St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LOPERAMIDE 0.2 MG/ML LIQUID

Facility

$4.00

Hospital Charge Code	41651235
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

LOPERAMIDE 1 MG/5 ML LIQUID UDC

Facility

$1.57

Hospital Charge Code	41645298
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$1.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.07
Rate for Payer: Group Health Inc Commercial	$0.79
Rate for Payer: Group Health Inc Medicare	$0.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.79
Rate for Payer: Hamaspik Choice Inc Medicare	$0.79
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.02

LOPERAMIDE 1 MG/5 ML LIQUID UDC

Facility

$1.57

Hospital Charge Code	41655298
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$1.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.07
Rate for Payer: Group Health Inc Commercial	$0.79
Rate for Payer: Group Health Inc Medicare	$0.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.79
Rate for Payer: Hamaspik Choice Inc Medicare	$0.79
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.02

LOPERAMIDE 2 MG/10 ML LIQUID UDC

Facility

$3.00

Hospital Charge Code	41651625
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

LOPERAMIDE 2 MG/10 ML LIQUID UDC

Facility

$3.00

Hospital Charge Code	41641625
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

LOPERAMIDE 2 MG CAP

Facility

$1.00

Hospital Charge Code	41650364
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LOPERAMIDE 2 MG CAP

Facility

$1.00

Hospital Charge Code	41640364
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LOPERAMIDE HCL 1 MG/5ML PO LIQD [4561]

Facility

$0.05

Service Code	NDC 00363037726
Hospital Charge Code	00363037726
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

LOPERAMIDE HCL 1 MG/7.5ML PO SOLN [173371]

Facility

$0.21

Service Code	NDC 68094012962
Hospital Charge Code	68094012962
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

LOPERAMIDE HCL 1 MG/7.5ML PO SOLN [173371]

Facility

$0.21

Service Code	NDC 68094012959
Hospital Charge Code	68094012959
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

LOPERAMIDE HCL 2 MG PO CAPS [4560]

Facility

$1.37

Service Code	NDC 69452027120
Hospital Charge Code	69452027120
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.68
Rate for Payer: Aetna Government	$0.68
Rate for Payer: Brighton Health Commercial	$1.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.93
Rate for Payer: Group Health Inc Commercial	$0.68
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

LOPERAMIDE HCL 2 MG PO CAPS [4560]

Facility

$1.02

Service Code	NDC 60687022901
Hospital Charge Code	60687022901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.56
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.51
Rate for Payer: Aetna Government	$0.51
Rate for Payer: Brighton Health Commercial	$0.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.69
Rate for Payer: Group Health Inc Commercial	$0.51
Rate for Payer: Group Health Inc Medicare	$0.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.51
Rate for Payer: Hamaspik Choice Inc Medicare	$0.51
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.66

LOPERAMIDE HCL 2 MG PO CAPS [4560]

Facility

$1.37

Service Code	NDC 00093031101
Hospital Charge Code	00093031101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.68
Rate for Payer: Aetna Government	$0.68
Rate for Payer: Brighton Health Commercial	$1.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.93
Rate for Payer: Group Health Inc Commercial	$0.68
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

LOPERAMIDE HCL 2 MG PO CAPS [4560]

Facility

$0.88

Service Code	NDC 51079069020
Hospital Charge Code	51079069020
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.44
Rate for Payer: Aetna Government	$0.44
Rate for Payer: Brighton Health Commercial	$0.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: Group Health Inc Commercial	$0.44
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.44
Rate for Payer: Hamaspik Choice Inc Medicare	$0.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.57

LOPINAVIR-RITONAVIR 200-50 MG PO TABS [43391]

Facility

$10.24

Service Code	NDC 00074679922
Hospital Charge Code	00074679922
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.12
Rate for Payer: Aetna Government	$5.12
Rate for Payer: Brighton Health Commercial	$7.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.96
Rate for Payer: Group Health Inc Commercial	$5.12
Rate for Payer: Group Health Inc Medicare	$3.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.12
Rate for Payer: Hamaspik Choice Inc Medicare	$5.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.66

LOPINAVIR + RITONAVIR 200 MG-50 MG TAB

Facility

$12.00

Hospital Charge Code	41642455
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$9.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.00
Rate for Payer: Aetna Government	$6.00
Rate for Payer: Brighton Health Commercial	$9.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.16
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

LOPINAVIR + RITONAVIR 200 MG-50 MG TAB

Facility

$12.00

Hospital Charge Code	41652455
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$9.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.00
Rate for Payer: Aetna Government	$6.00
Rate for Payer: Brighton Health Commercial	$9.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.16
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN [28929]

Facility

$3.84

Service Code	NDC 00074395646
Hospital Charge Code	00074395646
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$3.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.92
Rate for Payer: Aetna Government	$1.92
Rate for Payer: Brighton Health Commercial	$2.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.61
Rate for Payer: Group Health Inc Commercial	$1.92
Rate for Payer: Group Health Inc Medicare	$1.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.92
Rate for Payer: Hamaspik Choice Inc Medicare	$1.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.50

LOPINAVIR + RITONAVIR 400 MG-100 MG/5 ML

Facility

$4.49

Hospital Charge Code	41652456
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$3.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.24
Rate for Payer: Aetna Government	$2.24
Rate for Payer: Brighton Health Commercial	$3.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.05
Rate for Payer: Group Health Inc Commercial	$2.24
Rate for Payer: Group Health Inc Medicare	$1.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.24
Rate for Payer: Hamaspik Choice Inc Medicare	$2.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.92

LOPINAVIR + RITONAVIR 400 MG-100 MG/5 ML

Facility

$4.49

Hospital Charge Code	41642456
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$3.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.24
Rate for Payer: Aetna Government	$2.24
Rate for Payer: Brighton Health Commercial	$3.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.05
Rate for Payer: Group Health Inc Commercial	$2.24
Rate for Payer: Group Health Inc Medicare	$1.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.24
Rate for Payer: Hamaspik Choice Inc Medicare	$2.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.92

LOPRO WAND 90DEGREES WITH CABLE

Facility

$260.00

Hospital Charge Code	40200962
Hospital Revenue Code	270
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$208.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$143.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$130.00
Rate for Payer: Aetna Government	$130.00
Rate for Payer: Brighton Health Commercial	$195.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$208.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$176.80
Rate for Payer: Group Health Inc Commercial	$130.00
Rate for Payer: Group Health Inc Medicare	$91.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$130.00
Rate for Payer: Hamaspik Choice Inc Medicare	$130.00

LOPRO WITH CABLE

Facility

$360.00

Hospital Charge Code	64904640
Hospital Revenue Code	270
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$288.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$198.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$180.00
Rate for Payer: Aetna Government	$180.00
Rate for Payer: Brighton Health Commercial	$270.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$288.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$244.80
Rate for Payer: Group Health Inc Commercial	$180.00
Rate for Payer: Group Health Inc Medicare	$126.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$180.00
Rate for Payer: Hamaspik Choice Inc Medicare	$180.00

LORAZEPAM 0.4 MG/ML INJ NEONATAL

Facility

$4.00

Hospital Charge Code	41650016
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

LORAZEPAM 0.4 MG/ML INJ NEONATAL

Facility

$4.00

Hospital Charge Code	41640016
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

LORAZEPAM 0.5 MG PO TABS [4572]

Facility

$0.63

Service Code	NDC 69315090405
Hospital Charge Code	69315090405
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.31
Rate for Payer: Aetna Government	$0.31
Rate for Payer: Brighton Health Commercial	$0.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.43
Rate for Payer: Group Health Inc Commercial	$0.31
Rate for Payer: Group Health Inc Medicare	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31
Rate for Payer: Hamaspik Choice Inc Medicare	$0.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.41

Know your out-of-pocket cost for care.

All Charges