St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PILOCARPINE 2% OPHTHALMIC SOLN

Facility

$40.00

Hospital Charge Code	41653554
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$32.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.00
Rate for Payer: Aetna Government	$20.00
Rate for Payer: Brighton Health Commercial	$30.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.20
Rate for Payer: Group Health Inc Commercial	$20.00
Rate for Payer: Group Health Inc Medicare	$14.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.00
Rate for Payer: Hamaspik Choice Inc Medicare	$20.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.00

PILOCARPINE 2% OPHTHALMIC SOLN

Facility

$40.00

Hospital Charge Code	41643554
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$32.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.00
Rate for Payer: Aetna Government	$20.00
Rate for Payer: Brighton Health Commercial	$30.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.20
Rate for Payer: Group Health Inc Commercial	$20.00
Rate for Payer: Group Health Inc Medicare	$14.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.00
Rate for Payer: Hamaspik Choice Inc Medicare	$20.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.00

PILOCARPINE 3% OPHTHALMIC SOLN

Facility

$4.00

Hospital Charge Code	41643555
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

PILOCARPINE 3% OPHTHALMIC SOLN

Facility

$4.00

Hospital Charge Code	41653555
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

PILOCARPINE 4% OPHTHALMIC SOLN

Facility

$34.00

Hospital Charge Code	41651079
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$27.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.00
Rate for Payer: Aetna Government	$17.00
Rate for Payer: Brighton Health Commercial	$25.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.12
Rate for Payer: Group Health Inc Commercial	$17.00
Rate for Payer: Group Health Inc Medicare	$11.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.10

PILOCARPINE 4% OPHTHALMIC SOLN

Facility

$34.00

Hospital Charge Code	41641079
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$27.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.00
Rate for Payer: Aetna Government	$17.00
Rate for Payer: Brighton Health Commercial	$25.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.12
Rate for Payer: Group Health Inc Commercial	$17.00
Rate for Payer: Group Health Inc Medicare	$11.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.10

PILOCARPINE 6% OPHTHALMIC SOLN

Facility

$8.00

Hospital Charge Code	41643557
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.00
Rate for Payer: Aetna Government	$4.00
Rate for Payer: Brighton Health Commercial	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.44
Rate for Payer: Group Health Inc Commercial	$4.00
Rate for Payer: Group Health Inc Medicare	$2.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.20

PILOCARPINE 6% OPHTHALMIC SOLN

Facility

$8.00

Hospital Charge Code	41653557
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.00
Rate for Payer: Aetna Government	$4.00
Rate for Payer: Brighton Health Commercial	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.44
Rate for Payer: Group Health Inc Commercial	$4.00
Rate for Payer: Group Health Inc Medicare	$2.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.20

PILOCARPINE HCL 1 % OP SOLN [6279]

Facility

$6.32

Service Code	NDC 17478022312
Hospital Charge Code	17478022312
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$5.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.16
Rate for Payer: Aetna Government	$3.16
Rate for Payer: Brighton Health Commercial	$4.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.30
Rate for Payer: Group Health Inc Commercial	$3.16
Rate for Payer: Group Health Inc Medicare	$2.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.16
Rate for Payer: Hamaspik Choice Inc Medicare	$3.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.11

PILOCARPINE HCL 1 % OP SOLN [6279]

Facility

$6.57

Service Code	NDC 69238174508
Hospital Charge Code	69238174508
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.29
Rate for Payer: Aetna Government	$3.29
Rate for Payer: Brighton Health Commercial	$4.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.47
Rate for Payer: Group Health Inc Commercial	$3.29
Rate for Payer: Group Health Inc Medicare	$2.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.29
Rate for Payer: Hamaspik Choice Inc Medicare	$3.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.27

PILOCARPINE HCL 1 % OP SOLN [6279]

Facility

$6.57

Service Code	NDC 61314020315
Hospital Charge Code	61314020315
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.29
Rate for Payer: Aetna Government	$3.29
Rate for Payer: Brighton Health Commercial	$4.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.47
Rate for Payer: Group Health Inc Commercial	$3.29
Rate for Payer: Group Health Inc Medicare	$2.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.29
Rate for Payer: Hamaspik Choice Inc Medicare	$3.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.27

PILOCARPINE HCL 2 % OP SOLN [6280]

Facility

$6.72

Service Code	NDC 61314020415
Hospital Charge Code	61314020415
Hospital Revenue Code	250
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$5.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.36
Rate for Payer: Aetna Government	$3.36
Rate for Payer: Brighton Health Commercial	$5.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.57
Rate for Payer: Group Health Inc Commercial	$3.36
Rate for Payer: Group Health Inc Medicare	$2.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.36
Rate for Payer: Hamaspik Choice Inc Medicare	$3.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.37

PILOCARPINE HCL 4 % OP SOLN [6282]

Facility

$7.05

Service Code	NDC 61314020615
Hospital Charge Code	61314020615
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$5.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.52
Rate for Payer: Aetna Government	$3.52
Rate for Payer: Brighton Health Commercial	$5.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.79
Rate for Payer: Group Health Inc Commercial	$3.52
Rate for Payer: Group Health Inc Medicare	$2.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.52
Rate for Payer: Hamaspik Choice Inc Medicare	$3.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.58

PILOCARPINE HCL 4 % OP SOLN [6282]

Facility

$6.63

Service Code	NDC 70069020101
Hospital Charge Code	70069020101
Hospital Revenue Code	250
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	$3.31
Rate for Payer: Aetna Government	$3.31
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	$3.31
Rate for Payer: Group Health Inc Medicare	$2.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.31
Rate for Payer: Hamaspik Choice Inc Medicare	$3.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.31

PILOT-SCREW DOUBLETHREAD 4MMX52MM

Facility

$548.00

Service Code	HCPCS C1713
Hospital Charge Code	40202047
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$575.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$301.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$328.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$274.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$315.10
Rate for Payer: EmblemHealth Commercial	$274.00
Rate for Payer: Fidelis Medicare Advantage	$575.40
Rate for Payer: Group Health Inc Commercial	$274.00
Rate for Payer: Group Health Inc Medicare	$191.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$274.00
Rate for Payer: Hamaspik Choice Inc Medicare	$274.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$356.20

PILOT-SCREW DOUBLETHREAD 4MMX52MM

Facility

$548.00

Service Code	HCPCS C1713
Hospital Charge Code	40202047
Hospital Revenue Code	278
Min. Negotiated Rate	$274.00
Max. Negotiated Rate	$274.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$274.00
Rate for Payer: Hamaspik Choice Inc Medicare	$274.00

PIMOZIDE 2 MG PO TABS [11031]

Facility

$2.44

Service Code	NDC 49884034801
Hospital Charge Code	49884034801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.22
Rate for Payer: Aetna Government	$1.22
Rate for Payer: Brighton Health Commercial	$1.83
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.66
Rate for Payer: Group Health Inc Commercial	$1.22
Rate for Payer: Group Health Inc Medicare	$0.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.22
Rate for Payer: Hamaspik Choice Inc Medicare	$1.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.59

PIMOZIDE 2 MG TAB

Facility

$2.00

Hospital Charge Code	41641215
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

PIMOZIDE 2 MG TAB

Facility

$2.00

Hospital Charge Code	41651215
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

PIN 6MM X 250 HA

Facility

$414.38

Hospital Charge Code	64905893
Hospital Revenue Code	270
Min. Negotiated Rate	$145.03
Max. Negotiated Rate	$331.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$227.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$207.19
Rate for Payer: Aetna Government	$207.19
Rate for Payer: Brighton Health Commercial	$310.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$331.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$281.78
Rate for Payer: Group Health Inc Commercial	$207.19
Rate for Payer: Group Health Inc Medicare	$145.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.19
Rate for Payer: Hamaspik Choice Inc Medicare	$207.19

PINABALL TM PRELOADED PINS

Facility

$1,342.00

Hospital Charge Code	40205525
Hospital Revenue Code	270
Min. Negotiated Rate	$469.70
Max. Negotiated Rate	$1,073.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$738.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$671.00
Rate for Payer: Aetna Government	$671.00
Rate for Payer: Brighton Health Commercial	$1,006.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,073.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$912.56
Rate for Payer: Group Health Inc Commercial	$671.00
Rate for Payer: Group Health Inc Medicare	$469.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$671.00
Rate for Payer: Hamaspik Choice Inc Medicare	$671.00

PIN APEX

Facility

$210.00

Service Code	HCPCS C1713
Hospital Charge Code	40200779
Hospital Revenue Code	278
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$220.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$115.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$126.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$105.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$120.75
Rate for Payer: EmblemHealth Commercial	$105.00
Rate for Payer: Fidelis Medicare Advantage	$220.50
Rate for Payer: Group Health Inc Commercial	$105.00
Rate for Payer: Group Health Inc Medicare	$73.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.00
Rate for Payer: Hamaspik Choice Inc Medicare	$105.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$136.50

PIN APEX

Facility

$210.00

Service Code	HCPCS C1713
Hospital Charge Code	40200779
Hospital Revenue Code	278
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$105.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.00
Rate for Payer: Hamaspik Choice Inc Medicare	$105.00

PIN APEX 3MM 110/50

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	40200757
Hospital Revenue Code	278
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$134.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$69.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$75.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$63.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$72.45
Rate for Payer: EmblemHealth Commercial	$63.00
Rate for Payer: Fidelis Medicare Advantage	$132.30
Rate for Payer: Group Health Inc Commercial	$63.00
Rate for Payer: Group Health Inc Medicare	$44.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$63.00
Rate for Payer: Hamaspik Choice Inc Medicare	$63.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$81.90

PIN APEX 3MM 110/50

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	40200757
Hospital Revenue Code	278
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$63.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$63.00
Rate for Payer: Hamaspik Choice Inc Medicare	$63.00

Know your out-of-pocket cost for care.

All Charges