St. Barnabas Hospital

All Charges

Charge

Type

Price

9X315MM T2 TIBIAL NAIL STANDARD

Facility IP

$2,366.00

Service Code	HCPCS C1713
Hospital Charge Code	40200565
Hospital Revenue Code	278
Min. Negotiated Rate	$1,183.00
Max. Negotiated Rate	$1,183.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,183.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,183.00

9X315MM T2 TIBIAL NAIL STANDARD

Facility OP

$2,366.00

Service Code	HCPCS C1713
Hospital Charge Code	40200565
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,484.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,301.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,183.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,360.45
Rate for Payer: Fidelis Medicare Advantage	$2,484.30
Rate for Payer: Group Health Inc Commercial	$1,183.00
Rate for Payer: Group Health Inc Medicare	$828.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,183.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,183.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,537.90

9X360MM T2 TIBIAL NAIL STANDARD

Facility OP

$2,066.00

Service Code	HCPCS C1713
Hospital Charge Code	40200566
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,169.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,136.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,033.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,187.95
Rate for Payer: Fidelis Medicare Advantage	$2,169.30
Rate for Payer: Group Health Inc Commercial	$1,033.00
Rate for Payer: Group Health Inc Medicare	$723.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,033.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,033.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,342.90

9X360MM T2 TIBIAL NAIL STANDARD

Facility IP

$2,066.00

Service Code	HCPCS C1713
Hospital Charge Code	40200566
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.00
Max. Negotiated Rate	$1,033.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,033.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,033.00

A1 ANTIGEN

Facility OP

$858.38

Service Code	HCPCS 86905
Hospital Charge Code	40701266
Hospital Revenue Code	300
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$472.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$472.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$415.67
Rate for Payer: Aetna Government	$415.67
Rate for Payer: Cash Price	$415.67
Rate for Payer: Cash Price	$415.67
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$415.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.15
Rate for Payer: Elderplan Medicare Advantage	$415.67
Rate for Payer: EmblemHealth Commercial	$415.67
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3.45
Rate for Payer: Fidelis Essential Plan Aliesa	$353.32
Rate for Payer: Fidelis Essential Plan QHP	$369.95
Rate for Payer: Fidelis Medicare Advantage	$415.67
Rate for Payer: Fidelis Qualified Health Plan	$369.95
Rate for Payer: Group Health Inc Commercial	$415.67
Rate for Payer: Group Health Inc Medicare	$415.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$429.19
Rate for Payer: Hamaspik Choice Inc Medicare	$415.67
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3.83
Rate for Payer: Healthfirst Medicare Advantage	$415.67
Rate for Payer: Healthfirst QHP	$415.67
Rate for Payer: Senior Whole Health Medicare Advantage	$415.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$415.67
Rate for Payer: Wellcare CHP/FHP/Medicaid	$332.54
Rate for Payer: Wellcare Medicare	$374.10

ABACAV/DOLUTEGRAV/LAMIV TAB

Facility OP

$199.54

Hospital Charge Code	41656630
Hospital Revenue Code	250
Min. Negotiated Rate	$69.84
Max. Negotiated Rate	$159.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$109.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$99.77
Rate for Payer: Aetna Government	$99.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$159.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$135.69
Rate for Payer: Group Health Inc Commercial	$99.77
Rate for Payer: Group Health Inc Medicare	$69.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$99.77
Rate for Payer: Hamaspik Choice Inc Medicare	$99.77
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$129.70

ABACAV/DOLUTEGRAY/LAMIV TAB

Facility OP

$199.54

Hospital Charge Code	41646630
Hospital Revenue Code	250
Min. Negotiated Rate	$69.84
Max. Negotiated Rate	$159.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$109.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$99.77
Rate for Payer: Aetna Government	$99.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$159.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$135.69
Rate for Payer: Group Health Inc Commercial	$99.77
Rate for Payer: Group Health Inc Medicare	$69.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$99.77
Rate for Payer: Hamaspik Choice Inc Medicare	$99.77
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$129.70

ABACAVIR 20 MG/ML SOLN

Facility OP

$2.00

Hospital Charge Code	41652021
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: 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

ABACAVIR 20 MG/ML SOLN

Facility OP

$2.00

Hospital Charge Code	41642021
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: 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

ABACAVIR 300 MG TAB

Facility OP

$18.43

Hospital Charge Code	41642020
Hospital Revenue Code	250
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$14.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.22
Rate for Payer: Aetna Government	$9.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.53
Rate for Payer: Group Health Inc Commercial	$9.22
Rate for Payer: Group Health Inc Medicare	$6.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.22
Rate for Payer: Hamaspik Choice Inc Medicare	$9.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.98

ABACAVIR 300 MG TAB

Facility OP

$18.43

Hospital Charge Code	41652020
Hospital Revenue Code	250
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$14.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.22
Rate for Payer: Aetna Government	$9.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.53
Rate for Payer: Group Health Inc Commercial	$9.22
Rate for Payer: Group Health Inc Medicare	$6.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.22
Rate for Payer: Hamaspik Choice Inc Medicare	$9.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.98

ABBOTT 1PC MONO +10.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204768
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +10.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204767
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +11.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204766
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +11.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204765
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +12.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204764
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +12.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204763
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +13.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204762
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +13.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204761
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +14.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204760
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +14.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204759
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +15.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204758
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +15.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204853
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +16.0 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204757
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

ABBOTT 1PC MONO +16.5 D

Facility OP

$600.00

Service Code	HCPCS V2788
Hospital Charge Code	40204756
Hospital Revenue Code	276
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$630.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$330.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$85.06
Rate for Payer: Aetna Government	$85.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$480.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$408.00
Rate for Payer: Fidelis Medicare Advantage	$630.00
Rate for Payer: Group Health Inc Commercial	$300.00
Rate for Payer: Group Health Inc Medicare	$210.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$300.00
Rate for Payer: Hamaspik Choice Inc Medicare	$300.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$390.00

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