St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MIDAZOLAM 1 MG/ML INJ 2 ML

Facility

$0.40

Service Code	HCPCS J2250
Hospital Charge Code	41642388
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.26

MIDAZOLAM 1 MG/ML INJ 2 ML

Facility

$0.40

Service Code	HCPCS J2250
Hospital Charge Code	41652388
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.26

MIDAZOLAM 1 MG/ML INJ 2 ML

Facility

$0.40

Service Code	HCPCS J2250
Hospital Charge Code	41652388
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20

MIDAZOLAM 1 MG/ML INJ 2 ML

Facility

$0.40

Service Code	HCPCS J2250
Hospital Charge Code	41642388
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20

MIDAZOLAM 2 MG/ML SYRUP

Facility

$0.67

Hospital Charge Code	41652831
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.34
Rate for Payer: Aetna Government	$0.34
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.46
Rate for Payer: Group Health Inc Commercial	$0.34
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34
Rate for Payer: Hamaspik Choice Inc Medicare	$0.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.44

MIDAZOLAM 2 MG/ML SYRUP

Facility

$0.67

Hospital Charge Code	41642831
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.34
Rate for Payer: Aetna Government	$0.34
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.46
Rate for Payer: Group Health Inc Commercial	$0.34
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34
Rate for Payer: Hamaspik Choice Inc Medicare	$0.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.44

MIDAZOLAM 2 MG/ML SYRUP 5 ML UDC

Facility

$5.59

Hospital Charge Code	41645590
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$4.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.80
Rate for Payer: Aetna Government	$2.80
Rate for Payer: Brighton Health Commercial	$4.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.80
Rate for Payer: Group Health Inc Commercial	$2.80
Rate for Payer: Group Health Inc Medicare	$1.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.80
Rate for Payer: Hamaspik Choice Inc Medicare	$2.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.63

MIDAZOLAM 2 MG/ML SYRUP 5 ML UDC

Facility

$5.59

Hospital Charge Code	41655590
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$4.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.80
Rate for Payer: Aetna Government	$2.80
Rate for Payer: Brighton Health Commercial	$4.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.80
Rate for Payer: Group Health Inc Commercial	$2.80
Rate for Payer: Group Health Inc Medicare	$1.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.80
Rate for Payer: Hamaspik Choice Inc Medicare	$2.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.63

MIDAZOLAM 50MG/D5W100ML

Facility

$14.00

Hospital Charge Code	41657104
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

MIDAZOLAM 50MG/D5W100ML

Facility

$14.00

Hospital Charge Code	41647104
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

MIDAZOLAM 50MG/NS 100ML - PER 1MG

Facility

$17.00

Service Code	HCPCS J2250
Hospital Charge Code	41657166
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$11.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$10.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.78
Rate for Payer: Group Health Inc Commercial	$8.50
Rate for Payer: Group Health Inc Medicare	$5.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.05

MIDAZOLAM 50MG/NS 100ML - PER 1MG

Facility

$17.00

Service Code	HCPCS J2250
Hospital Charge Code	41647166
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$11.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$10.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.78
Rate for Payer: Group Health Inc Commercial	$8.50
Rate for Payer: Group Health Inc Medicare	$5.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.05

MIDAZOLAM 50MG/NS 100ML - PER 1MG

Facility

$17.00

Service Code	HCPCS J2250
Hospital Charge Code	41647166
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50

MIDAZOLAM 50MG/NS 100ML - PER 1MG

Facility

$17.00

Service Code	HCPCS J2250
Hospital Charge Code	41657166
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50

MIDAZOLAM 5 MG/ML INJ 10 ML

Facility

$0.25

Service Code	HCPCS J2250
Hospital Charge Code	41652389
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

MIDAZOLAM 5 MG/ML INJ 10 ML

Facility

$0.25

Service Code	HCPCS J2250
Hospital Charge Code	41652389
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

MIDAZOLAM 5 MG/ML INJ 10 ML

Facility

$0.25

Service Code	HCPCS J2250
Hospital Charge Code	41642389
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
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: SOMOS CHP/HARP/Medicaid	$0.14
Rate for Payer: SOMOS Essential	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

MIDAZOLAM 5 MG/ML INJ 10 ML

Facility

$0.25

Service Code	HCPCS J2250
Hospital Charge Code	41642389
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

MIDAZOLAM HCL 2 MG/2ML IJ SOLN [40872]

Facility

$0.39

Service Code	HCPCS J2250
Hospital Charge Code	00641605725
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

MIDAZOLAM HCL 2 MG/2ML IJ SOLN [40872]

Facility

$0.53

Service Code	HCPCS J2250
Hospital Charge Code	23155060031
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.36
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

MIDAZOLAM HCL 2 MG/2ML IJ SOLN [40872]

Facility

$0.53

Service Code	HCPCS J2250
Hospital Charge Code	23155060041
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.36
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.14
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.14
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.14
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

MIDAZOLAM HCL 2 MG/ML PO SYRP [24176]

Facility

$1.48

Service Code	NDC 60687057686
Hospital Charge Code	60687057686
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$1.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.74
Rate for Payer: Aetna Government	$0.74
Rate for Payer: Brighton Health Commercial	$1.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.01
Rate for Payer: Group Health Inc Commercial	$0.74
Rate for Payer: Group Health Inc Medicare	$0.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.74
Rate for Payer: Hamaspik Choice Inc Medicare	$0.74
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.96

MIDAZOLAM HCL 2 MG/ML PO SYRP [24176]

Facility

$1.47

Service Code	NDC 68094076459
Hospital Charge Code	68094076459
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$1.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.73
Rate for Payer: Aetna Government	$0.73
Rate for Payer: Brighton Health Commercial	$1.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.00
Rate for Payer: Group Health Inc Commercial	$0.73
Rate for Payer: Group Health Inc Medicare	$0.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.73
Rate for Payer: Hamaspik Choice Inc Medicare	$0.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.95

MIDAZOLAM HCL 2 MG/ML PO SYRP [24176]

Facility

$2.16

Service Code	NDC 00054356699
Hospital Charge Code	00054356699
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.08
Rate for Payer: Aetna Government	$1.08
Rate for Payer: Brighton Health Commercial	$1.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.47
Rate for Payer: Group Health Inc Commercial	$1.08
Rate for Payer: Group Health Inc Medicare	$0.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.08
Rate for Payer: Hamaspik Choice Inc Medicare	$1.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.40

MIDAZOLAM HCL 2 MG/ML PO SYRP [24176]

Facility

$1.47

Service Code	NDC 68094076462
Hospital Charge Code	68094076462
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$1.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.73
Rate for Payer: Aetna Government	$0.73
Rate for Payer: Brighton Health Commercial	$1.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.00
Rate for Payer: Group Health Inc Commercial	$0.73
Rate for Payer: Group Health Inc Medicare	$0.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.73
Rate for Payer: Hamaspik Choice Inc Medicare	$0.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.95

Know your out-of-pocket cost for care.

All Charges