St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DEFAZOLIN 1G/D5W 50ML-500MG

Facility

$3.00

Service Code	HCPCS J0690
Hospital Charge Code	41658856
Hospital Revenue Code	636
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.75
Rate for Payer: Aetna Government	$0.75
Rate for Payer: Brighton Health Commercial	$1.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.72
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.86
Rate for Payer: SOMOS Essential	$0.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DEFAZOLIN 2G/D5W 100ML IVPB

Facility

$4.67

Service Code	HCPCS J0690
Hospital Charge Code	41658457
Hospital Revenue Code	636
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$3.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.75
Rate for Payer: Aetna Government	$0.75
Rate for Payer: Brighton Health Commercial	$2.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.69
Rate for Payer: Group Health Inc Commercial	$2.34
Rate for Payer: Group Health Inc Medicare	$1.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.34
Rate for Payer: Hamaspik Choice Inc Medicare	$2.34
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.86
Rate for Payer: SOMOS Essential	$0.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.04

DEFAZOLIN 2G/D5W 100ML IVPB

Facility

$4.67

Service Code	HCPCS J0690
Hospital Charge Code	41658457
Hospital Revenue Code	636
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$2.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.34
Rate for Payer: Hamaspik Choice Inc Medicare	$2.34

DEFEROXAMINE 500 MG INJ

Facility

$13.66

Service Code	HCPCS J0895
Hospital Charge Code	41641400
Hospital Revenue Code	636
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83
Rate for Payer: Hamaspik Choice Inc Medicare	$6.83

DEFEROXAMINE 500 MG INJ

Facility

$13.66

Service Code	HCPCS J0895
Hospital Charge Code	41641400
Hospital Revenue Code	636
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$9.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.66
Rate for Payer: Aetna Government	$7.66
Rate for Payer: Brighton Health Commercial	$8.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.85
Rate for Payer: Group Health Inc Commercial	$6.83
Rate for Payer: Group Health Inc Medicare	$4.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83
Rate for Payer: Hamaspik Choice Inc Medicare	$6.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.56
Rate for Payer: SOMOS Essential	$9.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88

DEFEROXAMINE 500 MG INJ

Facility

$13.66

Service Code	HCPCS J0895
Hospital Charge Code	41651400
Hospital Revenue Code	636
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$9.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.66
Rate for Payer: Aetna Government	$7.66
Rate for Payer: Brighton Health Commercial	$8.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.85
Rate for Payer: Group Health Inc Commercial	$6.83
Rate for Payer: Group Health Inc Medicare	$4.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83
Rate for Payer: Hamaspik Choice Inc Medicare	$6.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9.56
Rate for Payer: SOMOS Essential	$9.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.88

DEFEROXAMINE 500 MG INJ

Facility

$13.66

Service Code	HCPCS J0895
Hospital Charge Code	41651400
Hospital Revenue Code	636
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$6.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.83
Rate for Payer: Hamaspik Choice Inc Medicare	$6.83

DEFIBRILLATOR

Facility

$54,607.50

Service Code	HCPCS C1882
Hospital Charge Code	64907351
Hospital Revenue Code	278
Min. Negotiated Rate	$27,303.75
Max. Negotiated Rate	$27,303.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$27,303.75
Rate for Payer: Hamaspik Choice Inc Medicare	$27,303.75

DEFIBRILLATOR

Facility

$54,607.50

Service Code	HCPCS C1882
Hospital Charge Code	64907351
Hospital Revenue Code	278
Min. Negotiated Rate	$4,752.01
Max. Negotiated Rate	$57,337.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30,034.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,752.01
Rate for Payer: Aetna Government	$4,752.01
Rate for Payer: Brighton Health Commercial	$32,764.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27,303.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$31,399.31
Rate for Payer: EmblemHealth Commercial	$27,303.75
Rate for Payer: Fidelis Medicare Advantage	$57,337.88
Rate for Payer: Group Health Inc Commercial	$27,303.75
Rate for Payer: Group Health Inc Medicare	$19,112.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$27,303.75
Rate for Payer: Hamaspik Choice Inc Medicare	$27,303.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35,494.88

DEFOGGER ST DEROYAL

Facility

$3.64

Hospital Charge Code	64904849
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$2.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.82
Rate for Payer: Aetna Government	$1.82
Rate for Payer: Brighton Health Commercial	$2.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.48
Rate for Payer: Group Health Inc Commercial	$1.82
Rate for Payer: Group Health Inc Medicare	$1.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1.82

DEFTAROLINE 200MG/NS 50ML IVPB

Facility

$7.76

Service Code	HCPCS J0712
Hospital Charge Code	41645721
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.88
Rate for Payer: Hamaspik Choice Inc Medicare	$3.88

DEFTAROLINE 200MG/NS 50ML IVPB

Facility

$7.76

Service Code	HCPCS J0712
Hospital Charge Code	41645721
Hospital Revenue Code	636
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$5.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.84
Rate for Payer: Aetna Government	$3.84
Rate for Payer: Affinity Essential Plan 1&2	$2.68
Rate for Payer: Affinity Essential Plan 3&4	$2.68
Rate for Payer: Affinity Medicaid/CHP/HARP	$2.68
Rate for Payer: Brighton Health Commercial	$4.66
Rate for Payer: Cash Price	$3.84
Rate for Payer: Cash Price	$3.84
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.46
Rate for Payer: Elderplan Medicare Advantage	$3.84
Rate for Payer: EmblemHealth Commercial	$3.84
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3.84
Rate for Payer: Fidelis Essential Plan Aliesa	$3.84
Rate for Payer: Fidelis Essential Plan QHP	$4.03
Rate for Payer: Fidelis Medicare Advantage	$3.84
Rate for Payer: Fidelis Qualified Health Plan	$4.03
Rate for Payer: Group Health Inc Commercial	$3.84
Rate for Payer: Group Health Inc Medicare	$3.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.88
Rate for Payer: Hamaspik Choice Inc Medicare	$3.88
Rate for Payer: Healthfirst Medicare Advantage	$3.26
Rate for Payer: Healthfirst QHP	$3.84
Rate for Payer: Humana Medicare	$3.91
Rate for Payer: Senior Whole Health Medicare Advantage	$3.84
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4.09
Rate for Payer: SOMOS Essential	$4.09
Rate for Payer: United Healthcare Commercial	$3.78
Rate for Payer: United Healthcare Medicare Advantage	$3.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.04
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3.07
Rate for Payer: Wellcare Medicare	$3.64

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$55,723.76

Service Code	MSDRG 056
Min. Negotiated Rate	$18,844.76
Max. Negotiated Rate	$55,723.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35,299.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$40,526.37
Rate for Payer: Aetna Government	$40,526.37
Rate for Payer: Brighton Health Commercial	$34,713.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$41,336.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$41,341.99
Rate for Payer: Cigna LocalPlus Benefit Plan	$34,117.18
Rate for Payer: Elderplan Medicare Advantage	$38,500.05
Rate for Payer: EmblemHealth Commercial	$20,528.60
Rate for Payer: Fidelis Medicare Advantage	$40,526.37
Rate for Payer: Group Health Inc Commercial	$40,526.37
Rate for Payer: Group Health Inc Medicare	$40,526.37
Rate for Payer: Hamaspik Choice Inc Medicare	$40,526.37
Rate for Payer: Healthfirst Medicare Advantage	$18,844.76
Rate for Payer: Humana Medicare	$55,723.76
Rate for Payer: Senior Whole Health Medicare Advantage	$40,526.37
Rate for Payer: United Healthcare Commercial	$47,609.48
Rate for Payer: United Healthcare Medicare Advantage	$40,526.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$40,526.37
Rate for Payer: Wellcare Medicare	$38,500.05

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$36,068.82

Service Code	MSDRG 057
Min. Negotiated Rate	$11,689.40
Max. Negotiated Rate	$36,068.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20,100.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26,231.87
Rate for Payer: Aetna Government	$26,231.87
Rate for Payer: Brighton Health Commercial	$19,766.40
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$26,756.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23,541.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$19,427.13
Rate for Payer: Elderplan Medicare Advantage	$24,920.28
Rate for Payer: EmblemHealth Commercial	$11,689.40
Rate for Payer: Fidelis Medicare Advantage	$26,231.87
Rate for Payer: Group Health Inc Commercial	$26,231.87
Rate for Payer: Group Health Inc Medicare	$26,231.87
Rate for Payer: Hamaspik Choice Inc Medicare	$26,231.87
Rate for Payer: Healthfirst Medicare Advantage	$12,197.82
Rate for Payer: Humana Medicare	$36,068.82
Rate for Payer: Senior Whole Health Medicare Advantage	$26,231.87
Rate for Payer: United Healthcare Commercial	$27,109.96
Rate for Payer: United Healthcare Medicare Advantage	$26,231.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26,231.87
Rate for Payer: Wellcare Medicare	$24,920.28

DELIVERY OF PLACENTA

Facility

$7,566.13

Service Code	HCPCS 59414
Hospital Charge Code	30102503
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,615.39

DELIVERY OF PLACENTA

Facility

$7,566.13

Service Code	HCPCS 59414
Hospital Charge Code	30102503
Hospital Revenue Code	450
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$3,783.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,615.39
Rate for Payer: Aetna Government	$3,615.39
Rate for Payer: Affinity Essential Plan 1&2	$2,530.77
Rate for Payer: Affinity Essential Plan 3&4	$2,530.77
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,530.77
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$3,615.39
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,615.39
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	$3,615.39
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,073.08
Rate for Payer: Fidelis Essential Plan QHP	$3,217.70
Rate for Payer: Fidelis Medicare Advantage	$3,615.39
Rate for Payer: Fidelis Qualified Health Plan	$3,217.70
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,783.06
Rate for Payer: Hamaspik Choice Inc Medicare	$3,615.39
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$3,615.39
Rate for Payer: Humana Medicare	$3,687.70
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$3,615.39
Rate for Payer: Senior Whole Health Medicare Advantage	$3,615.39
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$3,615.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,615.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,892.31
Rate for Payer: Wellcare Medicare	$3,434.62

DELIVERY OF PLACENTA

Facility

$7,566.13

Service Code	HCPCS 59414
Hospital Charge Code	40052237
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,615.39

DELIVERY OF PLACENTA

Facility

$7,566.13

Service Code	HCPCS 59414
Hospital Charge Code	40052237
Hospital Revenue Code	360
Min. Negotiated Rate	$1,468.00
Max. Negotiated Rate	$5,674.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,615.39
Rate for Payer: Aetna Government	$3,615.39
Rate for Payer: Affinity Essential Plan 1&2	$2,530.77
Rate for Payer: Affinity Essential Plan 3&4	$2,530.77
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,530.77
Rate for Payer: Brighton Health Commercial	$5,674.60
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Cash Price	$3,615.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$3,615.39
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	$3,615.39
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,073.08
Rate for Payer: Fidelis Essential Plan QHP	$3,217.70
Rate for Payer: Fidelis Medicare Advantage	$3,615.39
Rate for Payer: Fidelis Qualified Health Plan	$3,217.70
Rate for Payer: Group Health Inc Commercial	$3,615.39
Rate for Payer: Group Health Inc Medicare	$3,615.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,783.06
Rate for Payer: Hamaspik Choice Inc Medicare	$3,615.39
Rate for Payer: Healthfirst Medicare Advantage	$3,073.08
Rate for Payer: Healthfirst QHP	$3,615.39
Rate for Payer: Humana Medicare	$3,687.70
Rate for Payer: Senior Whole Health Medicare Advantage	$3,615.39
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$3,615.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,615.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,892.31
Rate for Payer: Wellcare Medicare	$3,434.62

DELIVERY ROOM

Facility

$921.38

Hospital Charge Code	40250001
Hospital Revenue Code	720
Min. Negotiated Rate	$322.48
Max. Negotiated Rate	$8,223.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$506.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$460.69
Rate for Payer: Aetna Government	$460.69
Rate for Payer: Brighton Health Commercial	$691.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$737.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$626.54
Rate for Payer: Group Health Inc Commercial	$460.69
Rate for Payer: Group Health Inc Medicare	$322.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$460.69
Rate for Payer: Hamaspik Choice Inc Medicare	$460.69
Rate for Payer: United Healthcare Commercial	$8,223.00

DELTA CER HEAD 12/14 36MM 1.5

Facility

$8,502.50

Service Code	HCPCS C1776
Hospital Charge Code	64905284
Hospital Revenue Code	278
Min. Negotiated Rate	$4,251.25
Max. Negotiated Rate	$4,251.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,251.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4,251.25

DELTA CER HEAD 12/14 36MM 1.5

Facility

$6,802.00

Service Code	HCPCS C1776
Hospital Charge Code	40005156
Hospital Revenue Code	278
Min. Negotiated Rate	$3,401.00
Max. Negotiated Rate	$3,401.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,401.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,401.00

DELTA CER HEAD 12/14 36MM 1.5

Facility

$6,802.00

Service Code	HCPCS C1776
Hospital Charge Code	40005156
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$7,142.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,741.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$4,081.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,401.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,911.15
Rate for Payer: EmblemHealth Commercial	$3,401.00
Rate for Payer: Fidelis Medicare Advantage	$7,142.10
Rate for Payer: Group Health Inc Commercial	$3,401.00
Rate for Payer: Group Health Inc Medicare	$2,380.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,401.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,401.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,421.30

DELTA CER HEAD 12/14 36MM 1.5

Facility

$8,502.50

Service Code	HCPCS C1776
Hospital Charge Code	64905284
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$8,927.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,676.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$5,101.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,251.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,888.94
Rate for Payer: EmblemHealth Commercial	$4,251.25
Rate for Payer: Fidelis Medicare Advantage	$8,927.62
Rate for Payer: Group Health Inc Commercial	$4,251.25
Rate for Payer: Group Health Inc Medicare	$2,975.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,251.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4,251.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,526.62

DEMECLOCYCLINE 150 MG TAB

Facility

$3.57

Hospital Charge Code	41654621
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$2.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.78
Rate for Payer: Aetna Government	$1.78
Rate for Payer: Brighton Health Commercial	$2.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.43
Rate for Payer: Group Health Inc Commercial	$1.78
Rate for Payer: Group Health Inc Medicare	$1.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.78
Rate for Payer: Hamaspik Choice Inc Medicare	$1.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.32

DEMECLOCYCLINE 150 MG TAB

Facility

$3.57

Hospital Charge Code	41644621
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$2.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.78
Rate for Payer: Aetna Government	$1.78
Rate for Payer: Brighton Health Commercial	$2.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.43
Rate for Payer: Group Health Inc Commercial	$1.78
Rate for Payer: Group Health Inc Medicare	$1.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.78
Rate for Payer: Hamaspik Choice Inc Medicare	$1.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.32

Know your out-of-pocket cost for care.

All Charges