St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PFIZER PEDS ADMIN 2ND DOSE

Facility

$102.55

Hospital Charge Code	30302523
Hospital Revenue Code	771
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$56.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$51.28
Rate for Payer: Aetna Government	$51.28
Rate for Payer: Brighton Health Commercial	$76.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$82.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$69.73
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	$51.28
Rate for Payer: Hamaspik Choice Inc Medicare	$51.28
Rate for Payer: United Healthcare Commercial	$44.00

PHACCO -ECCE -CATARACT W IOL

Facility

$6,123.70

Service Code	HCPCS 66982
Hospital Charge Code	40079511
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,694.88

PHACCO -ECCE -CATARACT W IOL

Facility

$6,123.70

Service Code	HCPCS 66982
Hospital Charge Code	40079511
Hospital Revenue Code	360
Min. Negotiated Rate	$1,468.00
Max. Negotiated Rate	$4,592.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,065.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,694.88
Rate for Payer: Aetna Government	$2,694.88
Rate for Payer: Affinity Essential Plan 1&2	$1,886.42
Rate for Payer: Affinity Essential Plan 3&4	$1,886.42
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,886.42
Rate for Payer: Brighton Health Commercial	$4,592.78
Rate for Payer: Cash Price	$2,694.88
Rate for Payer: Cash Price	$2,694.88
Rate for Payer: Cash Price	$2,694.88
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$2,694.88
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	$2,694.88
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$2,290.65
Rate for Payer: Fidelis Essential Plan QHP	$2,398.44
Rate for Payer: Fidelis Medicare Advantage	$2,694.88
Rate for Payer: Fidelis Qualified Health Plan	$2,398.44
Rate for Payer: Group Health Inc Commercial	$2,694.88
Rate for Payer: Group Health Inc Medicare	$2,694.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,061.85
Rate for Payer: Hamaspik Choice Inc Medicare	$2,694.88
Rate for Payer: Healthfirst Medicare Advantage	$2,290.65
Rate for Payer: Healthfirst QHP	$2,694.88
Rate for Payer: Humana Medicare	$2,748.78
Rate for Payer: Senior Whole Health Medicare Advantage	$2,694.88
Rate for Payer: United Healthcare Commercial	$1,468.00
Rate for Payer: United Healthcare Medicare Advantage	$2,694.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,694.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$2,155.90
Rate for Payer: Wellcare Medicare	$2,560.14

PHACO PACK 45D KELMAN0.9MM W/TUB

Facility

$312.50

Hospital Charge Code	64904003
Hospital Revenue Code	270
Min. Negotiated Rate	$109.38
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$171.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$156.25
Rate for Payer: Aetna Government	$156.25
Rate for Payer: Brighton Health Commercial	$234.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$212.50
Rate for Payer: Group Health Inc Commercial	$156.25
Rate for Payer: Group Health Inc Medicare	$109.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$156.25
Rate for Payer: Hamaspik Choice Inc Medicare	$156.25

PHALANGEAL SIZE 2

Facility

$3,550.00

Hospital Charge Code	64904475
Hospital Revenue Code	270
Min. Negotiated Rate	$1,242.50
Max. Negotiated Rate	$2,840.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,952.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,775.00
Rate for Payer: Aetna Government	$1,775.00
Rate for Payer: Brighton Health Commercial	$2,662.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,840.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,414.00
Rate for Payer: Group Health Inc Commercial	$1,775.00
Rate for Payer: Group Health Inc Medicare	$1,242.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,775.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,775.00

PHARMACIST COUNSLING 15MIN NEW PT

Facility

$0.01

Service Code	HCPCS 99605
Hospital Charge Code	30300360
Hospital Revenue Code	969
Max. Negotiated Rate	$42.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$42.84
Rate for Payer: Aetna Government	$42.84
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

PHARMACOLOGIC MGMT W/PSYCH TX

Facility

$453.95

Service Code	HCPCS 90863
Hospital Charge Code	30305732
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

PH CARTRIDGE

Facility

$70.88

Hospital Charge Code	40250700
Hospital Revenue Code	720
Min. Negotiated Rate	$24.81
Max. Negotiated Rate	$8,223.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.44
Rate for Payer: Aetna Government	$35.44
Rate for Payer: Brighton Health Commercial	$53.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$48.20
Rate for Payer: Group Health Inc Commercial	$35.44
Rate for Payer: Group Health Inc Medicare	$24.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.44
Rate for Payer: Hamaspik Choice Inc Medicare	$35.44
Rate for Payer: United Healthcare Commercial	$8,223.00

PHENAZOPYRIDINE 100 MG TAB

Facility

$1.00

Hospital Charge Code	41654333
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

PHENAZOPYRIDINE 100 MG TAB

Facility

$1.00

Hospital Charge Code	41644333
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

PHENAZOPYRIDINE 200 MG TAB

Facility

$0.27

Hospital Charge Code	41644555
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
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	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
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

PHENAZOPYRIDINE 200 MG TAB

Facility

$0.27

Hospital Charge Code	41654555
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
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	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
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

PHENAZOPYRIDINE HCL 100 MG PO TABS [6193]

Facility

$2.70

Service Code	NDC 65162068110
Hospital Charge Code	65162068110
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

PHENAZOPYRIDINE HCL 100 MG PO TABS [6193]

Facility

$2.70

Service Code	NDC 51293080101
Hospital Charge Code	51293080101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

PHENAZOPYRIDINE HCL 100 MG PO TABS [6193]

Facility

$2.70

Service Code	NDC 42192080101
Hospital Charge Code	42192080101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

PHENAZOPYRIDINE HCL 100 MG PO TABS [6193]

Facility

$2.70

Service Code	NDC 51293061101
Hospital Charge Code	51293061101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.35
Rate for Payer: Aetna Government	$1.35
Rate for Payer: Brighton Health Commercial	$2.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.84
Rate for Payer: Group Health Inc Commercial	$1.35
Rate for Payer: Group Health Inc Medicare	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.35
Rate for Payer: Hamaspik Choice Inc Medicare	$1.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.76

PHENAZOPYRIDINE HCL 200 MG PO TABS [6194]

Facility

$4.00

Service Code	NDC 65162068210
Hospital Charge Code	65162068210
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

PHENCYCLIDINE, (PCP), QUAL, UR

Facility

$15.50

Service Code	HCPCS 83992
Hospital Charge Code	40609011
Hospital Revenue Code	300
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$23.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$11.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.77
Rate for Payer: Group Health Inc Commercial	$7.75
Rate for Payer: Group Health Inc Medicare	$5.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.75
Rate for Payer: Hamaspik Choice Inc Medicare	$7.75
Rate for Payer: United Healthcare Commercial	$18.61

PHENELZINE 15 MG TAB

Facility

$1.00

Hospital Charge Code	41653231
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

PHENELZINE 15 MG TAB

Facility

$1.00

Hospital Charge Code	41643231
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

PHENELZINE SULFATE 15 MG PO TABS [10933]

Facility

$3.06

Service Code	NDC 00071035060
Hospital Charge Code	00071035060
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.53
Rate for Payer: Aetna Government	$1.53
Rate for Payer: Brighton Health Commercial	$2.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.08
Rate for Payer: Group Health Inc Commercial	$1.53
Rate for Payer: Group Health Inc Medicare	$1.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.53
Rate for Payer: Hamaspik Choice Inc Medicare	$1.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.99

PHENOBARB 10MG/ML INJ NEO 120MG

Facility

$4.00

Service Code	HCPCS J2560
Hospital Charge Code	41657085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$45.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$40.22
Rate for Payer: Aetna Government	$40.22
Rate for Payer: Brighton Health Commercial	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.30
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$34.77
Rate for Payer: SOMOS Essential	$34.77
Rate for Payer: United Healthcare Commercial	$45.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

PHENOBARB 10MG/ML INJ NEO 120MG

Facility

$4.00

Service Code	HCPCS J2560
Hospital Charge Code	41647085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$45.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$40.22
Rate for Payer: Aetna Government	$40.22
Rate for Payer: Brighton Health Commercial	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.30
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$34.77
Rate for Payer: SOMOS Essential	$34.77
Rate for Payer: United Healthcare Commercial	$45.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

PHENOBARB 10MG/ML INJ NEO 120MG

Facility

$4.00

Service Code	HCPCS J2560
Hospital Charge Code	41647085
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00

PHENOBARB 10MG/ML INJ NEO 120MG

Facility

$4.00

Service Code	HCPCS J2560
Hospital Charge Code	41657085
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00

Know your out-of-pocket cost for care.

All Charges