St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PROLACTIN ZONE

Facility

$485.60

Service Code	HCPCS 84146
Hospital Charge Code	40601238
Hospital Revenue Code	301
Min. Negotiated Rate	$13.57
Max. Negotiated Rate	$364.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$267.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.38
Rate for Payer: Aetna Government	$19.38
Rate for Payer: Affinity Essential Plan 1&2	$13.57
Rate for Payer: Affinity Essential Plan 3&4	$13.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$13.57
Rate for Payer: Brighton Health Commercial	$364.20
Rate for Payer: Cash Price	$19.38
Rate for Payer: Cash Price	$19.38
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$19.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$30.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.07
Rate for Payer: Elderplan Medicare Advantage	$19.38
Rate for Payer: EmblemHealth Commercial	$19.38
Rate for Payer: Fidelis Essential Plan Aliesa	$16.47
Rate for Payer: Fidelis Essential Plan QHP	$17.25
Rate for Payer: Fidelis Medicare Advantage	$19.38
Rate for Payer: Fidelis Qualified Health Plan	$17.25
Rate for Payer: Group Health Inc Commercial	$19.38
Rate for Payer: Group Health Inc Medicare	$19.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$242.80
Rate for Payer: Hamaspik Choice Inc Medicare	$19.38
Rate for Payer: Healthfirst Medicare Advantage	$19.38
Rate for Payer: Healthfirst QHP	$19.38
Rate for Payer: Humana Medicare	$19.77
Rate for Payer: Senior Whole Health Medicare Advantage	$19.38
Rate for Payer: United Healthcare Commercial	$24.54
Rate for Payer: United Healthcare Medicare Advantage	$19.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$19.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$15.50
Rate for Payer: Wellcare Medicare	$17.44

PROLACTIN ZONE

Facility

$485.60

Service Code	HCPCS 84146
Hospital Charge Code	40601238
Hospital Revenue Code	301
Rate for Payer: Cash Price	$19.38

PROLNG SVC O/P 1ST HOUR

Facility

$348.71

Service Code	HCPCS 99354
Hospital Charge Code	30105179
Hospital Revenue Code	450
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$874.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$694.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.40
Rate for Payer: Aetna Government	$69.40
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$747.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$635.21
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$174.36
Rate for Payer: Hamaspik Choice Inc Medicare	$174.36
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: United Healthcare Commercial	$569.00

PROLNG SVC O/P EA ADDL 30

Facility

$162.70

Service Code	HCPCS 99355
Hospital Charge Code	30305431
Hospital Revenue Code	510
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$89.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$67.05
Rate for Payer: Aetna Government	$67.05
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
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	$81.35
Rate for Payer: Hamaspik Choice Inc Medicare	$81.35
Rate for Payer: United Healthcare Commercial	$222.00

PROLONGED IV INF, REQ PUMP

Facility

$566.58

Service Code	HCPCS C8957
Hospital Charge Code	40509880
Hospital Revenue Code	260
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$453.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$311.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$391.64
Rate for Payer: Aetna Government	$391.64
Rate for Payer: Affinity Essential Plan 1&2	$274.15
Rate for Payer: Affinity Essential Plan 3&4	$274.15
Rate for Payer: Affinity Medicaid/CHP/HARP	$274.15
Rate for Payer: Brighton Health Commercial	$424.94
Rate for Payer: Cash Price	$391.64
Rate for Payer: Cash Price	$391.64
Rate for Payer: Cash Price	$391.64
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$391.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$453.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$385.27
Rate for Payer: Elderplan Medicare Advantage	$391.64
Rate for Payer: EmblemHealth Commercial	$391.64
Rate for Payer: Fidelis Essential Plan Aliesa	$332.89
Rate for Payer: Fidelis Essential Plan QHP	$348.56
Rate for Payer: Fidelis Medicare Advantage	$391.64
Rate for Payer: Fidelis Qualified Health Plan	$348.56
Rate for Payer: Group Health Inc Commercial	$391.64
Rate for Payer: Group Health Inc Medicare	$391.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$283.29
Rate for Payer: Hamaspik Choice Inc Medicare	$391.64
Rate for Payer: Healthfirst Medicare Advantage	$332.89
Rate for Payer: Healthfirst QHP	$391.64
Rate for Payer: Humana Medicare	$399.47
Rate for Payer: Senior Whole Health Medicare Advantage	$391.64
Rate for Payer: United Healthcare Commercial	$76.00
Rate for Payer: United Healthcare Medicare Advantage	$391.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$391.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$313.31
Rate for Payer: Wellcare Medicare	$372.06

PROLONGED IV INF, REQ PUMP

Facility

$566.58

Service Code	HCPCS C8957
Hospital Charge Code	40509880
Hospital Revenue Code	260
Rate for Payer: Cash Price	$391.64

PROLONGED SERVICES ADD'L 30 MIN.

Facility

$348.71

Service Code	HCPCS 99354
Hospital Charge Code	30305179
Hospital Revenue Code	450
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$874.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$694.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.40
Rate for Payer: Aetna Government	$69.40
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$747.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$635.21
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$174.36
Rate for Payer: Hamaspik Choice Inc Medicare	$174.36
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: United Healthcare Commercial	$569.00

PROLONG HIGHLY CROSS POLY

Facility

$4,192.63

Service Code	HCPCS C1713
Hospital Charge Code	64904000
Hospital Revenue Code	278
Min. Negotiated Rate	$2,096.32
Max. Negotiated Rate	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32

PROLONG HIGHLY CROSS POLY

Facility

$4,192.63

Service Code	HCPCS C1713
Hospital Charge Code	64904000
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,402.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,305.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,515.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,096.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,410.76
Rate for Payer: EmblemHealth Commercial	$2,096.32
Rate for Payer: Fidelis Medicare Advantage	$4,402.26
Rate for Payer: Group Health Inc Commercial	$2,096.32
Rate for Payer: Group Health Inc Medicare	$1,467.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,096.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2,096.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,725.21

PROLONG OUTPT/OFFICE VIS

Facility

$0.01

Service Code	HCPCS G2212
Hospital Charge Code	30300340
Hospital Revenue Code	929
Max. Negotiated Rate	$94.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.69
Rate for Payer: Aetna Government	$24.69
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: United Healthcare Commercial	$94.00

PROLONG SVC O/P 1ST HOUR

Facility

$271.30

Service Code	HCPCS 99354
Hospital Charge Code	30301425
Hospital Revenue Code	510
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$149.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.40
Rate for Payer: Aetna Government	$69.40
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
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	$135.65
Rate for Payer: Hamaspik Choice Inc Medicare	$135.65
Rate for Payer: United Healthcare Commercial	$222.00

PR OMALIZUMAB INJECTION

Professional

Both

$95.00

Service Code	HCPCS J2357
Min. Negotiated Rate	$71.25
Max. Negotiated Rate	$71.25
Rate for Payer: Cash Price	$36.81
Rate for Payer: SOMOS CHP/HARP/Medicaid	$71.25
Rate for Payer: SOMOS Essential	$71.25

PR OMENTAL FLAP EXTRA-ABDOMINAL

Professional

Both

$6,169.73

Service Code	HCPCS 49904
Min. Negotiated Rate	$4,627.30
Max. Negotiated Rate	$4,627.30
Rate for Payer: Cash Price	$1,655.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,627.30
Rate for Payer: SOMOS Essential	$4,627.30

PR OMENTAL FLAP INTRA-ABDOMINAL

Professional

Both

$1,573.39

Service Code	HCPCS 49905
Min. Negotiated Rate	$1,180.04
Max. Negotiated Rate	$1,180.04
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,180.04
Rate for Payer: SOMOS Essential	$1,180.04

PROMETHAZINE 25 MG/ML INJ

Facility

$2.85

Service Code	HCPCS J2550
Hospital Charge Code	41643271
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.64
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3.28
Rate for Payer: SOMOS Essential	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

PROMETHAZINE 25 MG/ML INJ

Facility

$2.85

Service Code	HCPCS J2550
Hospital Charge Code	41643271
Hospital Revenue Code	636
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$1.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42

PROMETHAZINE 25 MG/ML INJ

Facility

$2.85

Service Code	HCPCS J2550
Hospital Charge Code	41653271
Hospital Revenue Code	636
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$1.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42

PROMETHAZINE 25 MG/ML INJ

Facility

$2.85

Service Code	HCPCS J2550
Hospital Charge Code	41653271
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.64
Rate for Payer: Group Health Inc Commercial	$1.42
Rate for Payer: Group Health Inc Medicare	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.42
Rate for Payer: Hamaspik Choice Inc Medicare	$1.42
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3.28
Rate for Payer: SOMOS Essential	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.85

PROMETHAZINE HCL 25 MG/ML IJ SOLN [6618]

Facility

$2.50

Service Code	HCPCS J2550
Hospital Charge Code	39822552502
Hospital Revenue Code	250
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.70
Rate for Payer: Group Health Inc Commercial	$1.25
Rate for Payer: Group Health Inc Medicare	$0.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1.25
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3.10
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$3.28
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$3.28
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.62

PROMETHAZINE HCL 25 MG/ML IJ SOLN [6618]

Facility

$2.22

Service Code	HCPCS J2550
Hospital Charge Code	00641092825
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.51
Rate for Payer: Group Health Inc Commercial	$1.11
Rate for Payer: Group Health Inc Medicare	$0.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.11
Rate for Payer: Hamaspik Choice Inc Medicare	$1.11
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3.10
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$3.28
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$3.28
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.44

PROMETHAZINE HCL 25 MG/ML IJ SOLN [6618]

Facility

$2.22

Service Code	HCPCS J2550
Hospital Charge Code	00641149535
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.51
Rate for Payer: Group Health Inc Commercial	$1.11
Rate for Payer: Group Health Inc Medicare	$0.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.11
Rate for Payer: Hamaspik Choice Inc Medicare	$1.11
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3.10
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$3.28
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$3.28
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.44

PROMETHAZINE HCL 25 MG/ML IJ SOLN [6618]

Facility

$2.50

Service Code	HCPCS J2550
Hospital Charge Code	39822552503
Hospital Revenue Code	250
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$3.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.37
Rate for Payer: Aetna Government	$2.37
Rate for Payer: Brighton Health Commercial	$1.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.70
Rate for Payer: Group Health Inc Commercial	$1.25
Rate for Payer: Group Health Inc Medicare	$0.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1.25
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3.10
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$3.28
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$3.28
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$3.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.62

PROMETHAZINE HCL 25 MG PO TABS [6622]

Facility

$0.95

Service Code	HCPCS Q0169
Hospital Charge Code	00904646161
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.65
Rate for Payer: Group Health Inc Commercial	$0.48
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48
Rate for Payer: Hamaspik Choice Inc Medicare	$0.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.62

PROMETHAZINE HCL 25 MG RE SUPP [11144]

Facility

$17.71

Service Code	NDC 00713052612
Hospital Charge Code	00713052612
Hospital Revenue Code	250
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$14.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.85
Rate for Payer: Aetna Government	$8.85
Rate for Payer: Brighton Health Commercial	$13.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.04
Rate for Payer: Group Health Inc Commercial	$8.85
Rate for Payer: Group Health Inc Medicare	$6.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.85
Rate for Payer: Hamaspik Choice Inc Medicare	$8.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.51

PROMETHAZINE HCL 6.25 MG/5ML PO SOLN [97609]

Facility

$0.10

Service Code	HCPCS Q0169
Hospital Charge Code	60432060816
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

Know your out-of-pocket cost for care.

All Charges