St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

BIOTRONIK PROTEGO S65 LEAD 379969

Facility

$6,700.00

Service Code	HCPCS C1722
Hospital Charge Code	66576689
Hospital Revenue Code	275
Min. Negotiated Rate	$2,345.00
Max. Negotiated Rate	$7,035.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,685.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,988.80
Rate for Payer: Aetna Government	$3,988.80
Rate for Payer: Brighton Health Commercial	$4,020.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,350.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,852.50
Rate for Payer: EmblemHealth Commercial	$3,350.00
Rate for Payer: Fidelis Medicare Advantage	$7,035.00
Rate for Payer: Group Health Inc Commercial	$3,350.00
Rate for Payer: Group Health Inc Medicare	$2,345.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,350.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,355.00

BIOTRONIK SMART S DX 65/15 365500

Facility

$6,700.00

Service Code	HCPCS C1777
Hospital Charge Code	66576681
Hospital Revenue Code	275
Min. Negotiated Rate	$988.18
Max. Negotiated Rate	$7,035.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,685.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$988.18
Rate for Payer: Aetna Government	$988.18
Rate for Payer: Brighton Health Commercial	$4,020.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,350.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,852.50
Rate for Payer: EmblemHealth Commercial	$3,350.00
Rate for Payer: Fidelis Medicare Advantage	$7,035.00
Rate for Payer: Group Health Inc Commercial	$3,350.00
Rate for Payer: Group Health Inc Medicare	$2,345.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,350.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,355.00

BIOTRONIK SOLIA JT 45CM LEAD

Facility

$1,000.00

Service Code	HCPCS C1898
Hospital Charge Code	66570269
Hospital Revenue Code	278
Min. Negotiated Rate	$500.00
Max. Negotiated Rate	$500.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$500.00

BIOTRONIK SOLIA JT 45CM LEAD

Facility

$1,000.00

Service Code	HCPCS C1898
Hospital Charge Code	66570269
Hospital Revenue Code	278
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$1,050.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$550.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$600.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$500.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$575.00
Rate for Payer: EmblemHealth Commercial	$500.00
Rate for Payer: Fidelis Medicare Advantage	$1,050.00
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
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$650.00

BIOTRON ILIVIA 7 VR-T ICD 404626

Facility

$25,550.00

Service Code	HCPCS C1722
Hospital Charge Code	66573146
Hospital Revenue Code	275
Min. Negotiated Rate	$3,988.80
Max. Negotiated Rate	$26,827.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14,052.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,988.80
Rate for Payer: Aetna Government	$3,988.80
Rate for Payer: Brighton Health Commercial	$15,330.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12,775.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$14,691.25
Rate for Payer: EmblemHealth Commercial	$12,775.00
Rate for Payer: Fidelis Medicare Advantage	$26,827.50
Rate for Payer: Group Health Inc Commercial	$12,775.00
Rate for Payer: Group Health Inc Medicare	$8,942.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$12,775.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12,775.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16,607.50

BIOTRON ITREVIA 7 DR-T ICD 392412

Facility

$27,500.00

Service Code	HCPCS C1721
Hospital Charge Code	66576678
Hospital Revenue Code	275
Min. Negotiated Rate	$5,000.00
Max. Negotiated Rate	$28,875.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15,125.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,000.00
Rate for Payer: Aetna Government	$5,000.00
Rate for Payer: Brighton Health Commercial	$16,500.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13,750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$15,812.50
Rate for Payer: EmblemHealth Commercial	$13,750.00
Rate for Payer: Fidelis Medicare Advantage	$28,875.00
Rate for Payer: Group Health Inc Commercial	$13,750.00
Rate for Payer: Group Health Inc Medicare	$9,625.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$13,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$13,750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17,875.00

BIOTRON ITREVIA 7HF-T-ICD 393014

Facility

$35,000.00

Service Code	HCPCS C1882
Hospital Charge Code	66576692
Hospital Revenue Code	275
Min. Negotiated Rate	$4,752.01
Max. Negotiated Rate	$36,750.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19,250.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,752.01
Rate for Payer: Aetna Government	$4,752.01
Rate for Payer: Brighton Health Commercial	$21,000.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17,500.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$20,125.00
Rate for Payer: EmblemHealth Commercial	$17,500.00
Rate for Payer: Fidelis Medicare Advantage	$36,750.00
Rate for Payer: Group Health Inc Commercial	$17,500.00
Rate for Payer: Group Health Inc Medicare	$12,250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$17,500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17,500.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22,750.00

BIOTRON LLIVIA 7 VR-T ICD 40626

Facility

$25,550.00

Service Code	HCPCS C1722
Hospital Charge Code	66573483
Hospital Revenue Code	275
Min. Negotiated Rate	$3,988.80
Max. Negotiated Rate	$26,827.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14,052.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,988.80
Rate for Payer: Aetna Government	$3,988.80
Rate for Payer: Brighton Health Commercial	$15,330.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12,775.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$14,691.25
Rate for Payer: EmblemHealth Commercial	$12,775.00
Rate for Payer: Fidelis Medicare Advantage	$26,827.50
Rate for Payer: Group Health Inc Commercial	$12,775.00
Rate for Payer: Group Health Inc Medicare	$8,942.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$12,775.00
Rate for Payer: Hamaspik Choice Inc Medicare	$12,775.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16,607.50

BIOTRON PLEXA DX 65/15 ICD LEAD

Facility

$7,100.00

Service Code	HCPCS C1777
Hospital Charge Code	66573143
Hospital Revenue Code	275
Min. Negotiated Rate	$988.18
Max. Negotiated Rate	$7,455.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,905.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$988.18
Rate for Payer: Aetna Government	$988.18
Rate for Payer: Brighton Health Commercial	$4,260.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,550.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,082.50
Rate for Payer: EmblemHealth Commercial	$3,550.00
Rate for Payer: Fidelis Medicare Advantage	$7,455.00
Rate for Payer: Group Health Inc Commercial	$3,550.00
Rate for Payer: Group Health Inc Medicare	$2,485.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,550.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,550.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,615.00

BIOTRON PLEXA S 65 LEAD 402266

Facility

$7,100.00

Service Code	HCPCS C1777
Hospital Charge Code	66573147
Hospital Revenue Code	275
Min. Negotiated Rate	$988.18
Max. Negotiated Rate	$7,455.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,905.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$988.18
Rate for Payer: Aetna Government	$988.18
Rate for Payer: Brighton Health Commercial	$4,260.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,550.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,082.50
Rate for Payer: EmblemHealth Commercial	$3,550.00
Rate for Payer: Fidelis Medicare Advantage	$7,455.00
Rate for Payer: Group Health Inc Commercial	$3,550.00
Rate for Payer: Group Health Inc Medicare	$2,485.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,550.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,550.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,615.00

BIOTRON SETROX S53 LEAD 350974

Facility

$900.00

Service Code	HCPCS C1898
Hospital Charge Code	66573251
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$495.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$540.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.50
Rate for Payer: EmblemHealth Commercial	$450.00
Rate for Payer: Fidelis Medicare Advantage	$945.00
Rate for Payer: Group Health Inc Commercial	$450.00
Rate for Payer: Group Health Inc Medicare	$315.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$585.00

BIOTRON SETROX S60 LEAD 350975

Facility

$900.00

Service Code	HCPCS C1898
Hospital Charge Code	66573252
Hospital Revenue Code	275
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$495.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Brighton Health Commercial	$540.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.50
Rate for Payer: EmblemHealth Commercial	$450.00
Rate for Payer: Fidelis Medicare Advantage	$945.00
Rate for Payer: Group Health Inc Commercial	$450.00
Rate for Payer: Group Health Inc Medicare	$315.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$585.00

BIPAP THERAPY

Facility

$557.18

Service Code	HCPCS 94660
Hospital Charge Code	40306650
Hospital Revenue Code	410
Min. Negotiated Rate	$132.45
Max. Negotiated Rate	$417.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$306.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$246.65
Rate for Payer: Aetna Government	$246.65
Rate for Payer: Affinity Essential Plan 1&2	$172.66
Rate for Payer: Affinity Essential Plan 3&4	$172.66
Rate for Payer: Affinity Medicaid/CHP/HARP	$172.66
Rate for Payer: Brighton Health Commercial	$417.88
Rate for Payer: Cash Price	$246.65
Rate for Payer: Cash Price	$246.65
Rate for Payer: Cash Price	$246.65
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$246.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$155.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$132.45
Rate for Payer: Elderplan Medicare Advantage	$246.65
Rate for Payer: EmblemHealth Commercial	$246.65
Rate for Payer: Fidelis Essential Plan Aliesa	$209.65
Rate for Payer: Fidelis Essential Plan QHP	$219.52
Rate for Payer: Fidelis Medicare Advantage	$246.65
Rate for Payer: Fidelis Qualified Health Plan	$219.52
Rate for Payer: Group Health Inc Commercial	$246.65
Rate for Payer: Group Health Inc Medicare	$246.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$278.59
Rate for Payer: Hamaspik Choice Inc Medicare	$246.65
Rate for Payer: Healthfirst Medicare Advantage	$209.65
Rate for Payer: Healthfirst QHP	$246.65
Rate for Payer: Humana Medicare	$251.58
Rate for Payer: Senior Whole Health Medicare Advantage	$246.65
Rate for Payer: United Healthcare Commercial	$278.59
Rate for Payer: United Healthcare Medicare Advantage	$246.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$246.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$197.32
Rate for Payer: Wellcare Medicare	$234.32

BIPAP THERAPY

Facility

$557.18

Service Code	HCPCS 94660
Hospital Charge Code	40306650
Hospital Revenue Code	410
Rate for Payer: Cash Price	$246.65

BIPIV 0.0625%+FENT 1250MCG NS250M

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	41655943
Hospital Revenue Code	636
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

BIPIV 0.0625%+FENT 1250MCG NS250M

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	41645943
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

BIPIV 0.0625%+FENT 1250MCG NS250M

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	41645943
Hospital Revenue Code	636
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

BIPIV 0.0625%+FENT 1250MCG NS250M

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	41655943
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

BIPIV 0.0625%+FENT 500MCG NS250ML

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	41645935
Hospital Revenue Code	636
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$39.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.00
Rate for Payer: Aetna Government	$30.00
Rate for Payer: Brighton Health Commercial	$36.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$34.50
Rate for Payer: Group Health Inc Commercial	$30.00
Rate for Payer: Group Health Inc Medicare	$21.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00
Rate for Payer: Hamaspik Choice Inc Medicare	$30.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.00

BIPIV 0.0625%+FENT 500MCG NS250ML

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	41645935
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00
Rate for Payer: Hamaspik Choice Inc Medicare	$30.00

BIPIV 0.0625%+FENT 500MCG NS250ML

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	41655935
Hospital Revenue Code	636
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$39.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.00
Rate for Payer: Aetna Government	$30.00
Rate for Payer: Brighton Health Commercial	$36.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$34.50
Rate for Payer: Group Health Inc Commercial	$30.00
Rate for Payer: Group Health Inc Medicare	$21.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00
Rate for Payer: Hamaspik Choice Inc Medicare	$30.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.00

BIPIV 0.0625%+FENT 500MCG NS250ML

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	41655935
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.00
Rate for Payer: Hamaspik Choice Inc Medicare	$30.00

BIPIV 0.0625% NS 250ML

Facility

$6.00

Service Code	HCPCS J3490
Hospital Charge Code	41645937
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.90
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	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
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
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

BIPIV 0.0625% NS 250ML

Facility

$6.00

Service Code	HCPCS J3490
Hospital Charge Code	41645937
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

BIPIV 0.0625% NS 250ML

Facility

$6.00

Service Code	HCPCS J3490
Hospital Charge Code	41655937
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.90
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	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
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
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

Know your out-of-pocket cost for care.

All Charges