St. Barnabas Hospital

All Charges

Charge

Type

Price

DIGITAL COMPRES SCRW 1.8MMX30MM

Facility IP

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	40200806
Hospital Revenue Code	278
Min. Negotiated Rate	$128.00
Max. Negotiated Rate	$128.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$128.00
Rate for Payer: Hamaspik Choice Inc Medicare	$128.00

DIGITAL COMPRES SCRW 1.8MMX30MM

Facility OP

$256.00

Service Code	HCPCS C1713
Hospital Charge Code	40200806
Hospital Revenue Code	278
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$268.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.80
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	$128.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$147.20
Rate for Payer: Fidelis Medicare Advantage	$268.80
Rate for Payer: Group Health Inc Commercial	$128.00
Rate for Payer: Group Health Inc Medicare	$89.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$128.00
Rate for Payer: Hamaspik Choice Inc Medicare	$128.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$166.40

DIGITOXIN BLOOD

Facility OP

$46.60

Service Code	HCPCS 80299
Hospital Charge Code	40607195
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$25.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.64
Rate for Payer: Aetna Government	$18.64
Rate for Payer: Cash Price	$18.64
Rate for Payer: Cash Price	$18.64
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$18.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.42
Rate for Payer: Elderplan Medicare Advantage	$18.64
Rate for Payer: EmblemHealth Commercial	$18.64
Rate for Payer: Fidelis CHP/HARP/Medicaid	$16.78
Rate for Payer: Fidelis Essential Plan Aliesa	$15.84
Rate for Payer: Fidelis Essential Plan QHP	$16.59
Rate for Payer: Fidelis Medicare Advantage	$18.64
Rate for Payer: Fidelis Qualified Health Plan	$16.59
Rate for Payer: Group Health Inc Commercial	$18.64
Rate for Payer: Group Health Inc Medicare	$18.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.30
Rate for Payer: Hamaspik Choice Inc Medicare	$18.64
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18.64
Rate for Payer: Healthfirst Medicare Advantage	$18.64
Rate for Payer: Healthfirst QHP	$18.64
Rate for Payer: Senior Whole Health Medicare Advantage	$18.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$14.91
Rate for Payer: Wellcare Medicare	$16.78

DIGOXIN

Facility OP

$33.20

Service Code	HCPCS 80162
Hospital Charge Code	40602530
Hospital Revenue Code	301
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$21.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.28
Rate for Payer: Aetna Government	$13.28
Rate for Payer: Cash Price	$13.28
Rate for Payer: Cash Price	$13.28
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$13.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.86
Rate for Payer: Elderplan Medicare Advantage	$13.28
Rate for Payer: EmblemHealth Commercial	$13.28
Rate for Payer: Fidelis CHP/HARP/Medicaid	$11.95
Rate for Payer: Fidelis Essential Plan Aliesa	$11.29
Rate for Payer: Fidelis Essential Plan QHP	$11.82
Rate for Payer: Fidelis Medicare Advantage	$13.28
Rate for Payer: Fidelis Qualified Health Plan	$11.82
Rate for Payer: Group Health Inc Commercial	$13.28
Rate for Payer: Group Health Inc Medicare	$13.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.60
Rate for Payer: Hamaspik Choice Inc Medicare	$13.28
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$13.28
Rate for Payer: Healthfirst Medicare Advantage	$13.28
Rate for Payer: Healthfirst QHP	$13.28
Rate for Payer: Senior Whole Health Medicare Advantage	$13.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.28
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.62
Rate for Payer: Wellcare Medicare	$11.95

DIGOXIN 100 MCG/ML INJ PEDIATRIC

Facility OP

$12.00

Service Code	HCPCS J1160
Hospital Charge Code	41642959
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$14.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.90
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

DIGOXIN 100 MCG/ML INJ PEDIATRIC

Facility OP

$12.00

Service Code	HCPCS J1160
Hospital Charge Code	41652959
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$14.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.90
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

DIGOXIN 100 MCG/ML INJ PEDIATRIC

Facility IP

$12.00

Service Code	HCPCS J1160
Hospital Charge Code	41652959
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00

DIGOXIN 100 MCG/ML INJ PEDIATRIC

Facility IP

$12.00

Service Code	HCPCS J1160
Hospital Charge Code	41642959
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00

DIGOXIN 125 MCG TAB

Facility OP

$1.00

Hospital Charge Code	41642956
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: 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

DIGOXIN 125 MCG TAB

Facility OP

$1.00

Hospital Charge Code	41652956
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: 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

DIGOXIN 20 MCG/ML INJ NEONATAL

Facility IP

$11.00

Service Code	HCPCS J1160
Hospital Charge Code	41643138
Hospital Revenue Code	636
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$5.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.50
Rate for Payer: Hamaspik Choice Inc Medicare	$5.50

DIGOXIN 20 MCG/ML INJ NEONATAL

Facility OP

$11.00

Service Code	HCPCS J1160
Hospital Charge Code	41643138
Hospital Revenue Code	636
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$14.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.32
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
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
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.15

DIGOXIN 20 MCG/ML INJ NEONATAL

Facility OP

$11.00

Service Code	HCPCS J1160
Hospital Charge Code	41653138
Hospital Revenue Code	636
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$14.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.32
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
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
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.15

DIGOXIN 20 MCG/ML INJ NEONATAL

Facility IP

$11.00

Service Code	HCPCS J1160
Hospital Charge Code	41653138
Hospital Revenue Code	636
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$5.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.50
Rate for Payer: Hamaspik Choice Inc Medicare	$5.50

DIGOXIN 250 MCG/ML INJ

Facility OP

$373.00

Service Code	HCPCS J1160
Hospital Charge Code	41642958
Hospital Revenue Code	636
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$242.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$205.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$186.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$214.48
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
Rate for Payer: Group Health Inc Commercial	$186.50
Rate for Payer: Group Health Inc Medicare	$130.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.50
Rate for Payer: Hamaspik Choice Inc Medicare	$186.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$242.45

DIGOXIN 250 MCG/ML INJ

Facility OP

$373.00

Service Code	HCPCS J1160
Hospital Charge Code	41652958
Hospital Revenue Code	636
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$242.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$205.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.42
Rate for Payer: Aetna Government	$14.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$186.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$214.48
Rate for Payer: Fidelis CHP/HARP/Medicaid	$9.73
Rate for Payer: Group Health Inc Commercial	$186.50
Rate for Payer: Group Health Inc Medicare	$130.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.50
Rate for Payer: Hamaspik Choice Inc Medicare	$186.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$10.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.61
Rate for Payer: SOMOS Essential	$9.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$242.45

DIGOXIN 250 MCG/ML INJ

Facility IP

$373.00

Service Code	HCPCS J1160
Hospital Charge Code	41642958
Hospital Revenue Code	636
Min. Negotiated Rate	$186.50
Max. Negotiated Rate	$186.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.50
Rate for Payer: Hamaspik Choice Inc Medicare	$186.50

DIGOXIN 250 MCG/ML INJ

Facility IP

$373.00

Service Code	HCPCS J1160
Hospital Charge Code	41652958
Hospital Revenue Code	636
Min. Negotiated Rate	$186.50
Max. Negotiated Rate	$186.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.50
Rate for Payer: Hamaspik Choice Inc Medicare	$186.50

DIGOXIN 250 MCG TAB

Facility OP

$0.72

Hospital Charge Code	41642957
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.49
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.47

DIGOXIN 250 MCG TAB

Facility OP

$0.72

Hospital Charge Code	41652957
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.36
Rate for Payer: Aetna Government	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.49
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.47

DIGOXIN 50 MCG/ML ELIXIR 2.5 ML UDC

Facility OP

$2.00

Hospital Charge Code	41644331
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

DIGOXIN 50 MCG/ML ELIXIR 2.5 ML UDC

Facility OP

$2.00

Hospital Charge Code	41654331
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

DIGOXIN 50 MCG/ML ELIXIR PEDIATRIC

Facility OP

$0.70

Hospital Charge Code	41654330
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

DIGOXIN 50 MCG/ML ELIXIR PEDIATRIC

Facility OP

$0.70

Hospital Charge Code	41644330
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

DIGOXIN IMMUNE FAB (DIGIBIND) 38 MG INJ

Facility OP

$1,208.00

Service Code	HCPCS J1162
Hospital Charge Code	41651853
Hospital Revenue Code	636
Min. Negotiated Rate	$604.00
Max. Negotiated Rate	$5,064.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$664.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,777.44
Rate for Payer: Aetna Government	$4,777.44
Rate for Payer: Cash Price	$4,777.44
Rate for Payer: Cash Price	$4,777.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,777.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$604.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$694.60
Rate for Payer: Elderplan Medicare Advantage	$4,777.44
Rate for Payer: EmblemHealth Commercial	$4,777.44
Rate for Payer: Fidelis CHP/HARP/Medicaid	$4,777.44
Rate for Payer: Fidelis Essential Plan Aliesa	$4,777.44
Rate for Payer: Fidelis Essential Plan QHP	$5,016.31
Rate for Payer: Fidelis Medicare Advantage	$4,777.44
Rate for Payer: Fidelis Qualified Health Plan	$5,016.31
Rate for Payer: Group Health Inc Commercial	$4,777.44
Rate for Payer: Group Health Inc Medicare	$4,777.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$604.00
Rate for Payer: Hamaspik Choice Inc Medicare	$604.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$4,593.57
Rate for Payer: Healthfirst Medicare Advantage	$4,060.82
Rate for Payer: Healthfirst QHP	$4,777.44
Rate for Payer: Senior Whole Health Medicare Advantage	$4,777.44
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,064.09
Rate for Payer: SOMOS Essential	$5,064.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$785.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,821.95
Rate for Payer: Wellcare Medicare	$4,538.57

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