer: Humana Medicare	$62,328.76
Rate for Payer: Senior Whole Health Medicare Advantage	$45,330.01
Rate for Payer: United Healthcare Commercial	$54,498.33
Rate for Payer: United Healthcare Medicare Advantage	$45,330.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45,330.01
Rate for Payer: Wellcare Medicare	$43,063.51

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$34,631.11

Service Code	MSDRG 346
Min. Negotiated Rate	$11,042.90
Max. Negotiated Rate	$34,631.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18,988.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25,186.26
Rate for Payer: Aetna Government	$25,186.26
Rate for Payer: Brighton Health Commercial	$18,673.10
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$25,689.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22,239.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$18,352.59
Rate for Payer: Elderplan Medicare Advantage	$23,926.95
Rate for Payer: EmblemHealth Commercial	$11,042.90
Rate for Payer: Fidelis Medicare Advantage	$25,186.26
Rate for Payer: Group Health Inc Commercial	$25,186.26
Rate for Payer: Group Health Inc Medicare	$25,186.26
Rate for Payer: Hamaspik Choice Inc Medicare	$25,186.26
Rate for Payer: Healthfirst Medicare Advantage	$11,711.61
Rate for Payer: Humana Medicare	$34,631.11
Rate for Payer: Senior Whole Health Medicare Advantage	$25,186.26
Rate for Payer: United Healthcare Commercial	$25,610.48
Rate for Payer: United Healthcare Medicare Advantage	$25,186.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25,186.26
Rate for Payer: Wellcare Medicare	$23,926.95

MINOR WOUND REPAIR

Facility

$541.60

Service Code	HCPCS 12001
Hospital Charge Code	30302056
Hospital Revenue Code	510
Min. Negotiated Rate	$162.06
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$231.52
Rate for Payer: Aetna Government	$231.52
Rate for Payer: Affinity Essential Plan 1&2	$162.06
Rate for Payer: Affinity Essential Plan 3&4	$162.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$162.06
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Cash Price	$231.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$231.52
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	$231.52
Rate for Payer: Fidelis Essential Plan Aliesa	$196.79
Rate for Payer: Fidelis Essential Plan QHP	$206.05
Rate for Payer: Fidelis Medicare Advantage	$231.52
Rate for Payer: Fidelis Qualified Health Plan	$206.05
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	$270.80
Rate for Payer: Hamaspik Choice Inc Medicare	$231.52
Rate for Payer: Healthfirst Medicare Advantage	$196.79
Rate for Payer: Healthfirst QHP	$231.52
Rate for Payer: Humana Medicare	$236.15
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$231.52
Rate for Payer: Senior Whole Health Medicare Advantage	$231.52
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$231.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$231.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$185.22
Rate for Payer: Wellcare Medicare	$219.94

MINOR WOUND REPAIR

Facility

$541.60

Service Code	HCPCS 12001
Hospital Charge Code	30302056
Hospital Revenue Code	510
Rate for Payer: Cash Price	$231.52

MINOXIDIL 10 MG PO TABS [5114]

Facility

$2.12

Service Code	NDC 68084020501
Hospital Charge Code	68084020501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.44
Rate for Payer: Group Health Inc Commercial	$1.06
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.38

MINOXIDIL 10 MG PO TABS [5114]

Facility

$2.12

Service Code	NDC 68084020511
Hospital Charge Code	68084020511
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.44
Rate for Payer: Group Health Inc Commercial	$1.06
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.38

MINOXIDIL 10 MG TAB

Facility

$0.47

Hospital Charge Code	41643288
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
Rate for Payer: Brighton Health Commercial	$0.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.32
Rate for Payer: Group Health Inc Commercial	$0.24
Rate for Payer: Group Health Inc Medicare	$0.16
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	$0.31

MINOXIDIL 10 MG TAB

Facility

$0.47

Hospital Charge Code	41653288
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
Rate for Payer: Brighton Health Commercial	$0.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.32
Rate for Payer: Group Health Inc Commercial	$0.24
Rate for Payer: Group Health Inc Medicare	$0.16
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	$0.31

MINOXIDIL 2.5 MG PO TABS [5115]

Facility

$0.78

Service Code	NDC 49884025601
Hospital Charge Code	49884025601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.39
Rate for Payer: Aetna Government	$0.39
Rate for Payer: Brighton Health Commercial	$0.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.53
Rate for Payer: Group Health Inc Commercial	$0.39
Rate for Payer: Group Health Inc Medicare	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39
Rate for Payer: Hamaspik Choice Inc Medicare	$0.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.51

MINOXIDIL 2.5 MG PO TABS [5115]

Facility

$1.70

Service Code	NDC 68084020401
Hospital Charge Code	68084020401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.85
Rate for Payer: Aetna Government	$0.85
Rate for Payer: Brighton Health Commercial	$1.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.15
Rate for Payer: Group Health Inc Commercial	$0.85
Rate for Payer: Group Health Inc Medicare	$0.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.85
Rate for Payer: Hamaspik Choice Inc Medicare	$0.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.10

MINOXIDIL 2.5 MG PO TABS [5115]

Facility

$1.70

Service Code	NDC 68084020411
Hospital Charge Code	68084020411
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.85
Rate for Payer: Aetna Government	$0.85
Rate for Payer: Brighton Health Commercial	$1.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.15
Rate for Payer: Group Health Inc Commercial	$0.85
Rate for Payer: Group Health Inc Medicare	$0.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.85
Rate for Payer: Hamaspik Choice Inc Medicare	$0.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.10

MINOXIDIL 2.5 MG TAB

Facility

$0.26

Hospital Charge Code	41643406
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
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	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

MINOXIDIL 2.5 MG TAB

Facility

$0.26

Hospital Charge Code	41653406
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
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	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

MIP

Facility

$166.60

Service Code	HCPCS 94200 TC
Hospital Charge Code	40402911
Hospital Revenue Code	460
Rate for Payer: Cash Price	$70.74

MIP

Facility

$166.60

Service Code	HCPCS 94200 TC
Hospital Charge Code	40402911
Hospital Revenue Code	460
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$133.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.74
Rate for Payer: Aetna Government	$70.74
Rate for Payer: Affinity Essential Plan 1&2	$49.52
Rate for Payer: Affinity Essential Plan 3&4	$49.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.52
Rate for Payer: Brighton Health Commercial	$124.95
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$133.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$113.29
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: EmblemHealth Commercial	$70.74
Rate for Payer: Fidelis Essential Plan Aliesa	$60.13
Rate for Payer: Fidelis Essential Plan QHP	$62.96
Rate for Payer: Fidelis Medicare Advantage	$70.74
Rate for Payer: Fidelis Qualified Health Plan	$62.96
Rate for Payer: Group Health Inc Commercial	$70.74
Rate for Payer: Group Health Inc Medicare	$70.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
Rate for Payer: Hamaspik Choice Inc Medicare	$70.74
Rate for Payer: Healthfirst Medicare Advantage	$60.13
Rate for Payer: Healthfirst QHP	$70.74
Rate for Payer: Humana Medicare	$72.15
Rate for Payer: Senior Whole Health Medicare Advantage	$70.74
Rate for Payer: United Healthcare Commercial	$83.30
Rate for Payer: United Healthcare Medicare Advantage	$70.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.59
Rate for Payer: Wellcare Medicare	$67.20

MIRENA IUD

Facility

$283.00

Service Code	HCPCS J7298
Hospital Charge Code	30301401
Hospital Revenue Code	636
Min. Negotiated Rate	$99.05
Max. Negotiated Rate	$999.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$155.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$999.28
Rate for Payer: Aetna Government	$999.28
Rate for Payer: Brighton Health Commercial	$169.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$141.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$162.72
Rate for Payer: Group Health Inc Commercial	$141.50
Rate for Payer: Group Health Inc Medicare	$99.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.50
Rate for Payer: Hamaspik Choice Inc Medicare	$141.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$183.95

MIRENA IUD

Facility

$283.00

Service Code	HCPCS J7298
Hospital Charge Code	30301401
Hospital Revenue Code	636
Min. Negotiated Rate	$141.50
Max. Negotiated Rate	$141.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.50
Rate for Payer: Hamaspik Choice Inc Medicare	$141.50

MIRTAZAPINE 15 MG PO TABS [17466]

Facility

$2.70

Service Code	NDC 57237000830
Hospital Charge Code	57237000830
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

MIRTAZAPINE 15 MG PO TABS [17466]

Facility

$1.05

Service Code	NDC 68084011901
Hospital Charge Code	68084011901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.52
Rate for Payer: Aetna Government	$0.52
Rate for Payer: Brighton Health Commercial	$0.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.71
Rate for Payer: Group Health Inc Commercial	$0.52
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.68

MIRTAZAPINE 15 MG PO TABS [17466]

Facility

$2.86

Service Code	NDC 00904651961
Hospital Charge Code	00904651961
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.43
Rate for Payer: Aetna Government	$1.43
Rate for Payer: Brighton Health Commercial	$2.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.94
Rate for Payer: Group Health Inc Commercial	$1.43
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.43
Rate for Payer: Hamaspik Choice Inc Medicare	$1.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.86

MIRTAZAPINE 15 MG PO TABS [17466]

Facility

$2.70

Service Code	NDC 57237000805
Hospital Charge Code	57237000805
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

MIRTAZAPINE 15 MG PO TABS [17466]

Facility

$2.72

Service Code	NDC 57664049983
Hospital Charge Code	57664049983
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.36
Rate for Payer: Aetna Government	$1.36
Rate for Payer: Brighton Health Commercial	$2.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.85
Rate for Payer: Group Health Inc Commercial	$1.36
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.36
Rate for Payer: Hamaspik Choice Inc Medicare	$1.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

Know your out-of-pocket cost for care.

All Charges