St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

VANCOMYCIN TROUGH

Facility

$33.85

Service Code	HCPCS 80202
Hospital Charge Code	40602595
Hospital Revenue Code	301
Min. Negotiated Rate	$9.48
Max. Negotiated Rate	$25.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.54
Rate for Payer: Aetna Government	$13.54
Rate for Payer: Affinity Essential Plan 1&2	$9.48
Rate for Payer: Affinity Essential Plan 3&4	$9.48
Rate for Payer: Affinity Medicaid/CHP/HARP	$9.48
Rate for Payer: Brighton Health Commercial	$25.39
Rate for Payer: Cash Price	$13.54
Rate for Payer: Cash Price	$13.54
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$13.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.22
Rate for Payer: Elderplan Medicare Advantage	$13.54
Rate for Payer: EmblemHealth Commercial	$13.54
Rate for Payer: Fidelis Essential Plan Aliesa	$11.51
Rate for Payer: Fidelis Essential Plan QHP	$12.05
Rate for Payer: Fidelis Medicare Advantage	$13.54
Rate for Payer: Fidelis Qualified Health Plan	$12.05
Rate for Payer: Group Health Inc Commercial	$13.54
Rate for Payer: Group Health Inc Medicare	$13.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.92
Rate for Payer: Hamaspik Choice Inc Medicare	$13.54
Rate for Payer: Healthfirst Medicare Advantage	$13.54
Rate for Payer: Healthfirst QHP	$13.54
Rate for Payer: Humana Medicare	$13.81
Rate for Payer: Senior Whole Health Medicare Advantage	$13.54
Rate for Payer: United Healthcare Commercial	$17.15
Rate for Payer: United Healthcare Medicare Advantage	$13.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.54
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.83
Rate for Payer: Wellcare Medicare	$12.19

VANCOMYCIN TROUGH

Facility

$33.85

Service Code	HCPCS 80202
Hospital Charge Code	40602595
Hospital Revenue Code	301
Rate for Payer: Cash Price	$13.54

VANCO ORAL SOL 125MG/5ML

Facility

$2.00

Hospital Charge Code	41655873
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

VANCO ORAL SOL 125MG/5ML

Facility

$2.00

Hospital Charge Code	41645873
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

VANCO ORAL SOL 250MG/10ML

Facility

$3.00

Hospital Charge Code	41655875
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

VANCO ORAL SOL 250MG/10ML SOL

Facility

$3.00

Hospital Charge Code	41645875
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

VANCO ORAL SOL 500MG/20ML

Facility

$5.00

Hospital Charge Code	41655877
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.50
Rate for Payer: Aetna Government	$2.50
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

VANCO ORAL SOL 500MG/20ML

Facility

$5.00

Hospital Charge Code	41645877
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.50
Rate for Payer: Aetna Government	$2.50
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

VANGRD DCM CR TIB 10MMX71/75MM

Facility

$2,208.00

Service Code	HCPCS C1776
Hospital Charge Code	40202084
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,318.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,214.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,324.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,104.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,269.60
Rate for Payer: EmblemHealth Commercial	$1,104.00
Rate for Payer: Fidelis Medicare Advantage	$2,318.40
Rate for Payer: Group Health Inc Commercial	$1,104.00
Rate for Payer: Group Health Inc Medicare	$772.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,104.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,104.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,435.20

VANGRD DCM CR TIB 10MMX71/75MM

Facility

$2,208.00

Service Code	HCPCS C1776
Hospital Charge Code	40202084
Hospital Revenue Code	278
Min. Negotiated Rate	$1,104.00
Max. Negotiated Rate	$1,104.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,104.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,104.00

VANILLYLMANDELIC ACID, 24-HR U

Facility

$38.75

Service Code	HCPCS 84585
Hospital Charge Code	40609825
Hospital Revenue Code	305
Rate for Payer: Cash Price	$15.50

VANILLYLMANDELIC ACID, 24-HR U

Facility

$38.75

Service Code	HCPCS 84585
Hospital Charge Code	40609825
Hospital Revenue Code	305
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$29.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.50
Rate for Payer: Aetna Government	$15.50
Rate for Payer: Affinity Essential Plan 1&2	$10.85
Rate for Payer: Affinity Essential Plan 3&4	$10.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.85
Rate for Payer: Brighton Health Commercial	$29.06
Rate for Payer: Cash Price	$15.50
Rate for Payer: Cash Price	$15.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$15.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.86
Rate for Payer: Elderplan Medicare Advantage	$15.50
Rate for Payer: EmblemHealth Commercial	$15.50
Rate for Payer: Fidelis Essential Plan Aliesa	$13.18
Rate for Payer: Fidelis Essential Plan QHP	$13.80
Rate for Payer: Fidelis Medicare Advantage	$15.50
Rate for Payer: Fidelis Qualified Health Plan	$13.80
Rate for Payer: Group Health Inc Commercial	$15.50
Rate for Payer: Group Health Inc Medicare	$15.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.38
Rate for Payer: Hamaspik Choice Inc Medicare	$15.50
Rate for Payer: Healthfirst Medicare Advantage	$15.50
Rate for Payer: Healthfirst QHP	$15.50
Rate for Payer: Humana Medicare	$15.81
Rate for Payer: Senior Whole Health Medicare Advantage	$15.50
Rate for Payer: United Healthcare Commercial	$19.64
Rate for Payer: United Healthcare Medicare Advantage	$15.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$12.40
Rate for Payer: Wellcare Medicare	$13.95

VANILLYMANDELIC ACID 24 HR URINE

Facility

$38.75

Service Code	HCPCS 84585
Hospital Charge Code	40608260
Hospital Revenue Code	301
Rate for Payer: Cash Price	$15.50

VANILLYMANDELIC ACID 24 HR URINE

Facility

$38.75

Service Code	HCPCS 84585
Hospital Charge Code	40608260
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$29.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.50
Rate for Payer: Aetna Government	$15.50
Rate for Payer: Affinity Essential Plan 1&2	$10.85
Rate for Payer: Affinity Essential Plan 3&4	$10.85
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.85
Rate for Payer: Brighton Health Commercial	$29.06
Rate for Payer: Cash Price	$15.50
Rate for Payer: Cash Price	$15.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$15.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.86
Rate for Payer: Elderplan Medicare Advantage	$15.50
Rate for Payer: EmblemHealth Commercial	$15.50
Rate for Payer: Fidelis Essential Plan Aliesa	$13.18
Rate for Payer: Fidelis Essential Plan QHP	$13.80
Rate for Payer: Fidelis Medicare Advantage	$15.50
Rate for Payer: Fidelis Qualified Health Plan	$13.80
Rate for Payer: Group Health Inc Commercial	$15.50
Rate for Payer: Group Health Inc Medicare	$15.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.38
Rate for Payer: Hamaspik Choice Inc Medicare	$15.50
Rate for Payer: Healthfirst Medicare Advantage	$15.50
Rate for Payer: Healthfirst QHP	$15.50
Rate for Payer: Humana Medicare	$15.81
Rate for Payer: Senior Whole Health Medicare Advantage	$15.50
Rate for Payer: United Healthcare Commercial	$19.64
Rate for Payer: United Healthcare Medicare Advantage	$15.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$12.40
Rate for Payer: Wellcare Medicare	$13.95

VARADY TYPE VEIN HOOKS D/E

Facility

$337.50

Hospital Charge Code	64903609
Hospital Revenue Code	270
Min. Negotiated Rate	$118.12
Max. Negotiated Rate	$270.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$168.75
Rate for Payer: Aetna Government	$168.75
Rate for Payer: Brighton Health Commercial	$253.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$270.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$229.50
Rate for Payer: Group Health Inc Commercial	$168.75
Rate for Payer: Group Health Inc Medicare	$118.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$168.75
Rate for Payer: Hamaspik Choice Inc Medicare	$168.75

VARADY TYPE VEIN HOOKS D/E

Facility

$337.50

Hospital Charge Code	64903607
Hospital Revenue Code	270
Min. Negotiated Rate	$118.12
Max. Negotiated Rate	$270.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$168.75
Rate for Payer: Aetna Government	$168.75
Rate for Payer: Brighton Health Commercial	$253.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$270.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$229.50
Rate for Payer: Group Health Inc Commercial	$168.75
Rate for Payer: Group Health Inc Medicare	$118.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$168.75
Rate for Payer: Hamaspik Choice Inc Medicare	$168.75

VARICELLA VACC (VFC) 0.5ML SQ VIA

Facility

$0.01

Service Code	HCPCS 90716
Hospital Charge Code	41649573
Hospital Revenue Code	636
Max. Negotiated Rate	$153.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$153.87
Rate for Payer: Aetna Government	$153.87
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

VARICELLA VACC (VFC) 0.5ML SQ VIA

Facility

$0.01

Service Code	HCPCS 90716
Hospital Charge Code	41659573
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

VARICELLA VACC (VFC) 0.5ML SQ VIA

Facility

$0.01

Service Code	HCPCS 90716
Hospital Charge Code	41659573
Hospital Revenue Code	636
Max. Negotiated Rate	$153.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$153.87
Rate for Payer: Aetna Government	$153.87
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

VARICELLA VACC (VFC) 0.5ML SQ VIA

Facility

$0.01

Service Code	HCPCS 90716
Hospital Charge Code	41649573
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

VARICELLA VIRUS VACCINE INJ

Facility

$172.19

Hospital Charge Code	41642431
Hospital Revenue Code	250
Min. Negotiated Rate	$60.27
Max. Negotiated Rate	$137.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$94.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$86.10
Rate for Payer: Aetna Government	$86.10
Rate for Payer: Brighton Health Commercial	$129.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$137.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$117.09
Rate for Payer: Group Health Inc Commercial	$86.10
Rate for Payer: Group Health Inc Medicare	$60.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$86.10
Rate for Payer: Hamaspik Choice Inc Medicare	$86.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$111.92

VARICELLA VIRUS VACCINE INJ

Facility

$172.19

Hospital Charge Code	41652431
Hospital Revenue Code	250
Min. Negotiated Rate	$60.27
Max. Negotiated Rate	$137.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$94.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$86.10
Rate for Payer: Aetna Government	$86.10
Rate for Payer: Brighton Health Commercial	$129.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$137.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$117.09
Rate for Payer: Group Health Inc Commercial	$86.10
Rate for Payer: Group Health Inc Medicare	$60.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$86.10
Rate for Payer: Hamaspik Choice Inc Medicare	$86.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$111.92

VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ [113088]

Facility

$209.04

Service Code	NDC 00006482700
Hospital Charge Code	00006482700
Hospital Revenue Code	250
Min. Negotiated Rate	$73.16
Max. Negotiated Rate	$167.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$114.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$104.52
Rate for Payer: Aetna Government	$104.52
Rate for Payer: Brighton Health Commercial	$156.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$167.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.15
Rate for Payer: Group Health Inc Commercial	$104.52
Rate for Payer: Group Health Inc Medicare	$73.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$104.52
Rate for Payer: Hamaspik Choice Inc Medicare	$104.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$135.87

VARICELLA ZOSTER AB

Facility

$32.20

Service Code	HCPCS 86787
Hospital Charge Code	40617759
Hospital Revenue Code	300
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$24.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.88
Rate for Payer: Aetna Government	$12.88
Rate for Payer: Affinity Essential Plan 1&2	$9.02
Rate for Payer: Affinity Essential Plan 3&4	$9.02
Rate for Payer: Affinity Medicaid/CHP/HARP	$9.02
Rate for Payer: Brighton Health Commercial	$24.15
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cash Price	$12.88
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.32
Rate for Payer: Elderplan Medicare Advantage	$12.88
Rate for Payer: EmblemHealth Commercial	$12.88
Rate for Payer: Fidelis Essential Plan Aliesa	$10.95
Rate for Payer: Fidelis Essential Plan QHP	$11.46
Rate for Payer: Fidelis Medicare Advantage	$12.88
Rate for Payer: Fidelis Qualified Health Plan	$11.46
Rate for Payer: Group Health Inc Commercial	$12.88
Rate for Payer: Group Health Inc Medicare	$12.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.10
Rate for Payer: Hamaspik Choice Inc Medicare	$12.88
Rate for Payer: Healthfirst Medicare Advantage	$12.88
Rate for Payer: Healthfirst QHP	$12.88
Rate for Payer: Humana Medicare	$13.14
Rate for Payer: Senior Whole Health Medicare Advantage	$12.88
Rate for Payer: United Healthcare Commercial	$16.32
Rate for Payer: United Healthcare Medicare Advantage	$12.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.30
Rate for Payer: Wellcare Medicare	$11.59

VARICELLA ZOSTER AB

Facility

$32.20

Service Code	HCPCS 86787
Hospital Charge Code	40617759
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.88

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