St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DRONABINOL 2.5 MG CAP

Facility

$7.00

Service Code	HCPCS Q0167
Hospital Charge Code	41651050
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.89
Rate for Payer: SOMOS Essential	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

DRONABINOL 2.5 MG CAP

Facility

$7.00

Service Code	HCPCS Q0167
Hospital Charge Code	41641050
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.89
Rate for Payer: SOMOS Essential	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

DRONABINOL 2.5 MG CAP

Facility

$7.00

Service Code	HCPCS Q0167
Hospital Charge Code	41651050
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

DRONABINOL 2.5 MG CAP

Facility

$7.00

Service Code	HCPCS Q0167
Hospital Charge Code	41641050
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

DRONABINOL 2.5 MG PO CAPS [9904]

Facility

$1.66

Service Code	HCPCS Q0167
Hospital Charge Code	42858086706
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$1.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$1.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.13
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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.84
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.89
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.89
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.08

DRONABINOL 2.5 MG PO CAPS [9904]

Facility

$5.30

Service Code	HCPCS Q0167
Hospital Charge Code	60687037511
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$4.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$3.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.61
Rate for Payer: Group Health Inc Commercial	$2.65
Rate for Payer: Group Health Inc Medicare	$1.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.65
Rate for Payer: Hamaspik Choice Inc Medicare	$2.65
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.84
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.89
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.89
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.45

DRONABINOL 2.5 MG PO CAPS [9904]

Facility

$5.67

Service Code	HCPCS Q0167
Hospital Charge Code	00904714461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$4.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$4.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.85
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.84
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.89
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.89
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.68

DRONABINOL 2.5 MG PO CAPS [9904]

Facility

$6.51

Service Code	HCPCS Q0167
Hospital Charge Code	67877075360
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$5.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$4.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.43
Rate for Payer: Group Health Inc Commercial	$3.26
Rate for Payer: Group Health Inc Medicare	$2.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.26
Rate for Payer: Hamaspik Choice Inc Medicare	$3.26
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.84
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.89
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.89
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.23

DRONEDARONE 400 MG TAB

Facility

$8.46

Hospital Charge Code	41645293
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$6.77
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.23
Rate for Payer: Aetna Government	$4.23
Rate for Payer: Brighton Health Commercial	$6.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.75
Rate for Payer: Group Health Inc Commercial	$4.23
Rate for Payer: Group Health Inc Medicare	$2.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.23
Rate for Payer: Hamaspik Choice Inc Medicare	$4.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.50

DRONEDARONE 400 MG TAB

Facility

$8.46

Hospital Charge Code	41655293
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$6.77
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.23
Rate for Payer: Aetna Government	$4.23
Rate for Payer: Brighton Health Commercial	$6.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.75
Rate for Payer: Group Health Inc Commercial	$4.23
Rate for Payer: Group Health Inc Medicare	$2.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.23
Rate for Payer: Hamaspik Choice Inc Medicare	$4.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.50

DRONEDARONE HCL 400 MG PO TABS [98329]

Facility

$15.96

Service Code	NDC 00024414260
Hospital Charge Code	00024414260
Hospital Revenue Code	250
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$12.77
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.98
Rate for Payer: Aetna Government	$7.98
Rate for Payer: Brighton Health Commercial	$11.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.85
Rate for Payer: Group Health Inc Commercial	$7.98
Rate for Payer: Group Health Inc Medicare	$5.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.98
Rate for Payer: Hamaspik Choice Inc Medicare	$7.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.37

DROTRECOGIN ALFA 20 MG INJ

Facility

$2,657.00

Hospital Charge Code	41642784
Hospital Revenue Code	250
Min. Negotiated Rate	$929.95
Max. Negotiated Rate	$2,125.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,461.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,328.50
Rate for Payer: Aetna Government	$1,328.50
Rate for Payer: Brighton Health Commercial	$1,992.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,125.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,806.76
Rate for Payer: Group Health Inc Commercial	$1,328.50
Rate for Payer: Group Health Inc Medicare	$929.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,328.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,328.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,727.05

DROTRECOGIN ALFA 20 MG INJ

Facility

$2,657.00

Hospital Charge Code	41652784
Hospital Revenue Code	250
Min. Negotiated Rate	$929.95
Max. Negotiated Rate	$2,125.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,461.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,328.50
Rate for Payer: Aetna Government	$1,328.50
Rate for Payer: Brighton Health Commercial	$1,992.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,125.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,806.76
Rate for Payer: Group Health Inc Commercial	$1,328.50
Rate for Payer: Group Health Inc Medicare	$929.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,328.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,328.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,727.05

DROTRECOGIN ALFA 5 MG INJ

Facility

$665.00

Hospital Charge Code	41652783
Hospital Revenue Code	250
Min. Negotiated Rate	$232.75
Max. Negotiated Rate	$532.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$365.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$332.50
Rate for Payer: Aetna Government	$332.50
Rate for Payer: Brighton Health Commercial	$498.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$532.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$452.20
Rate for Payer: Group Health Inc Commercial	$332.50
Rate for Payer: Group Health Inc Medicare	$232.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$332.50
Rate for Payer: Hamaspik Choice Inc Medicare	$332.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$432.25

DROTRECOGIN ALFA 5 MG INJ

Facility

$665.00

Hospital Charge Code	41642783
Hospital Revenue Code	250
Min. Negotiated Rate	$232.75
Max. Negotiated Rate	$532.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$365.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$332.50
Rate for Payer: Aetna Government	$332.50
Rate for Payer: Brighton Health Commercial	$498.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$532.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$452.20
Rate for Payer: Group Health Inc Commercial	$332.50
Rate for Payer: Group Health Inc Medicare	$232.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$332.50
Rate for Payer: Hamaspik Choice Inc Medicare	$332.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$432.25

DRUG ELUTING PERIPH STENT

Facility

$4,487.50

Service Code	HCPCS C1874
Hospital Charge Code	64904187
Hospital Revenue Code	278
Min. Negotiated Rate	$2,243.75
Max. Negotiated Rate	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,243.75

DRUG ELUTING PERIPH STENT

Facility

$4,487.50

Service Code	HCPCS C1874
Hospital Charge Code	64904187
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$4,711.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,468.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Brighton Health Commercial	$2,692.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,243.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,580.31
Rate for Payer: EmblemHealth Commercial	$2,243.75
Rate for Payer: Fidelis Medicare Advantage	$4,711.88
Rate for Payer: Group Health Inc Commercial	$2,243.75
Rate for Payer: Group Health Inc Medicare	$1,570.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,243.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,916.88

DRUG MANAGEMENT

Facility

$453.95

Service Code	HCPCS 90863
Hospital Charge Code	30300005
Hospital Revenue Code	914
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$363.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$188.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.00
Rate for Payer: Aetna Government	$30.00
Rate for Payer: Brighton Health Commercial	$340.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$363.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$308.69
Rate for Payer: Group Health Inc Commercial	$226.98
Rate for Payer: Group Health Inc Medicare	$158.88
Rate for Payer: Hamaspik Choice Inc Medicare	$226.98

DRUG SCREEN 10 W/CONF, SE

Facility

$31.50

Service Code	HCPCS 80305
Hospital Charge Code	40609156
Hospital Revenue Code	300
Rate for Payer: Cash Price	$12.60

DRUG SCREEN 10 W/CONF, SE

Facility

$31.50

Service Code	HCPCS 80305
Hospital Charge Code	40609156
Hospital Revenue Code	300
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$1,414.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.60
Rate for Payer: Aetna Government	$12.60
Rate for Payer: Affinity Essential Plan 1&2	$31.82
Rate for Payer: Affinity Essential Plan 3&4	$31.82
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.14
Rate for Payer: Amida Care Medicaid	$14.14
Rate for Payer: Brighton Health Commercial	$23.62
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$25.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$21.42
Rate for Payer: Elderplan Medicare Advantage	$12.60
Rate for Payer: EmblemHealth Commercial	$12.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,414.00
Rate for Payer: Fidelis Essential Plan Aliesa	$14.14
Rate for Payer: Fidelis Essential Plan QHP	$14.14
Rate for Payer: Fidelis Medicare Advantage	$12.60
Rate for Payer: Fidelis Qualified Health Plan	$14.85
Rate for Payer: Group Health Inc Commercial	$12.60
Rate for Payer: Group Health Inc Medicare	$12.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.14
Rate for Payer: Hamaspik Choice Inc Medicare	$12.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$14.14
Rate for Payer: Healthfirst Essential Plan	$31.82
Rate for Payer: Healthfirst Medicare Advantage	$12.60
Rate for Payer: Healthfirst QHP	$14.14
Rate for Payer: Humana Medicare	$12.85
Rate for Payer: Senior Whole Health Medicare Advantage	$12.60
Rate for Payer: SOMOS CHP/HARP/Medicaid	$14.14
Rate for Payer: SOMOS Essential	$31.82
Rate for Payer: United Healthcare Commercial	$13.46
Rate for Payer: United Healthcare Essential Plan 1&2	$31.82
Rate for Payer: United Healthcare Essential Plan 3&4	$15.55
Rate for Payer: United Healthcare Medicaid	$14.14
Rate for Payer: United Healthcare Medicare Advantage	$12.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.08
Rate for Payer: Wellcare Medicare	$11.34

DRUG SCREEN METH

Facility

$155.35

Service Code	HCPCS 80358
Hospital Charge Code	40602386
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$124.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$85.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$116.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$124.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$105.64
Rate for Payer: Group Health Inc Commercial	$77.68
Rate for Payer: Group Health Inc Medicare	$54.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$77.68
Rate for Payer: Hamaspik Choice Inc Medicare	$77.68
Rate for Payer: United Healthcare Commercial	$20.00

DRVVT SCRN W/RFL PHOS NEUT

Facility

$23.95

Service Code	HCPCS 85613
Hospital Charge Code	40628343
Hospital Revenue Code	305
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$17.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.58
Rate for Payer: Aetna Government	$9.58
Rate for Payer: Affinity Essential Plan 1&2	$6.71
Rate for Payer: Affinity Essential Plan 3&4	$6.71
Rate for Payer: Affinity Medicaid/CHP/HARP	$6.71
Rate for Payer: Brighton Health Commercial	$17.96
Rate for Payer: Cash Price	$9.58
Rate for Payer: Cash Price	$9.58
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$9.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.88
Rate for Payer: Elderplan Medicare Advantage	$9.58
Rate for Payer: EmblemHealth Commercial	$9.58
Rate for Payer: Fidelis Essential Plan Aliesa	$8.14
Rate for Payer: Fidelis Essential Plan QHP	$8.53
Rate for Payer: Fidelis Medicare Advantage	$9.58
Rate for Payer: Fidelis Qualified Health Plan	$8.53
Rate for Payer: Group Health Inc Commercial	$9.58
Rate for Payer: Group Health Inc Medicare	$9.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.98
Rate for Payer: Hamaspik Choice Inc Medicare	$9.58
Rate for Payer: Healthfirst Medicare Advantage	$9.58
Rate for Payer: Healthfirst QHP	$9.58
Rate for Payer: Humana Medicare	$9.77
Rate for Payer: Senior Whole Health Medicare Advantage	$9.58
Rate for Payer: United Healthcare Commercial	$12.12
Rate for Payer: United Healthcare Medicare Advantage	$9.58
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.58
Rate for Payer: Wellcare CHP/FHP/Medicaid	$7.66
Rate for Payer: Wellcare Medicare	$8.62

DRVVT SCRN W/RFL PHOS NEUT

Facility

$23.95

Service Code	HCPCS 85613
Hospital Charge Code	40628343
Hospital Revenue Code	305
Rate for Payer: Cash Price	$9.58

D-STAT FLOWABLE HEMOSTAT #4000

Facility

$282.00

Hospital Charge Code	66576691
Hospital Revenue Code	272
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$225.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$155.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$141.00
Rate for Payer: Aetna Government	$141.00
Rate for Payer: Brighton Health Commercial	$211.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$225.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$191.76
Rate for Payer: Group Health Inc Commercial	$141.00
Rate for Payer: Group Health Inc Medicare	$98.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00

DST CEMNT TAP ASSY

Facility

$2,548.00

Hospital Charge Code	64907311
Hospital Revenue Code	279
Min. Negotiated Rate	$891.80
Max. Negotiated Rate	$2,038.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,401.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,274.00
Rate for Payer: Aetna Government	$1,274.00
Rate for Payer: Brighton Health Commercial	$1,911.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,038.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,732.64
Rate for Payer: Group Health Inc Commercial	$1,274.00
Rate for Payer: Group Health Inc Medicare	$891.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,274.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,274.00

Know your out-of-pocket cost for care.

All Charges