St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PLUG LIGHT PERFIX LG 1.6X1.9

Facility

$860.00

Service Code	HCPCS C1781
Hospital Charge Code	64905927
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$903.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$473.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Brighton Health Commercial	$516.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$430.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$494.50
Rate for Payer: EmblemHealth Commercial	$430.00
Rate for Payer: Fidelis Medicare Advantage	$903.00
Rate for Payer: Group Health Inc Commercial	$430.00
Rate for Payer: Group Health Inc Medicare	$301.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$430.00
Rate for Payer: Hamaspik Choice Inc Medicare	$430.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$559.00

PLUG LIGHT PERFIX MED 1.3X1.6

Facility

$837.50

Hospital Charge Code	64904944
Hospital Revenue Code	270
Min. Negotiated Rate	$293.12
Max. Negotiated Rate	$670.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$460.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$418.75
Rate for Payer: Aetna Government	$418.75
Rate for Payer: Brighton Health Commercial	$628.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$670.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$569.50
Rate for Payer: Group Health Inc Commercial	$418.75
Rate for Payer: Group Health Inc Medicare	$293.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$418.75
Rate for Payer: Hamaspik Choice Inc Medicare	$418.75

PLUG OMNIFIT UNIV

Facility

$407.75

Service Code	HCPCS C1776
Hospital Charge Code	64907315
Hospital Revenue Code	278
Min. Negotiated Rate	$142.71
Max. Negotiated Rate	$428.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$224.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$244.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$203.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$234.46
Rate for Payer: EmblemHealth Commercial	$203.88
Rate for Payer: Fidelis Medicare Advantage	$428.14
Rate for Payer: Group Health Inc Commercial	$203.88
Rate for Payer: Group Health Inc Medicare	$142.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$203.88
Rate for Payer: Hamaspik Choice Inc Medicare	$203.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$265.04

PLUG OMNIFIT UNIV

Facility

$407.75

Service Code	HCPCS C1776
Hospital Charge Code	64907315
Hospital Revenue Code	278
Min. Negotiated Rate	$203.88
Max. Negotiated Rate	$203.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$203.88
Rate for Payer: Hamaspik Choice Inc Medicare	$203.88

PLUG OSTEONICS SIZED CMNT

Facility

$407.75

Service Code	HCPCS C1776
Hospital Charge Code	64907291
Hospital Revenue Code	278
Min. Negotiated Rate	$142.71
Max. Negotiated Rate	$428.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$224.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$244.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$203.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$234.46
Rate for Payer: EmblemHealth Commercial	$203.88
Rate for Payer: Fidelis Medicare Advantage	$428.14
Rate for Payer: Group Health Inc Commercial	$203.88
Rate for Payer: Group Health Inc Medicare	$142.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$203.88
Rate for Payer: Hamaspik Choice Inc Medicare	$203.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$265.04

PLUG OSTEONICS SIZED CMNT

Facility

$407.75

Service Code	HCPCS C1776
Hospital Charge Code	64907291
Hospital Revenue Code	278
Min. Negotiated Rate	$203.88
Max. Negotiated Rate	$203.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$203.88
Rate for Payer: Hamaspik Choice Inc Medicare	$203.88

PLUG PERFLEX LIGHT

Facility

$1,170.00

Hospital Charge Code	64906717
Hospital Revenue Code	279
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$936.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$585.00
Rate for Payer: Aetna Government	$585.00
Rate for Payer: Brighton Health Commercial	$877.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$936.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$795.60
Rate for Payer: Group Health Inc Commercial	$585.00
Rate for Payer: Group Health Inc Medicare	$409.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$585.00
Rate for Payer: Hamaspik Choice Inc Medicare	$585.00

PLUG TAPER NEXGEN

Facility

$3,877.50

Service Code	HCPCS C1713
Hospital Charge Code	64901706
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,071.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,132.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,326.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,938.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,229.56
Rate for Payer: EmblemHealth Commercial	$1,938.75
Rate for Payer: Fidelis Medicare Advantage	$4,071.38
Rate for Payer: Group Health Inc Commercial	$1,938.75
Rate for Payer: Group Health Inc Medicare	$1,357.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,938.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,938.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,520.38

PLUG TAPER NEXGEN

Facility

$3,877.50

Service Code	HCPCS C1713
Hospital Charge Code	64901706
Hospital Revenue Code	278
Min. Negotiated Rate	$1,938.75
Max. Negotiated Rate	$1,938.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,938.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,938.75

PLUG TAPER NEXGEN

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Charge Code	40204058
Hospital Revenue Code	278
Min. Negotiated Rate	$846.00
Max. Negotiated Rate	$846.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$846.00
Rate for Payer: Hamaspik Choice Inc Medicare	$846.00

PLUG TAPER NEXGEN

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Charge Code	40204058
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,776.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$930.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,015.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$846.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$972.90
Rate for Payer: EmblemHealth Commercial	$846.00
Rate for Payer: Fidelis Medicare Advantage	$1,776.60
Rate for Payer: Group Health Inc Commercial	$846.00
Rate for Payer: Group Health Inc Medicare	$592.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$846.00
Rate for Payer: Hamaspik Choice Inc Medicare	$846.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,099.80

PLUG TAPER STEM KNEE SOLUT

Facility

$3,877.50

Hospital Charge Code	64906058
Hospital Revenue Code	270
Min. Negotiated Rate	$1,357.12
Max. Negotiated Rate	$3,102.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,132.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,938.75
Rate for Payer: Aetna Government	$1,938.75
Rate for Payer: Brighton Health Commercial	$2,908.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,102.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,636.70
Rate for Payer: Group Health Inc Commercial	$1,938.75
Rate for Payer: Group Health Inc Medicare	$1,357.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,938.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,938.75

PLUM FUNCTION TEST BY GAS

Facility

$419.03

Service Code	HCPCS 94727 TC
Hospital Charge Code	30305590
Hospital Revenue Code	460
Rate for Payer: Cash Price	$180.64

PLUM FUNCTION TEST BY GAS

Facility

$419.03

Service Code	HCPCS 94727 TC
Hospital Charge Code	30305590
Hospital Revenue Code	460
Min. Negotiated Rate	$126.45
Max. Negotiated Rate	$335.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$230.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$180.64
Rate for Payer: Aetna Government	$180.64
Rate for Payer: Affinity Essential Plan 1&2	$126.45
Rate for Payer: Affinity Essential Plan 3&4	$126.45
Rate for Payer: Affinity Medicaid/CHP/HARP	$126.45
Rate for Payer: Brighton Health Commercial	$314.27
Rate for Payer: Cash Price	$180.64
Rate for Payer: Cash Price	$180.64
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$180.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$335.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$284.94
Rate for Payer: Elderplan Medicare Advantage	$180.64
Rate for Payer: EmblemHealth Commercial	$180.64
Rate for Payer: Fidelis Essential Plan Aliesa	$153.54
Rate for Payer: Fidelis Essential Plan QHP	$160.77
Rate for Payer: Fidelis Medicare Advantage	$180.64
Rate for Payer: Fidelis Qualified Health Plan	$160.77
Rate for Payer: Group Health Inc Commercial	$180.64
Rate for Payer: Group Health Inc Medicare	$180.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$209.52
Rate for Payer: Hamaspik Choice Inc Medicare	$180.64
Rate for Payer: Healthfirst Medicare Advantage	$153.54
Rate for Payer: Healthfirst QHP	$180.64
Rate for Payer: Humana Medicare	$184.25
Rate for Payer: Senior Whole Health Medicare Advantage	$180.64
Rate for Payer: United Healthcare Commercial	$209.52
Rate for Payer: United Healthcare Medicare Advantage	$180.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$180.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$144.51
Rate for Payer: Wellcare Medicare	$171.61

PLYM PK CUTTING FORCEPS 5MMX33CM

Facility

$1,280.00

Hospital Charge Code	40005325
Hospital Revenue Code	272
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$1,024.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$704.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$640.00
Rate for Payer: Aetna Government	$640.00
Rate for Payer: Brighton Health Commercial	$960.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,024.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$870.40
Rate for Payer: Group Health Inc Commercial	$640.00
Rate for Payer: Group Health Inc Medicare	$448.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$640.00
Rate for Payer: Hamaspik Choice Inc Medicare	$640.00

PM DEVICE EVAL IN PERSON

Facility

$109.80

Service Code	HCPCS 93288 TC
Hospital Charge Code	40804118
Hospital Revenue Code	480
Rate for Payer: Cash Price	$43.61

PM DEVICE EVAL IN PERSON

Facility

$109.80

Service Code	HCPCS 93288 TC
Hospital Charge Code	40804118
Hospital Revenue Code	480
Min. Negotiated Rate	$30.53
Max. Negotiated Rate	$342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.61
Rate for Payer: Aetna Government	$43.61
Rate for Payer: Affinity Essential Plan 1&2	$30.53
Rate for Payer: Affinity Essential Plan 3&4	$30.53
Rate for Payer: Affinity Medicaid/CHP/HARP	$30.53
Rate for Payer: Brighton Health Commercial	$82.35
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.66
Rate for Payer: Elderplan Medicare Advantage	$43.61
Rate for Payer: EmblemHealth Commercial	$43.61
Rate for Payer: Fidelis Essential Plan Aliesa	$37.07
Rate for Payer: Fidelis Essential Plan QHP	$38.81
Rate for Payer: Fidelis Medicare Advantage	$43.61
Rate for Payer: Fidelis Qualified Health Plan	$38.81
Rate for Payer: Group Health Inc Commercial	$43.61
Rate for Payer: Group Health Inc Medicare	$43.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.90
Rate for Payer: Hamaspik Choice Inc Medicare	$43.61
Rate for Payer: Healthfirst Medicare Advantage	$37.07
Rate for Payer: Healthfirst QHP	$43.61
Rate for Payer: Humana Medicare	$44.48
Rate for Payer: Senior Whole Health Medicare Advantage	$43.61
Rate for Payer: United Healthcare Commercial	$316.00
Rate for Payer: United Healthcare Medicare Advantage	$43.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34.89
Rate for Payer: Wellcare Medicare	$41.43

PM DEVICE PROGR EVAL SINGLE

Facility

$109.80

Service Code	HCPCS 93279 TC
Hospital Charge Code	40804117
Hospital Revenue Code	480
Min. Negotiated Rate	$30.53
Max. Negotiated Rate	$342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.61
Rate for Payer: Aetna Government	$43.61
Rate for Payer: Affinity Essential Plan 1&2	$30.53
Rate for Payer: Affinity Essential Plan 3&4	$30.53
Rate for Payer: Affinity Medicaid/CHP/HARP	$30.53
Rate for Payer: Brighton Health Commercial	$82.35
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.66
Rate for Payer: Elderplan Medicare Advantage	$43.61
Rate for Payer: EmblemHealth Commercial	$43.61
Rate for Payer: Fidelis Essential Plan Aliesa	$37.07
Rate for Payer: Fidelis Essential Plan QHP	$38.81
Rate for Payer: Fidelis Medicare Advantage	$43.61
Rate for Payer: Fidelis Qualified Health Plan	$38.81
Rate for Payer: Group Health Inc Commercial	$43.61
Rate for Payer: Group Health Inc Medicare	$43.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.90
Rate for Payer: Hamaspik Choice Inc Medicare	$43.61
Rate for Payer: Healthfirst Medicare Advantage	$37.07
Rate for Payer: Healthfirst QHP	$43.61
Rate for Payer: Humana Medicare	$44.48
Rate for Payer: Senior Whole Health Medicare Advantage	$43.61
Rate for Payer: United Healthcare Commercial	$316.00
Rate for Payer: United Healthcare Medicare Advantage	$43.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34.89
Rate for Payer: Wellcare Medicare	$41.43

PM DEVICE PROGR EVAL SINGLE

Facility

$109.80

Service Code	HCPCS 93279 TC
Hospital Charge Code	40804117
Hospital Revenue Code	480
Rate for Payer: Cash Price	$43.61

PMMA CUSTOMIZED IMPANT LRG

Facility

$31,942.50

Hospital Charge Code	64905287
Hospital Revenue Code	272
Min. Negotiated Rate	$11,179.88
Max. Negotiated Rate	$25,554.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17,568.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15,971.25
Rate for Payer: Aetna Government	$15,971.25
Rate for Payer: Brighton Health Commercial	$23,956.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$25,554.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$21,720.90
Rate for Payer: Group Health Inc Commercial	$15,971.25
Rate for Payer: Group Health Inc Medicare	$11,179.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,971.25
Rate for Payer: Hamaspik Choice Inc Medicare	$15,971.25

PM PHONE R-STRIP DEVICE EVAL =<90

Facility

$109.80

Service Code	HCPCS 93293 TC
Hospital Charge Code	40804103
Hospital Revenue Code	480
Rate for Payer: Cash Price	$43.61

PM PHONE R-STRIP DEVICE EVAL =<90

Facility

$109.80

Service Code	HCPCS 93293 TC
Hospital Charge Code	40804103
Hospital Revenue Code	480
Min. Negotiated Rate	$30.53
Max. Negotiated Rate	$316.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.61
Rate for Payer: Aetna Government	$43.61
Rate for Payer: Affinity Essential Plan 1&2	$30.53
Rate for Payer: Affinity Essential Plan 3&4	$30.53
Rate for Payer: Affinity Medicaid/CHP/HARP	$30.53
Rate for Payer: Brighton Health Commercial	$82.35
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$43.61
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.66
Rate for Payer: Elderplan Medicare Advantage	$43.61
Rate for Payer: EmblemHealth Commercial	$43.61
Rate for Payer: Fidelis Essential Plan Aliesa	$37.07
Rate for Payer: Fidelis Essential Plan QHP	$38.81
Rate for Payer: Fidelis Medicare Advantage	$43.61
Rate for Payer: Fidelis Qualified Health Plan	$38.81
Rate for Payer: Group Health Inc Commercial	$43.61
Rate for Payer: Group Health Inc Medicare	$43.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.90
Rate for Payer: Hamaspik Choice Inc Medicare	$43.61
Rate for Payer: Healthfirst Medicare Advantage	$37.07
Rate for Payer: Healthfirst QHP	$43.61
Rate for Payer: Humana Medicare	$44.48
Rate for Payer: Senior Whole Health Medicare Advantage	$43.61
Rate for Payer: United Healthcare Commercial	$316.00
Rate for Payer: United Healthcare Medicare Advantage	$43.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34.89
Rate for Payer: Wellcare Medicare	$41.43

PNEUM HOSE 5.0M W/DIFF /AGG-LRG

Facility

$4,255.68

Hospital Charge Code	40209549
Hospital Revenue Code	270
Min. Negotiated Rate	$1,489.49
Max. Negotiated Rate	$3,404.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,340.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,127.84
Rate for Payer: Aetna Government	$2,127.84
Rate for Payer: Brighton Health Commercial	$3,191.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,404.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,893.86
Rate for Payer: Group Health Inc Commercial	$2,127.84
Rate for Payer: Group Health Inc Medicare	$1,489.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,127.84
Rate for Payer: Hamaspik Choice Inc Medicare	$2,127.84

PNEUMOCOCCAL 13 VALENT(VFC)0.5IM

Facility

$0.01

Service Code	HCPCS 90670
Hospital Charge Code	41649564
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

PNEUMOCOCCAL 13 VALENT(VFC)0.5IM

Facility

$0.01

Service Code	HCPCS 90670
Hospital Charge Code	41649564
Hospital Revenue Code	636
Max. Negotiated Rate	$273.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$241.38
Rate for Payer: Aetna Government	$241.38
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: SOMOS CHP/HARP/Medicaid	$273.47
Rate for Payer: SOMOS Essential	$273.47
Rate for Payer: United Healthcare Commercial	$257.99
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

Know your out-of-pocket cost for care.

All Charges