St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.72

Service Code	NDC 10702000610
Hospital Charge Code	10702000610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.86
Rate for Payer: Aetna Government	$0.86
Rate for Payer: Brighton Health Commercial	$1.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.17
Rate for Payer: Group Health Inc Commercial	$0.86
Rate for Payer: Group Health Inc Medicare	$0.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86
Rate for Payer: Hamaspik Choice Inc Medicare	$0.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.12

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.23

Service Code	NDC 50268019015
Hospital Charge Code	50268019015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.62
Rate for Payer: Aetna Government	$0.62
Rate for Payer: Brighton Health Commercial	$0.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.84
Rate for Payer: Group Health Inc Commercial	$0.62
Rate for Payer: Group Health Inc Medicare	$0.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.62
Rate for Payer: Hamaspik Choice Inc Medicare	$0.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.80

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.73

Service Code	NDC 10702000601
Hospital Charge Code	10702000601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.87
Rate for Payer: Aetna Government	$0.87
Rate for Payer: Brighton Health Commercial	$1.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.18
Rate for Payer: Group Health Inc Commercial	$0.87
Rate for Payer: Group Health Inc Medicare	$0.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.13

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.64

Service Code	NDC 52817033010
Hospital Charge Code	52817033010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$1.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.12
Rate for Payer: Group Health Inc Commercial	$0.82
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.82
Rate for Payer: Hamaspik Choice Inc Medicare	$0.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.07

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.64

Service Code	NDC 69097084507
Hospital Charge Code	69097084507
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$1.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.12
Rate for Payer: Group Health Inc Commercial	$0.82
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.82
Rate for Payer: Hamaspik Choice Inc Medicare	$0.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.07

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$1.64

Service Code	NDC 72888001201
Hospital Charge Code	72888001201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$1.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.12
Rate for Payer: Group Health Inc Commercial	$0.82
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.82
Rate for Payer: Hamaspik Choice Inc Medicare	$0.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.07

CYCLOBENZAPRINE HCL 5 MG PO TABS [35184]

Facility

$0.32

Service Code	NDC 00904740006
Hospital Charge Code	00904740006
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.16
Rate for Payer: Aetna Government	$0.16
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.16
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16
Rate for Payer: Hamaspik Choice Inc Medicare	$0.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

CYCLOPENTOLATE 0.2% + PHENYLEPHRINE 1% O

Facility

$35.35

Hospital Charge Code	41654690
Hospital Revenue Code	250
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$28.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.68
Rate for Payer: Aetna Government	$17.68
Rate for Payer: Brighton Health Commercial	$26.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.04
Rate for Payer: Group Health Inc Commercial	$17.68
Rate for Payer: Group Health Inc Medicare	$12.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.68
Rate for Payer: Hamaspik Choice Inc Medicare	$17.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.98

CYCLOPENTOLATE 0.2% + PHENYLEPHRINE 1% O

Facility

$35.35

Hospital Charge Code	41644690
Hospital Revenue Code	250
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$28.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.68
Rate for Payer: Aetna Government	$17.68
Rate for Payer: Brighton Health Commercial	$26.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.04
Rate for Payer: Group Health Inc Commercial	$17.68
Rate for Payer: Group Health Inc Medicare	$12.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.68
Rate for Payer: Hamaspik Choice Inc Medicare	$17.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.98

CYCLOPENTOLATE 0.5% OPHTHALMIC SOLN 15 M

Facility

$96.64

Hospital Charge Code	41642337
Hospital Revenue Code	250
Min. Negotiated Rate	$33.82
Max. Negotiated Rate	$77.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$48.32
Rate for Payer: Aetna Government	$48.32
Rate for Payer: Brighton Health Commercial	$72.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$65.72
Rate for Payer: Group Health Inc Commercial	$48.32
Rate for Payer: Group Health Inc Medicare	$33.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.32
Rate for Payer: Hamaspik Choice Inc Medicare	$48.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$62.82

CYCLOPENTOLATE 0.5% OPHTHALMIC SOLN 15 M

Facility

$96.64

Hospital Charge Code	41652337
Hospital Revenue Code	250
Min. Negotiated Rate	$33.82
Max. Negotiated Rate	$77.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$48.32
Rate for Payer: Aetna Government	$48.32
Rate for Payer: Brighton Health Commercial	$72.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$77.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$65.72
Rate for Payer: Group Health Inc Commercial	$48.32
Rate for Payer: Group Health Inc Medicare	$33.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.32
Rate for Payer: Hamaspik Choice Inc Medicare	$48.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$62.82

CYCLOPENTOLATE 1% OPHTHALMIC SOLN 2 ML

Facility

$0.48

Hospital Charge Code	41654186
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.31

CYCLOPENTOLATE 1% OPHTHALMIC SOLN 2 ML

Facility

$0.48

Hospital Charge Code	41644186
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.24
Rate for Payer: Aetna Government	$0.24
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.31

CYCLOPENTOLATE 1% OPHTHALMIC SOLN 5 ML

Facility

$3.00

Hospital Charge Code	41642979
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

CYCLOPENTOLATE 1% OPHTHALMIC SOLN 5 ML

Facility

$3.00

Hospital Charge Code	41652979
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

CYCLOPENTOLATE 2% OPHTHALMIC SOLN 2 ML

Facility

$5.00

Hospital Charge Code	41640847
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

CYCLOPENTOLATE 2% OPHTHALMIC SOLN 2 ML

Facility

$5.00

Hospital Charge Code	41650847
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

CYCLOPENTOLATE HCL 0.5 % OP SOLN [9699]

Facility

$7.71

Service Code	NDC 00065039515
Hospital Charge Code	00065039515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$6.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.86
Rate for Payer: Aetna Government	$3.86
Rate for Payer: Brighton Health Commercial	$5.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.24
Rate for Payer: Group Health Inc Commercial	$3.86
Rate for Payer: Group Health Inc Medicare	$2.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.86
Rate for Payer: Hamaspik Choice Inc Medicare	$3.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.01

CYCLOPENTOLATE HCL 1 % OP SOLN [2025]

Facility

$7.39

Service Code	NDC 17478010002
Hospital Charge Code	17478010002
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$5.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.69
Rate for Payer: Aetna Government	$3.69
Rate for Payer: Brighton Health Commercial	$5.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.02
Rate for Payer: Group Health Inc Commercial	$3.69
Rate for Payer: Group Health Inc Medicare	$2.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.69
Rate for Payer: Hamaspik Choice Inc Medicare	$3.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.80

CYCLOPENTOLATE HCL 1 % OP SOLN [2025]

Facility

$2.70

Service Code	NDC 61314039603
Hospital Charge Code	61314039603
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

CYCLOPENTOLATE HCL 1 % OP SOLN [2025]

Facility

$8.40

Service Code	NDC 61314039601
Hospital Charge Code	61314039601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.20
Rate for Payer: Aetna Government	$4.20
Rate for Payer: Brighton Health Commercial	$6.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.71
Rate for Payer: Group Health Inc Commercial	$4.20
Rate for Payer: Group Health Inc Medicare	$2.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.20
Rate for Payer: Hamaspik Choice Inc Medicare	$4.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.46

CYCLOPENTOLATE HCL 1 % OP SOLN [2025]

Facility

$8.17

Service Code	NDC 24208073501
Hospital Charge Code	24208073501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$6.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Brighton Health Commercial	$6.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.55
Rate for Payer: Group Health Inc Commercial	$4.08
Rate for Payer: Group Health Inc Medicare	$2.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.08
Rate for Payer: Hamaspik Choice Inc Medicare	$4.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.31

CYCLOPENTOLATE HCL 1 % OP SOLN [2025]

Facility

$14.56

Service Code	NDC 00065039605
Hospital Charge Code	00065039605
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$11.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.28
Rate for Payer: Aetna Government	$7.28
Rate for Payer: Brighton Health Commercial	$10.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.90
Rate for Payer: Group Health Inc Commercial	$7.28
Rate for Payer: Group Health Inc Medicare	$5.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.28
Rate for Payer: Hamaspik Choice Inc Medicare	$7.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.46

CYCLOPENTOLATE HCL 2 % OP SOLN [9700]

Facility

$26.50

Service Code	NDC 00065039702
Hospital Charge Code	00065039702
Hospital Revenue Code	250
Min. Negotiated Rate	$9.27
Max. Negotiated Rate	$21.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.25
Rate for Payer: Aetna Government	$13.25
Rate for Payer: Brighton Health Commercial	$19.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.02
Rate for Payer: Group Health Inc Commercial	$13.25
Rate for Payer: Group Health Inc Medicare	$9.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.25
Rate for Payer: Hamaspik Choice Inc Medicare	$13.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17.22

CYCLOPENTOLATE HCL 2 % OP SOLN [9700]

Facility

$14.76

Service Code	NDC 17478009702
Hospital Charge Code	17478009702
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$11.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.38
Rate for Payer: Aetna Government	$7.38
Rate for Payer: Brighton Health Commercial	$11.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.03
Rate for Payer: Group Health Inc Commercial	$7.38
Rate for Payer: Group Health Inc Medicare	$5.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.38
Rate for Payer: Hamaspik Choice Inc Medicare	$7.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.59

Know your out-of-pocket cost for care.

All Charges