St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

BUPRENORPHINE/NALOX SL/FL 8-2MG

Facility

$20.35

Service Code	HCPCS J0574
Hospital Charge Code	41647839
Hospital Revenue Code	636
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$10.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.18
Rate for Payer: Hamaspik Choice Inc Medicare	$10.18

BUPRENORPHINE/NALOX SL/FL 8-2MG

Facility

$20.35

Service Code	HCPCS J0574
Hospital Charge Code	41657839
Hospital Revenue Code	636
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$10.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.18
Rate for Payer: Hamaspik Choice Inc Medicare	$10.18

BUPRENORPHINE/NALOX SL/FL 8-2MG

Facility

$20.35

Service Code	HCPCS J0574
Hospital Charge Code	41657839
Hospital Revenue Code	636
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$708.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.42
Rate for Payer: Aetna Government	$6.42
Rate for Payer: Affinity Essential Plan 1&2	$15.93
Rate for Payer: Affinity Essential Plan 3&4	$15.93
Rate for Payer: Affinity Medicaid/CHP/HARP	$7.08
Rate for Payer: Amida Care Medicaid	$7.08
Rate for Payer: Brighton Health Commercial	$12.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.70
Rate for Payer: Fidelis CHP/HARP/Medicaid	$708.00
Rate for Payer: Fidelis Essential Plan Aliesa	$7.08
Rate for Payer: Fidelis Essential Plan QHP	$7.08
Rate for Payer: Fidelis Qualified Health Plan	$7.43
Rate for Payer: Group Health Inc Commercial	$10.18
Rate for Payer: Group Health Inc Medicare	$7.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.08
Rate for Payer: Hamaspik Choice Inc Medicare	$10.18
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7.08
Rate for Payer: Healthfirst Essential Plan	$15.93
Rate for Payer: Healthfirst QHP	$7.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7.08
Rate for Payer: SOMOS Essential	$7.08
Rate for Payer: United Healthcare Essential Plan 1&2	$15.93
Rate for Payer: United Healthcare Essential Plan 3&4	$7.79
Rate for Payer: United Healthcare Medicaid	$7.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.23
Rate for Payer: Wellcare CHP/FHP/Medicaid	$7.08

BUPRENORPHINE, ORAL, 1MG

Facility

$0.08

Service Code	HCPCS J0571
Hospital Charge Code	30401103
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04

BUPRENORPHINE, ORAL, 1MG

Facility

$0.08

Service Code	HCPCS J0571
Hospital Charge Code	30401103
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$24.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.31
Rate for Payer: Aetna Government	$0.31
Rate for Payer: Affinity Essential Plan 1&2	$0.54
Rate for Payer: Affinity Essential Plan 3&4	$0.54
Rate for Payer: Affinity Medicaid/CHP/HARP	$0.24
Rate for Payer: Amida Care Medicaid	$0.24
Rate for Payer: Brighton Health Commercial	$0.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24.00
Rate for Payer: Fidelis Essential Plan Aliesa	$0.24
Rate for Payer: Fidelis Essential Plan QHP	$0.24
Rate for Payer: Fidelis Qualified Health Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.24
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.24
Rate for Payer: Healthfirst Essential Plan	$0.54
Rate for Payer: Healthfirst QHP	$0.24
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.24
Rate for Payer: SOMOS Essential	$0.24
Rate for Payer: United Healthcare Essential Plan 1&2	$0.54
Rate for Payer: United Healthcare Essential Plan 3&4	$0.26
Rate for Payer: United Healthcare Medicaid	$0.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$0.24

BUPRENORPHINE TAKE-HOME ADMIN WK2

Facility

$86.26

Service Code	HCPCS H0030
Hospital Charge Code	30400267
Hospital Revenue Code	900
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$69.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$47.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.32
Rate for Payer: Aetna Government	$5.32
Rate for Payer: Brighton Health Commercial	$64.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$69.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$58.66
Rate for Payer: Group Health Inc Commercial	$43.13
Rate for Payer: Group Health Inc Medicare	$30.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.13
Rate for Payer: Hamaspik Choice Inc Medicare	$43.13
Rate for Payer: United Healthcare Commercial	$43.13

BUPRENORPHINE, URINE

Facility

$45.00

Service Code	HCPCS 80348
Hospital Charge Code	40609008
Hospital Revenue Code	300
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$33.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.60
Rate for Payer: Group Health Inc Commercial	$22.50
Rate for Payer: Group Health Inc Medicare	$15.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50
Rate for Payer: Hamaspik Choice Inc Medicare	$22.50
Rate for Payer: United Healthcare Commercial	$14.58

BUPRENORPHNE DISPENSE BDL WK1,3,4

Facility

$260.59

Service Code	HCPCS G2068
Hospital Charge Code	30400265
Hospital Revenue Code	900
Min. Negotiated Rate	$91.21
Max. Negotiated Rate	$284.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$143.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$284.13
Rate for Payer: Aetna Government	$284.13
Rate for Payer: Brighton Health Commercial	$195.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$208.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$177.20
Rate for Payer: Group Health Inc Commercial	$130.30
Rate for Payer: Group Health Inc Medicare	$91.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$130.30
Rate for Payer: Hamaspik Choice Inc Medicare	$130.30
Rate for Payer: United Healthcare Commercial	$130.30

BUPROPION 100 MG TAB

Facility

$0.36

Hospital Charge Code	41653233
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

BUPROPION 100 MG TAB

Facility

$0.36

Hospital Charge Code	41643233
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

BUPROPION 75 MG TAB

Facility

$0.33

Hospital Charge Code	41653232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

BUPROPION 75 MG TAB

Facility

$0.33

Hospital Charge Code	41643232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

BUPROPION HCL 100 MG PO TABS [9321]

Facility

$1.06

Service Code	NDC 60505015701
Hospital Charge Code	60505015701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.53
Rate for Payer: Aetna Government	$0.53
Rate for Payer: Brighton Health Commercial	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.72
Rate for Payer: Group Health Inc Commercial	$0.53
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.53
Rate for Payer: Hamaspik Choice Inc Medicare	$0.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.69

BUPROPION HCL 100 MG PO TABS [9321]

Facility

$1.97

Service Code	NDC 00904663661
Hospital Charge Code	00904663661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.34
Rate for Payer: Group Health Inc Commercial	$0.98
Rate for Payer: Group Health Inc Medicare	$0.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98
Rate for Payer: Hamaspik Choice Inc Medicare	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.28

BUPROPION HCL 100 MG PO TABS [9321]

Facility

$2.12

Service Code	NDC 50268014315
Hospital Charge Code	50268014315
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.44
Rate for Payer: Group Health Inc Commercial	$1.06
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.38

BUPROPION HCL 75 MG PO TABS [9322]

Facility

$1.45

Service Code	NDC 00904663561
Hospital Charge Code	00904663561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$1.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.73
Rate for Payer: Aetna Government	$0.73
Rate for Payer: Brighton Health Commercial	$1.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.99
Rate for Payer: Group Health Inc Commercial	$0.73
Rate for Payer: Group Health Inc Medicare	$0.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.73
Rate for Payer: Hamaspik Choice Inc Medicare	$0.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.94

BUPROPION HCL 75 MG PO TABS [9322]

Facility

$0.79

Service Code	NDC 60505015801
Hospital Charge Code	60505015801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.40
Rate for Payer: Aetna Government	$0.40
Rate for Payer: Brighton Health Commercial	$0.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.54
Rate for Payer: Group Health Inc Commercial	$0.40
Rate for Payer: Group Health Inc Medicare	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.40
Rate for Payer: Hamaspik Choice Inc Medicare	$0.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.52

BUR BARREL 6 FLUTE 4.0MM

Facility

$100.06

Hospital Charge Code	64904974
Hospital Revenue Code	270
Min. Negotiated Rate	$35.02
Max. Negotiated Rate	$80.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$50.03
Rate for Payer: Aetna Government	$50.03
Rate for Payer: Brighton Health Commercial	$75.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$80.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$68.04
Rate for Payer: Group Health Inc Commercial	$50.03
Rate for Payer: Group Health Inc Medicare	$35.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.03
Rate for Payer: Hamaspik Choice Inc Medicare	$50.03

BUR BARREL 6 FLUTE 5.0MM

Facility

$145.10

Hospital Charge Code	64904976
Hospital Revenue Code	270
Min. Negotiated Rate	$50.78
Max. Negotiated Rate	$116.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$79.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.55
Rate for Payer: Aetna Government	$72.55
Rate for Payer: Brighton Health Commercial	$108.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$116.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$98.67
Rate for Payer: Group Health Inc Commercial	$72.55
Rate for Payer: Group Health Inc Medicare	$50.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.55
Rate for Payer: Hamaspik Choice Inc Medicare	$72.55

BUR BARREL 6 FLUTE 5.5.MM

Facility

$20.00

Hospital Charge Code	64904978
Hospital Revenue Code	270
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$16.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.00
Rate for Payer: Aetna Government	$10.00
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	$10.00
Rate for Payer: Group Health Inc Medicare	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00

BUR BARREL SURG 6 5MM RPRC

Facility

$54.35

Hospital Charge Code	64903594
Hospital Revenue Code	270
Min. Negotiated Rate	$19.02
Max. Negotiated Rate	$43.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.18
Rate for Payer: Aetna Government	$27.18
Rate for Payer: Brighton Health Commercial	$40.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$36.96
Rate for Payer: Group Health Inc Commercial	$27.18
Rate for Payer: Group Health Inc Medicare	$19.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.18
Rate for Payer: Hamaspik Choice Inc Medicare	$27.18

BUR CARBIDE 2.1MM SIDE CUT

Facility

$31.03

Hospital Charge Code	64904314
Hospital Revenue Code	270
Min. Negotiated Rate	$10.86
Max. Negotiated Rate	$24.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.52
Rate for Payer: Aetna Government	$15.52
Rate for Payer: Brighton Health Commercial	$23.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$21.10
Rate for Payer: Group Health Inc Commercial	$15.52
Rate for Payer: Group Health Inc Medicare	$10.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.52
Rate for Payer: Hamaspik Choice Inc Medicare	$15.52

BUR DIAMOND AM-8D 2.9MMD/5.8L

Facility

$515.00

Hospital Charge Code	64904782
Hospital Revenue Code	270
Min. Negotiated Rate	$180.25
Max. Negotiated Rate	$412.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$283.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$257.50
Rate for Payer: Aetna Government	$257.50
Rate for Payer: Brighton Health Commercial	$386.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$412.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$350.20
Rate for Payer: Group Health Inc Commercial	$257.50
Rate for Payer: Group Health Inc Medicare	$180.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$257.50
Rate for Payer: Hamaspik Choice Inc Medicare	$257.50

BUR DIAMOND G4-360D

Facility

$320.00

Hospital Charge Code	64906848
Hospital Revenue Code	270
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$256.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$176.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$160.00
Rate for Payer: Aetna Government	$160.00
Rate for Payer: Brighton Health Commercial	$240.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$256.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$217.60
Rate for Payer: Group Health Inc Commercial	$160.00
Rate for Payer: Group Health Inc Medicare	$112.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$160.00
Rate for Payer: Hamaspik Choice Inc Medicare	$160.00

BUR DIAMOND M-340D

Facility

$507.50

Hospital Charge Code	64904788
Hospital Revenue Code	270
Min. Negotiated Rate	$177.62
Max. Negotiated Rate	$406.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$279.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$253.75
Rate for Payer: Aetna Government	$253.75
Rate for Payer: Brighton Health Commercial	$380.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$406.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$345.10
Rate for Payer: Group Health Inc Commercial	$253.75
Rate for Payer: Group Health Inc Medicare	$177.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$253.75
Rate for Payer: Hamaspik Choice Inc Medicare	$253.75

Know your out-of-pocket cost for care.

All Charges