St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MONSELS SOL 450ML

Facility

$127.00

Hospital Charge Code	41647181
Hospital Revenue Code	250
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$101.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$69.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$63.50
Rate for Payer: Aetna Government	$63.50
Rate for Payer: Brighton Health Commercial	$95.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$101.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$86.36
Rate for Payer: Group Health Inc Commercial	$63.50
Rate for Payer: Group Health Inc Medicare	$44.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$63.50
Rate for Payer: Hamaspik Choice Inc Medicare	$63.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$82.55

MONSELS SOL 450ML

Facility

$127.00

Hospital Charge Code	41657181
Hospital Revenue Code	250
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$101.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$69.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$63.50
Rate for Payer: Aetna Government	$63.50
Rate for Payer: Brighton Health Commercial	$95.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$101.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$86.36
Rate for Payer: Group Health Inc Commercial	$63.50
Rate for Payer: Group Health Inc Medicare	$44.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$63.50
Rate for Payer: Hamaspik Choice Inc Medicare	$63.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$82.55

MONTELUKAST 10 MG TAB

Facility

$10.37

Hospital Charge Code	41652005
Hospital Revenue Code	250
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$8.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.18
Rate for Payer: Aetna Government	$5.18
Rate for Payer: Brighton Health Commercial	$7.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.05
Rate for Payer: Group Health Inc Commercial	$5.18
Rate for Payer: Group Health Inc Medicare	$3.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.18
Rate for Payer: Hamaspik Choice Inc Medicare	$5.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.74

MONTELUKAST 10 MG TAB

Facility

$10.37

Hospital Charge Code	41642005
Hospital Revenue Code	250
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$8.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.18
Rate for Payer: Aetna Government	$5.18
Rate for Payer: Brighton Health Commercial	$7.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.05
Rate for Payer: Group Health Inc Commercial	$5.18
Rate for Payer: Group Health Inc Medicare	$3.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.18
Rate for Payer: Hamaspik Choice Inc Medicare	$5.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.74

MONTELUKAST 4 MG CHEW TAB

Facility

$9.00

Hospital Charge Code	41642485
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$7.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.50
Rate for Payer: Aetna Government	$4.50
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

MONTELUKAST 4 MG CHEW TAB

Facility

$9.00

Hospital Charge Code	41652485
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$7.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.50
Rate for Payer: Aetna Government	$4.50
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

MONTELUKAST 5 MG CHEW TAB

Facility

$9.00

Hospital Charge Code	41652268
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$7.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.50
Rate for Payer: Aetna Government	$4.50
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

MONTELUKAST 5 MG CHEW TAB

Facility

$9.00

Hospital Charge Code	41642268
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$7.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.50
Rate for Payer: Aetna Government	$4.50
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.03

Service Code	NDC 13668008190
Hospital Charge Code	13668008190
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.51
Rate for Payer: Aetna Government	$2.51
Rate for Payer: Brighton Health Commercial	$3.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.42
Rate for Payer: Group Health Inc Commercial	$2.51
Rate for Payer: Group Health Inc Medicare	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.51
Rate for Payer: Hamaspik Choice Inc Medicare	$2.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.27

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.66

Service Code	NDC 16729011917
Hospital Charge Code	16729011917
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$0.40

Service Code	NDC 00904680861
Hospital Charge Code	00904680861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.20
Rate for Payer: Aetna Government	$0.20
Rate for Payer: Brighton Health Commercial	$0.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.26

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.65

Service Code	NDC 65862057490
Hospital Charge Code	65862057490
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.82
Rate for Payer: Aetna Government	$2.82
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.84
Rate for Payer: Group Health Inc Commercial	$2.82
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.82
Rate for Payer: Hamaspik Choice Inc Medicare	$2.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.67

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.66

Service Code	NDC 55111072510
Hospital Charge Code	55111072510
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.66

Service Code	NDC 16729011910
Hospital Charge Code	16729011910
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

MONTELUKAST SODIUM 10 MG PO TABS [22509]

Facility

$5.66

Service Code	NDC 31722072630
Hospital Charge Code	31722072630
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

MONTELUKAST SODIUM 4 MG PO CHEW [27234]

Facility

$5.03

Service Code	NDC 33342011007
Hospital Charge Code	33342011007
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.51
Rate for Payer: Aetna Government	$2.51
Rate for Payer: Brighton Health Commercial	$3.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.42
Rate for Payer: Group Health Inc Commercial	$2.51
Rate for Payer: Group Health Inc Medicare	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.51
Rate for Payer: Hamaspik Choice Inc Medicare	$2.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.27

MONTELUKAST SODIUM 4 MG PO CHEW [27234]

Facility

$5.03

Service Code	NDC 13668007930
Hospital Charge Code	13668007930
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.51
Rate for Payer: Aetna Government	$2.51
Rate for Payer: Brighton Health Commercial	$3.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.42
Rate for Payer: Group Health Inc Commercial	$2.51
Rate for Payer: Group Health Inc Medicare	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.51
Rate for Payer: Hamaspik Choice Inc Medicare	$2.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.27

MONTELUKAST SODIUM 4 MG PO CHEW [27234]

Facility

$5.66

Service Code	NDC 31722072730
Hospital Charge Code	31722072730
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

MONTELUKAST SODIUM 4 MG PO CHEW [27234]

Facility

$3.66

Service Code	NDC 50268057311
Hospital Charge Code	50268057311
Hospital Revenue Code	250
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$2.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.83
Rate for Payer: Aetna Government	$1.83
Rate for Payer: Brighton Health Commercial	$2.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.49
Rate for Payer: Group Health Inc Commercial	$1.83
Rate for Payer: Group Health Inc Medicare	$1.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.83
Rate for Payer: Hamaspik Choice Inc Medicare	$1.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.38

MONTELUKAST SODIUM 5 MG PO CHEW [22510]

Facility

$4.11

Service Code	NDC 50268057415
Hospital Charge Code	50268057415
Hospital Revenue Code	250
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.05
Rate for Payer: Aetna Government	$2.05
Rate for Payer: Brighton Health Commercial	$3.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.79
Rate for Payer: Group Health Inc Commercial	$2.05
Rate for Payer: Group Health Inc Medicare	$1.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.05
Rate for Payer: Hamaspik Choice Inc Medicare	$2.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.67

MONTELUKAST SODIUM 5 MG PO CHEW [22510]

Facility

$5.03

Service Code	NDC 57237021330
Hospital Charge Code	57237021330
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.51
Rate for Payer: Aetna Government	$2.51
Rate for Payer: Brighton Health Commercial	$3.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.42
Rate for Payer: Group Health Inc Commercial	$2.51
Rate for Payer: Group Health Inc Medicare	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.51
Rate for Payer: Hamaspik Choice Inc Medicare	$2.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.27

MONTELUKAST SODIUM 5 MG PO CHEW [22510]

Facility

$5.03

Service Code	NDC 33342011110
Hospital Charge Code	33342011110
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.51
Rate for Payer: Aetna Government	$2.51
Rate for Payer: Brighton Health Commercial	$3.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.42
Rate for Payer: Group Health Inc Commercial	$2.51
Rate for Payer: Group Health Inc Medicare	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.51
Rate for Payer: Hamaspik Choice Inc Medicare	$2.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.27

MONTGOMERY STRAP

Facility

$6.73

Hospital Charge Code	40203917
Hospital Revenue Code	270
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$5.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.36
Rate for Payer: Aetna Government	$3.36
Rate for Payer: Brighton Health Commercial	$5.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.58
Rate for Payer: Group Health Inc Commercial	$3.36
Rate for Payer: Group Health Inc Medicare	$2.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.36
Rate for Payer: Hamaspik Choice Inc Medicare	$3.36

MOPATH PROCDURE LEVEL 2

Facility

$342.50

Service Code	HCPCS 81401
Hospital Charge Code	40609902
Hospital Revenue Code	310
Rate for Payer: Cash Price	$137.00

MOPATH PROCDURE LEVEL 2

Facility

$342.50

Service Code	HCPCS 81401
Hospital Charge Code	40609902
Hospital Revenue Code	310
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$274.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$188.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$137.00
Rate for Payer: Aetna Government	$137.00
Rate for Payer: Affinity Essential Plan 1&2	$95.90
Rate for Payer: Affinity Essential Plan 3&4	$95.90
Rate for Payer: Affinity Medicaid/CHP/HARP	$95.90
Rate for Payer: Brighton Health Commercial	$137.00
Rate for Payer: Cash Price	$137.00
Rate for Payer: Cash Price	$137.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$137.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$274.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$232.90
Rate for Payer: Elderplan Medicare Advantage	$137.00
Rate for Payer: EmblemHealth Commercial	$137.00
Rate for Payer: Fidelis Essential Plan Aliesa	$116.45
Rate for Payer: Fidelis Essential Plan QHP	$121.93
Rate for Payer: Fidelis Medicare Advantage	$137.00
Rate for Payer: Fidelis Qualified Health Plan	$121.93
Rate for Payer: Group Health Inc Commercial	$137.00
Rate for Payer: Group Health Inc Medicare	$137.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$171.25
Rate for Payer: Hamaspik Choice Inc Medicare	$137.00
Rate for Payer: Healthfirst Medicare Advantage	$137.00
Rate for Payer: Healthfirst QHP	$137.00
Rate for Payer: Humana Medicare	$139.74
Rate for Payer: Senior Whole Health Medicare Advantage	$137.00
Rate for Payer: United Healthcare Medicare Advantage	$137.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$137.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$109.60
Rate for Payer: Wellcare Medicare	$123.30

Know your out-of-pocket cost for care.

All Charges