St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

GRP MNT 2 OR MORE - 30 MIN

Facility

$45.85

Service Code	HCPCS G0271
Hospital Charge Code	30305707
Hospital Revenue Code	942
Min. Negotiated Rate	$9.09
Max. Negotiated Rate	$3,192.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.09
Rate for Payer: Aetna Government	$9.09
Rate for Payer: Affinity Essential Plan 1&2	$71.82
Rate for Payer: Affinity Essential Plan 3&4	$71.82
Rate for Payer: Affinity Medicaid/CHP/HARP	$31.92
Rate for Payer: Amida Care Medicaid	$31.92
Rate for Payer: Brighton Health Commercial	$34.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$31.18
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,192.00
Rate for Payer: Fidelis Essential Plan Aliesa	$31.92
Rate for Payer: Fidelis Essential Plan QHP	$31.92
Rate for Payer: Fidelis Qualified Health Plan	$33.52
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.92
Rate for Payer: Hamaspik Choice Inc Medicare	$22.92
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$31.92
Rate for Payer: Healthfirst Essential Plan	$71.82
Rate for Payer: Healthfirst QHP	$31.92
Rate for Payer: SOMOS CHP/HARP/Medicaid	$31.92
Rate for Payer: SOMOS Essential	$71.82
Rate for Payer: United Healthcare Commercial	$22.92
Rate for Payer: United Healthcare Essential Plan 1&2	$71.82
Rate for Payer: United Healthcare Essential Plan 3&4	$35.11
Rate for Payer: United Healthcare Medicaid	$31.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$31.92

GT TOE M-P JNT MD-LG 21.5MM NONPO

Facility

$2,500.00

Hospital Charge Code	40209928
Hospital Revenue Code	272
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$2,000.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,375.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,250.00
Rate for Payer: Aetna Government	$1,250.00
Rate for Payer: Brighton Health Commercial	$1,875.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,000.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,700.00
Rate for Payer: Group Health Inc Commercial	$1,250.00
Rate for Payer: Group Health Inc Medicare	$875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,250.00

GUAIFENESIN 100 MG/5 ML ELIXIR SUGAR FRE

Facility

$1.00

Hospital Charge Code	41652280
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

GUAIFENESIN 100 MG/5 ML ELIXIR SUGAR FRE

Facility

$1.00

Hospital Charge Code	41642280
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

GUAIFENESIN 100 MG/5ML PO LIQD [13748]

Facility

$0.19

Service Code	NDC 00121148810
Hospital Charge Code	00121148810
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

GUAIFENESIN 100 MG/5ML PO LIQD [13748]

Facility

$0.01

Service Code	NDC 00904676320
Hospital Charge Code	00904676320
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
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

GUAIFENESIN 100 MG/5ML PO LIQD [13748]

Facility

$0.19

Service Code	NDC 00121148800
Hospital Charge Code	00121148800
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

GUAIFENESIN 100 MG/5ML PO LIQD [13748]

Facility

$0.02

Service Code	NDC 00536118297
Hospital Charge Code	00536118297
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
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	$0.01
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

GUAIFENESIN 100 MG/5ML PO LIQD [13748]

Facility

$0.22

Service Code	NDC 81033010210
Hospital Charge Code	81033010210
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

GUAIFENESIN 200 MG/10 ML ELIXIR SUGAR FR

Facility

$1.00

Hospital Charge Code	41653995
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

GUAIFENESIN 200 MG/10 ML ELIXIR SUGAR FR

Facility

$1.00

Hospital Charge Code	41643995
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

GUAIFENESIN-DM 100-10 MG/5ML PO SYRP [15816]

Facility

$0.28

Service Code	NDC 00121127600
Hospital Charge Code	00121127600
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.14
Rate for Payer: Aetna Government	$0.14
Rate for Payer: Brighton Health Commercial	$0.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.19
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

GUAIFENESIN DM 5ML LIQ

Facility

$1.00

Hospital Charge Code	41648002
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

GUAIFENESIN DM 5ML LIQ

Facility

$1.00

Hospital Charge Code	41658002
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

GUAIFENESIN ER 600 MG PO TB12 [37651]

Facility

$0.61

Service Code	NDC 63824000834
Hospital Charge Code	63824000834
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.30
Rate for Payer: Aetna Government	$0.30
Rate for Payer: Brighton Health Commercial	$0.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.40

GUANFACINE 1MG TAB

Facility

$0.12

Hospital Charge Code	41648047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
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	$0.08

GUANFACINE 1MG TAB

Facility

$0.12

Hospital Charge Code	41658047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
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	$0.08

GUARD PIN GREEN

Facility

$2.18

Hospital Charge Code	64902892
Hospital Revenue Code	270
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.09
Rate for Payer: Aetna Government	$1.09
Rate for Payer: Brighton Health Commercial	$1.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.48
Rate for Payer: Group Health Inc Commercial	$1.09
Rate for Payer: Group Health Inc Medicare	$0.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.09
Rate for Payer: Hamaspik Choice Inc Medicare	$1.09

GUARD PIN WHITE

Facility

$2.18

Hospital Charge Code	64902876
Hospital Revenue Code	270
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.09
Rate for Payer: Aetna Government	$1.09
Rate for Payer: Brighton Health Commercial	$1.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.48
Rate for Payer: Group Health Inc Commercial	$1.09
Rate for Payer: Group Health Inc Medicare	$0.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.09
Rate for Payer: Hamaspik Choice Inc Medicare	$1.09

GUARD TEETH ADULT LATEX-FREE

Facility

$506.00

Hospital Charge Code	40202194
Hospital Revenue Code	270
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$404.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$278.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$253.00
Rate for Payer: Aetna Government	$253.00
Rate for Payer: Brighton Health Commercial	$379.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$404.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$344.08
Rate for Payer: Group Health Inc Commercial	$253.00
Rate for Payer: Group Health Inc Medicare	$177.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$253.00
Rate for Payer: Hamaspik Choice Inc Medicare	$253.00

GUAR GUM (BENEFIBER) SACHET POWDER

Facility

$0.97

Hospital Charge Code	41643633
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.49
Rate for Payer: Aetna Government	$0.49
Rate for Payer: Brighton Health Commercial	$0.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.66
Rate for Payer: Group Health Inc Commercial	$0.49
Rate for Payer: Group Health Inc Medicare	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49
Rate for Payer: Hamaspik Choice Inc Medicare	$0.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.63

GUAR GUM (BENEFIBER) SACHET POWDER

Facility

$0.97

Hospital Charge Code	41653633
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.49
Rate for Payer: Aetna Government	$0.49
Rate for Payer: Brighton Health Commercial	$0.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.66
Rate for Payer: Group Health Inc Commercial	$0.49
Rate for Payer: Group Health Inc Medicare	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49
Rate for Payer: Hamaspik Choice Inc Medicare	$0.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.63

GUIDANCE FOR RADIAJ TX DLVR

Facility

$351.97

Service Code	HCPCS 77387
Hospital Charge Code	66541308
Hospital Revenue Code	333
Min. Negotiated Rate	$81.56
Max. Negotiated Rate	$294.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$193.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$81.56
Rate for Payer: Aetna Government	$81.56
Rate for Payer: Brighton Health Commercial	$263.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$281.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$239.34
Rate for Payer: Fidelis CHP/HARP/Medicaid	$279.92
Rate for Payer: Fidelis Essential Plan Aliesa	$279.92
Rate for Payer: Fidelis Essential Plan QHP	$294.00
Rate for Payer: Fidelis Qualified Health Plan	$294.00
Rate for Payer: Group Health Inc Commercial	$175.98
Rate for Payer: Group Health Inc Medicare	$123.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.98
Rate for Payer: Hamaspik Choice Inc Medicare	$175.98

GUIDE AIM 1.5MM

Facility

$72.00

Service Code	HCPCS C1769
Hospital Charge Code	64906909
Hospital Revenue Code	278
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$36.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.00
Rate for Payer: Hamaspik Choice Inc Medicare	$36.00

GUIDE AIM 1.5MM

Facility

$72.00

Service Code	HCPCS C1769
Hospital Charge Code	64906909
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$75.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$39.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Brighton Health Commercial	$43.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$41.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Fidelis Medicare Advantage	$75.60
Rate for Payer: Group Health Inc Commercial	$36.00
Rate for Payer: Group Health Inc Medicare	$25.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.00
Rate for Payer: Hamaspik Choice Inc Medicare	$36.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$46.80

Know your out-of-pocket cost for care.

All Charges