St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

POLYSOM < 6 YRS CPAP/BILVL

Facility

$2,752.98

Service Code	HCPCS 95783 TC
Hospital Charge Code	40401402
Hospital Revenue Code	922
Rate for Payer: Cash Price	$1,209.08

POLYSORB SUTURES C

Facility

$6.00

Hospital Charge Code	64907067
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.00
Rate for Payer: Aetna Government	$3.00
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

POLYVINYL ALCOHOL 1.4 % OP SOLN [27994]

Facility

$0.49

Service Code	NDC 50268067815
Hospital Charge Code	50268067815
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.34
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.32

POLY-VI-SOL PO SOLN [6374]

Facility

$0.20

Service Code	NDC 00087040203
Hospital Charge Code	00087040203
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

POLY-VITA PO SOLN [177283]

Facility

$0.20

Service Code	NDC 00087040203
Hospital Charge Code	00087040203
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

PON DRILL 1/8 X 5

Facility

$125.88

Hospital Charge Code	64905708
Hospital Revenue Code	270
Min. Negotiated Rate	$44.06
Max. Negotiated Rate	$100.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$69.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$62.94
Rate for Payer: Aetna Government	$62.94
Rate for Payer: Brighton Health Commercial	$94.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$85.60
Rate for Payer: Group Health Inc Commercial	$62.94
Rate for Payer: Group Health Inc Medicare	$44.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$62.94
Rate for Payer: Hamaspik Choice Inc Medicare	$62.94

PONTIC-CAST HIGH NOBLE METAL

Facility

$1,000.00

Service Code	HCPCS D6210
Hospital Charge Code	42301455
Hospital Revenue Code	361
Min. Negotiated Rate	$292.02
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$292.02
Rate for Payer: Aetna Government	$292.02
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-CAST NOBLE METAL

Facility

$1,000.00

Service Code	HCPCS D6212
Hospital Charge Code	42301465
Hospital Revenue Code	361
Min. Negotiated Rate	$284.79
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$284.79
Rate for Payer: Aetna Government	$284.79
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-CAST PREDOMINANTLY BASE ME

Facility

$1,000.00

Service Code	HCPCS D6211
Hospital Charge Code	42301460
Hospital Revenue Code	361
Min. Negotiated Rate	$273.49
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$273.49
Rate for Payer: Aetna Government	$273.49
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC- PORCELAIN/CERAMIC

Facility

$1,000.00

Service Code	HCPCS D6245
Hospital Charge Code	42303324
Hospital Revenue Code	361
Min. Negotiated Rate	$297.47
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$297.47
Rate for Payer: Aetna Government	$297.47
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-PORCELAIN FUSED TO HIGH NO

Facility

$1,000.00

Service Code	HCPCS D6240
Hospital Charge Code	42301470
Hospital Revenue Code	361
Min. Negotiated Rate	$288.22
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$288.22
Rate for Payer: Aetna Government	$288.22
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-PORCELAIN FUSED TO NOBLE M

Facility

$1,000.00

Service Code	HCPCS D6242
Hospital Charge Code	42301480
Hospital Revenue Code	361
Min. Negotiated Rate	$280.98
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$280.98
Rate for Payer: Aetna Government	$280.98
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-PORCELAIN FUSED TO PREDOM.

Facility

$1,000.00

Service Code	HCPCS D6241
Hospital Charge Code	42301475
Hospital Revenue Code	361
Min. Negotiated Rate	$266.25
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$266.25
Rate for Payer: Aetna Government	$266.25
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-PORCELAIN FUSED TO TITANIU

Facility

$1,000.00

Service Code	HCPCS D6243
Hospital Charge Code	42300722
Hospital Revenue Code	361
Min. Negotiated Rate	$241.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$241.35
Rate for Payer: Aetna Government	$241.35
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-RESIN WITH HIGH NOBLE META

Facility

$1,000.00

Service Code	HCPCS D6250
Hospital Charge Code	42301485
Hospital Revenue Code	361
Min. Negotiated Rate	$284.79
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$284.79
Rate for Payer: Aetna Government	$284.79
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-RESIN WITH NOBLE METAL

Facility

$1,000.00

Service Code	HCPCS D6252
Hospital Charge Code	42301495
Hospital Revenue Code	361
Min. Negotiated Rate	$271.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$271.00
Rate for Payer: Aetna Government	$271.00
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

PONTIC-RESIN WITH PREDOMINANTLY B

Facility

$1,000.00

Service Code	HCPCS D6251
Hospital Charge Code	42301490
Hospital Revenue Code	361
Min. Negotiated Rate	$262.60
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$262.60
Rate for Payer: Aetna Government	$262.60
Rate for Payer: Brighton Health Commercial	$750.00
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: Group Health Inc Commercial	$500.00
Rate for Payer: Group Health Inc Medicare	$350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

POOLED CRYOPRECIPITATE

Facility

$700.00

Service Code	HCPCS P9012
Hospital Charge Code	40708600
Hospital Revenue Code	300
Min. Negotiated Rate	$50.87
Max. Negotiated Rate	$560.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$385.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.67
Rate for Payer: Aetna Government	$72.67
Rate for Payer: Affinity Essential Plan 1&2	$50.87
Rate for Payer: Affinity Essential Plan 3&4	$50.87
Rate for Payer: Affinity Medicaid/CHP/HARP	$50.87
Rate for Payer: Brighton Health Commercial	$525.00
Rate for Payer: Cash Price	$72.67
Rate for Payer: Cash Price	$72.67
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$72.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$560.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$476.00
Rate for Payer: Elderplan Medicare Advantage	$72.67
Rate for Payer: EmblemHealth Commercial	$72.67
Rate for Payer: Fidelis Essential Plan Aliesa	$61.77
Rate for Payer: Fidelis Essential Plan QHP	$64.68
Rate for Payer: Fidelis Medicare Advantage	$72.67
Rate for Payer: Fidelis Qualified Health Plan	$64.68
Rate for Payer: Group Health Inc Commercial	$72.67
Rate for Payer: Group Health Inc Medicare	$72.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$72.67
Rate for Payer: Healthfirst Medicare Advantage	$61.77
Rate for Payer: Healthfirst QHP	$72.67
Rate for Payer: Humana Medicare	$74.12
Rate for Payer: Senior Whole Health Medicare Advantage	$72.67
Rate for Payer: United Healthcare Medicare Advantage	$72.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$72.67
Rate for Payer: Wellcare CHP/FHP/Medicaid	$58.14
Rate for Payer: Wellcare Medicare	$65.40

POOLED CRYOPRECIPITATE

Facility

$700.00

Service Code	HCPCS P9012
Hospital Charge Code	40708600
Hospital Revenue Code	300
Rate for Payer: Cash Price	$72.67

POOLING PLTS & OTHER- CHRG ONLY

Facility

$434.63

Service Code	HCPCS 86965
Hospital Charge Code	40701071
Hospital Revenue Code	300
Rate for Payer: Cash Price	$197.52

POOLING PLTS & OTHER- CHRG ONLY

Facility

$434.63

Service Code	HCPCS 86965
Hospital Charge Code	40701071
Hospital Revenue Code	300
Min. Negotiated Rate	$20.78
Max. Negotiated Rate	$325.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.52
Rate for Payer: Aetna Government	$197.52
Rate for Payer: Affinity Essential Plan 1&2	$138.26
Rate for Payer: Affinity Essential Plan 3&4	$138.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.26
Rate for Payer: Brighton Health Commercial	$325.97
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cash Price	$197.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.78
Rate for Payer: Elderplan Medicare Advantage	$197.52
Rate for Payer: EmblemHealth Commercial	$197.52
Rate for Payer: Fidelis Essential Plan Aliesa	$167.89
Rate for Payer: Fidelis Essential Plan QHP	$175.79
Rate for Payer: Fidelis Medicare Advantage	$197.52
Rate for Payer: Fidelis Qualified Health Plan	$175.79
Rate for Payer: Group Health Inc Commercial	$197.52
Rate for Payer: Group Health Inc Medicare	$197.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.32
Rate for Payer: Hamaspik Choice Inc Medicare	$197.52
Rate for Payer: Healthfirst Medicare Advantage	$197.52
Rate for Payer: Healthfirst QHP	$197.52
Rate for Payer: Humana Medicare	$201.47
Rate for Payer: Senior Whole Health Medicare Advantage	$197.52
Rate for Payer: United Healthcare Commercial	$22.57
Rate for Payer: United Healthcare Medicare Advantage	$197.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$158.02
Rate for Payer: Wellcare Medicare	$177.77

PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP [137065]

Facility

$456.79

Service Code	NDC 10122051001
Hospital Charge Code	10122051001
Hospital Revenue Code	250
Min. Negotiated Rate	$159.88
Max. Negotiated Rate	$365.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$251.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$228.39
Rate for Payer: Aetna Government	$228.39
Rate for Payer: Brighton Health Commercial	$342.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$365.43
Rate for Payer: Cigna LocalPlus Benefit Plan	$310.62
Rate for Payer: Group Health Inc Commercial	$228.39
Rate for Payer: Group Health Inc Medicare	$159.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$228.39
Rate for Payer: Hamaspik Choice Inc Medicare	$228.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$296.91

PORACTANT ALFA 240MG/3ML

Facility

$1.00

Hospital Charge Code	41648455
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

PORACTANT ALFA 240MG/3ML

Facility

$1.00

Hospital Charge Code	41658455
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP [137066]

Facility

$450.36

Service Code	NDC 10122051003
Hospital Charge Code	10122051003
Hospital Revenue Code	250
Min. Negotiated Rate	$157.63
Max. Negotiated Rate	$360.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$247.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$225.18
Rate for Payer: Aetna Government	$225.18
Rate for Payer: Brighton Health Commercial	$337.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$360.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$306.25
Rate for Payer: Group Health Inc Commercial	$225.18
Rate for Payer: Group Health Inc Medicare	$157.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$225.18
Rate for Payer: Hamaspik Choice Inc Medicare	$225.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$292.74

Know your out-of-pocket cost for care.

All Charges