St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PHENYTOIN 100 MG CAP ER

Facility

$2.00

Hospital Charge Code	41644802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

PHENYTOIN 100 MG CAP ER

Facility

$2.00

Hospital Charge Code	41654802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

PHENYTOIN 125 MG/5ML PO SUSP [6255]

Facility

$2.16

Service Code	NDC 66689003601
Hospital Charge Code	66689003601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.08
Rate for Payer: Aetna Government	$1.08
Rate for Payer: Brighton Health Commercial	$1.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.47
Rate for Payer: Group Health Inc Commercial	$1.08
Rate for Payer: Group Health Inc Medicare	$0.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.08
Rate for Payer: Hamaspik Choice Inc Medicare	$1.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.40

PHENYTOIN 125 MG/5ML PO SUSP [6255]

Facility

$2.16

Service Code	NDC 66689003650
Hospital Charge Code	66689003650
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.08
Rate for Payer: Aetna Government	$1.08
Rate for Payer: Brighton Health Commercial	$1.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.47
Rate for Payer: Group Health Inc Commercial	$1.08
Rate for Payer: Group Health Inc Medicare	$0.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.08
Rate for Payer: Hamaspik Choice Inc Medicare	$1.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.40

PHENYTOIN 250MG/5ML INJ - 50MG

Facility

$0.41

Service Code	HCPCS J1165
Hospital Charge Code	41658405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.68
Rate for Payer: SOMOS Essential	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.27

PHENYTOIN 250MG/5ML INJ - 50MG

Facility

$0.41

Service Code	HCPCS J1165
Hospital Charge Code	41648405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21

PHENYTOIN 250MG/5ML INJ - 50MG

Facility

$0.41

Service Code	HCPCS J1165
Hospital Charge Code	41648405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.68
Rate for Payer: SOMOS Essential	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.27

PHENYTOIN 250MG/5ML INJ - 50MG

Facility

$0.41

Service Code	HCPCS J1165
Hospital Charge Code	41658405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21

PHENYTOIN 25MG/ML,237ML BULK LIQ

Facility

$1.00

Hospital Charge Code	41657159
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

PHENYTOIN 25MG/ML.237 ML BULK LIQ

Facility

$1.00

Hospital Charge Code	41647159
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

PHENYTOIN 30 MG CAP ER

Facility

$0.89

Hospital Charge Code	41653104
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.61
Rate for Payer: Group Health Inc Commercial	$0.45
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.45
Rate for Payer: Hamaspik Choice Inc Medicare	$0.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.58

PHENYTOIN 30 MG CAP ER

Facility

$0.89

Hospital Charge Code	41643104
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.61
Rate for Payer: Group Health Inc Commercial	$0.45
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.45
Rate for Payer: Hamaspik Choice Inc Medicare	$0.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.58

PHENYTOIN 50 MG CHEW TAB

Facility

$2.00

Hospital Charge Code	41650309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

PHENYTOIN 50 MG CHEW TAB

Facility

$2.00

Hospital Charge Code	41640309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

PHENYTOIN 50 MG PO CHEW [11018]

Facility

$2.68

Service Code	NDC 00071000740
Hospital Charge Code	00071000740
Hospital Revenue Code	250
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$2.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.34
Rate for Payer: Aetna Government	$1.34
Rate for Payer: Brighton Health Commercial	$2.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.82
Rate for Payer: Group Health Inc Commercial	$1.34
Rate for Payer: Group Health Inc Medicare	$0.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.34
Rate for Payer: Hamaspik Choice Inc Medicare	$1.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.74

PHENYTOIN 50 MG PO CHEW [11018]

Facility

$1.80

Service Code	NDC 60687015695
Hospital Charge Code	60687015695
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.90
Rate for Payer: Aetna Government	$0.90
Rate for Payer: Brighton Health Commercial	$1.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.22
Rate for Payer: Group Health Inc Commercial	$0.90
Rate for Payer: Group Health Inc Medicare	$0.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.90
Rate for Payer: Hamaspik Choice Inc Medicare	$0.90
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.17

PHENYTOIN 50 MG PO CHEW [11018]

Facility

$1.80

Service Code	NDC 60687015625
Hospital Charge Code	60687015625
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.90
Rate for Payer: Aetna Government	$0.90
Rate for Payer: Brighton Health Commercial	$1.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.22
Rate for Payer: Group Health Inc Commercial	$0.90
Rate for Payer: Group Health Inc Medicare	$0.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.90
Rate for Payer: Hamaspik Choice Inc Medicare	$0.90
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.17

PHENYTOIN FREE SERUM

Facility

$34.40

Service Code	HCPCS 80186
Hospital Charge Code	40609724
Hospital Revenue Code	301
Rate for Payer: Cash Price	$13.76

PHENYTOIN FREE SERUM

Facility

$34.40

Service Code	HCPCS 80186
Hospital Charge Code	40609724
Hospital Revenue Code	301
Min. Negotiated Rate	$9.63
Max. Negotiated Rate	$25.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.76
Rate for Payer: Aetna Government	$13.76
Rate for Payer: Affinity Essential Plan 1&2	$9.63
Rate for Payer: Affinity Essential Plan 3&4	$9.63
Rate for Payer: Affinity Medicaid/CHP/HARP	$9.63
Rate for Payer: Brighton Health Commercial	$25.80
Rate for Payer: Cash Price	$13.76
Rate for Payer: Cash Price	$13.76
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$13.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.51
Rate for Payer: Elderplan Medicare Advantage	$13.76
Rate for Payer: EmblemHealth Commercial	$13.76
Rate for Payer: Fidelis Essential Plan Aliesa	$11.70
Rate for Payer: Fidelis Essential Plan QHP	$12.25
Rate for Payer: Fidelis Medicare Advantage	$13.76
Rate for Payer: Fidelis Qualified Health Plan	$12.25
Rate for Payer: Group Health Inc Commercial	$13.76
Rate for Payer: Group Health Inc Medicare	$13.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.20
Rate for Payer: Hamaspik Choice Inc Medicare	$13.76
Rate for Payer: Healthfirst Medicare Advantage	$13.76
Rate for Payer: Healthfirst QHP	$13.76
Rate for Payer: Humana Medicare	$14.04
Rate for Payer: Senior Whole Health Medicare Advantage	$13.76
Rate for Payer: United Healthcare Commercial	$17.43
Rate for Payer: United Healthcare Medicare Advantage	$13.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.76
Rate for Payer: Wellcare CHP/FHP/Medicaid	$11.01
Rate for Payer: Wellcare Medicare	$12.38

PHENYTOIN SODIUM 50 MG/ML IJ SOLN [6256]

Facility

$0.48

Service Code	HCPCS J1165
Hospital Charge Code	00641255545
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.33
Rate for Payer: Group Health Inc Commercial	$0.24
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.24
Rate for Payer: Hamaspik Choice Inc Medicare	$0.24
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.64
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.68
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.68
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.31

PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS [6257]

Facility

$0.64

Service Code	NDC 51672411103
Hospital Charge Code	51672411103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: Group Health Inc Commercial	$0.32
Rate for Payer: Group Health Inc Medicare	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.32
Rate for Payer: Hamaspik Choice Inc Medicare	$0.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS [6257]

Facility

$0.64

Service Code	NDC 68084037601
Hospital Charge Code	68084037601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.32
Rate for Payer: Aetna Government	$0.32
Rate for Payer: Brighton Health Commercial	$0.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: Group Health Inc Commercial	$0.32
Rate for Payer: Group Health Inc Medicare	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.32
Rate for Payer: Hamaspik Choice Inc Medicare	$0.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS [6257]

Facility

$0.73

Service Code	NDC 00904618761
Hospital Charge Code	00904618761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.37
Rate for Payer: Aetna Government	$0.37
Rate for Payer: Brighton Health Commercial	$0.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.50
Rate for Payer: Group Health Inc Commercial	$0.37
Rate for Payer: Group Health Inc Medicare	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.37
Rate for Payer: Hamaspik Choice Inc Medicare	$0.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.48

PHENYTOIN SUSPENSION 125MG/5ML

Facility

$2.00

Hospital Charge Code	41650194
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

PHENYTOIN SUSPENSION 125MG/5ML

Facility

$2.00

Hospital Charge Code	41640194
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

Know your out-of-pocket cost for care.

All Charges