St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PHYTONADIONE 10 MG/ML INJ

Facility

$27.00

Service Code	HCPCS J3430
Hospital Charge Code	41644294
Hospital Revenue Code	636
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.50
Rate for Payer: Hamaspik Choice Inc Medicare	$13.50

PHYTONADIONE 10 MG/ML INJ

Facility

$27.00

Service Code	HCPCS J3430
Hospital Charge Code	41654294
Hospital Revenue Code	636
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.50
Rate for Payer: Hamaspik Choice Inc Medicare	$13.50

PHYTONADIONE 10 MG/ML INJ

Facility

$27.00

Service Code	HCPCS J3430
Hospital Charge Code	41654294
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$17.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$16.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.52
Rate for Payer: Group Health Inc Commercial	$13.50
Rate for Payer: Group Health Inc Medicare	$9.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.50
Rate for Payer: Hamaspik Choice Inc Medicare	$13.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.97
Rate for Payer: SOMOS Essential	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17.55

PHYTONADIONE 1 MG/0.5ML IJ SOLN [117592]

Facility

$14.40

Service Code	HCPCS J3430
Hospital Charge Code	69097070930
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$11.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$10.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.79
Rate for Payer: Group Health Inc Commercial	$7.20
Rate for Payer: Group Health Inc Medicare	$5.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.20
Rate for Payer: Hamaspik Choice Inc Medicare	$7.20
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.36

PHYTONADIONE 1 MG/0.5ML IJ SOLN [117592]

Facility

$14.40

Service Code	HCPCS J3430
Hospital Charge Code	69097070996
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$11.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$10.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.79
Rate for Payer: Group Health Inc Commercial	$7.20
Rate for Payer: Group Health Inc Medicare	$5.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.20
Rate for Payer: Hamaspik Choice Inc Medicare	$7.20
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.36

PHYTONADIONE 1 MG/0.5ML IJ SOLN [117592]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	76329124001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$47.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$32.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$44.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$40.36
Rate for Payer: Group Health Inc Commercial	$29.68
Rate for Payer: Group Health Inc Medicare	$20.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.68
Rate for Payer: Hamaspik Choice Inc Medicare	$29.68
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$38.58

PHYTONADIONE 1 MG/0.5ML IJ SOLN [117592]

Facility

$11.39

Service Code	HCPCS J3430
Hospital Charge Code	00409915701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$9.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$8.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.75
Rate for Payer: Group Health Inc Commercial	$5.70
Rate for Payer: Group Health Inc Medicare	$3.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.70
Rate for Payer: Hamaspik Choice Inc Medicare	$5.70
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.80
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.40

PHYTONADIONE 1 MG/0.5 ML INJ PEDIATRIC

Facility

$8.21

Service Code	HCPCS J3430
Hospital Charge Code	41654434
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$5.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$4.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.72
Rate for Payer: Group Health Inc Commercial	$4.10
Rate for Payer: Group Health Inc Medicare	$2.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.97
Rate for Payer: SOMOS Essential	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.34

PHYTONADIONE 1 MG/0.5 ML INJ PEDIATRIC

Facility

$8.21

Service Code	HCPCS J3430
Hospital Charge Code	41644434
Hospital Revenue Code	636
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$4.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4.10

PHYTONADIONE 1 MG/0.5 ML INJ PEDIATRIC

Facility

$8.21

Service Code	HCPCS J3430
Hospital Charge Code	41654434
Hospital Revenue Code	636
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$4.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4.10

PHYTONADIONE 1 MG/0.5 ML INJ PEDIATRIC

Facility

$8.21

Service Code	HCPCS J3430
Hospital Charge Code	41644434
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$5.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.56
Rate for Payer: Aetna Government	$3.56
Rate for Payer: Brighton Health Commercial	$4.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.72
Rate for Payer: Group Health Inc Commercial	$4.10
Rate for Payer: Group Health Inc Medicare	$2.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.97
Rate for Payer: SOMOS Essential	$2.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.34

PHYTONADIONE 5 MG PO TABS [11024]

Facility

$102.71

Service Code	NDC 00904688210
Hospital Charge Code	00904688210
Hospital Revenue Code	250
Min. Negotiated Rate	$35.95
Max. Negotiated Rate	$82.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$56.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$51.35
Rate for Payer: Aetna Government	$51.35
Rate for Payer: Brighton Health Commercial	$77.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$82.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$69.84
Rate for Payer: Group Health Inc Commercial	$51.35
Rate for Payer: Group Health Inc Medicare	$35.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.35
Rate for Payer: Hamaspik Choice Inc Medicare	$51.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$66.76

PHYTONADIONE 5 MG TAB

Facility

$13.00

Hospital Charge Code	41641112
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$10.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Brighton Health Commercial	$9.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.84
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$4.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.45

PHYTONADIONE 5 MG TAB

Facility

$13.00

Hospital Charge Code	41651112
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$10.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Brighton Health Commercial	$9.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.84
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$4.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.45

PIERCE EARLOBES

Facility

$0.01

Service Code	HCPCS 69090
Hospital Charge Code	30300129
Hospital Revenue Code	510
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,888.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.46
Rate for Payer: Aetna Government	$29.46
Rate for Payer: Brighton Health Commercial	$233.00
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: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$222.00

PILLOW ABDUCTION LG

Facility

$56.19

Hospital Charge Code	40200619
Hospital Revenue Code	270
Min. Negotiated Rate	$19.67
Max. Negotiated Rate	$44.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28.10
Rate for Payer: Aetna Government	$28.10
Rate for Payer: Brighton Health Commercial	$42.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$44.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$38.21
Rate for Payer: Group Health Inc Commercial	$28.10
Rate for Payer: Group Health Inc Medicare	$19.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.10
Rate for Payer: Hamaspik Choice Inc Medicare	$28.10

PILLOW ABDUCTION MEDIUM

Facility

$51.50

Hospital Charge Code	40200614
Hospital Revenue Code	270
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$41.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25.75
Rate for Payer: Aetna Government	$25.75
Rate for Payer: Brighton Health Commercial	$38.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$41.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.02
Rate for Payer: Group Health Inc Commercial	$25.75
Rate for Payer: Group Health Inc Medicare	$18.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$25.75
Rate for Payer: Hamaspik Choice Inc Medicare	$25.75

PILLOW APPLAUSE 18X24 BLUE

Facility

$6.63

Hospital Charge Code	64902083
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$5.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.32
Rate for Payer: Aetna Government	$3.32
Rate for Payer: Brighton Health Commercial	$4.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.51
Rate for Payer: Group Health Inc Commercial	$3.32
Rate for Payer: Group Health Inc Medicare	$2.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.32
Rate for Payer: Hamaspik Choice Inc Medicare	$3.32

PILLOW CAREGUARD SECONDARY

Facility

$9.62

Hospital Charge Code	64901607
Hospital Revenue Code	270
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$7.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.81
Rate for Payer: Aetna Government	$4.81
Rate for Payer: Brighton Health Commercial	$7.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.54
Rate for Payer: Group Health Inc Commercial	$4.81
Rate for Payer: Group Health Inc Medicare	$3.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.81
Rate for Payer: Hamaspik Choice Inc Medicare	$4.81

PILLOW CAREGUARD TAN 19X25

Facility

$9.78

Hospital Charge Code	64901563
Hospital Revenue Code	270
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$7.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.89
Rate for Payer: Aetna Government	$4.89
Rate for Payer: Brighton Health Commercial	$7.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.65
Rate for Payer: Group Health Inc Commercial	$4.89
Rate for Payer: Group Health Inc Medicare	$3.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.89
Rate for Payer: Hamaspik Choice Inc Medicare	$4.89

PILLOW GENTLETOUCH 7RT INTUB SLOT

Facility

$23.54

Hospital Charge Code	64904853
Hospital Revenue Code	270
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$18.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.77
Rate for Payer: Aetna Government	$11.77
Rate for Payer: Brighton Health Commercial	$17.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.01
Rate for Payer: Group Health Inc Commercial	$11.77
Rate for Payer: Group Health Inc Medicare	$8.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.77
Rate for Payer: Hamaspik Choice Inc Medicare	$11.77

PILOCARPINE 0.5% OPHTHALMIC SOLN

Facility

$5.00

Hospital Charge Code	41643420
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.50
Rate for Payer: Aetna Government	$2.50
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

PILOCARPINE 0.5% OPHTHALMIC SOLN

Facility

$5.00

Hospital Charge Code	41653420
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.50
Rate for Payer: Aetna Government	$2.50
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

PILOCARPINE 1% OPHTHALMIC SOLN

Facility

$74.00

Hospital Charge Code	41643553
Hospital Revenue Code	250
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$59.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.00
Rate for Payer: Aetna Government	$37.00
Rate for Payer: Brighton Health Commercial	$55.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$59.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$50.32
Rate for Payer: Group Health Inc Commercial	$37.00
Rate for Payer: Group Health Inc Medicare	$25.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$48.10

PILOCARPINE 1% OPHTHALMIC SOLN

Facility

$74.00

Hospital Charge Code	41653553
Hospital Revenue Code	250
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$59.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.00
Rate for Payer: Aetna Government	$37.00
Rate for Payer: Brighton Health Commercial	$55.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$59.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$50.32
Rate for Payer: Group Health Inc Commercial	$37.00
Rate for Payer: Group Health Inc Medicare	$25.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.00
Rate for Payer: Hamaspik Choice Inc Medicare	$37.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$48.10

Know your out-of-pocket cost for care.

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