St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

WEDGE PLEXUR 40X15MM X 15DEG

Facility

$1,712.50

Service Code	HCPCS C1713
Hospital Charge Code	64904658
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,798.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$941.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,027.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$856.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$984.69
Rate for Payer: EmblemHealth Commercial	$856.25
Rate for Payer: Fidelis Medicare Advantage	$1,798.12
Rate for Payer: Group Health Inc Commercial	$856.25
Rate for Payer: Group Health Inc Medicare	$599.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$856.25
Rate for Payer: Hamaspik Choice Inc Medicare	$856.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,113.12

WEDGE PLEXUR 40X15MM X 15DEG

Facility

$1,712.50

Service Code	HCPCS C1713
Hospital Charge Code	64904658
Hospital Revenue Code	278
Min. Negotiated Rate	$856.25
Max. Negotiated Rate	$856.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$856.25
Rate for Payer: Hamaspik Choice Inc Medicare	$856.25

WEDGE RESEC OVARY UNI OR BILATERA

Facility

$20,303.53

Service Code	HCPCS 58920
Hospital Charge Code	40059984
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$15,227.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8,738.54
Rate for Payer: Aetna Government	$8,738.54
Rate for Payer: Brighton Health Commercial	$15,227.65
Rate for Payer: Cash Price	$8,738.54
Rate for Payer: Cash Price	$8,738.54
Rate for Payer: Cash Price	$8,738.54
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$8,738.54
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: Elderplan Medicare Advantage	$8,738.54
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$7,427.76
Rate for Payer: Fidelis Essential Plan QHP	$7,777.30
Rate for Payer: Fidelis Medicare Advantage	$8,738.54
Rate for Payer: Fidelis Qualified Health Plan	$7,777.30
Rate for Payer: Group Health Inc Commercial	$8,738.54
Rate for Payer: Group Health Inc Medicare	$8,738.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,151.76
Rate for Payer: Hamaspik Choice Inc Medicare	$8,738.54
Rate for Payer: Healthfirst Medicare Advantage	$7,427.76
Rate for Payer: Healthfirst QHP	$8,738.54
Rate for Payer: Senior Whole Health Medicare Advantage	$8,738.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8,738.54
Rate for Payer: Wellcare CHP/FHP/Medicaid	$6,990.83
Rate for Payer: Wellcare Medicare	$8,301.61

WEDGE RESEC OVARY UNI OR BILATERA

Facility

$20,303.53

Service Code	HCPCS 58920
Hospital Charge Code	40059984
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,738.54

WEEDS

Facility

$13.05

Service Code	HCPCS 86003
Hospital Charge Code	40729316
Hospital Revenue Code	300
Rate for Payer: Cash Price	$5.22

WEEDS

Facility

$13.05

Service Code	HCPCS 86003
Hospital Charge Code	40729316
Hospital Revenue Code	300
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$9.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.22
Rate for Payer: Aetna Government	$5.22
Rate for Payer: Brighton Health Commercial	$9.79
Rate for Payer: Cash Price	$5.22
Rate for Payer: Cash Price	$5.22
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$5.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.01
Rate for Payer: Elderplan Medicare Advantage	$5.22
Rate for Payer: EmblemHealth Commercial	$5.22
Rate for Payer: Fidelis Essential Plan Aliesa	$4.44
Rate for Payer: Fidelis Essential Plan QHP	$4.65
Rate for Payer: Fidelis Medicare Advantage	$5.22
Rate for Payer: Fidelis Qualified Health Plan	$4.65
Rate for Payer: Group Health Inc Commercial	$5.22
Rate for Payer: Group Health Inc Medicare	$5.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.52
Rate for Payer: Hamaspik Choice Inc Medicare	$5.22
Rate for Payer: Healthfirst Medicare Advantage	$5.22
Rate for Payer: Healthfirst QHP	$5.22
Rate for Payer: Senior Whole Health Medicare Advantage	$5.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.22
Rate for Payer: Wellcare CHP/FHP/Medicaid	$4.18
Rate for Payer: Wellcare Medicare	$4.70

WEIGHT MGMT CLASS

Facility

$20.00

Service Code	HCPCS S9449
Hospital Charge Code	30305708
Hospital Revenue Code	942
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$42.77
Rate for Payer: Aetna Government	$42.77
Rate for Payer: Brighton Health Commercial	$15.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.60
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00

WEST NILE (IGG, IGM) CSF

Facility

$42.13

Service Code	HCPCS 86788
Hospital Charge Code	40728283
Hospital Revenue Code	302
Min. Negotiated Rate	$13.48
Max. Negotiated Rate	$31.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.85
Rate for Payer: Aetna Government	$16.85
Rate for Payer: Brighton Health Commercial	$31.60
Rate for Payer: Cash Price	$16.85
Rate for Payer: Cash Price	$16.85
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$16.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.66
Rate for Payer: Elderplan Medicare Advantage	$16.85
Rate for Payer: EmblemHealth Commercial	$16.85
Rate for Payer: Fidelis Essential Plan Aliesa	$14.32
Rate for Payer: Fidelis Essential Plan QHP	$15.00
Rate for Payer: Fidelis Medicare Advantage	$16.85
Rate for Payer: Fidelis Qualified Health Plan	$15.00
Rate for Payer: Group Health Inc Commercial	$16.85
Rate for Payer: Group Health Inc Medicare	$16.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$21.06
Rate for Payer: Hamaspik Choice Inc Medicare	$16.85
Rate for Payer: Healthfirst Medicare Advantage	$16.85
Rate for Payer: Healthfirst QHP	$16.85
Rate for Payer: Senior Whole Health Medicare Advantage	$16.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$13.48
Rate for Payer: Wellcare Medicare	$15.16

WEST NILE (IGG, IGM) CSF

Facility

$42.13

Service Code	HCPCS 86788
Hospital Charge Code	40728283
Hospital Revenue Code	302
Rate for Payer: Cash Price	$16.85

WEST NILE VIRUS ANTIBODY

Facility

$35.98

Service Code	HCPCS 86789
Hospital Charge Code	40729626
Hospital Revenue Code	300
Rate for Payer: Cash Price	$14.39

WEST NILE VIRUS ANTIBODY

Facility

$35.98

Service Code	HCPCS 86789
Hospital Charge Code	40729626
Hospital Revenue Code	300
Min. Negotiated Rate	$11.51
Max. Negotiated Rate	$26.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.39
Rate for Payer: Aetna Government	$14.39
Rate for Payer: Brighton Health Commercial	$26.98
Rate for Payer: Cash Price	$14.39
Rate for Payer: Cash Price	$14.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$14.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.35
Rate for Payer: Elderplan Medicare Advantage	$14.39
Rate for Payer: EmblemHealth Commercial	$14.39
Rate for Payer: Fidelis Essential Plan Aliesa	$12.23
Rate for Payer: Fidelis Essential Plan QHP	$12.81
Rate for Payer: Fidelis Medicare Advantage	$14.39
Rate for Payer: Fidelis Qualified Health Plan	$12.81
Rate for Payer: Group Health Inc Commercial	$14.39
Rate for Payer: Group Health Inc Medicare	$14.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.99
Rate for Payer: Hamaspik Choice Inc Medicare	$14.39
Rate for Payer: Healthfirst Medicare Advantage	$14.39
Rate for Payer: Healthfirst QHP	$14.39
Rate for Payer: Senior Whole Health Medicare Advantage	$14.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.51
Rate for Payer: Wellcare Medicare	$12.95

WEST NILE VIRUS ANTIBODY, CSF

Facility

$42.13

Service Code	HCPCS 86788
Hospital Charge Code	40729384
Hospital Revenue Code	300
Min. Negotiated Rate	$13.48
Max. Negotiated Rate	$31.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.85
Rate for Payer: Aetna Government	$16.85
Rate for Payer: Brighton Health Commercial	$31.60
Rate for Payer: Cash Price	$16.85
Rate for Payer: Cash Price	$16.85
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$16.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.66
Rate for Payer: Elderplan Medicare Advantage	$16.85
Rate for Payer: EmblemHealth Commercial	$16.85
Rate for Payer: Fidelis Essential Plan Aliesa	$14.32
Rate for Payer: Fidelis Essential Plan QHP	$15.00
Rate for Payer: Fidelis Medicare Advantage	$16.85
Rate for Payer: Fidelis Qualified Health Plan	$15.00
Rate for Payer: Group Health Inc Commercial	$16.85
Rate for Payer: Group Health Inc Medicare	$16.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$21.06
Rate for Payer: Hamaspik Choice Inc Medicare	$16.85
Rate for Payer: Healthfirst Medicare Advantage	$16.85
Rate for Payer: Healthfirst QHP	$16.85
Rate for Payer: Senior Whole Health Medicare Advantage	$16.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$13.48
Rate for Payer: Wellcare Medicare	$15.16

WEST NILE VIRUS ANTIBODY, CSF

Facility

$42.13

Service Code	HCPCS 86788
Hospital Charge Code	40729384
Hospital Revenue Code	300
Rate for Payer: Cash Price	$16.85

WET DRESSING

Facility

$13.47

Hospital Charge Code	40206961
Hospital Revenue Code	270
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$10.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.74
Rate for Payer: Aetna Government	$6.74
Rate for Payer: Brighton Health Commercial	$10.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.16
Rate for Payer: Group Health Inc Commercial	$6.74
Rate for Payer: Group Health Inc Medicare	$4.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.74
Rate for Payer: Hamaspik Choice Inc Medicare	$6.74

WET-FIELD ERSR HMSTTC BIPLR INSTR

Facility

$154.00

Hospital Charge Code	40200848
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$123.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$84.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$77.00
Rate for Payer: Aetna Government	$77.00
Rate for Payer: Brighton Health Commercial	$115.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$123.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$104.72
Rate for Payer: Group Health Inc Commercial	$77.00
Rate for Payer: Group Health Inc Medicare	$53.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.00
Rate for Payer: Hamaspik Choice Inc Medicare	$77.00

WHEEL ATTACHMENTS FIXED 3 SINGLE

Facility

$33.15

Hospital Charge Code	64903191
Hospital Revenue Code	270
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$26.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.58
Rate for Payer: Aetna Government	$16.58
Rate for Payer: Brighton Health Commercial	$24.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.54
Rate for Payer: Group Health Inc Commercial	$16.58
Rate for Payer: Group Health Inc Medicare	$11.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.58
Rate for Payer: Hamaspik Choice Inc Medicare	$16.58

WHEELER REPAIR

Facility

$5,861.23

Service Code	HCPCS 67924
Hospital Charge Code	40072550
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,702.32

WHEELER REPAIR

Facility

$5,861.23

Service Code	HCPCS 67924
Hospital Charge Code	40072550
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$4,395.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,702.32
Rate for Payer: Aetna Government	$2,702.32
Rate for Payer: Brighton Health Commercial	$4,395.92
Rate for Payer: Cash Price	$2,702.32
Rate for Payer: Cash Price	$2,702.32
Rate for Payer: Cash Price	$2,702.32
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$2,702.32
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: Elderplan Medicare Advantage	$2,702.32
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$2,296.97
Rate for Payer: Fidelis Essential Plan QHP	$2,405.06
Rate for Payer: Fidelis Medicare Advantage	$2,702.32
Rate for Payer: Fidelis Qualified Health Plan	$2,405.06
Rate for Payer: Group Health Inc Commercial	$2,702.32
Rate for Payer: Group Health Inc Medicare	$2,702.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,930.62
Rate for Payer: Hamaspik Choice Inc Medicare	$2,702.32
Rate for Payer: Healthfirst Medicare Advantage	$2,296.97
Rate for Payer: Healthfirst QHP	$2,702.32
Rate for Payer: Senior Whole Health Medicare Advantage	$2,702.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,702.32
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,161.86
Rate for Payer: Wellcare Medicare	$2,567.20

WHIPPLE PROCEDURE

Facility

$9,099.13

Service Code	HCPCS 48150
Hospital Charge Code	40011085
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$6,824.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,004.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,706.77
Rate for Payer: Aetna Government	$3,706.77
Rate for Payer: Brighton Health Commercial	$6,824.35
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: EmblemHealth Commercial	$1,505.00
Rate for Payer: Group Health Inc Commercial	$4,549.56
Rate for Payer: Group Health Inc Medicare	$3,184.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,549.56
Rate for Payer: Hamaspik Choice Inc Medicare	$4,549.56

WHITE BLOOD CELLS (WBC), STOOL

Facility

$18.73

Service Code	HCPCS 89055
Hospital Charge Code	40614217
Hospital Revenue Code	300
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$14.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.27
Rate for Payer: Aetna Government	$4.27
Rate for Payer: Brighton Health Commercial	$14.05
Rate for Payer: Cash Price	$4.27
Rate for Payer: Cash Price	$4.27
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.79
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.74
Rate for Payer: Elderplan Medicare Advantage	$4.27
Rate for Payer: EmblemHealth Commercial	$4.27
Rate for Payer: Fidelis Essential Plan Aliesa	$3.63
Rate for Payer: Fidelis Essential Plan QHP	$3.80
Rate for Payer: Fidelis Medicare Advantage	$4.27
Rate for Payer: Fidelis Qualified Health Plan	$3.80
Rate for Payer: Group Health Inc Commercial	$4.27
Rate for Payer: Group Health Inc Medicare	$4.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.36
Rate for Payer: Hamaspik Choice Inc Medicare	$4.27
Rate for Payer: Healthfirst Medicare Advantage	$4.27
Rate for Payer: Healthfirst QHP	$4.27
Rate for Payer: Senior Whole Health Medicare Advantage	$4.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.27
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3.42
Rate for Payer: Wellcare Medicare	$3.84

WHITE BLOOD CELLS (WBC), STOOL

Facility

$18.73

Service Code	HCPCS 89055
Hospital Charge Code	40614217
Hospital Revenue Code	300
Rate for Payer: Cash Price	$4.27

WHITE NUT

Facility

$11.00

Hospital Charge Code	64905971
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$8.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.50
Rate for Payer: Aetna Government	$5.50
Rate for Payer: Brighton Health Commercial	$8.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.48
Rate for Payer: Group Health Inc Commercial	$5.50
Rate for Payer: Group Health Inc Medicare	$3.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.50
Rate for Payer: Hamaspik Choice Inc Medicare	$5.50

WHITE PETROLATUM EX OINT [8780]

Facility

$0.04

Service Code	NDC 58980035050
Hospital Charge Code	58980035050
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

WHITE PETROLATUM EX OINT [8780]

Facility

$0.02

Service Code	NDC 53329006804
Hospital Charge Code	53329006804
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.01
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

WHITE RELOAD FOR ECHELON 45

Facility

$330.31

Hospital Charge Code	64905171
Hospital Revenue Code	270
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$264.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$181.67
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$165.16
Rate for Payer: Aetna Government	$165.16
Rate for Payer: Brighton Health Commercial	$247.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$264.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.61
Rate for Payer: Group Health Inc Commercial	$165.16
Rate for Payer: Group Health Inc Medicare	$115.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$165.16
Rate for Payer: Hamaspik Choice Inc Medicare	$165.16

Know your out-of-pocket cost for care.

All Charges