St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

Peripheral & other vascular disorders

Facility

$42,322.93

Service Code	APR-DRG 1971
Min. Negotiated Rate	$7,006.00
Max. Negotiated Rate	$42,322.93
Rate for Payer: Affinity Essential Plan 1&2	$42,322.93
Rate for Payer: Affinity Essential Plan 3&4	$42,322.93
Rate for Payer: Affinity Medicaid/CHP/HARP	$18,810.19
Rate for Payer: Amida Care Medicaid	$18,810.19
Rate for Payer: EmblemHealth Essential Plan 1&2	$42,322.93
Rate for Payer: EmblemHealth Essential Plan 3&4	$18,810.19
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18,810.19
Rate for Payer: Fidelis Qualified Health Plan	$22,572.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$18,810.19
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18,810.19
Rate for Payer: Healthfirst Commercial	$11,587.00
Rate for Payer: Healthfirst Essential Plan	$42,322.93
Rate for Payer: Healthfirst QHP	$7,006.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$18,810.19
Rate for Payer: SOMOS Essential	$42,322.93
Rate for Payer: United Healthcare Essential Plan 1&2	$42,322.93
Rate for Payer: United Healthcare Essential Plan 3&4	$42,322.93
Rate for Payer: United Healthcare Medicaid	$18,810.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$18,810.19

Peripheral & other vascular disorders

Facility

$82,385.39

Service Code	APR-DRG 1974
Min. Negotiated Rate	$25,004.00
Max. Negotiated Rate	$82,385.39
Rate for Payer: Affinity Essential Plan 1&2	$82,385.39
Rate for Payer: Affinity Essential Plan 3&4	$82,385.39
Rate for Payer: Affinity Medicaid/CHP/HARP	$36,615.73
Rate for Payer: Amida Care Medicaid	$36,615.73
Rate for Payer: EmblemHealth Essential Plan 1&2	$82,385.39
Rate for Payer: EmblemHealth Essential Plan 3&4	$36,615.73
Rate for Payer: Fidelis CHP/HARP/Medicaid	$36,615.73
Rate for Payer: Fidelis Qualified Health Plan	$43,938.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$36,615.73
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$36,615.73
Rate for Payer: Healthfirst Commercial	$43,874.00
Rate for Payer: Healthfirst Essential Plan	$82,385.39
Rate for Payer: Healthfirst QHP	$25,004.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$36,615.73
Rate for Payer: SOMOS Essential	$82,385.39
Rate for Payer: United Healthcare Essential Plan 1&2	$82,385.39
Rate for Payer: United Healthcare Essential Plan 3&4	$82,385.39
Rate for Payer: United Healthcare Medicaid	$36,615.73
Rate for Payer: Wellcare CHP/FHP/Medicaid	$36,615.73

Peripheral & other vascular disorders

Facility

$45,951.21

Service Code	APR-DRG 1972
Min. Negotiated Rate	$8,856.00
Max. Negotiated Rate	$45,951.21
Rate for Payer: Affinity Essential Plan 1&2	$45,951.21
Rate for Payer: Affinity Essential Plan 3&4	$45,951.21
Rate for Payer: Affinity Medicaid/CHP/HARP	$20,422.76
Rate for Payer: Amida Care Medicaid	$20,422.76
Rate for Payer: EmblemHealth Essential Plan 1&2	$45,951.21
Rate for Payer: EmblemHealth Essential Plan 3&4	$20,422.76
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20,422.76
Rate for Payer: Fidelis Qualified Health Plan	$24,507.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$20,422.76
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20,422.76
Rate for Payer: Healthfirst Commercial	$14,824.00
Rate for Payer: Healthfirst Essential Plan	$45,951.21
Rate for Payer: Healthfirst QHP	$8,856.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$20,422.76
Rate for Payer: SOMOS Essential	$45,951.21
Rate for Payer: United Healthcare Essential Plan 1&2	$45,951.21
Rate for Payer: United Healthcare Essential Plan 3&4	$45,951.21
Rate for Payer: United Healthcare Medicaid	$20,422.76
Rate for Payer: Wellcare CHP/FHP/Medicaid	$20,422.76

PERIPHERAL VASCULAR BYPASS PROCEDURES

Facility

$2,966.93

Service Code	EAPG 00123
Min. Negotiated Rate	$2,966.93
Max. Negotiated Rate	$2,966.93
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$2,966.93

Peritoneal adhesiolysis

Facility

$53,153.28

Service Code	APR-DRG 2241
Min. Negotiated Rate	$14,484.00
Max. Negotiated Rate	$53,153.28
Rate for Payer: Affinity Essential Plan 1&2	$53,153.28
Rate for Payer: Affinity Essential Plan 3&4	$53,153.28
Rate for Payer: Affinity Medicaid/CHP/HARP	$23,623.68
Rate for Payer: Amida Care Medicaid	$23,623.68
Rate for Payer: EmblemHealth Essential Plan 1&2	$53,153.28
Rate for Payer: EmblemHealth Essential Plan 3&4	$23,623.68
Rate for Payer: Fidelis CHP/HARP/Medicaid	$23,623.68
Rate for Payer: Fidelis Qualified Health Plan	$28,348.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$23,623.68
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23,623.68
Rate for Payer: Healthfirst Commercial	$24,015.00
Rate for Payer: Healthfirst Essential Plan	$53,153.28
Rate for Payer: Healthfirst QHP	$14,484.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$23,623.68
Rate for Payer: SOMOS Essential	$53,153.28
Rate for Payer: United Healthcare Essential Plan 1&2	$53,153.28
Rate for Payer: United Healthcare Essential Plan 3&4	$53,153.28
Rate for Payer: United Healthcare Medicaid	$23,623.68
Rate for Payer: Wellcare CHP/FHP/Medicaid	$23,623.68

Peritoneal adhesiolysis

Facility

$60,179.47

Service Code	APR-DRG 2242
Min. Negotiated Rate	$18,414.00
Max. Negotiated Rate	$60,179.47
Rate for Payer: Affinity Essential Plan 1&2	$60,179.47
Rate for Payer: Affinity Essential Plan 3&4	$60,179.47
Rate for Payer: Affinity Medicaid/CHP/HARP	$26,746.43
Rate for Payer: Amida Care Medicaid	$26,746.43
Rate for Payer: EmblemHealth Essential Plan 1&2	$60,179.47
Rate for Payer: EmblemHealth Essential Plan 3&4	$26,746.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$26,746.43
Rate for Payer: Fidelis Qualified Health Plan	$32,095.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$26,746.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$26,746.43
Rate for Payer: Healthfirst Commercial	$31,106.00
Rate for Payer: Healthfirst Essential Plan	$60,179.47
Rate for Payer: Healthfirst QHP	$18,414.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$26,746.43
Rate for Payer: SOMOS Essential	$60,179.47
Rate for Payer: United Healthcare Essential Plan 1&2	$60,179.47
Rate for Payer: United Healthcare Essential Plan 3&4	$60,179.47
Rate for Payer: United Healthcare Medicaid	$26,746.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$26,746.43

Peritoneal adhesiolysis

Facility

$129,954.22

Service Code	APR-DRG 2244
Min. Negotiated Rate	$48,656.00
Max. Negotiated Rate	$129,954.22
Rate for Payer: Affinity Essential Plan 1&2	$129,954.22
Rate for Payer: Affinity Essential Plan 3&4	$129,954.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$57,757.43
Rate for Payer: Amida Care Medicaid	$57,757.43
Rate for Payer: EmblemHealth Essential Plan 1&2	$129,954.22
Rate for Payer: EmblemHealth Essential Plan 3&4	$57,757.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$57,757.43
Rate for Payer: Fidelis Qualified Health Plan	$69,308.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$57,757.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$57,757.43
Rate for Payer: Healthfirst Commercial	$77,179.00
Rate for Payer: Healthfirst Essential Plan	$129,954.22
Rate for Payer: Healthfirst QHP	$48,656.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$57,757.43
Rate for Payer: SOMOS Essential	$129,954.22
Rate for Payer: United Healthcare Essential Plan 1&2	$129,954.22
Rate for Payer: United Healthcare Essential Plan 3&4	$129,954.22
Rate for Payer: United Healthcare Medicaid	$57,757.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$57,757.43

Peritoneal adhesiolysis

Facility

$78,690.29

Service Code	APR-DRG 2243
Min. Negotiated Rate	$29,505.00
Max. Negotiated Rate	$78,690.29
Rate for Payer: Affinity Essential Plan 1&2	$78,690.29
Rate for Payer: Affinity Essential Plan 3&4	$78,690.29
Rate for Payer: Affinity Medicaid/CHP/HARP	$34,973.46
Rate for Payer: Amida Care Medicaid	$34,973.46
Rate for Payer: EmblemHealth Essential Plan 1&2	$78,690.29
Rate for Payer: EmblemHealth Essential Plan 3&4	$34,973.46
Rate for Payer: Fidelis CHP/HARP/Medicaid	$34,973.46
Rate for Payer: Fidelis Qualified Health Plan	$41,968.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$34,973.46
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$34,973.46
Rate for Payer: Healthfirst Commercial	$51,110.00
Rate for Payer: Healthfirst Essential Plan	$78,690.29
Rate for Payer: Healthfirst QHP	$29,505.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$34,973.46
Rate for Payer: SOMOS Essential	$78,690.29
Rate for Payer: United Healthcare Essential Plan 1&2	$78,690.29
Rate for Payer: United Healthcare Essential Plan 3&4	$78,690.29
Rate for Payer: United Healthcare Medicaid	$34,973.46
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34,973.46

Permanent cardiac pacemaker implant w AMI, heart failure or shock

Facility

$80,125.40

Service Code	APR-DRG 1702
Min. Negotiated Rate	$32,533.00
Max. Negotiated Rate	$80,125.40
Rate for Payer: Affinity Essential Plan 1&2	$80,125.40
Rate for Payer: Affinity Essential Plan 3&4	$80,125.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$35,611.29
Rate for Payer: Amida Care Medicaid	$35,611.29
Rate for Payer: EmblemHealth Essential Plan 1&2	$80,125.40
Rate for Payer: EmblemHealth Essential Plan 3&4	$35,611.29
Rate for Payer: Fidelis CHP/HARP/Medicaid	$35,611.29
Rate for Payer: Fidelis Qualified Health Plan	$42,733.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$35,611.29
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$35,611.29
Rate for Payer: Healthfirst Commercial	$55,952.00
Rate for Payer: Healthfirst Essential Plan	$80,125.40
Rate for Payer: Healthfirst QHP	$32,533.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$35,611.29
Rate for Payer: SOMOS Essential	$80,125.40
Rate for Payer: United Healthcare Essential Plan 1&2	$80,125.40
Rate for Payer: United Healthcare Essential Plan 3&4	$80,125.40
Rate for Payer: United Healthcare Medicaid	$35,611.29
Rate for Payer: Wellcare CHP/FHP/Medicaid	$35,611.29

Permanent cardiac pacemaker implant w AMI, heart failure or shock

Facility

$79,601.31

Service Code	APR-DRG 1701
Min. Negotiated Rate	$32,533.00
Max. Negotiated Rate	$79,601.31
Rate for Payer: Affinity Essential Plan 1&2	$79,601.31
Rate for Payer: Affinity Essential Plan 3&4	$79,601.31
Rate for Payer: Affinity Medicaid/CHP/HARP	$35,378.36
Rate for Payer: Amida Care Medicaid	$35,378.36
Rate for Payer: EmblemHealth Essential Plan 1&2	$79,601.31
Rate for Payer: EmblemHealth Essential Plan 3&4	$35,378.36
Rate for Payer: Fidelis CHP/HARP/Medicaid	$35,378.36
Rate for Payer: Fidelis Qualified Health Plan	$42,454.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$35,378.36
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$35,378.36
Rate for Payer: Healthfirst Commercial	$55,952.00
Rate for Payer: Healthfirst Essential Plan	$79,601.31
Rate for Payer: Healthfirst QHP	$32,533.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$35,378.36
Rate for Payer: SOMOS Essential	$79,601.31
Rate for Payer: United Healthcare Essential Plan 1&2	$79,601.31
Rate for Payer: United Healthcare Essential Plan 3&4	$79,601.31
Rate for Payer: United Healthcare Medicaid	$35,378.36
Rate for Payer: Wellcare CHP/FHP/Medicaid	$35,378.36

Permanent cardiac pacemaker implant w AMI, heart failure or shock

Facility

$95,384.29

Service Code	APR-DRG 1703
Min. Negotiated Rate	$42,271.00
Max. Negotiated Rate	$95,384.29
Rate for Payer: Affinity Essential Plan 1&2	$95,384.29
Rate for Payer: Affinity Essential Plan 3&4	$95,384.29
Rate for Payer: Affinity Medicaid/CHP/HARP	$42,393.02
Rate for Payer: Amida Care Medicaid	$42,393.02
Rate for Payer: EmblemHealth Essential Plan 1&2	$95,384.29
Rate for Payer: EmblemHealth Essential Plan 3&4	$42,393.02
Rate for Payer: Fidelis CHP/HARP/Medicaid	$42,393.02
Rate for Payer: Fidelis Qualified Health Plan	$50,871.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$42,393.02
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$42,393.02
Rate for Payer: Healthfirst Commercial	$65,542.00
Rate for Payer: Healthfirst Essential Plan	$95,384.29
Rate for Payer: Healthfirst QHP	$42,271.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$42,393.02
Rate for Payer: SOMOS Essential	$95,384.29
Rate for Payer: United Healthcare Essential Plan 1&2	$95,384.29
Rate for Payer: United Healthcare Essential Plan 3&4	$95,384.29
Rate for Payer: United Healthcare Medicaid	$42,393.02
Rate for Payer: Wellcare CHP/FHP/Medicaid	$42,393.02

Permanent cardiac pacemaker implant w AMI, heart failure or shock

Facility

$116,656.34

Service Code	APR-DRG 1704
Min. Negotiated Rate	$44,870.00
Max. Negotiated Rate	$116,656.34
Rate for Payer: Affinity Essential Plan 1&2	$116,656.34
Rate for Payer: Affinity Essential Plan 3&4	$116,656.34
Rate for Payer: Affinity Medicaid/CHP/HARP	$51,847.26
Rate for Payer: Amida Care Medicaid	$51,847.26
Rate for Payer: EmblemHealth Essential Plan 1&2	$116,656.34
Rate for Payer: EmblemHealth Essential Plan 3&4	$51,847.26
Rate for Payer: Fidelis CHP/HARP/Medicaid	$51,847.26
Rate for Payer: Fidelis Qualified Health Plan	$62,216.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$51,847.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$51,847.26
Rate for Payer: Healthfirst Commercial	$110,030.00
Rate for Payer: Healthfirst Essential Plan	$116,656.34
Rate for Payer: Healthfirst QHP	$44,870.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$51,847.26
Rate for Payer: SOMOS Essential	$116,656.34
Rate for Payer: United Healthcare Essential Plan 1&2	$116,656.34
Rate for Payer: United Healthcare Essential Plan 3&4	$116,656.34
Rate for Payer: United Healthcare Medicaid	$51,847.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$51,847.26

Perm cardiac pacemaker implant w/o AMI, heart failure or shock

Facility

$62,615.34

Service Code	APR-DRG 1711
Min. Negotiated Rate	$22,406.00
Max. Negotiated Rate	$62,615.34
Rate for Payer: Affinity Essential Plan 1&2	$62,615.34
Rate for Payer: Affinity Essential Plan 3&4	$62,615.34
Rate for Payer: Affinity Medicaid/CHP/HARP	$27,829.04
Rate for Payer: Amida Care Medicaid	$27,829.04
Rate for Payer: EmblemHealth Essential Plan 1&2	$62,615.34
Rate for Payer: EmblemHealth Essential Plan 3&4	$27,829.04
Rate for Payer: Fidelis CHP/HARP/Medicaid	$27,829.04
Rate for Payer: Fidelis Qualified Health Plan	$33,394.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$27,829.04
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$27,829.04
Rate for Payer: Healthfirst Commercial	$34,616.00
Rate for Payer: Healthfirst Essential Plan	$62,615.34
Rate for Payer: Healthfirst QHP	$22,406.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$27,829.04
Rate for Payer: SOMOS Essential	$62,615.34
Rate for Payer: United Healthcare Essential Plan 1&2	$62,615.34
Rate for Payer: United Healthcare Essential Plan 3&4	$62,615.34
Rate for Payer: United Healthcare Medicaid	$27,829.04
Rate for Payer: Wellcare CHP/FHP/Medicaid	$27,829.04

Perm cardiac pacemaker implant w/o AMI, heart failure or shock

Facility

$136,904.78

Service Code	APR-DRG 1714
Min. Negotiated Rate	$58,033.00
Max. Negotiated Rate	$136,904.78
Rate for Payer: Affinity Essential Plan 1&2	$136,904.78
Rate for Payer: Affinity Essential Plan 3&4	$136,904.78
Rate for Payer: Affinity Medicaid/CHP/HARP	$60,846.57
Rate for Payer: Amida Care Medicaid	$60,846.57
Rate for Payer: EmblemHealth Essential Plan 1&2	$136,904.78
Rate for Payer: EmblemHealth Essential Plan 3&4	$60,846.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$60,846.57
Rate for Payer: Fidelis Qualified Health Plan	$73,015.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$60,846.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$60,846.57
Rate for Payer: Healthfirst Commercial	$103,751.00
Rate for Payer: Healthfirst Essential Plan	$136,904.78
Rate for Payer: Healthfirst QHP	$58,033.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$60,846.57
Rate for Payer: SOMOS Essential	$136,904.78
Rate for Payer: United Healthcare Essential Plan 1&2	$136,904.78
Rate for Payer: United Healthcare Essential Plan 3&4	$136,904.78
Rate for Payer: United Healthcare Medicaid	$60,846.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$60,846.57

Perm cardiac pacemaker implant w/o AMI, heart failure or shock

Facility

$69,724.19

Service Code	APR-DRG 1712
Min. Negotiated Rate	$26,055.00
Max. Negotiated Rate	$69,724.19
Rate for Payer: Affinity Essential Plan 1&2	$69,724.19
Rate for Payer: Affinity Essential Plan 3&4	$69,724.19
Rate for Payer: Affinity Medicaid/CHP/HARP	$30,988.53
Rate for Payer: Amida Care Medicaid	$30,988.53
Rate for Payer: EmblemHealth Essential Plan 1&2	$69,724.19
Rate for Payer: EmblemHealth Essential Plan 3&4	$30,988.53
Rate for Payer: Fidelis CHP/HARP/Medicaid	$30,988.53
Rate for Payer: Fidelis Qualified Health Plan	$37,186.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$30,988.53
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$30,988.53
Rate for Payer: Healthfirst Commercial	$41,563.00
Rate for Payer: Healthfirst Essential Plan	$69,724.19
Rate for Payer: Healthfirst QHP	$26,055.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$30,988.53
Rate for Payer: SOMOS Essential	$69,724.19
Rate for Payer: United Healthcare Essential Plan 1&2	$69,724.19
Rate for Payer: United Healthcare Essential Plan 3&4	$69,724.19
Rate for Payer: United Healthcare Medicaid	$30,988.53
Rate for Payer: Wellcare CHP/FHP/Medicaid	$30,988.53

Perm cardiac pacemaker implant w/o AMI, heart failure or shock

Facility

$84,566.25

Service Code	APR-DRG 1713
Min. Negotiated Rate	$33,372.00
Max. Negotiated Rate	$84,566.25
Rate for Payer: Affinity Essential Plan 1&2	$84,566.25
Rate for Payer: Affinity Essential Plan 3&4	$84,566.25
Rate for Payer: Affinity Medicaid/CHP/HARP	$37,585.00
Rate for Payer: Amida Care Medicaid	$37,585.00
Rate for Payer: EmblemHealth Essential Plan 1&2	$84,566.25
Rate for Payer: EmblemHealth Essential Plan 3&4	$37,585.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$37,585.00
Rate for Payer: Fidelis Qualified Health Plan	$45,102.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$37,585.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37,585.00
Rate for Payer: Healthfirst Commercial	$58,526.00
Rate for Payer: Healthfirst Essential Plan	$84,566.25
Rate for Payer: Healthfirst QHP	$33,372.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$37,585.00
Rate for Payer: SOMOS Essential	$84,566.25
Rate for Payer: United Healthcare Essential Plan 1&2	$84,566.25
Rate for Payer: United Healthcare Essential Plan 3&4	$84,566.25
Rate for Payer: United Healthcare Medicaid	$37,585.00
Rate for Payer: Wellcare CHP/FHP/Medicaid	$37,585.00

PERMETHRIN 1 % EX LIQD

Facility

$0.26

Service Code	NDC 6373612002
Hospital Charge Code	6373612002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13

PERMETHRIN 1 % EX LIQD

Facility

$0.26

Service Code	NDC 6373612002
Hospital Charge Code	6373612002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

PERMETHRIN 5 % EX CREA

Facility

$1.97

Service Code	NDC 2192202107
Hospital Charge Code	2192202107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.34
Rate for Payer: EmblemHealth Commercial	$0.98
Rate for Payer: Group Health Inc Commercial	$0.98
Rate for Payer: Group Health Inc Medicare	$0.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98
Rate for Payer: Hamaspik Choice Inc Medicare	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.28

PERMETHRIN 5 % EX CREA

Facility

$1.98

Service Code	NDC 4580226937
Hospital Charge Code	4580226937
Hospital Revenue Code	250
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$0.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.99

PERMETHRIN 5 % EX CREA

Facility

$1.97

Service Code	NDC 2192202107
Hospital Charge Code	2192202107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$0.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98

PERMETHRIN 5 % EX CREA

Facility

$1.98

Service Code	NDC 4580226937
Hospital Charge Code	4580226937
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.99
Rate for Payer: Aetna Government	$0.99
Rate for Payer: Brighton Health Commercial	$1.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.35
Rate for Payer: EmblemHealth Commercial	$0.99
Rate for Payer: Group Health Inc Commercial	$0.99
Rate for Payer: Group Health Inc Medicare	$0.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.99
Rate for Payer: Hamaspik Choice Inc Medicare	$0.99
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.29

PERMETHRIN 5 % EX CREA

Facility

$2.06

Service Code	NDC 0472024260
Hospital Charge Code	0472024260
Hospital Revenue Code	250
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.03

PERMETHRIN 5 % EX CREA

Facility

$2.06

Service Code	NDC 0472024260
Hospital Charge Code	0472024260
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.03
Rate for Payer: Aetna Government	$1.03
Rate for Payer: Brighton Health Commercial	$1.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.40
Rate for Payer: EmblemHealth Commercial	$1.03
Rate for Payer: Group Health Inc Commercial	$1.03
Rate for Payer: Group Health Inc Medicare	$0.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.03
Rate for Payer: Hamaspik Choice Inc Medicare	$1.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.34

PERPHENAZINE 16 MG PO TABS

Facility

$3.90

Service Code	NDC 5253617001
Hospital Charge Code	5253617001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.95
Rate for Payer: Aetna Government	$1.95
Rate for Payer: Brighton Health Commercial	$2.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.65
Rate for Payer: EmblemHealth Commercial	$1.95
Rate for Payer: Group Health Inc Commercial	$1.95
Rate for Payer: Group Health Inc Medicare	$1.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.95
Rate for Payer: Hamaspik Choice Inc Medicare	$1.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.53

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