St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR

Facility

$21.00

Service Code	HCPCS J9309
Hospital Charge Code	5024210501
Hospital Revenue Code	258
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$10.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.50

POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR

Facility

$21.00

Service Code	HCPCS J9309
Hospital Charge Code	5024210501
Hospital Revenue Code	258
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$139.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$136.67
Rate for Payer: Aetna Government	$136.67
Rate for Payer: Affinity Essential Plan 1&2	$95.67
Rate for Payer: Affinity Essential Plan 3&4	$95.67
Rate for Payer: Affinity Medicaid/CHP/HARP	$95.67
Rate for Payer: Brighton Health Commercial	$15.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$136.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.28
Rate for Payer: Elderplan Medicare Advantage	$136.67
Rate for Payer: EmblemHealth Commercial	$136.67
Rate for Payer: Fidelis CHP/HARP/Medicaid	$123.00
Rate for Payer: Fidelis Essential Plan Aliesa	$116.17
Rate for Payer: Fidelis Essential Plan QHP	$121.64
Rate for Payer: Fidelis Medicare Advantage	$136.67
Rate for Payer: Fidelis Qualified Health Plan	$121.64
Rate for Payer: Group Health Inc Commercial	$136.67
Rate for Payer: Group Health Inc Medicare	$136.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$136.67
Rate for Payer: Hamaspik Choice Inc Medicare	$136.67
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$136.67
Rate for Payer: Healthfirst Medicare Advantage	$116.17
Rate for Payer: Healthfirst QHP	$136.67
Rate for Payer: Humana Medicare	$139.40
Rate for Payer: Senior Whole Health Medicare Advantage	$136.67
Rate for Payer: United Healthcare Medicare Advantage	$136.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$129.84
Rate for Payer: Wellcare Medicare	$129.84

POLATUZUMAB VEDOTIN-PIIQ 30 MG IV SOLR

Facility

$4.00

Service Code	HCPCS J9309
Hospital Charge Code	5024210301
Hospital Revenue Code	258
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00

POLATUZUMAB VEDOTIN-PIIQ 30 MG IV SOLR

Facility

$4.00

Service Code	HCPCS J9309
Hospital Charge Code	5024210301
Hospital Revenue Code	258
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$139.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$136.67
Rate for Payer: Aetna Government	$136.67
Rate for Payer: Affinity Essential Plan 1&2	$95.67
Rate for Payer: Affinity Essential Plan 3&4	$95.67
Rate for Payer: Affinity Medicaid/CHP/HARP	$95.67
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$136.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Elderplan Medicare Advantage	$136.67
Rate for Payer: EmblemHealth Commercial	$136.67
Rate for Payer: Fidelis CHP/HARP/Medicaid	$123.00
Rate for Payer: Fidelis Essential Plan Aliesa	$116.17
Rate for Payer: Fidelis Essential Plan QHP	$121.64
Rate for Payer: Fidelis Medicare Advantage	$136.67
Rate for Payer: Fidelis Qualified Health Plan	$121.64
Rate for Payer: Group Health Inc Commercial	$136.67
Rate for Payer: Group Health Inc Medicare	$136.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$136.67
Rate for Payer: Hamaspik Choice Inc Medicare	$136.67
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$136.67
Rate for Payer: Healthfirst Medicare Advantage	$116.17
Rate for Payer: Healthfirst QHP	$136.67
Rate for Payer: Humana Medicare	$139.40
Rate for Payer: Senior Whole Health Medicare Advantage	$136.67
Rate for Payer: United Healthcare Medicare Advantage	$136.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60
Rate for Payer: Wellcare CHP/FHP/Medicaid	$129.84
Rate for Payer: Wellcare Medicare	$129.84

POLIOVIRUS VACCINE INACTIVATED IJ INJ

Facility

$102.03

Service Code	NDC 4928186010
Hospital Charge Code	4928186010
Hospital Revenue Code	250
Min. Negotiated Rate	$51.02
Max. Negotiated Rate	$51.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.02

POLIOVIRUS VACCINE INACTIVATED IJ INJ

Facility

$102.03

Service Code	NDC 4928186010
Hospital Charge Code	4928186010
Hospital Revenue Code	250
Min. Negotiated Rate	$35.71
Max. Negotiated Rate	$81.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$56.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$51.02
Rate for Payer: Aetna Government	$51.02
Rate for Payer: Brighton Health Commercial	$76.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$81.63
Rate for Payer: Cigna LocalPlus Benefit Plan	$69.38
Rate for Payer: EmblemHealth Commercial	$51.02
Rate for Payer: Group Health Inc Commercial	$51.02
Rate for Payer: Group Health Inc Medicare	$35.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.02
Rate for Payer: Hamaspik Choice Inc Medicare	$51.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$66.32

POLYETHYLENE GLYCOL 3350 17 G PO PACK

Facility

$2.78

Service Code	NDC 6068743198
Hospital Charge Code	6068743198
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.39

POLYETHYLENE GLYCOL 3350 17 G PO PACK

Facility

$1.67

Service Code	NDC 6255915710
Hospital Charge Code	6255915710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$0.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.84

POLYETHYLENE GLYCOL 3350 17 G PO PACK

Facility

$1.67

Service Code	NDC 6255915710
Hospital Charge Code	6255915710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$1.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.84
Rate for Payer: Aetna Government	$0.84
Rate for Payer: Brighton Health Commercial	$1.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.14
Rate for Payer: EmblemHealth Commercial	$0.84
Rate for Payer: Group Health Inc Commercial	$0.84
Rate for Payer: Group Health Inc Medicare	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.84
Rate for Payer: Hamaspik Choice Inc Medicare	$0.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.09

POLYETHYLENE GLYCOL 3350 17 G PO PACK

Facility

$2.78

Service Code	NDC 6068743198
Hospital Charge Code	6068743198
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$2.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.39
Rate for Payer: Aetna Government	$1.39
Rate for Payer: Brighton Health Commercial	$2.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.89
Rate for Payer: EmblemHealth Commercial	$1.39
Rate for Payer: Group Health Inc Commercial	$1.39
Rate for Payer: Group Health Inc Medicare	$0.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.39
Rate for Payer: Hamaspik Choice Inc Medicare	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.81

POLYETHYLENE GLYCOL 400 1 % OP SOLN

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	7430001067
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21

POLYETHYLENE GLYCOL 400 1 % OP SOLN

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	7430001067
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.21
Rate for Payer: Aetna Government	$0.21
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.29
Rate for Payer: EmblemHealth Commercial	$0.21
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.27

POLYMYXIN B SULFATE 500000 UNITS IJ SOLR

Facility

$11.99

Service Code	NDC 6332332110
Hospital Charge Code	6332332110
Hospital Revenue Code	250
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$5.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.99

POLYMYXIN B SULFATE 500000 UNITS IJ SOLR

Facility

$11.99

Service Code	NDC 6332332110
Hospital Charge Code	6332332110
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$9.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.99
Rate for Payer: Aetna Government	$5.99
Rate for Payer: Brighton Health Commercial	$8.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.15
Rate for Payer: EmblemHealth Commercial	$5.99
Rate for Payer: Group Health Inc Commercial	$5.99
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.99
Rate for Payer: Hamaspik Choice Inc Medicare	$5.99
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.79

POLYMYXIN B SULFATE 500000 UNITS IJ SOLR

Facility

$17.50

Service Code	NDC 5515023410
Hospital Charge Code	5515023410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$14.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.75
Rate for Payer: Aetna Government	$8.75
Rate for Payer: Brighton Health Commercial	$13.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.90
Rate for Payer: EmblemHealth Commercial	$8.75
Rate for Payer: Group Health Inc Commercial	$8.75
Rate for Payer: Group Health Inc Medicare	$6.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.75
Rate for Payer: Hamaspik Choice Inc Medicare	$8.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.38

POLYMYXIN B SULFATE 500000 UNITS IJ SOLR

Facility

$17.50

Service Code	NDC 5515023410
Hospital Charge Code	5515023410
Hospital Revenue Code	250
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$8.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.75

POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN

Facility

$1.74

Service Code	NDC 6131462810
Hospital Charge Code	6131462810
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87

POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN

Facility

$1.34

Service Code	NDC 2420831510
Hospital Charge Code	2420831510
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.67

POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN

Facility

$1.74

Service Code	NDC 6131462810
Hospital Charge Code	6131462810
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.87
Rate for Payer: Aetna Government	$0.87
Rate for Payer: Brighton Health Commercial	$1.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.18
Rate for Payer: EmblemHealth Commercial	$0.87
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

POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN

Facility

$1.34

Service Code	NDC 2420831510
Hospital Charge Code	2420831510
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$1.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.67
Rate for Payer: Aetna Government	$0.67
Rate for Payer: Brighton Health Commercial	$1.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.91
Rate for Payer: EmblemHealth Commercial	$0.67
Rate for Payer: Group Health Inc Commercial	$0.67
Rate for Payer: Group Health Inc Medicare	$0.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.67
Rate for Payer: Hamaspik Choice Inc Medicare	$0.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.87

POLYVINYL ALCOHOL 1.4 % OP SOLN

Facility

$0.49

Service Code	NDC 5026867815
Hospital Charge Code	5026867815
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25

POLYVINYL ALCOHOL 1.4 % OP SOLN

Facility

$0.49

Service Code	NDC 5026867815
Hospital Charge Code	5026867815
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.34
Rate for Payer: EmblemHealth Commercial	$0.25
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.32

POLY-VI-SOL PO SOLN

Facility

$0.20

Service Code	NDC 0087040203
Hospital Charge Code	0087040203
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10

POLY-VI-SOL PO SOLN

Facility

$0.20

Service Code	NDC 0087040203
Hospital Charge Code	0087040203
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: EmblemHealth Commercial	$0.10
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

POLY-VITA PO SOLN

Facility

$0.20

Service Code	NDC 0087040203
Hospital Charge Code	0087040203
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10

Know your out-of-pocket cost for care.

All Charges