St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

VITAMIN E 50 INTL UNITS/ML LIQUID

Facility

$2.00

Hospital Charge Code	41652951
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

VITAMIN E 50 INTL UNITS/ML LIQUID

Facility

$2.00

Hospital Charge Code	41642951
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

VITAMIN E SERUM

Facility

$35.45

Service Code	HCPCS 84446
Hospital Charge Code	40609730
Hospital Revenue Code	301
Rate for Payer: Cash Price	$14.18

VITAMIN E SERUM

Facility

$35.45

Service Code	HCPCS 84446
Hospital Charge Code	40609730
Hospital Revenue Code	301
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$26.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.18
Rate for Payer: Aetna Government	$14.18
Rate for Payer: Brighton Health Commercial	$26.59
Rate for Payer: Cash Price	$14.18
Rate for Payer: Cash Price	$14.18
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$14.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.06
Rate for Payer: Elderplan Medicare Advantage	$14.18
Rate for Payer: EmblemHealth Commercial	$14.18
Rate for Payer: Fidelis Essential Plan Aliesa	$12.05
Rate for Payer: Fidelis Essential Plan QHP	$12.62
Rate for Payer: Fidelis Medicare Advantage	$14.18
Rate for Payer: Fidelis Qualified Health Plan	$12.62
Rate for Payer: Group Health Inc Commercial	$14.18
Rate for Payer: Group Health Inc Medicare	$14.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.72
Rate for Payer: Hamaspik Choice Inc Medicare	$14.18
Rate for Payer: Healthfirst Medicare Advantage	$14.18
Rate for Payer: Healthfirst QHP	$14.18
Rate for Payer: Senior Whole Health Medicare Advantage	$14.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.18
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.34
Rate for Payer: Wellcare Medicare	$12.76

VITAMIN K1 1 MG/0.5ML IJ SOLN [41624]

Facility

$11.39

Service Code	HCPCS J3430
Hospital Charge Code	00409915701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$9.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$8.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.75
Rate for Payer: Group Health Inc Commercial	$5.70
Rate for Payer: Group Health Inc Medicare	$3.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.70
Rate for Payer: Hamaspik Choice Inc Medicare	$5.70
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.40

VITAMIN K1 1 MG/0.5ML IJ SOLN [41624]

Facility

$14.40

Service Code	HCPCS J3430
Hospital Charge Code	69097070996
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$11.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$10.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.79
Rate for Payer: Group Health Inc Commercial	$7.20
Rate for Payer: Group Health Inc Medicare	$5.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.20
Rate for Payer: Hamaspik Choice Inc Medicare	$7.20
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.36

VITAMIN K1 1 MG/0.5ML IJ SOLN [41624]

Facility

$11.40

Service Code	HCPCS J3430
Hospital Charge Code	00409915731
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$9.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$8.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.75
Rate for Payer: Group Health Inc Commercial	$5.70
Rate for Payer: Group Health Inc Medicare	$3.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.70
Rate for Payer: Hamaspik Choice Inc Medicare	$5.70
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.41

VITAMIN K1 1 MG/0.5ML IJ SOLN [41624]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	76329124001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$47.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$32.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$44.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$40.36
Rate for Payer: Group Health Inc Commercial	$29.68
Rate for Payer: Group Health Inc Medicare	$20.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.68
Rate for Payer: Hamaspik Choice Inc Medicare	$29.68
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$38.58

VITAMIN-K ORAL LIQ 1MG/ML

Facility

$7.31

Hospital Charge Code	41646568
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$5.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$5.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.97
Rate for Payer: Group Health Inc Commercial	$3.66
Rate for Payer: Group Health Inc Medicare	$2.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.66
Rate for Payer: Hamaspik Choice Inc Medicare	$3.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.75

VITAMIN-K ORAL LIQ 1MG/ML

Facility

$7.31

Hospital Charge Code	41656568
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$5.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$5.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.97
Rate for Payer: Group Health Inc Commercial	$3.66
Rate for Payer: Group Health Inc Medicare	$2.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.66
Rate for Payer: Hamaspik Choice Inc Medicare	$3.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.75

VIT. B1, WHOLE BLOOD

Facility

$30.38

Hospital Charge Code	40609166
Hospital Revenue Code	300
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$24.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.19
Rate for Payer: Aetna Government	$15.19
Rate for Payer: Brighton Health Commercial	$22.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.66
Rate for Payer: Group Health Inc Commercial	$15.19
Rate for Payer: Group Health Inc Medicare	$10.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.19
Rate for Payer: Hamaspik Choice Inc Medicare	$15.19

VITOSS 10CC BIMODAL ORTHO

Facility

$13,991.25

Service Code	HCPCS C1713
Hospital Charge Code	64906985
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$14,690.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7,695.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$8,394.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6,995.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,044.97
Rate for Payer: EmblemHealth Commercial	$6,995.62
Rate for Payer: Fidelis Medicare Advantage	$14,690.81
Rate for Payer: Group Health Inc Commercial	$6,995.62
Rate for Payer: Group Health Inc Medicare	$4,896.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,995.62
Rate for Payer: Hamaspik Choice Inc Medicare	$6,995.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,094.31

VITOSS 10CC BIMODAL ORTHO

Facility

$13,991.25

Service Code	HCPCS C1713
Hospital Charge Code	64906985
Hospital Revenue Code	278
Min. Negotiated Rate	$6,995.62
Max. Negotiated Rate	$6,995.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,995.62
Rate for Payer: Hamaspik Choice Inc Medicare	$6,995.62

VITOSS 5CC PACK

Facility

$6,187.50

Hospital Charge Code	64902658
Hospital Revenue Code	279
Min. Negotiated Rate	$2,165.62
Max. Negotiated Rate	$4,950.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,403.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,093.75
Rate for Payer: Aetna Government	$3,093.75
Rate for Payer: Brighton Health Commercial	$4,640.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,950.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,207.50
Rate for Payer: Group Health Inc Commercial	$3,093.75
Rate for Payer: Group Health Inc Medicare	$2,165.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,093.75
Rate for Payer: Hamaspik Choice Inc Medicare	$3,093.75

VITOSS BIMODAL

Facility

$9,340.83

Hospital Charge Code	64904783
Hospital Revenue Code	279
Min. Negotiated Rate	$3,269.29
Max. Negotiated Rate	$7,472.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,137.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,670.42
Rate for Payer: Aetna Government	$4,670.42
Rate for Payer: Brighton Health Commercial	$7,005.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,472.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,351.76
Rate for Payer: Group Health Inc Commercial	$4,670.42
Rate for Payer: Group Health Inc Medicare	$3,269.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,670.42
Rate for Payer: Hamaspik Choice Inc Medicare	$4,670.42

VITOSS BIMODAL 25CC

Facility

$2,672.58

Service Code	HCPCS C1713
Hospital Charge Code	64905417
Hospital Revenue Code	278
Min. Negotiated Rate	$1,336.29
Max. Negotiated Rate	$1,336.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,336.29
Rate for Payer: Hamaspik Choice Inc Medicare	$1,336.29

VITOSS BIMODAL 25CC

Facility

$2,672.58

Service Code	HCPCS C1713
Hospital Charge Code	64905417
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,806.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,469.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,603.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,336.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,536.73
Rate for Payer: EmblemHealth Commercial	$1,336.29
Rate for Payer: Fidelis Medicare Advantage	$2,806.21
Rate for Payer: Group Health Inc Commercial	$1,336.29
Rate for Payer: Group Health Inc Medicare	$935.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,336.29
Rate for Payer: Hamaspik Choice Inc Medicare	$1,336.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,737.18

VITOSS BIMODAL 2.5CC FOAM PACK

Facility

$2,138.00

Service Code	HCPCS C1776
Hospital Charge Code	40001786
Hospital Revenue Code	278
Min. Negotiated Rate	$1,069.00
Max. Negotiated Rate	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,069.00

VITOSS BIMODAL 2.5CC FOAM PACK

Facility

$2,138.00

Service Code	HCPCS C1776
Hospital Charge Code	40001786
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,244.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,175.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,282.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,069.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,229.35
Rate for Payer: EmblemHealth Commercial	$1,069.00
Rate for Payer: Fidelis Medicare Advantage	$2,244.90
Rate for Payer: Group Health Inc Commercial	$1,069.00
Rate for Payer: Group Health Inc Medicare	$748.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,069.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,389.70

VITOSS BIMODAL 2.5CC FOAM PK

Facility

$2,138.00

Service Code	HCPCS C1776
Hospital Charge Code	40001797
Hospital Revenue Code	278
Min. Negotiated Rate	$1,069.00
Max. Negotiated Rate	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,069.00

VITOSS BIMODAL 2.5CC FOAM PK

Facility

$2,138.00

Service Code	HCPCS C1776
Hospital Charge Code	40001797
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,244.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,175.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,282.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,069.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,229.35
Rate for Payer: EmblemHealth Commercial	$1,069.00
Rate for Payer: Fidelis Medicare Advantage	$2,244.90
Rate for Payer: Group Health Inc Commercial	$1,069.00
Rate for Payer: Group Health Inc Medicare	$748.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,069.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,069.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,389.70

VITOSS BIMODAL FOAM PACK 10CC

Facility

$3,700.00

Service Code	HCPCS C1776
Hospital Charge Code	40001799
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,885.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,035.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,220.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,850.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,127.50
Rate for Payer: EmblemHealth Commercial	$1,850.00
Rate for Payer: Fidelis Medicare Advantage	$3,885.00
Rate for Payer: Group Health Inc Commercial	$1,850.00
Rate for Payer: Group Health Inc Medicare	$1,295.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,850.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,850.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,405.00

VITOSS BIMODAL FOAM PACK 10CC

Facility

$3,700.00

Service Code	HCPCS C1776
Hospital Charge Code	40001799
Hospital Revenue Code	278
Min. Negotiated Rate	$1,850.00
Max. Negotiated Rate	$1,850.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,850.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,850.00

VITOSS BIMODAL FOAM PACK 5CC

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	40001798
Hospital Revenue Code	278
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,500.00

VITOSS BIMODAL FOAM PACK 5CC

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	40001798
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$5,250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,750.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$3,000.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,500.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,875.00
Rate for Payer: EmblemHealth Commercial	$2,500.00
Rate for Payer: Fidelis Medicare Advantage	$5,250.00
Rate for Payer: Group Health Inc Commercial	$2,500.00
Rate for Payer: Group Health Inc Medicare	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,500.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,250.00

Know your out-of-pocket cost for care.

All Charges