St. Barnabas Hospital

All Charges

Charge

Type

Price

ALLODERM RTU 8 X 16 THICK

Facility IP

$102.32

Service Code	HCPCS Q4116
Hospital Charge Code	64903241
Hospital Revenue Code	636
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$51.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.16
Rate for Payer: Hamaspik Choice Inc Medicare	$51.16

ALLOGENEIC BONE MARROW TRANSPLANT

Facility IP

$197,918.28

Service Code	MS-DRG 014
Min. Negotiated Rate	$77,311.16
Max. Negotiated Rate	$197,918.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$168,990.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$166,260.55
Rate for Payer: Aetna Government	$166,260.55
Rate for Payer: Brighton Health Commercial	$166,183.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$169,585.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$197,918.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$163,330.66
Rate for Payer: Elderplan Medicare Advantage	$157,947.52
Rate for Payer: EmblemHealth Commercial	$98,277.20
Rate for Payer: Fidelis Medicare Advantage	$166,260.55
Rate for Payer: Group Health Inc Commercial	$166,260.55
Rate for Payer: Group Health Inc Medicare	$166,260.55
Rate for Payer: Hamaspik Choice Inc Medicare	$166,260.55
Rate for Payer: Healthfirst Medicare Advantage	$77,311.16
Rate for Payer: Senior Whole Health Medicare Advantage	$166,260.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$166,260.55
Rate for Payer: Wellcare Medicare	$157,947.52

ALLOMAX 1MM GRAFT 3.9X5.9

Facility OP

$571.20

Service Code	HCPCS Q4100
Hospital Charge Code	64903687
Hospital Revenue Code	636
Min. Negotiated Rate	$9.74
Max. Negotiated Rate	$371.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$314.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.74
Rate for Payer: Aetna Government	$9.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$285.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$328.44
Rate for Payer: Group Health Inc Commercial	$285.60
Rate for Payer: Group Health Inc Medicare	$199.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$285.60
Rate for Payer: Hamaspik Choice Inc Medicare	$285.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$371.28

ALLOMAX 1MM GRAFT 3.9X5.9

Facility IP

$571.20

Service Code	HCPCS Q4100
Hospital Charge Code	64903687
Hospital Revenue Code	636
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$285.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$285.60
Rate for Payer: Hamaspik Choice Inc Medicare	$285.60

ALLOPURE COTTON 6MM

Facility OP

$6,150.00

Service Code	HCPCS C1713
Hospital Charge Code	64904445
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$6,457.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,382.50
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	$3,075.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,536.25
Rate for Payer: Fidelis Medicare Advantage	$6,457.50
Rate for Payer: Group Health Inc Commercial	$3,075.00
Rate for Payer: Group Health Inc Medicare	$2,152.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,075.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,075.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,997.50

ALLOPURE COTTON 6MM

Facility IP

$6,150.00

Service Code	HCPCS C1713
Hospital Charge Code	64904445
Hospital Revenue Code	278
Min. Negotiated Rate	$3,075.00
Max. Negotiated Rate	$3,075.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,075.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,075.00

ALLOPURE EVANS 8MM

Facility OP

$7,487.50

Service Code	HCPCS C1713
Hospital Charge Code	64904443
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$7,861.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,118.12
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	$3,743.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,305.31
Rate for Payer: Fidelis Medicare Advantage	$7,861.88
Rate for Payer: Group Health Inc Commercial	$3,743.75
Rate for Payer: Group Health Inc Medicare	$2,620.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,743.75
Rate for Payer: Hamaspik Choice Inc Medicare	$3,743.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,866.88

ALLOPURE EVANS 8MM

Facility IP

$7,487.50

Service Code	HCPCS C1713
Hospital Charge Code	64904443
Hospital Revenue Code	278
Min. Negotiated Rate	$3,743.75
Max. Negotiated Rate	$3,743.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,743.75
Rate for Payer: Hamaspik Choice Inc Medicare	$3,743.75

ALLOPURINOL 100 MG TAB

Facility OP

$0.11

Hospital Charge Code	41642666
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

ALLOPURINOL 100 MG TAB

Facility OP

$0.11

Hospital Charge Code	41652666
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

ALLOPURINOL 1 MG/ML SUSP

Facility OP

$2.00

Hospital Charge Code	41642019
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

ALLOPURINOL 1 MG/ML SUSP

Facility OP

$2.00

Hospital Charge Code	41652019
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

ALLOPURINOL 300 MG TAB

Facility OP

$1.00

Hospital Charge Code	41650757
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

ALLOPURINOL 300 MG TAB

Facility OP

$1.00

Hospital Charge Code	41640757
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

ALL POLY BUTTON PATELLA

Facility OP

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209577
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,289.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$675.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$614.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$706.10
Rate for Payer: Fidelis Medicare Advantage	$1,289.40
Rate for Payer: Group Health Inc Commercial	$614.00
Rate for Payer: Group Health Inc Medicare	$429.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$798.20

ALL POLY BUTTON PATELLA

Facility IP

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209577
Hospital Revenue Code	278
Min. Negotiated Rate	$614.00
Max. Negotiated Rate	$614.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00

ALL POLY BUTTON PATELLA STD #11-1

Facility OP

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209578
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,289.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$675.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$614.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$706.10
Rate for Payer: Fidelis Medicare Advantage	$1,289.40
Rate for Payer: Group Health Inc Commercial	$614.00
Rate for Payer: Group Health Inc Medicare	$429.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$798.20

ALL POLY BUTTON PATELLA STD #11-1

Facility IP

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209578
Hospital Revenue Code	278
Min. Negotiated Rate	$614.00
Max. Negotiated Rate	$614.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00

ALOGRFT ILICREST/WDGE24-26MMX31MM

Facility IP

$181.90

Service Code	HCPCS C1762
Hospital Charge Code	40209425
Hospital Revenue Code	278
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$90.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.95
Rate for Payer: Hamaspik Choice Inc Medicare	$90.95

ALOGRFT ILICREST/WDGE24-26MMX31MM

Facility OP

$181.90

Service Code	HCPCS C1762
Hospital Charge Code	40209425
Hospital Revenue Code	278
Min. Negotiated Rate	$63.66
Max. Negotiated Rate	$1,879.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$100.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,879.82
Rate for Payer: Aetna Government	$1,879.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$104.59
Rate for Payer: Fidelis Medicare Advantage	$191.00
Rate for Payer: Group Health Inc Commercial	$90.95
Rate for Payer: Group Health Inc Medicare	$63.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.95
Rate for Payer: Hamaspik Choice Inc Medicare	$90.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$118.24

ALPHA-1-ANTITRYPSIN DEFICIENCY

Facility OP

$109.13

Service Code	HCPCS 81332
Hospital Charge Code	40609030
Hospital Revenue Code	310
Min. Negotiated Rate	$34.92
Max. Negotiated Rate	$87.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.65
Rate for Payer: Aetna Government	$43.65
Rate for Payer: Brighton Health Commercial	$43.65
Rate for Payer: Cash Price	$43.65
Rate for Payer: Cash Price	$43.65
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.21
Rate for Payer: Elderplan Medicare Advantage	$43.65
Rate for Payer: EmblemHealth Commercial	$43.65
Rate for Payer: Fidelis CHP/HARP/Medicaid	$39.28
Rate for Payer: Fidelis Essential Plan Aliesa	$37.10
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Medicare Advantage	$43.65
Rate for Payer: Fidelis Qualified Health Plan	$38.85
Rate for Payer: Group Health Inc Commercial	$43.65
Rate for Payer: Group Health Inc Medicare	$43.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.56
Rate for Payer: Hamaspik Choice Inc Medicare	$43.65
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$43.65
Rate for Payer: Healthfirst Medicare Advantage	$43.65
Rate for Payer: Healthfirst QHP	$43.65
Rate for Payer: Senior Whole Health Medicare Advantage	$43.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34.92
Rate for Payer: Wellcare Medicare	$39.28

ALPHA-1-ANTITRYPSIN, SERUM

Facility OP

$33.60

Service Code	HCPCS 82103
Hospital Charge Code	40609036
Hospital Revenue Code	300
Min. Negotiated Rate	$10.75
Max. Negotiated Rate	$21.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.44
Rate for Payer: Aetna Government	$13.44
Rate for Payer: Cash Price	$13.44
Rate for Payer: Cash Price	$13.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$13.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.07
Rate for Payer: Elderplan Medicare Advantage	$13.44
Rate for Payer: EmblemHealth Commercial	$13.44
Rate for Payer: Fidelis CHP/HARP/Medicaid	$12.10
Rate for Payer: Fidelis Essential Plan Aliesa	$11.42
Rate for Payer: Fidelis Essential Plan QHP	$11.96
Rate for Payer: Fidelis Medicare Advantage	$13.44
Rate for Payer: Fidelis Qualified Health Plan	$11.96
Rate for Payer: Group Health Inc Commercial	$13.44
Rate for Payer: Group Health Inc Medicare	$13.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.80
Rate for Payer: Hamaspik Choice Inc Medicare	$13.44
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$13.44
Rate for Payer: Healthfirst Medicare Advantage	$13.44
Rate for Payer: Healthfirst QHP	$13.44
Rate for Payer: Senior Whole Health Medicare Advantage	$13.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.44
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.75
Rate for Payer: Wellcare Medicare	$12.10

ALPHA-THALASSEMIA

Facility OP

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	40629206
Hospital Revenue Code	310
Min. Negotiated Rate	$81.81
Max. Negotiated Rate	$204.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$102.26
Rate for Payer: Aetna Government	$102.26
Rate for Payer: Brighton Health Commercial	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$102.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.84
Rate for Payer: Elderplan Medicare Advantage	$102.26
Rate for Payer: EmblemHealth Commercial	$102.26
Rate for Payer: Fidelis CHP/HARP/Medicaid	$92.03
Rate for Payer: Fidelis Essential Plan Aliesa	$86.92
Rate for Payer: Fidelis Essential Plan QHP	$91.01
Rate for Payer: Fidelis Medicare Advantage	$102.26
Rate for Payer: Fidelis Qualified Health Plan	$91.01
Rate for Payer: Group Health Inc Commercial	$102.26
Rate for Payer: Group Health Inc Medicare	$102.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.82
Rate for Payer: Hamaspik Choice Inc Medicare	$102.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$102.26
Rate for Payer: Healthfirst Medicare Advantage	$102.26
Rate for Payer: Healthfirst QHP	$102.26
Rate for Payer: Senior Whole Health Medicare Advantage	$102.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$102.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$81.81
Rate for Payer: Wellcare Medicare	$92.03

ALPHA THALASSEMIA, DNA N

Facility OP

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	30305803
Hospital Revenue Code	310
Min. Negotiated Rate	$81.81
Max. Negotiated Rate	$204.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$102.26
Rate for Payer: Aetna Government	$102.26
Rate for Payer: Brighton Health Commercial	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$102.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.84
Rate for Payer: Elderplan Medicare Advantage	$102.26
Rate for Payer: EmblemHealth Commercial	$102.26
Rate for Payer: Fidelis CHP/HARP/Medicaid	$92.03
Rate for Payer: Fidelis Essential Plan Aliesa	$86.92
Rate for Payer: Fidelis Essential Plan QHP	$91.01
Rate for Payer: Fidelis Medicare Advantage	$102.26
Rate for Payer: Fidelis Qualified Health Plan	$91.01
Rate for Payer: Group Health Inc Commercial	$102.26
Rate for Payer: Group Health Inc Medicare	$102.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.82
Rate for Payer: Hamaspik Choice Inc Medicare	$102.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$102.26
Rate for Payer: Healthfirst Medicare Advantage	$102.26
Rate for Payer: Healthfirst QHP	$102.26
Rate for Payer: Senior Whole Health Medicare Advantage	$102.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$102.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$81.81
Rate for Payer: Wellcare Medicare	$92.03

ALPRAZOLAM 0.25 MG TAB

Facility OP

$1.00

Hospital Charge Code	41640899
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

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