St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SITAGLIPTIN PHOSPHATE 50 MG PO TABS

Facility

$22.92

Service Code	NDC 0006011228
Hospital Charge Code	0006011228
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: EmblemHealth Commercial	$11.46
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SITAGLIPTIN PHOSPHATE 50 MG PO TABS

Facility

$22.92

Service Code	NDC 0006011231
Hospital Charge Code	0006011231
Hospital Revenue Code	250
Min. Negotiated Rate	$11.46
Max. Negotiated Rate	$11.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46

SITAGLIPTIN PHOSPHATE 50 MG PO TABS

Facility

$22.92

Service Code	NDC 0006011201
Hospital Charge Code	0006011201
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.46
Rate for Payer: Aetna Government	$11.46
Rate for Payer: Brighton Health Commercial	$17.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.59
Rate for Payer: EmblemHealth Commercial	$11.46
Rate for Payer: Group Health Inc Commercial	$11.46
Rate for Payer: Group Health Inc Medicare	$8.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.46
Rate for Payer: Hamaspik Choice Inc Medicare	$11.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.90

SKIN AND CONNECTIVE TISSUE GRAFTING AND FLAP PROCEDURES

Facility

$1,830.61

Service Code	EAPG 00056
Min. Negotiated Rate	$1,830.61
Max. Negotiated Rate	$1,830.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,830.61

Skin graft, except hand, for musculoskeletal & connective tissue diagnoses

Facility

$53,454.01

Service Code	APR-DRG 3121
Min. Negotiated Rate	$22,940.00
Max. Negotiated Rate	$53,454.01
Rate for Payer: Affinity Essential Plan 1&2	$53,454.01
Rate for Payer: Affinity Essential Plan 3&4	$53,454.01
Rate for Payer: Affinity Medicaid/CHP/HARP	$23,757.34
Rate for Payer: Amida Care Medicaid	$23,757.34
Rate for Payer: EmblemHealth Essential Plan 1&2	$53,454.01
Rate for Payer: EmblemHealth Essential Plan 3&4	$23,757.34
Rate for Payer: Fidelis CHP/HARP/Medicaid	$23,757.34
Rate for Payer: Fidelis Qualified Health Plan	$28,508.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$23,757.34
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23,757.34
Rate for Payer: Healthfirst Commercial	$37,824.00
Rate for Payer: Healthfirst Essential Plan	$53,454.01
Rate for Payer: Healthfirst QHP	$22,940.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23,757.34
Rate for Payer: SOMOS Essential	$53,454.01
Rate for Payer: United Healthcare Essential Plan 1&2	$53,454.01
Rate for Payer: United Healthcare Essential Plan 3&4	$53,454.01
Rate for Payer: United Healthcare Medicaid	$23,757.34
Rate for Payer: Wellcare CHP/FHP/Medicaid	$23,757.34

Skin graft, except hand, for musculoskeletal & connective tissue diagnoses

Facility

$71,646.50

Service Code	APR-DRG 3122
Min. Negotiated Rate	$31,842.89
Max. Negotiated Rate	$71,646.50
Rate for Payer: Affinity Essential Plan 1&2	$71,646.50
Rate for Payer: Affinity Essential Plan 3&4	$71,646.50
Rate for Payer: Affinity Medicaid/CHP/HARP	$31,842.89
Rate for Payer: Amida Care Medicaid	$31,842.89
Rate for Payer: EmblemHealth Essential Plan 1&2	$71,646.50
Rate for Payer: EmblemHealth Essential Plan 3&4	$31,842.89
Rate for Payer: Fidelis CHP/HARP/Medicaid	$31,842.89
Rate for Payer: Fidelis Qualified Health Plan	$38,211.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$31,842.89
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$31,842.89
Rate for Payer: Healthfirst Commercial	$56,870.00
Rate for Payer: Healthfirst Essential Plan	$71,646.50
Rate for Payer: Healthfirst QHP	$34,190.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$31,842.89
Rate for Payer: SOMOS Essential	$71,646.50
Rate for Payer: United Healthcare Essential Plan 1&2	$71,646.50
Rate for Payer: United Healthcare Essential Plan 3&4	$71,646.50
Rate for Payer: United Healthcare Medicaid	$31,842.89
Rate for Payer: Wellcare CHP/FHP/Medicaid	$31,842.89

Skin graft, except hand, for musculoskeletal & connective tissue diagnoses

Facility

$116,572.00

Service Code	APR-DRG 3123
Min. Negotiated Rate	$49,621.08
Max. Negotiated Rate	$116,572.00
Rate for Payer: Affinity Essential Plan 1&2	$111,647.43
Rate for Payer: Affinity Essential Plan 3&4	$111,647.43
Rate for Payer: Affinity Medicaid/CHP/HARP	$49,621.08
Rate for Payer: Amida Care Medicaid	$49,621.08
Rate for Payer: EmblemHealth Essential Plan 1&2	$111,647.43
Rate for Payer: EmblemHealth Essential Plan 3&4	$49,621.08
Rate for Payer: Fidelis CHP/HARP/Medicaid	$49,621.08
Rate for Payer: Fidelis Qualified Health Plan	$59,545.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$49,621.08
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$49,621.08
Rate for Payer: Healthfirst Commercial	$116,572.00
Rate for Payer: Healthfirst Essential Plan	$111,647.43
Rate for Payer: Healthfirst QHP	$71,707.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$49,621.08
Rate for Payer: SOMOS Essential	$111,647.43
Rate for Payer: United Healthcare Essential Plan 1&2	$111,647.43
Rate for Payer: United Healthcare Essential Plan 3&4	$111,647.43
Rate for Payer: United Healthcare Medicaid	$49,621.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$49,621.08

Skin graft, except hand, for musculoskeletal & connective tissue diagnoses

Facility

$278,771.00

Service Code	APR-DRG 3124
Min. Negotiated Rate	$84,597.46
Max. Negotiated Rate	$278,771.00
Rate for Payer: Affinity Essential Plan 1&2	$190,344.29
Rate for Payer: Affinity Essential Plan 3&4	$190,344.29
Rate for Payer: Affinity Medicaid/CHP/HARP	$84,597.46
Rate for Payer: Amida Care Medicaid	$84,597.46
Rate for Payer: EmblemHealth Essential Plan 1&2	$190,344.29
Rate for Payer: EmblemHealth Essential Plan 3&4	$84,597.46
Rate for Payer: Fidelis CHP/HARP/Medicaid	$84,597.46
Rate for Payer: Fidelis Qualified Health Plan	$101,516.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$84,597.46
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$84,597.46
Rate for Payer: Healthfirst Commercial	$278,771.00
Rate for Payer: Healthfirst Essential Plan	$190,344.29
Rate for Payer: Healthfirst QHP	$194,370.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$84,597.46
Rate for Payer: SOMOS Essential	$190,344.29
Rate for Payer: United Healthcare Essential Plan 1&2	$190,344.29
Rate for Payer: United Healthcare Essential Plan 3&4	$190,344.29
Rate for Payer: United Healthcare Medicaid	$84,597.46
Rate for Payer: Wellcare CHP/FHP/Medicaid	$84,597.46

Skin graft for skin & subcutaneous tissue diagnoses

Facility

$55,342.91

Service Code	APR-DRG 3611
Min. Negotiated Rate	$21,942.00
Max. Negotiated Rate	$55,342.91
Rate for Payer: Affinity Essential Plan 1&2	$55,342.91
Rate for Payer: Affinity Essential Plan 3&4	$55,342.91
Rate for Payer: Affinity Medicaid/CHP/HARP	$24,596.85
Rate for Payer: Amida Care Medicaid	$24,596.85
Rate for Payer: EmblemHealth Essential Plan 1&2	$55,342.91
Rate for Payer: EmblemHealth Essential Plan 3&4	$24,596.85
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24,596.85
Rate for Payer: Fidelis Qualified Health Plan	$29,516.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,596.85
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24,596.85
Rate for Payer: Healthfirst Commercial	$34,410.00
Rate for Payer: Healthfirst Essential Plan	$55,342.91
Rate for Payer: Healthfirst QHP	$21,942.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$24,596.85
Rate for Payer: SOMOS Essential	$55,342.91
Rate for Payer: United Healthcare Essential Plan 1&2	$55,342.91
Rate for Payer: United Healthcare Essential Plan 3&4	$55,342.91
Rate for Payer: United Healthcare Medicaid	$24,596.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24,596.85

Skin graft for skin & subcutaneous tissue diagnoses

Facility

$65,044.17

Service Code	APR-DRG 3612
Min. Negotiated Rate	$28,908.52
Max. Negotiated Rate	$65,044.17
Rate for Payer: Affinity Essential Plan 1&2	$65,044.17
Rate for Payer: Affinity Essential Plan 3&4	$65,044.17
Rate for Payer: Affinity Medicaid/CHP/HARP	$28,908.52
Rate for Payer: Amida Care Medicaid	$28,908.52
Rate for Payer: EmblemHealth Essential Plan 1&2	$65,044.17
Rate for Payer: EmblemHealth Essential Plan 3&4	$28,908.52
Rate for Payer: Fidelis CHP/HARP/Medicaid	$28,908.52
Rate for Payer: Fidelis Qualified Health Plan	$34,690.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$28,908.52
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$28,908.52
Rate for Payer: Healthfirst Commercial	$51,155.00
Rate for Payer: Healthfirst Essential Plan	$65,044.17
Rate for Payer: Healthfirst QHP	$30,605.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$28,908.52
Rate for Payer: SOMOS Essential	$65,044.17
Rate for Payer: United Healthcare Essential Plan 1&2	$65,044.17
Rate for Payer: United Healthcare Essential Plan 3&4	$65,044.17
Rate for Payer: United Healthcare Medicaid	$28,908.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$28,908.52

Skin graft for skin & subcutaneous tissue diagnoses

Facility

$90,920.00

Service Code	APR-DRG 3613
Min. Negotiated Rate	$40,335.68
Max. Negotiated Rate	$90,920.00
Rate for Payer: Affinity Essential Plan 1&2	$90,755.28
Rate for Payer: Affinity Essential Plan 3&4	$90,755.28
Rate for Payer: Affinity Medicaid/CHP/HARP	$40,335.68
Rate for Payer: Amida Care Medicaid	$40,335.68
Rate for Payer: EmblemHealth Essential Plan 1&2	$90,755.28
Rate for Payer: EmblemHealth Essential Plan 3&4	$40,335.68
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40,335.68
Rate for Payer: Fidelis Qualified Health Plan	$48,402.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$40,335.68
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$40,335.68
Rate for Payer: Healthfirst Commercial	$90,920.00
Rate for Payer: Healthfirst Essential Plan	$90,755.28
Rate for Payer: Healthfirst QHP	$55,041.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$40,335.68
Rate for Payer: SOMOS Essential	$90,755.28
Rate for Payer: United Healthcare Essential Plan 1&2	$90,755.28
Rate for Payer: United Healthcare Essential Plan 3&4	$90,755.28
Rate for Payer: United Healthcare Medicaid	$40,335.68
Rate for Payer: Wellcare CHP/FHP/Medicaid	$40,335.68

Skin graft for skin & subcutaneous tissue diagnoses

Facility

$217,030.00

Service Code	APR-DRG 3614
Min. Negotiated Rate	$89,273.38
Max. Negotiated Rate	$217,030.00
Rate for Payer: Affinity Essential Plan 1&2	$200,865.11
Rate for Payer: Affinity Essential Plan 3&4	$200,865.11
Rate for Payer: Affinity Medicaid/CHP/HARP	$89,273.38
Rate for Payer: Amida Care Medicaid	$89,273.38
Rate for Payer: EmblemHealth Essential Plan 1&2	$200,865.11
Rate for Payer: EmblemHealth Essential Plan 3&4	$89,273.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$89,273.38
Rate for Payer: Fidelis Qualified Health Plan	$107,128.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$89,273.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$89,273.38
Rate for Payer: Healthfirst Commercial	$217,030.00
Rate for Payer: Healthfirst Essential Plan	$200,865.11
Rate for Payer: Healthfirst QHP	$152,380.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$89,273.38
Rate for Payer: SOMOS Essential	$200,865.11
Rate for Payer: United Healthcare Essential Plan 1&2	$200,865.11
Rate for Payer: United Healthcare Essential Plan 3&4	$200,865.11
Rate for Payer: United Healthcare Medicaid	$89,273.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$89,273.38

Skin ulcers

Facility

$44,090.46

Service Code	APR-DRG 3801
Min. Negotiated Rate	$7,494.00
Max. Negotiated Rate	$44,090.46
Rate for Payer: Affinity Essential Plan 1&2	$44,090.46
Rate for Payer: Affinity Essential Plan 3&4	$44,090.46
Rate for Payer: Affinity Medicaid/CHP/HARP	$19,595.76
Rate for Payer: Amida Care Medicaid	$19,595.76
Rate for Payer: EmblemHealth Essential Plan 1&2	$44,090.46
Rate for Payer: EmblemHealth Essential Plan 3&4	$19,595.76
Rate for Payer: Fidelis CHP/HARP/Medicaid	$19,595.76
Rate for Payer: Fidelis Qualified Health Plan	$23,514.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$19,595.76
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$19,595.76
Rate for Payer: Healthfirst Commercial	$12,348.00
Rate for Payer: Healthfirst Essential Plan	$44,090.46
Rate for Payer: Healthfirst QHP	$7,494.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$19,595.76
Rate for Payer: SOMOS Essential	$44,090.46
Rate for Payer: United Healthcare Essential Plan 1&2	$44,090.46
Rate for Payer: United Healthcare Essential Plan 3&4	$44,090.46
Rate for Payer: United Healthcare Medicaid	$19,595.76
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19,595.76

Skin ulcers

Facility

$46,689.89

Service Code	APR-DRG 3802
Min. Negotiated Rate	$9,165.00
Max. Negotiated Rate	$46,689.89
Rate for Payer: Affinity Essential Plan 1&2	$46,689.89
Rate for Payer: Affinity Essential Plan 3&4	$46,689.89
Rate for Payer: Affinity Medicaid/CHP/HARP	$20,751.06
Rate for Payer: Amida Care Medicaid	$20,751.06
Rate for Payer: EmblemHealth Essential Plan 1&2	$46,689.89
Rate for Payer: EmblemHealth Essential Plan 3&4	$20,751.06
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20,751.06
Rate for Payer: Fidelis Qualified Health Plan	$24,901.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$20,751.06
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20,751.06
Rate for Payer: Healthfirst Commercial	$14,913.00
Rate for Payer: Healthfirst Essential Plan	$46,689.89
Rate for Payer: Healthfirst QHP	$9,165.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20,751.06
Rate for Payer: SOMOS Essential	$46,689.89
Rate for Payer: United Healthcare Essential Plan 1&2	$46,689.89
Rate for Payer: United Healthcare Essential Plan 3&4	$46,689.89
Rate for Payer: United Healthcare Medicaid	$20,751.06
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20,751.06

Skin ulcers

Facility

$54,841.68

Service Code	APR-DRG 3803
Min. Negotiated Rate	$13,216.00
Max. Negotiated Rate	$54,841.68
Rate for Payer: Affinity Essential Plan 1&2	$54,841.68
Rate for Payer: Affinity Essential Plan 3&4	$54,841.68
Rate for Payer: Affinity Medicaid/CHP/HARP	$24,374.08
Rate for Payer: Amida Care Medicaid	$24,374.08
Rate for Payer: EmblemHealth Essential Plan 1&2	$54,841.68
Rate for Payer: EmblemHealth Essential Plan 3&4	$24,374.08
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24,374.08
Rate for Payer: Fidelis Qualified Health Plan	$29,248.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,374.08
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24,374.08
Rate for Payer: Healthfirst Commercial	$22,953.00
Rate for Payer: Healthfirst Essential Plan	$54,841.68
Rate for Payer: Healthfirst QHP	$13,216.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$24,374.08
Rate for Payer: SOMOS Essential	$54,841.68
Rate for Payer: United Healthcare Essential Plan 1&2	$54,841.68
Rate for Payer: United Healthcare Essential Plan 3&4	$54,841.68
Rate for Payer: United Healthcare Medicaid	$24,374.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24,374.08

Skin ulcers

Facility

$75,849.91

Service Code	APR-DRG 3804
Min. Negotiated Rate	$27,505.00
Max. Negotiated Rate	$75,849.91
Rate for Payer: Affinity Essential Plan 1&2	$75,849.91
Rate for Payer: Affinity Essential Plan 3&4	$75,849.91
Rate for Payer: Affinity Medicaid/CHP/HARP	$33,711.07
Rate for Payer: Amida Care Medicaid	$33,711.07
Rate for Payer: EmblemHealth Essential Plan 1&2	$75,849.91
Rate for Payer: EmblemHealth Essential Plan 3&4	$33,711.07
Rate for Payer: Fidelis CHP/HARP/Medicaid	$33,711.07
Rate for Payer: Fidelis Qualified Health Plan	$40,453.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$33,711.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$33,711.07
Rate for Payer: Healthfirst Commercial	$55,942.00
Rate for Payer: Healthfirst Essential Plan	$75,849.91
Rate for Payer: Healthfirst QHP	$27,505.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$33,711.07
Rate for Payer: SOMOS Essential	$75,849.91
Rate for Payer: United Healthcare Essential Plan 1&2	$75,849.91
Rate for Payer: United Healthcare Essential Plan 3&4	$75,849.91
Rate for Payer: United Healthcare Medicaid	$33,711.07
Rate for Payer: Wellcare CHP/FHP/Medicaid	$33,711.07

SLEEP STUDIES ATTENDED

Facility

$1,491.69

Service Code	EAPG 00222
Min. Negotiated Rate	$1,083.09
Max. Negotiated Rate	$1,491.69
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,083.09
Rate for Payer: Healthfirst Commercial	$1,491.69

SLEEP STUDIES UNATTENDED

Facility

$610.98

Service Code	EAPG 00226
Min. Negotiated Rate	$610.98
Max. Negotiated Rate	$610.98
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$610.98

SMALLPOX & MONKEYPOX VAC, LIVE 0.5 ML SC SUSP

Facility

$648.00

Service Code	NDC 5063200103
Hospital Charge Code	5063200103
Hospital Revenue Code	250
Min. Negotiated Rate	$324.00
Max. Negotiated Rate	$324.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$324.00

SMALLPOX & MONKEYPOX VAC, LIVE 0.5 ML SC SUSP

Facility

$648.00

Service Code	NDC 5063200101
Hospital Charge Code	5063200101
Hospital Revenue Code	250
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$518.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$356.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$324.00
Rate for Payer: Aetna Government	$324.00
Rate for Payer: Brighton Health Commercial	$486.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$518.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$440.64
Rate for Payer: EmblemHealth Commercial	$324.00
Rate for Payer: Group Health Inc Commercial	$324.00
Rate for Payer: Group Health Inc Medicare	$226.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$324.00
Rate for Payer: Hamaspik Choice Inc Medicare	$324.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$421.20

SMALLPOX & MONKEYPOX VAC, LIVE 0.5 ML SC SUSP

Facility

$648.00

Service Code	NDC 5063200103
Hospital Charge Code	5063200103
Hospital Revenue Code	250
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$518.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$356.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$324.00
Rate for Payer: Aetna Government	$324.00
Rate for Payer: Brighton Health Commercial	$486.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$518.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$440.64
Rate for Payer: EmblemHealth Commercial	$324.00
Rate for Payer: Group Health Inc Commercial	$324.00
Rate for Payer: Group Health Inc Medicare	$226.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$324.00
Rate for Payer: Hamaspik Choice Inc Medicare	$324.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$421.20

SMALLPOX & MONKEYPOX VAC, LIVE 0.5 ML SC SUSP

Facility

$648.00

Service Code	NDC 5063200101
Hospital Charge Code	5063200101
Hospital Revenue Code	250
Min. Negotiated Rate	$324.00
Max. Negotiated Rate	$324.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$324.00

SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN

Facility

$0.19

Service Code	NDC 0121119030
Hospital Charge Code	0121119030
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN

Facility

$0.19

Service Code	NDC 0121119000
Hospital Charge Code	0121119000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN

Facility

$0.19

Service Code	NDC 0121119000
Hospital Charge Code	0121119000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.12

Know your out-of-pocket cost for care.

All Charges