St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.74

Service Code	NDC 62756079713
Hospital Charge Code	62756079713
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.87
Rate for Payer: Aetna Government	$0.87
Rate for Payer: Brighton Health Commercial	$1.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.19
Rate for Payer: Group Health Inc Commercial	$0.87
Rate for Payer: Group Health Inc Medicare	$0.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.13

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.07

Service Code	NDC 00832712389
Hospital Charge Code	00832712389
Hospital Revenue Code	250
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.54
Rate for Payer: Aetna Government	$0.54
Rate for Payer: Brighton Health Commercial	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.70

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.76

Service Code	NDC 68084077601
Hospital Charge Code	68084077601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.88
Rate for Payer: Aetna Government	$0.88
Rate for Payer: Brighton Health Commercial	$1.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.20
Rate for Payer: Group Health Inc Commercial	$0.88
Rate for Payer: Group Health Inc Medicare	$0.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.88
Rate for Payer: Hamaspik Choice Inc Medicare	$0.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.15

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.74

Service Code	NDC 62756079788
Hospital Charge Code	62756079788
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.87
Rate for Payer: Aetna Government	$0.87
Rate for Payer: Brighton Health Commercial	$1.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.19
Rate for Payer: Group Health Inc Commercial	$0.87
Rate for Payer: Group Health Inc Medicare	$0.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.13

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.76

Service Code	NDC 29300013905
Hospital Charge Code	29300013905
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.88
Rate for Payer: Aetna Government	$0.88
Rate for Payer: Brighton Health Commercial	$1.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.20
Rate for Payer: Group Health Inc Commercial	$0.88
Rate for Payer: Group Health Inc Medicare	$0.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.88
Rate for Payer: Hamaspik Choice Inc Medicare	$0.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.15

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$0.24

Service Code	NDC 00904686061
Hospital Charge Code	00904686061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

DIVALPROEX SODIUM 250 MG PO TBEC [2552]

Facility

$1.07

Service Code	NDC 00832712301
Hospital Charge Code	00832712301
Hospital Revenue Code	250
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.54
Rate for Payer: Aetna Government	$0.54
Rate for Payer: Brighton Health Commercial	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.70

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$0.23

Service Code	NDC 00904686161
Hospital Charge Code	00904686161
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.15

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$3.25

Service Code	NDC 29300014005
Hospital Charge Code	29300014005
Hospital Revenue Code	250
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.62
Rate for Payer: Aetna Government	$1.62
Rate for Payer: Brighton Health Commercial	$2.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.21
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.11

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$1.42

Service Code	NDC 00832712401
Hospital Charge Code	00832712401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.71
Rate for Payer: Aetna Government	$0.71
Rate for Payer: Brighton Health Commercial	$1.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.97
Rate for Payer: Group Health Inc Commercial	$0.71
Rate for Payer: Group Health Inc Medicare	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.71
Rate for Payer: Hamaspik Choice Inc Medicare	$0.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.92

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$3.21

Service Code	NDC 57237004801
Hospital Charge Code	57237004801
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.61
Rate for Payer: Aetna Government	$1.61
Rate for Payer: Brighton Health Commercial	$2.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.19
Rate for Payer: Group Health Inc Commercial	$1.61
Rate for Payer: Group Health Inc Medicare	$1.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.61
Rate for Payer: Hamaspik Choice Inc Medicare	$1.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.09

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$3.21

Service Code	NDC 57237004805
Hospital Charge Code	57237004805
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.61
Rate for Payer: Aetna Government	$1.61
Rate for Payer: Brighton Health Commercial	$2.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.19
Rate for Payer: Group Health Inc Commercial	$1.61
Rate for Payer: Group Health Inc Medicare	$1.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.61
Rate for Payer: Hamaspik Choice Inc Medicare	$1.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.09

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$3.23

Service Code	NDC 68084078261
Hospital Charge Code	68084078261
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.62
Rate for Payer: Aetna Government	$1.62
Rate for Payer: Brighton Health Commercial	$2.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.20
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.10

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$3.21

Service Code	NDC 62756079888
Hospital Charge Code	62756079888
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.61
Rate for Payer: Aetna Government	$1.61
Rate for Payer: Brighton Health Commercial	$2.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.19
Rate for Payer: Group Health Inc Commercial	$1.61
Rate for Payer: Group Health Inc Medicare	$1.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.61
Rate for Payer: Hamaspik Choice Inc Medicare	$1.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.09

DIVALPROEX SODIUM 500 MG PO TBEC [2553]

Facility

$0.39

Service Code	NDC 00904686190
Hospital Charge Code	00904686190
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.26
Rate for Payer: Group Health Inc Commercial	$0.19
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19
Rate for Payer: Hamaspik Choice Inc Medicare	$0.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

DIVALPROEX SODIUM ER 250 MG PO TB24 [34418]

Facility

$2.46

Service Code	NDC 00378047201
Hospital Charge Code	00378047201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.23
Rate for Payer: Aetna Government	$1.23
Rate for Payer: Brighton Health Commercial	$1.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.67
Rate for Payer: Group Health Inc Commercial	$1.23
Rate for Payer: Group Health Inc Medicare	$0.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.23
Rate for Payer: Hamaspik Choice Inc Medicare	$1.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.60

DIVALPROEX SODIUM ER 500 MG PO TB24 [81426]

Facility

$4.08

Service Code	NDC 65162075750
Hospital Charge Code	65162075750
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$3.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.04
Rate for Payer: Aetna Government	$2.04
Rate for Payer: Brighton Health Commercial	$3.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.77
Rate for Payer: Group Health Inc Commercial	$2.04
Rate for Payer: Group Health Inc Medicare	$1.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.04
Rate for Payer: Hamaspik Choice Inc Medicare	$2.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.65

DIVALPROEX SODIUM ER 500 MG PO TB24 [81426]

Facility

$2.47

Service Code	NDC 00904636461
Hospital Charge Code	00904636461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.24
Rate for Payer: Aetna Government	$1.24
Rate for Payer: Brighton Health Commercial	$1.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.68
Rate for Payer: Group Health Inc Commercial	$1.24
Rate for Payer: Group Health Inc Medicare	$0.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.24
Rate for Payer: Hamaspik Choice Inc Medicare	$1.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.61

DIVISION OF FALLOPIAN TUBE

Facility

$7,566.13

Service Code	HCPCS 58600
Hospital Charge Code	40054170
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,615.39

DIVISION OF FALLOPIAN TUBE

Facility

$7,566.13

Service Code	HCPCS 58600
Hospital Charge Code	40054170
Hospital Revenue Code	360
Min. Negotiated Rate	$1,468.00
Max. Negotiated Rate	$5,674.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,134.00
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

DJD BODY

Facility

$5,710.60

Hospital Charge Code	40200856
Hospital Revenue Code	270
Min. Negotiated Rate	$1,998.71
Max. Negotiated Rate	$4,568.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,140.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,855.30
Rate for Payer: Aetna Government	$2,855.30
Rate for Payer: Brighton Health Commercial	$4,282.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,568.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,883.21
Rate for Payer: Group Health Inc Commercial	$2,855.30
Rate for Payer: Group Health Inc Medicare	$1,998.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,855.30
Rate for Payer: Hamaspik Choice Inc Medicare	$2,855.30

DJD CLAMP

Facility

$8,206.25

Hospital Charge Code	64905802
Hospital Revenue Code	270
Min. Negotiated Rate	$2,872.19
Max. Negotiated Rate	$6,565.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,513.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,103.12
Rate for Payer: Aetna Government	$4,103.12
Rate for Payer: Brighton Health Commercial	$6,154.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6,565.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,580.25
Rate for Payer: Group Health Inc Commercial	$4,103.12
Rate for Payer: Group Health Inc Medicare	$2,872.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,103.12
Rate for Payer: Hamaspik Choice Inc Medicare	$4,103.12

DMNDBK 360 1.25 MCR CRX145CM OAS

Facility

$10,790.00

Hospital Charge Code	40005128
Hospital Revenue Code	272
Min. Negotiated Rate	$3,776.50
Max. Negotiated Rate	$8,632.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,934.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,395.00
Rate for Payer: Aetna Government	$5,395.00
Rate for Payer: Brighton Health Commercial	$8,092.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,632.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,337.20
Rate for Payer: Group Health Inc Commercial	$5,395.00
Rate for Payer: Group Health Inc Medicare	$3,776.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,395.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,395.00

DMNDBK 360 1.25 SLD CRX145CM OAS

Facility

$10,790.00

Hospital Charge Code	40005129
Hospital Revenue Code	272
Min. Negotiated Rate	$3,776.50
Max. Negotiated Rate	$8,632.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,934.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,395.00
Rate for Payer: Aetna Government	$5,395.00
Rate for Payer: Brighton Health Commercial	$8,092.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,632.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,337.20
Rate for Payer: Group Health Inc Commercial	$5,395.00
Rate for Payer: Group Health Inc Medicare	$3,776.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,395.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,395.00

DMNDBK 360 1.50 SLD CRX145CM OAS

Facility

$10,790.00

Hospital Charge Code	40005130
Hospital Revenue Code	272
Min. Negotiated Rate	$3,776.50
Max. Negotiated Rate	$8,632.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,934.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,395.00
Rate for Payer: Aetna Government	$5,395.00
Rate for Payer: Brighton Health Commercial	$8,092.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,632.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,337.20
Rate for Payer: Group Health Inc Commercial	$5,395.00
Rate for Payer: Group Health Inc Medicare	$3,776.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,395.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,395.00

Know your out-of-pocket cost for care.

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