St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIPHTHERIA + TETANUS TOXOIDS INJ ADULT

Facility

$34.00

Service Code	HCPCS 90714
Hospital Charge Code	41644588
Hospital Revenue Code	636
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$26.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$20.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.55
Rate for Payer: Group Health Inc Commercial	$17.00
Rate for Payer: Group Health Inc Medicare	$11.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$19.96
Rate for Payer: SOMOS Essential	$19.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.10

DIPIVEFRIN 0.1% OPHTHALMIC SOLN

Facility

$6.00

Hospital Charge Code	41643410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.00
Rate for Payer: Aetna Government	$3.00
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

DIPIVEFRIN 0.1% OPHTHALMIC SOLN

Facility

$6.00

Hospital Charge Code	41653410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.00
Rate for Payer: Aetna Government	$3.00
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

DIPTHER/TETANUS/PERT/POLIO VACC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41657811
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

DIPTHER/TETANUS/PERT/POLIO VACC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41647811
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

DIPTHER/TETANUS/PERT/POLIO VACC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41647811
Hospital Revenue Code	636
Max. Negotiated Rate	$56.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.24
Rate for Payer: Aetna Government	$56.24
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

DIPTHER/TETANUS/PERT/POLIO VACC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41657811
Hospital Revenue Code	636
Max. Negotiated Rate	$56.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.24
Rate for Payer: Aetna Government	$56.24
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

DIPTHER/TETANUS/PERT/POLIO VFC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41647810
Hospital Revenue Code	636
Max. Negotiated Rate	$56.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.24
Rate for Payer: Aetna Government	$56.24
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

DIPTHER/TETANUS/PERT/POLIO VFC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41657810
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

DIPTHER/TETANUS/PERT/POLIO VFC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41657810
Hospital Revenue Code	636
Max. Negotiated Rate	$56.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.24
Rate for Payer: Aetna Government	$56.24
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

DIPTHER/TETANUS/PERT/POLIO VFC

Facility

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	41647810
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

DIPYRIDAMOLE 25 MG TAB

Facility

$1.00

Hospital Charge Code	41652963
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

DIPYRIDAMOLE 25 MG TAB

Facility

$1.00

Hospital Charge Code	41642963
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

DIPYRIDAMOLE 50 MG TAB

Facility

$1.00

Hospital Charge Code	41652964
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

DIPYRIDAMOLE 50 MG TAB

Facility

$1.00

Hospital Charge Code	41642964
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

DIPYRIDAMOLE 5 MG/ML INJ

Facility

$1.65

Service Code	HCPCS J1245
Hospital Charge Code	41653733
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$3.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.65
Rate for Payer: Aetna Government	$3.65
Rate for Payer: Brighton Health Commercial	$0.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.95
Rate for Payer: Group Health Inc Commercial	$0.83
Rate for Payer: Group Health Inc Medicare	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.83
Rate for Payer: Hamaspik Choice Inc Medicare	$0.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3.96
Rate for Payer: SOMOS Essential	$3.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.07

DIPYRIDAMOLE 5 MG/ML INJ

Facility

$1.65

Service Code	HCPCS J1245
Hospital Charge Code	41643733
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$0.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.83
Rate for Payer: Hamaspik Choice Inc Medicare	$0.83

DIPYRIDAMOLE 5 MG/ML INJ

Facility

$1.65

Service Code	HCPCS J1245
Hospital Charge Code	41653733
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$0.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.83
Rate for Payer: Hamaspik Choice Inc Medicare	$0.83

DIPYRIDAMOLE 5 MG/ML INJ

Facility

$1.65

Service Code	HCPCS J1245
Hospital Charge Code	41643733
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$3.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.65
Rate for Payer: Aetna Government	$3.65
Rate for Payer: Brighton Health Commercial	$0.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.95
Rate for Payer: Group Health Inc Commercial	$0.83
Rate for Payer: Group Health Inc Medicare	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.83
Rate for Payer: Hamaspik Choice Inc Medicare	$0.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3.96
Rate for Payer: SOMOS Essential	$3.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.07

DIPYRIDAMOLE 75 MG TAB

Facility

$1.00

Hospital Charge Code	41653521
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

DIPYRIDAMOLE 75 MG TAB

Facility

$1.00

Hospital Charge Code	41643521
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

DIRECT COOMBS

Facility

$101.25

Service Code	HCPCS 86880
Hospital Charge Code	40701080
Hospital Revenue Code	300
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$75.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.69
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.74
Rate for Payer: Aetna Government	$70.74
Rate for Payer: Affinity Essential Plan 1&2	$49.52
Rate for Payer: Affinity Essential Plan 3&4	$49.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.52
Rate for Payer: Brighton Health Commercial	$75.94
Rate for Payer: Cash Price	$70.74
Rate for Payer: Cash Price	$70.74
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$70.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.22
Rate for Payer: Elderplan Medicare Advantage	$70.74
Rate for Payer: EmblemHealth Commercial	$70.74
Rate for Payer: Fidelis Essential Plan Aliesa	$60.13
Rate for Payer: Fidelis Essential Plan QHP	$62.96
Rate for Payer: Fidelis Medicare Advantage	$70.74
Rate for Payer: Fidelis Qualified Health Plan	$62.96
Rate for Payer: Group Health Inc Commercial	$70.74
Rate for Payer: Group Health Inc Medicare	$70.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.62
Rate for Payer: Hamaspik Choice Inc Medicare	$70.74
Rate for Payer: Healthfirst Medicare Advantage	$70.74
Rate for Payer: Healthfirst QHP	$70.74
Rate for Payer: Humana Medicare	$72.15
Rate for Payer: Senior Whole Health Medicare Advantage	$70.74
Rate for Payer: United Healthcare Commercial	$6.80
Rate for Payer: United Healthcare Medicare Advantage	$70.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$70.74
Rate for Payer: Wellcare CHP/FHP/Medicaid	$56.59
Rate for Payer: Wellcare Medicare	$63.67

DIRECT COOMBS

Facility

$101.25

Service Code	HCPCS 86880
Hospital Charge Code	40701080
Hospital Revenue Code	300
Rate for Payer: Cash Price	$70.74

DIRECT IMMUNOFLUORESCENCE, SKIN

Facility

$858.38

Service Code	HCPCS 88346
Hospital Charge Code	40639230
Hospital Revenue Code	300
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$643.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$472.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.52
Rate for Payer: Aetna Government	$197.52
Rate for Payer: Affinity Essential Plan 1&2	$138.26
Rate for Payer: Affinity Essential Plan 3&4	$138.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.26
Rate for Payer: Brighton Health Commercial	$643.78
Rate for Payer: Cash Price	$197.52
Rate for Payer: Cash Price	$197.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$197.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$68.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$58.14
Rate for Payer: Elderplan Medicare Advantage	$197.52
Rate for Payer: EmblemHealth Commercial	$197.52
Rate for Payer: Fidelis Essential Plan Aliesa	$167.89
Rate for Payer: Fidelis Essential Plan QHP	$175.79
Rate for Payer: Fidelis Medicare Advantage	$197.52
Rate for Payer: Fidelis Qualified Health Plan	$175.79
Rate for Payer: Group Health Inc Commercial	$197.52
Rate for Payer: Group Health Inc Medicare	$197.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$429.19
Rate for Payer: Hamaspik Choice Inc Medicare	$197.52
Rate for Payer: Healthfirst Medicare Advantage	$197.52
Rate for Payer: Healthfirst QHP	$197.52
Rate for Payer: Humana Medicare	$201.47
Rate for Payer: Senior Whole Health Medicare Advantage	$197.52
Rate for Payer: United Healthcare Commercial	$32.83
Rate for Payer: United Healthcare Medicare Advantage	$197.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$158.02
Rate for Payer: Wellcare Medicare	$177.77

DIRECT IMMUNOFLUORESCENCE, SKIN

Facility

$858.38

Service Code	HCPCS 88346
Hospital Charge Code	40639230
Hospital Revenue Code	300
Rate for Payer: Cash Price	$197.52

Know your out-of-pocket cost for care.

All Charges