St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SACUBITRIL-VALSARTAN 49-51 MG PO TABS [129912]

Facility

$13.76

Service Code	NDC 00078077720
Hospital Charge Code	00078077720
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$11.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.88
Rate for Payer: Aetna Government	$6.88
Rate for Payer: Brighton Health Commercial	$10.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.36
Rate for Payer: Group Health Inc Commercial	$6.88
Rate for Payer: Group Health Inc Medicare	$4.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.88
Rate for Payer: Hamaspik Choice Inc Medicare	$6.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.94

SACUBITRIL/VALSARTAN 49MG-51MG

Facility

$52.70

Hospital Charge Code	41650209
Hospital Revenue Code	250
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$42.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.35
Rate for Payer: Aetna Government	$26.35
Rate for Payer: Brighton Health Commercial	$39.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$42.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.84
Rate for Payer: Group Health Inc Commercial	$26.35
Rate for Payer: Group Health Inc Medicare	$18.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.35
Rate for Payer: Hamaspik Choice Inc Medicare	$26.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.26

SACUBITRIL/VALSARTAN 49MG-51MG

Facility

$52.70

Hospital Charge Code	41640209
Hospital Revenue Code	250
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$42.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.35
Rate for Payer: Aetna Government	$26.35
Rate for Payer: Brighton Health Commercial	$39.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$42.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.84
Rate for Payer: Group Health Inc Commercial	$26.35
Rate for Payer: Group Health Inc Medicare	$18.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.35
Rate for Payer: Hamaspik Choice Inc Medicare	$26.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.26

SACUBITRIL-VALSARTAN 97-103 MG PO TABS [129913]

Facility

$13.76

Service Code	NDC 00078069620
Hospital Charge Code	00078069620
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$11.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.88
Rate for Payer: Aetna Government	$6.88
Rate for Payer: Brighton Health Commercial	$10.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.36
Rate for Payer: Group Health Inc Commercial	$6.88
Rate for Payer: Group Health Inc Medicare	$4.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.88
Rate for Payer: Hamaspik Choice Inc Medicare	$6.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.94

SACUBITRIL/VALSARTAN 97MG-103MG

Facility

$52.70

Hospital Charge Code	41640208
Hospital Revenue Code	250
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$42.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.35
Rate for Payer: Aetna Government	$26.35
Rate for Payer: Brighton Health Commercial	$39.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$42.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.84
Rate for Payer: Group Health Inc Commercial	$26.35
Rate for Payer: Group Health Inc Medicare	$18.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.35
Rate for Payer: Hamaspik Choice Inc Medicare	$26.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.26

SACUBITRIL/VALSARTAN 97MG-103MG

Facility

$52.70

Hospital Charge Code	41650208
Hospital Revenue Code	250
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$42.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.35
Rate for Payer: Aetna Government	$26.35
Rate for Payer: Brighton Health Commercial	$39.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$42.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$35.84
Rate for Payer: Group Health Inc Commercial	$26.35
Rate for Payer: Group Health Inc Medicare	$18.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.35
Rate for Payer: Hamaspik Choice Inc Medicare	$26.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.26

SAFEPICO 22G X 1 1/4 0.7-1.5

Facility

$2.38

Hospital Charge Code	64902056
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.19
Rate for Payer: Aetna Government	$1.19
Rate for Payer: Brighton Health Commercial	$1.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.62
Rate for Payer: Group Health Inc Commercial	$1.19
Rate for Payer: Group Health Inc Medicare	$0.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.19
Rate for Payer: Hamaspik Choice Inc Medicare	$1.19

SAFEPICO 23G X 1 0.7-1.5

Facility

$2.38

Hospital Charge Code	64902058
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.19
Rate for Payer: Aetna Government	$1.19
Rate for Payer: Brighton Health Commercial	$1.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.62
Rate for Payer: Group Health Inc Commercial	$1.19
Rate for Payer: Group Health Inc Medicare	$0.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.19
Rate for Payer: Hamaspik Choice Inc Medicare	$1.19

SAFEPICO 25G X 5/8 0.7-1.5

Facility

$2.38

Hospital Charge Code	64902060
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.19
Rate for Payer: Aetna Government	$1.19
Rate for Payer: Brighton Health Commercial	$1.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.62
Rate for Payer: Group Health Inc Commercial	$1.19
Rate for Payer: Group Health Inc Medicare	$0.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.19
Rate for Payer: Hamaspik Choice Inc Medicare	$1.19

SAFESHEATH II PLI KIT 7FR 23CM

Facility

$657.00

Hospital Charge Code	40005901
Hospital Revenue Code	272
Min. Negotiated Rate	$229.95
Max. Negotiated Rate	$525.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$361.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$328.50
Rate for Payer: Aetna Government	$328.50
Rate for Payer: Brighton Health Commercial	$492.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$525.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$446.76
Rate for Payer: Group Health Inc Commercial	$328.50
Rate for Payer: Group Health Inc Medicare	$229.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$328.50
Rate for Payer: Hamaspik Choice Inc Medicare	$328.50

SAFE SHEATH WORLEY STD 19M

Facility

$836.00

Service Code	HCPCS C1776
Hospital Charge Code	66570514
Hospital Revenue Code	278
Min. Negotiated Rate	$292.60
Max. Negotiated Rate	$877.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$459.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$501.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$418.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$480.70
Rate for Payer: EmblemHealth Commercial	$418.00
Rate for Payer: Fidelis Medicare Advantage	$877.80
Rate for Payer: Group Health Inc Commercial	$418.00
Rate for Payer: Group Health Inc Medicare	$292.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$418.00
Rate for Payer: Hamaspik Choice Inc Medicare	$418.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$543.40

SAFE SHEATH WORLEY STD 19M

Facility

$836.00

Service Code	HCPCS C1776
Hospital Charge Code	66570514
Hospital Revenue Code	278
Min. Negotiated Rate	$418.00
Max. Negotiated Rate	$418.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$418.00
Rate for Payer: Hamaspik Choice Inc Medicare	$418.00

SAFETY SCREW

Facility

$104.00

Service Code	HCPCS C1713
Hospital Charge Code	40200061
Hospital Revenue Code	278
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$52.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00

SAFETY SCREW

Facility

$104.00

Service Code	HCPCS C1713
Hospital Charge Code	40200061
Hospital Revenue Code	278
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$134.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$62.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$52.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$59.80
Rate for Payer: EmblemHealth Commercial	$52.00
Rate for Payer: Fidelis Medicare Advantage	$109.20
Rate for Payer: Group Health Inc Commercial	$52.00
Rate for Payer: Group Health Inc Medicare	$36.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$67.60

SAFETY SCREW 1.9X4MM

Facility

$140.00

Service Code	HCPCS C1713
Hospital Charge Code	40200168
Hospital Revenue Code	278
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$147.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$77.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$84.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$80.50
Rate for Payer: EmblemHealth Commercial	$70.00
Rate for Payer: Fidelis Medicare Advantage	$147.00
Rate for Payer: Group Health Inc Commercial	$70.00
Rate for Payer: Group Health Inc Medicare	$49.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$70.00
Rate for Payer: Hamaspik Choice Inc Medicare	$70.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$91.00

SAFETY SCREW 1.9X4MM

Facility

$140.00

Service Code	HCPCS C1713
Hospital Charge Code	40200168
Hospital Revenue Code	278
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$70.00
Rate for Payer: Hamaspik Choice Inc Medicare	$70.00

SALICYLATE QUANTITATION

Facility

$107.50

Service Code	HCPCS 80329
Hospital Charge Code	40602225
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$86.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$59.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$80.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$86.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$73.10
Rate for Payer: Group Health Inc Commercial	$53.75
Rate for Payer: Group Health Inc Medicare	$37.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$53.75
Rate for Payer: Hamaspik Choice Inc Medicare	$53.75
Rate for Payer: United Healthcare Commercial	$24.79

SALICYLIC ACID 30% 60ML

Facility

$54.00

Hospital Charge Code	41648012
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$43.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.00
Rate for Payer: Aetna Government	$27.00
Rate for Payer: Brighton Health Commercial	$40.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$36.72
Rate for Payer: Group Health Inc Commercial	$27.00
Rate for Payer: Group Health Inc Medicare	$18.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.00
Rate for Payer: Hamaspik Choice Inc Medicare	$27.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35.10

SALICYLIC ACID 30% 60ML

Facility

$54.00

Hospital Charge Code	41658012
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$43.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.00
Rate for Payer: Aetna Government	$27.00
Rate for Payer: Brighton Health Commercial	$40.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$36.72
Rate for Payer: Group Health Inc Commercial	$27.00
Rate for Payer: Group Health Inc Medicare	$18.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.00
Rate for Payer: Hamaspik Choice Inc Medicare	$27.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35.10

SALICYLIC ACID 6 % EX GEL [11308]

Facility

$8.90

Service Code	NDC 42192013440
Hospital Charge Code	42192013440
Hospital Revenue Code	250
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$7.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.45
Rate for Payer: Aetna Government	$4.45
Rate for Payer: Brighton Health Commercial	$6.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.05
Rate for Payer: Group Health Inc Commercial	$4.45
Rate for Payer: Group Health Inc Medicare	$3.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.45
Rate for Payer: Hamaspik Choice Inc Medicare	$4.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.79

SALICYLIC ACID-SULFUR 2-2 % EX SHAM [11327]

Facility

$0.04

Service Code	NDC 00536196297
Hospital Charge Code	00536196297
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
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	$0.03
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	$0.01
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	$0.02

SALICYLIC ACID-SULFUR SHAMPOO

Facility

$2.88

Hospital Charge Code	41643290
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.44
Rate for Payer: Aetna Government	$1.44
Rate for Payer: Brighton Health Commercial	$2.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.96
Rate for Payer: Group Health Inc Commercial	$1.44
Rate for Payer: Group Health Inc Medicare	$1.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.87

SALICYLIC ACID-SULFUR SHAMPOO

Facility

$2.88

Hospital Charge Code	41653290
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.44
Rate for Payer: Aetna Government	$1.44
Rate for Payer: Brighton Health Commercial	$2.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.96
Rate for Payer: Group Health Inc Commercial	$1.44
Rate for Payer: Group Health Inc Medicare	$1.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.87

SALICYLIC ACID TOPICAL 6% GEL

Facility

$64.36

Hospital Charge Code	41643564
Hospital Revenue Code	250
Min. Negotiated Rate	$22.53
Max. Negotiated Rate	$51.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$32.18
Rate for Payer: Aetna Government	$32.18
Rate for Payer: Brighton Health Commercial	$48.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$51.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$43.76
Rate for Payer: Group Health Inc Commercial	$32.18
Rate for Payer: Group Health Inc Medicare	$22.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.18
Rate for Payer: Hamaspik Choice Inc Medicare	$32.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$41.83

SALICYLIC ACID TOPICAL 6% GEL

Facility

$64.36

Hospital Charge Code	41653564
Hospital Revenue Code	250
Min. Negotiated Rate	$22.53
Max. Negotiated Rate	$51.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$32.18
Rate for Payer: Aetna Government	$32.18
Rate for Payer: Brighton Health Commercial	$48.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$51.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$43.76
Rate for Payer: Group Health Inc Commercial	$32.18
Rate for Payer: Group Health Inc Medicare	$22.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.18
Rate for Payer: Hamaspik Choice Inc Medicare	$32.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$41.83

Know your out-of-pocket cost for care.

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