St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIPH/TET/PERT (VFC) 0.5ML VIAL

Facility

$0.01

Service Code	HCPCS 90700
Hospital Charge Code	41646907
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP [145970]

Facility

$69.45

Service Code	HCPCS 90700
Hospital Charge Code	49281028610
Hospital Revenue Code	250
Min. Negotiated Rate	$24.31
Max. Negotiated Rate	$55.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.70
Rate for Payer: Aetna Government	$27.70
Rate for Payer: Brighton Health Commercial	$52.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.22
Rate for Payer: Group Health Inc Commercial	$34.72
Rate for Payer: Group Health Inc Medicare	$24.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$34.72
Rate for Payer: Hamaspik Choice Inc Medicare	$34.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.14

DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP [19451]

Facility

$68.21

Service Code	HCPCS 90700
Hospital Charge Code	58160081052
Hospital Revenue Code	250
Min. Negotiated Rate	$23.87
Max. Negotiated Rate	$54.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$37.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.70
Rate for Payer: Aetna Government	$27.70
Rate for Payer: Brighton Health Commercial	$51.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$54.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$46.38
Rate for Payer: Group Health Inc Commercial	$34.10
Rate for Payer: Group Health Inc Medicare	$23.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$34.10
Rate for Payer: Hamaspik Choice Inc Medicare	$34.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$44.34

DIPHTHERIA ANTIBODIES

Facility

$38.03

Service Code	HCPCS 86648
Hospital Charge Code	40728009
Hospital Revenue Code	302
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$28.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.21
Rate for Payer: Aetna Government	$15.21
Rate for Payer: Affinity Essential Plan 1&2	$10.65
Rate for Payer: Affinity Essential Plan 3&4	$10.65
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.65
Rate for Payer: Brighton Health Commercial	$28.52
Rate for Payer: Cash Price	$15.21
Rate for Payer: Cash Price	$15.21
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$15.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.46
Rate for Payer: Elderplan Medicare Advantage	$15.21
Rate for Payer: EmblemHealth Commercial	$15.21
Rate for Payer: Fidelis Essential Plan Aliesa	$12.93
Rate for Payer: Fidelis Essential Plan QHP	$13.54
Rate for Payer: Fidelis Medicare Advantage	$15.21
Rate for Payer: Fidelis Qualified Health Plan	$13.54
Rate for Payer: Group Health Inc Commercial	$15.21
Rate for Payer: Group Health Inc Medicare	$15.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.02
Rate for Payer: Hamaspik Choice Inc Medicare	$15.21
Rate for Payer: Healthfirst Medicare Advantage	$15.21
Rate for Payer: Healthfirst QHP	$15.21
Rate for Payer: Humana Medicare	$15.51
Rate for Payer: Senior Whole Health Medicare Advantage	$15.21
Rate for Payer: United Healthcare Commercial	$19.27
Rate for Payer: United Healthcare Medicare Advantage	$15.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.21
Rate for Payer: Wellcare CHP/FHP/Medicaid	$12.17
Rate for Payer: Wellcare Medicare	$13.69

DIPHTHERIA ANTIBODIES

Facility

$38.03

Service Code	HCPCS 86648
Hospital Charge Code	40728009
Hospital Revenue Code	302
Rate for Payer: Cash Price	$15.21

DIPHTHERIA ANTITOXOID AB

Facility

$37.48

Service Code	HCPCS 86317
Hospital Charge Code	40729340
Hospital Revenue Code	300
Min. Negotiated Rate	$10.49
Max. Negotiated Rate	$28.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.99
Rate for Payer: Aetna Government	$14.99
Rate for Payer: Affinity Essential Plan 1&2	$10.49
Rate for Payer: Affinity Essential Plan 3&4	$10.49
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.49
Rate for Payer: Brighton Health Commercial	$28.11
Rate for Payer: Cash Price	$14.99
Rate for Payer: Cash Price	$14.99
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$14.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.17
Rate for Payer: Elderplan Medicare Advantage	$14.99
Rate for Payer: EmblemHealth Commercial	$14.99
Rate for Payer: Fidelis Essential Plan Aliesa	$12.74
Rate for Payer: Fidelis Essential Plan QHP	$13.34
Rate for Payer: Fidelis Medicare Advantage	$14.99
Rate for Payer: Fidelis Qualified Health Plan	$13.34
Rate for Payer: Group Health Inc Commercial	$14.99
Rate for Payer: Group Health Inc Medicare	$14.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.74
Rate for Payer: Hamaspik Choice Inc Medicare	$14.99
Rate for Payer: Healthfirst Medicare Advantage	$14.99
Rate for Payer: Healthfirst QHP	$14.99
Rate for Payer: Humana Medicare	$15.29
Rate for Payer: Senior Whole Health Medicare Advantage	$14.99
Rate for Payer: United Healthcare Commercial	$18.99
Rate for Payer: United Healthcare Medicare Advantage	$14.99
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.99
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.99
Rate for Payer: Wellcare Medicare	$13.49

DIPHTHERIA ANTITOXOID AB

Facility

$37.48

Service Code	HCPCS 86317
Hospital Charge Code	40729340
Hospital Revenue Code	300
Rate for Payer: Cash Price	$14.99

DIPHTHERIA + TETANUS + PERTUSSIS + HAEMO

Facility

$86.00

Hospital Charge Code	41643440
Hospital Revenue Code	636
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$55.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$47.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.00
Rate for Payer: Aetna Government	$43.00
Rate for Payer: Brighton Health Commercial	$51.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.45
Rate for Payer: Group Health Inc Commercial	$43.00
Rate for Payer: Group Health Inc Medicare	$30.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.00
Rate for Payer: Hamaspik Choice Inc Medicare	$43.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$55.90

DIPHTHERIA + TETANUS + PERTUSSIS + HAEMO

Facility

$86.00

Hospital Charge Code	41653440
Hospital Revenue Code	636
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$55.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$47.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.00
Rate for Payer: Aetna Government	$43.00
Rate for Payer: Brighton Health Commercial	$51.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.45
Rate for Payer: Group Health Inc Commercial	$43.00
Rate for Payer: Group Health Inc Medicare	$30.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.00
Rate for Payer: Hamaspik Choice Inc Medicare	$43.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$55.90

DIPHTHERIA + TETANUS + PERTUSSIS + HAEMO

Facility

$86.00

Hospital Charge Code	41653440
Hospital Revenue Code	636
Min. Negotiated Rate	$43.00
Max. Negotiated Rate	$43.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.00
Rate for Payer: Hamaspik Choice Inc Medicare	$43.00

DIPHTHERIA + TETANUS + PERTUSSIS + HAEMO

Facility

$86.00

Hospital Charge Code	41643440
Hospital Revenue Code	636
Min. Negotiated Rate	$43.00
Max. Negotiated Rate	$43.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.00
Rate for Payer: Hamaspik Choice Inc Medicare	$43.00

DIPHTHERIA + TETANUS + PERTUSSIS (INFANR

Facility

$42.00

Hospital Charge Code	41655204
Hospital Revenue Code	250
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$33.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.00
Rate for Payer: Aetna Government	$21.00
Rate for Payer: Brighton Health Commercial	$31.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.56
Rate for Payer: Group Health Inc Commercial	$21.00
Rate for Payer: Group Health Inc Medicare	$14.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$21.00
Rate for Payer: Hamaspik Choice Inc Medicare	$21.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27.30

DIPHTHERIA + TETANUS + PERTUSSIS (INFANR

Facility

$42.00

Hospital Charge Code	41645204
Hospital Revenue Code	250
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$33.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.00
Rate for Payer: Aetna Government	$21.00
Rate for Payer: Brighton Health Commercial	$31.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.56
Rate for Payer: Group Health Inc Commercial	$21.00
Rate for Payer: Group Health Inc Medicare	$14.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$21.00
Rate for Payer: Hamaspik Choice Inc Medicare	$21.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27.30

DIPHTHERIA + TETANUS + PERTUSSIS INJ (AD

Facility

$65.00

Service Code	HCPCS 90715
Hospital Charge Code	41644223
Hospital Revenue Code	636
Min. Negotiated Rate	$32.50
Max. Negotiated Rate	$32.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.50
Rate for Payer: Hamaspik Choice Inc Medicare	$32.50

DIPHTHERIA + TETANUS + PERTUSSIS INJ (AD

Facility

$65.00

Service Code	HCPCS 90715
Hospital Charge Code	41654223
Hospital Revenue Code	636
Min. Negotiated Rate	$22.75
Max. Negotiated Rate	$42.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$39.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.38
Rate for Payer: Group Health Inc Commercial	$32.50
Rate for Payer: Group Health Inc Medicare	$22.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.50
Rate for Payer: Hamaspik Choice Inc Medicare	$32.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.43
Rate for Payer: SOMOS Essential	$41.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$42.25

DIPHTHERIA + TETANUS + PERTUSSIS INJ (AD

Facility

$65.00

Service Code	HCPCS 90715
Hospital Charge Code	41644223
Hospital Revenue Code	636
Min. Negotiated Rate	$22.75
Max. Negotiated Rate	$42.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$39.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.38
Rate for Payer: Group Health Inc Commercial	$32.50
Rate for Payer: Group Health Inc Medicare	$22.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.50
Rate for Payer: Hamaspik Choice Inc Medicare	$32.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.43
Rate for Payer: SOMOS Essential	$41.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$42.25

DIPHTHERIA + TETANUS + PERTUSSIS INJ (AD

Facility

$65.00

Service Code	HCPCS 90715
Hospital Charge Code	41654223
Hospital Revenue Code	636
Min. Negotiated Rate	$32.50
Max. Negotiated Rate	$32.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.50
Rate for Payer: Hamaspik Choice Inc Medicare	$32.50

DIPHTHERIA + TETANUS + PERTUSSIS INJ (BO

Facility

$74.00

Service Code	HCPCS 90715
Hospital Charge Code	41654662
Hospital Revenue Code	636
Min. Negotiated Rate	$37.00
Max. Negotiated Rate	$37.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00

DIPHTHERIA + TETANUS + PERTUSSIS INJ (BO

Facility

$74.00

Service Code	HCPCS 90715
Hospital Charge Code	41644662
Hospital Revenue Code	636
Min. Negotiated Rate	$37.00
Max. Negotiated Rate	$37.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00

DIPHTHERIA + TETANUS + PERTUSSIS INJ (BO

Facility

$74.00

Service Code	HCPCS 90715
Hospital Charge Code	41654662
Hospital Revenue Code	636
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$48.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$44.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$42.55
Rate for Payer: Group Health Inc Commercial	$37.00
Rate for Payer: Group Health Inc Medicare	$25.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.43
Rate for Payer: SOMOS Essential	$41.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$48.10

DIPHTHERIA + TETANUS + PERTUSSIS INJ (BO

Facility

$74.00

Service Code	HCPCS 90715
Hospital Charge Code	41644662
Hospital Revenue Code	636
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$48.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$44.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$42.55
Rate for Payer: Group Health Inc Commercial	$37.00
Rate for Payer: Group Health Inc Medicare	$25.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.43
Rate for Payer: SOMOS Essential	$41.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$48.10

DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA

Facility

$48.55

Hospital Charge Code	41654070
Hospital Revenue Code	636
Min. Negotiated Rate	$24.28
Max. Negotiated Rate	$24.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.28
Rate for Payer: Hamaspik Choice Inc Medicare	$24.28

DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA

Facility

$48.55

Hospital Charge Code	41644070
Hospital Revenue Code	636
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$31.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.28
Rate for Payer: Aetna Government	$24.28
Rate for Payer: Brighton Health Commercial	$29.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.92
Rate for Payer: Group Health Inc Commercial	$24.28
Rate for Payer: Group Health Inc Medicare	$16.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.28
Rate for Payer: Hamaspik Choice Inc Medicare	$24.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.56

DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA

Facility

$48.55

Hospital Charge Code	41644070
Hospital Revenue Code	636
Min. Negotiated Rate	$24.28
Max. Negotiated Rate	$24.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.28
Rate for Payer: Hamaspik Choice Inc Medicare	$24.28

DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA

Facility

$48.55

Hospital Charge Code	41654070
Hospital Revenue Code	636
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$31.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.28
Rate for Payer: Aetna Government	$24.28
Rate for Payer: Brighton Health Commercial	$29.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$24.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.92
Rate for Payer: Group Health Inc Commercial	$24.28
Rate for Payer: Group Health Inc Medicare	$16.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.28
Rate for Payer: Hamaspik Choice Inc Medicare	$24.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.56

Know your out-of-pocket cost for care.

All Charges