St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MUPIROCIN 2% OINT 22 GRAMS

Facility

$19.00

Hospital Charge Code	41652790
Hospital Revenue Code	250
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$15.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.50
Rate for Payer: Aetna Government	$9.50
Rate for Payer: Brighton Health Commercial	$14.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.92
Rate for Payer: Group Health Inc Commercial	$9.50
Rate for Payer: Group Health Inc Medicare	$6.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.50
Rate for Payer: Hamaspik Choice Inc Medicare	$9.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.35

MURPHY DRIP TRAY

Facility

$40.40

Hospital Charge Code	40203920
Hospital Revenue Code	270
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$32.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.20
Rate for Payer: Aetna Government	$20.20
Rate for Payer: Brighton Health Commercial	$30.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.47
Rate for Payer: Group Health Inc Commercial	$20.20
Rate for Payer: Group Health Inc Medicare	$14.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.20
Rate for Payer: Hamaspik Choice Inc Medicare	$20.20

MUSCLE/SKIN GRAFT HEAD/NECK

Facility

$9,017.48

Service Code	HCPCS 15733
Hospital Charge Code	40019444
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,148.81

MUSCLE/SKIN GRAFT HEAD/NECK

Facility

$9,017.48

Service Code	HCPCS 15733
Hospital Charge Code	40019444
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$6,763.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,148.81
Rate for Payer: Aetna Government	$4,148.81
Rate for Payer: Affinity Essential Plan 1&2	$2,904.17
Rate for Payer: Affinity Essential Plan 3&4	$2,904.17
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,904.17
Rate for Payer: Brighton Health Commercial	$6,763.11
Rate for Payer: Cash Price	$4,148.81
Rate for Payer: Cash Price	$4,148.81
Rate for Payer: Cash Price	$4,148.81
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,148.81
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	$4,148.81
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,526.49
Rate for Payer: Fidelis Essential Plan QHP	$3,692.44
Rate for Payer: Fidelis Medicare Advantage	$4,148.81
Rate for Payer: Fidelis Qualified Health Plan	$3,692.44
Rate for Payer: Group Health Inc Commercial	$4,148.81
Rate for Payer: Group Health Inc Medicare	$4,148.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,508.74
Rate for Payer: Hamaspik Choice Inc Medicare	$4,148.81
Rate for Payer: Healthfirst Medicare Advantage	$3,526.49
Rate for Payer: Healthfirst QHP	$4,148.81
Rate for Payer: Humana Medicare	$4,231.79
Rate for Payer: Senior Whole Health Medicare Advantage	$4,148.81
Rate for Payer: United Healthcare Commercial	$1,835.00
Rate for Payer: United Healthcare Medicare Advantage	$4,148.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,148.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,319.05
Rate for Payer: Wellcare Medicare	$3,941.37

MYCOBACTERIC IDENTIFICATION

Facility

$36.53

Service Code	HCPCS 87118
Hospital Charge Code	40614323
Hospital Revenue Code	300
Rate for Payer: Cash Price	$14.61

MYCOBACTERIC IDENTIFICATION

Facility

$36.53

Service Code	HCPCS 87118
Hospital Charge Code	40614323
Hospital Revenue Code	300
Min. Negotiated Rate	$10.23
Max. Negotiated Rate	$27.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.61
Rate for Payer: Aetna Government	$14.61
Rate for Payer: Affinity Essential Plan 1&2	$10.23
Rate for Payer: Affinity Essential Plan 3&4	$10.23
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.23
Rate for Payer: Brighton Health Commercial	$27.40
Rate for Payer: Cash Price	$14.61
Rate for Payer: Cash Price	$14.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$14.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.72
Rate for Payer: Elderplan Medicare Advantage	$14.61
Rate for Payer: EmblemHealth Commercial	$14.61
Rate for Payer: Fidelis Essential Plan Aliesa	$12.42
Rate for Payer: Fidelis Essential Plan QHP	$13.00
Rate for Payer: Fidelis Medicare Advantage	$14.61
Rate for Payer: Fidelis Qualified Health Plan	$13.00
Rate for Payer: Group Health Inc Commercial	$14.61
Rate for Payer: Group Health Inc Medicare	$14.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.26
Rate for Payer: Hamaspik Choice Inc Medicare	$14.61
Rate for Payer: Healthfirst Medicare Advantage	$14.61
Rate for Payer: Healthfirst QHP	$14.61
Rate for Payer: Humana Medicare	$14.90
Rate for Payer: Senior Whole Health Medicare Advantage	$14.61
Rate for Payer: United Healthcare Commercial	$13.86
Rate for Payer: United Healthcare Medicare Advantage	$14.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.69
Rate for Payer: Wellcare Medicare	$13.15

MYCOBACTERIUM BOVIS

Facility

$280.00

Hospital Charge Code	64902727
Hospital Revenue Code	270
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$224.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$140.00
Rate for Payer: Aetna Government	$140.00
Rate for Payer: Brighton Health Commercial	$210.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$190.40
Rate for Payer: Group Health Inc Commercial	$140.00
Rate for Payer: Group Health Inc Medicare	$98.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.00
Rate for Payer: Hamaspik Choice Inc Medicare	$140.00

MYCOBACTERIUM KANSAII

Facility

$174.78

Hospital Charge Code	64902733
Hospital Revenue Code	270
Min. Negotiated Rate	$61.17
Max. Negotiated Rate	$139.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$96.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$87.39
Rate for Payer: Aetna Government	$87.39
Rate for Payer: Brighton Health Commercial	$131.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$139.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$118.85
Rate for Payer: Group Health Inc Commercial	$87.39
Rate for Payer: Group Health Inc Medicare	$61.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$87.39
Rate for Payer: Hamaspik Choice Inc Medicare	$87.39

MYCOBACTERIUM KANSASII

Facility

$416.25

Hospital Charge Code	64902775
Hospital Revenue Code	270
Min. Negotiated Rate	$145.69
Max. Negotiated Rate	$333.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$208.12
Rate for Payer: Aetna Government	$208.12
Rate for Payer: Brighton Health Commercial	$312.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$333.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$283.05
Rate for Payer: Group Health Inc Commercial	$208.12
Rate for Payer: Group Health Inc Medicare	$145.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$208.12
Rate for Payer: Hamaspik Choice Inc Medicare	$208.12

MYCOBACTERIUM TB/RIFAMPIN PCR-SBH

Facility

$104.20

Service Code	HCPCS 87556
Hospital Charge Code	40614109
Hospital Revenue Code	306
Min. Negotiated Rate	$29.18
Max. Negotiated Rate	$78.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$41.68
Rate for Payer: Aetna Government	$41.68
Rate for Payer: Affinity Essential Plan 1&2	$29.18
Rate for Payer: Affinity Essential Plan 3&4	$29.18
Rate for Payer: Affinity Medicaid/CHP/HARP	$29.18
Rate for Payer: Brighton Health Commercial	$78.15
Rate for Payer: Cash Price	$41.68
Rate for Payer: Cash Price	$41.68
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$41.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.20
Rate for Payer: Elderplan Medicare Advantage	$41.68
Rate for Payer: EmblemHealth Commercial	$41.68
Rate for Payer: Fidelis Essential Plan Aliesa	$35.43
Rate for Payer: Fidelis Essential Plan QHP	$37.10
Rate for Payer: Fidelis Medicare Advantage	$41.68
Rate for Payer: Fidelis Qualified Health Plan	$37.10
Rate for Payer: Group Health Inc Commercial	$41.68
Rate for Payer: Group Health Inc Medicare	$41.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.10
Rate for Payer: Hamaspik Choice Inc Medicare	$41.68
Rate for Payer: Healthfirst Medicare Advantage	$41.68
Rate for Payer: Healthfirst QHP	$41.68
Rate for Payer: Humana Medicare	$42.51
Rate for Payer: Senior Whole Health Medicare Advantage	$41.68
Rate for Payer: United Healthcare Commercial	$44.45
Rate for Payer: United Healthcare Medicare Advantage	$41.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$41.68
Rate for Payer: Wellcare CHP/FHP/Medicaid	$33.34
Rate for Payer: Wellcare Medicare	$37.51

MYCOBACTERIUM TB/RIFAMPIN PCR-SBH

Facility

$104.20

Service Code	HCPCS 87556
Hospital Charge Code	40614109
Hospital Revenue Code	306
Rate for Payer: Cash Price	$41.68

MYCOPHENOLATE 100MG/ML SUSP

Facility

$0.63

Service Code	HCPCS J7517
Hospital Charge Code	41656607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.36
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: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.41

MYCOPHENOLATE 100MG/ML SUSP

Facility

$0.63

Service Code	HCPCS J7517
Hospital Charge Code	41656607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.32
Rate for Payer: Hamaspik Choice Inc Medicare	$0.32

MYCOPHENOLATE 100MG/ML SUSP

Facility

$0.63

Service Code	HCPCS J7517
Hospital Charge Code	41646607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.36
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: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.41

MYCOPHENOLATE 100MG/ML SUSP

Facility

$0.63

Service Code	HCPCS J7517
Hospital Charge Code	41646607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.32
Rate for Payer: Hamaspik Choice Inc Medicare	$0.32

MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR [25005]

Facility

$9.06

Service Code	HCPCS J7517
Hospital Charge Code	00527516082
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$7.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$6.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.16
Rate for Payer: Group Health Inc Commercial	$4.53
Rate for Payer: Group Health Inc Medicare	$3.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.53
Rate for Payer: Hamaspik Choice Inc Medicare	$4.53
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.20
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.21
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.21
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.89

MYCOPHENOLATE MOFETIL 200 MG/ML SUSP NF

Facility

$7.00

Service Code	HCPCS J7517
Hospital Charge Code	41645054
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

MYCOPHENOLATE MOFETIL 200 MG/ML SUSP NF

Facility

$7.00

Service Code	HCPCS J7517
Hospital Charge Code	41645054
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

MYCOPHENOLATE MOFETIL 200 MG/ML SUSP NF

Facility

$7.00

Service Code	HCPCS J7517
Hospital Charge Code	41655054
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

MYCOPHENOLATE MOFETIL 200 MG/ML SUSP NF

Facility

$7.00

Service Code	HCPCS J7517
Hospital Charge Code	41655054
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

MYCOPHENOLATE MOFETIL 250 MG CAP

Facility

$0.65

Service Code	HCPCS J7517
Hospital Charge Code	41650735
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

MYCOPHENOLATE MOFETIL 250 MG CAP

Facility

$0.65

Service Code	HCPCS J7517
Hospital Charge Code	41640735
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

MYCOPHENOLATE MOFETIL 250 MG CAP

Facility

$0.65

Service Code	HCPCS J7517
Hospital Charge Code	41650735
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

MYCOPHENOLATE MOFETIL 250 MG CAP

Facility

$0.65

Service Code	HCPCS J7517
Hospital Charge Code	41640735
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.21
Rate for Payer: SOMOS Essential	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

MYCOPHENOLATE MOFETIL 250 MG PO CAPS [15113]

Facility

$3.96

Service Code	HCPCS J7517
Hospital Charge Code	51079072120
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$3.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$2.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.69
Rate for Payer: Group Health Inc Commercial	$1.98
Rate for Payer: Group Health Inc Medicare	$1.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.98
Rate for Payer: Hamaspik Choice Inc Medicare	$1.98
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.20
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.21
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.21
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.58

Know your out-of-pocket cost for care.

All Charges