St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CHIN PLATE 6MM

Facility

$580.60

Service Code	HCPCS C1713
Hospital Charge Code	40200706
Hospital Revenue Code	278
Min. Negotiated Rate	$290.30
Max. Negotiated Rate	$290.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$290.30
Rate for Payer: Hamaspik Choice Inc Medicare	$290.30

CHIN PLATE 6MM

Facility

$580.60

Service Code	HCPCS C1713
Hospital Charge Code	40200706
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$609.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$319.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$348.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$290.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$333.84
Rate for Payer: EmblemHealth Commercial	$290.30
Rate for Payer: Fidelis Medicare Advantage	$609.63
Rate for Payer: Group Health Inc Commercial	$290.30
Rate for Payer: Group Health Inc Medicare	$203.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$290.30
Rate for Payer: Hamaspik Choice Inc Medicare	$290.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$377.39

CHIN PLATE 6MM

Facility

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	40200076
Hospital Revenue Code	278
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$399.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$228.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.50
Rate for Payer: EmblemHealth Commercial	$190.00
Rate for Payer: Fidelis Medicare Advantage	$399.00
Rate for Payer: Group Health Inc Commercial	$190.00
Rate for Payer: Group Health Inc Medicare	$133.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$247.00

CHIN PLATE 6MM

Facility

$380.00

Service Code	HCPCS C1713
Hospital Charge Code	40200076
Hospital Revenue Code	278
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00

CHIN PLT 6MM

Facility

$380.00

Service Code	HCPCS C1781
Hospital Charge Code	40209728
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$399.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Brighton Health Commercial	$228.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.50
Rate for Payer: EmblemHealth Commercial	$190.00
Rate for Payer: Fidelis Medicare Advantage	$399.00
Rate for Payer: Group Health Inc Commercial	$190.00
Rate for Payer: Group Health Inc Medicare	$133.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$247.00

CHIN PLT 6MM

Facility

$380.00

Service Code	HCPCS C1781
Hospital Charge Code	40209728
Hospital Revenue Code	278
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$190.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.00
Rate for Payer: Hamaspik Choice Inc Medicare	$190.00

CHIN PLT 8MM

Facility

$608.00

Service Code	HCPCS C1781
Hospital Charge Code	40209729
Hospital Revenue Code	278
Min. Negotiated Rate	$304.00
Max. Negotiated Rate	$304.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$304.00
Rate for Payer: Hamaspik Choice Inc Medicare	$304.00

CHIN PLT 8MM

Facility

$608.00

Service Code	HCPCS C1781
Hospital Charge Code	40209729
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$638.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$334.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Brighton Health Commercial	$364.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$304.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$349.60
Rate for Payer: EmblemHealth Commercial	$304.00
Rate for Payer: Fidelis Medicare Advantage	$638.40
Rate for Payer: Group Health Inc Commercial	$304.00
Rate for Payer: Group Health Inc Medicare	$212.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$304.00
Rate for Payer: Hamaspik Choice Inc Medicare	$304.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$395.20

CHLAMYDIA ANTIBODIES, IGG

Facility

$29.55

Service Code	HCPCS 86631
Hospital Charge Code	40729353
Hospital Revenue Code	300
Rate for Payer: Cash Price	$11.82

CHLAMYDIA ANTIBODIES, IGG

Facility

$29.55

Service Code	HCPCS 86631
Hospital Charge Code	40729353
Hospital Revenue Code	300
Min. Negotiated Rate	$8.27
Max. Negotiated Rate	$22.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.82
Rate for Payer: Aetna Government	$11.82
Rate for Payer: Affinity Essential Plan 1&2	$8.27
Rate for Payer: Affinity Essential Plan 3&4	$8.27
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.27
Rate for Payer: Brighton Health Commercial	$22.16
Rate for Payer: Cash Price	$11.82
Rate for Payer: Cash Price	$11.82
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$11.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.91
Rate for Payer: Elderplan Medicare Advantage	$11.82
Rate for Payer: EmblemHealth Commercial	$11.82
Rate for Payer: Fidelis Essential Plan Aliesa	$10.05
Rate for Payer: Fidelis Essential Plan QHP	$10.52
Rate for Payer: Fidelis Medicare Advantage	$11.82
Rate for Payer: Fidelis Qualified Health Plan	$10.52
Rate for Payer: Group Health Inc Commercial	$11.82
Rate for Payer: Group Health Inc Medicare	$11.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.78
Rate for Payer: Hamaspik Choice Inc Medicare	$11.82
Rate for Payer: Healthfirst Medicare Advantage	$11.82
Rate for Payer: Healthfirst QHP	$11.82
Rate for Payer: Humana Medicare	$12.06
Rate for Payer: Senior Whole Health Medicare Advantage	$11.82
Rate for Payer: United Healthcare Commercial	$14.98
Rate for Payer: United Healthcare Medicare Advantage	$11.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.82
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.46
Rate for Payer: Wellcare Medicare	$10.64

CHLAMYDIA/GC AMPLIFICATION

Facility

$87.73

Service Code	HCPCS 87491
Hospital Charge Code	40619197
Hospital Revenue Code	300
Rate for Payer: Cash Price	$35.09

CHLAMYDIA/GC AMPLIFICATION

Facility

$87.73

Service Code	HCPCS 87491
Hospital Charge Code	40619197
Hospital Revenue Code	300
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$65.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.09
Rate for Payer: Aetna Government	$35.09
Rate for Payer: Affinity Essential Plan 1&2	$24.56
Rate for Payer: Affinity Essential Plan 3&4	$24.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$24.56
Rate for Payer: Brighton Health Commercial	$65.80
Rate for Payer: Cash Price	$35.09
Rate for Payer: Cash Price	$35.09
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$35.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.20
Rate for Payer: Elderplan Medicare Advantage	$35.09
Rate for Payer: EmblemHealth Commercial	$35.09
Rate for Payer: Fidelis Essential Plan Aliesa	$29.83
Rate for Payer: Fidelis Essential Plan QHP	$31.23
Rate for Payer: Fidelis Medicare Advantage	$35.09
Rate for Payer: Fidelis Qualified Health Plan	$31.23
Rate for Payer: Group Health Inc Commercial	$35.09
Rate for Payer: Group Health Inc Medicare	$35.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.86
Rate for Payer: Hamaspik Choice Inc Medicare	$35.09
Rate for Payer: Healthfirst Medicare Advantage	$35.09
Rate for Payer: Healthfirst QHP	$35.09
Rate for Payer: Humana Medicare	$35.79
Rate for Payer: Senior Whole Health Medicare Advantage	$35.09
Rate for Payer: United Healthcare Commercial	$44.45
Rate for Payer: United Healthcare Medicare Advantage	$35.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35.09
Rate for Payer: Wellcare CHP/FHP/Medicaid	$28.07
Rate for Payer: Wellcare Medicare	$31.58

CHLAMYDIA IGM ANTIBODY

Facility

$31.70

Service Code	HCPCS 86632
Hospital Charge Code	40729456
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.68

CHLAMYDIA IGM ANTIBODY

Facility

$31.70

Service Code	HCPCS 86632
Hospital Charge Code	40729456
Hospital Revenue Code	300
Min. Negotiated Rate	$8.88
Max. Negotiated Rate	$23.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.68
Rate for Payer: Aetna Government	$12.68
Rate for Payer: Affinity Essential Plan 1&2	$8.88
Rate for Payer: Affinity Essential Plan 3&4	$8.88
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.88
Rate for Payer: Brighton Health Commercial	$23.78
Rate for Payer: Cash Price	$12.68
Rate for Payer: Cash Price	$12.68
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.07
Rate for Payer: Elderplan Medicare Advantage	$12.68
Rate for Payer: EmblemHealth Commercial	$12.68
Rate for Payer: Fidelis Essential Plan Aliesa	$10.78
Rate for Payer: Fidelis Essential Plan QHP	$11.29
Rate for Payer: Fidelis Medicare Advantage	$12.68
Rate for Payer: Fidelis Qualified Health Plan	$11.29
Rate for Payer: Group Health Inc Commercial	$12.68
Rate for Payer: Group Health Inc Medicare	$12.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.85
Rate for Payer: Hamaspik Choice Inc Medicare	$12.68
Rate for Payer: Healthfirst Medicare Advantage	$12.68
Rate for Payer: Healthfirst QHP	$12.68
Rate for Payer: Humana Medicare	$12.93
Rate for Payer: Senior Whole Health Medicare Advantage	$12.68
Rate for Payer: United Healthcare Commercial	$16.07
Rate for Payer: United Healthcare Medicare Advantage	$12.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.68
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.14
Rate for Payer: Wellcare Medicare	$11.41

CHLAMYDIA SPECIES AB, IGG

Facility

$29.55

Service Code	HCPCS 86631
Hospital Charge Code	40728121
Hospital Revenue Code	302
Rate for Payer: Cash Price	$11.82

CHLAMYDIA SPECIES AB, IGG

Facility

$29.55

Service Code	HCPCS 86631
Hospital Charge Code	40728121
Hospital Revenue Code	302
Min. Negotiated Rate	$8.27
Max. Negotiated Rate	$22.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.82
Rate for Payer: Aetna Government	$11.82
Rate for Payer: Affinity Essential Plan 1&2	$8.27
Rate for Payer: Affinity Essential Plan 3&4	$8.27
Rate for Payer: Affinity Medicaid/CHP/HARP	$8.27
Rate for Payer: Brighton Health Commercial	$22.16
Rate for Payer: Cash Price	$11.82
Rate for Payer: Cash Price	$11.82
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$11.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.91
Rate for Payer: Elderplan Medicare Advantage	$11.82
Rate for Payer: EmblemHealth Commercial	$11.82
Rate for Payer: Fidelis Essential Plan Aliesa	$10.05
Rate for Payer: Fidelis Essential Plan QHP	$10.52
Rate for Payer: Fidelis Medicare Advantage	$11.82
Rate for Payer: Fidelis Qualified Health Plan	$10.52
Rate for Payer: Group Health Inc Commercial	$11.82
Rate for Payer: Group Health Inc Medicare	$11.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.78
Rate for Payer: Hamaspik Choice Inc Medicare	$11.82
Rate for Payer: Healthfirst Medicare Advantage	$11.82
Rate for Payer: Healthfirst QHP	$11.82
Rate for Payer: Humana Medicare	$12.06
Rate for Payer: Senior Whole Health Medicare Advantage	$11.82
Rate for Payer: United Healthcare Commercial	$14.98
Rate for Payer: United Healthcare Medicare Advantage	$11.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.82
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.46
Rate for Payer: Wellcare Medicare	$10.64

CHLAMYDIA TRACHOMATIS CULTURE

Facility

$49.00

Service Code	HCPCS 87110
Hospital Charge Code	40619188
Hospital Revenue Code	300
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$36.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.60
Rate for Payer: Aetna Government	$19.60
Rate for Payer: Affinity Essential Plan 1&2	$13.72
Rate for Payer: Affinity Essential Plan 3&4	$13.72
Rate for Payer: Affinity Medicaid/CHP/HARP	$13.72
Rate for Payer: Brighton Health Commercial	$36.75
Rate for Payer: Cash Price	$19.60
Rate for Payer: Cash Price	$19.60
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$19.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.34
Rate for Payer: Elderplan Medicare Advantage	$19.60
Rate for Payer: EmblemHealth Commercial	$19.60
Rate for Payer: Fidelis Essential Plan Aliesa	$16.66
Rate for Payer: Fidelis Essential Plan QHP	$17.44
Rate for Payer: Fidelis Medicare Advantage	$19.60
Rate for Payer: Fidelis Qualified Health Plan	$17.44
Rate for Payer: Group Health Inc Commercial	$19.60
Rate for Payer: Group Health Inc Medicare	$19.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.50
Rate for Payer: Hamaspik Choice Inc Medicare	$19.60
Rate for Payer: Healthfirst Medicare Advantage	$19.60
Rate for Payer: Healthfirst QHP	$19.60
Rate for Payer: Humana Medicare	$19.99
Rate for Payer: Senior Whole Health Medicare Advantage	$19.60
Rate for Payer: United Healthcare Commercial	$24.81
Rate for Payer: United Healthcare Medicare Advantage	$19.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$19.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$15.68
Rate for Payer: Wellcare Medicare	$17.64

CHLAMYDIA TRACHOMATIS CULTURE

Facility

$49.00

Service Code	HCPCS 87110
Hospital Charge Code	40619188
Hospital Revenue Code	300
Rate for Payer: Cash Price	$19.60

CHLORAL HYDRATE 100 MG/ML SYRUP NEONATAL

Facility

$1.00

Hospital Charge Code	41640715
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

CHLORAL HYDRATE 100 MG/ML SYRUP NEONATAL

Facility

$1.00

Hospital Charge Code	41650715
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

CHLORAL HYDRATE 500 MG/5 ML SYRUP UDC

Facility

$1.00

Hospital Charge Code	41652357
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

CHLORAL HYDRATE 500 MG/5 ML SYRUP UDC

Facility

$1.00

Hospital Charge Code	41642357
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

CHLORAMBUCIL 2 MG PO TABS [9513]

Facility

$316.80

Service Code	NDC 69784061025
Hospital Charge Code	69784061025
Hospital Revenue Code	250
Min. Negotiated Rate	$110.88
Max. Negotiated Rate	$253.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$174.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$158.40
Rate for Payer: Aetna Government	$158.40
Rate for Payer: Brighton Health Commercial	$237.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$253.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$215.42
Rate for Payer: Group Health Inc Commercial	$158.40
Rate for Payer: Group Health Inc Medicare	$110.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$158.40
Rate for Payer: Hamaspik Choice Inc Medicare	$158.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$205.92

CHLORAMBUCIL 2 MG TAB

Facility

$7.00

Service Code	HCPCS J8999
Hospital Charge Code	41654054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.50
Rate for Payer: Aetna Government	$3.50
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

CHLORAMBUCIL 2 MG TAB

Facility

$7.00

Service Code	HCPCS J8999
Hospital Charge Code	41644054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.50
Rate for Payer: Aetna Government	$3.50
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

Know your out-of-pocket cost for care.

All Charges