St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.5 MG PO TABS

Facility

$0.74

Service Code	NDC 5976237201
Hospital Charge Code	5976237201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.37

ALPRAZOLAM 0.5 MG PO TABS

Facility

$0.74

Service Code	NDC 5976237201
Hospital Charge Code	5976237201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.37
Rate for Payer: Aetna Government	$0.37
Rate for Payer: Brighton Health Commercial	$0.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.59
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.51
Rate for Payer: EmblemHealth Commercial	$0.37
Rate for Payer: Group Health Inc Commercial	$0.37
Rate for Payer: Group Health Inc Medicare	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.37
Rate for Payer: Hamaspik Choice Inc Medicare	$0.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.48

ALPRAZOLAM 0.5 MG PO TABS

Facility

$0.93

Service Code	NDC 0228202910
Hospital Charge Code	0228202910
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.47
Rate for Payer: Aetna Government	$0.47
Rate for Payer: Brighton Health Commercial	$0.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: EmblemHealth Commercial	$0.47
Rate for Payer: Group Health Inc Commercial	$0.47
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.47
Rate for Payer: Hamaspik Choice Inc Medicare	$0.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.61

ALPRAZOLAM 0.5 MG PO TABS

Facility

$0.44

Service Code	NDC 6068738801
Hospital Charge Code	6068738801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22

ALPROSTADIL 500 MCG/ML IJ SOLN

Facility

$175.54

Service Code	NDC 0009316906
Hospital Charge Code	0009316906
Hospital Revenue Code	250
Min. Negotiated Rate	$61.44
Max. Negotiated Rate	$140.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$96.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$87.77
Rate for Payer: Aetna Government	$87.77
Rate for Payer: Brighton Health Commercial	$131.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$140.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$119.37
Rate for Payer: EmblemHealth Commercial	$87.77
Rate for Payer: Group Health Inc Commercial	$87.77
Rate for Payer: Group Health Inc Medicare	$61.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$87.77
Rate for Payer: Hamaspik Choice Inc Medicare	$87.77
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$114.10

ALPROSTADIL 500 MCG/ML IJ SOLN

Facility

$175.55

Service Code	NDC 0009316901
Hospital Charge Code	0009316901
Hospital Revenue Code	250
Min. Negotiated Rate	$61.44
Max. Negotiated Rate	$140.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$96.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$87.78
Rate for Payer: Aetna Government	$87.78
Rate for Payer: Brighton Health Commercial	$131.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$140.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$119.37
Rate for Payer: EmblemHealth Commercial	$87.78
Rate for Payer: Group Health Inc Commercial	$87.78
Rate for Payer: Group Health Inc Medicare	$61.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$87.78
Rate for Payer: Hamaspik Choice Inc Medicare	$87.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$114.11

ALPROSTADIL 500 MCG/ML IJ SOLN

Facility

$175.54

Service Code	NDC 0009316906
Hospital Charge Code	0009316906
Hospital Revenue Code	250
Min. Negotiated Rate	$87.77
Max. Negotiated Rate	$87.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$87.77

ALPROSTADIL 500 MCG/ML IJ SOLN

Facility

$175.55

Service Code	NDC 0009316901
Hospital Charge Code	0009316901
Hospital Revenue Code	250
Min. Negotiated Rate	$87.78
Max. Negotiated Rate	$87.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$87.78

ALTEPLASE 100 MG IV SOLR

Facility

$88.00

Service Code	HCPCS J2997
Hospital Charge Code	5024208525
Hospital Revenue Code	258
Min. Negotiated Rate	$48.40
Max. Negotiated Rate	$7,378.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$94.45
Rate for Payer: Aetna Government	$94.45
Rate for Payer: Affinity Essential Plan 1&2	$166.00
Rate for Payer: Affinity Essential Plan 3&4	$166.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.78
Rate for Payer: Amida Care Medicaid	$73.78
Rate for Payer: Brighton Health Commercial	$66.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$94.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$59.84
Rate for Payer: Elderplan Medicare Advantage	$94.45
Rate for Payer: EmblemHealth Commercial	$94.45
Rate for Payer: EmblemHealth Essential Plan 1&2	$166.00
Rate for Payer: EmblemHealth Essential Plan 3&4	$73.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$73.78
Rate for Payer: Fidelis Essential Plan Aliesa	$166.00
Rate for Payer: Fidelis Essential Plan QHP	$166.00
Rate for Payer: Fidelis Medicare Advantage	$94.45
Rate for Payer: Fidelis Qualified Health Plan	$77.47
Rate for Payer: Group Health Inc Commercial	$94.45
Rate for Payer: Group Health Inc Medicare	$94.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.78
Rate for Payer: Hamaspik Choice Inc Medicare	$94.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7,378.00
Rate for Payer: Healthfirst Essential Plan	$166.00
Rate for Payer: Healthfirst Medicare Advantage	$80.28
Rate for Payer: Healthfirst QHP	$120.26
Rate for Payer: Humana Medicare	$96.34
Rate for Payer: Senior Whole Health Medicare Advantage	$94.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$73.78
Rate for Payer: SOMOS Essential	$166.00
Rate for Payer: United Healthcare Essential Plan 1&2	$166.00
Rate for Payer: United Healthcare Essential Plan 3&4	$81.16
Rate for Payer: United Healthcare Medicaid	$73.78
Rate for Payer: United Healthcare Medicare Advantage	$94.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$73.78
Rate for Payer: Wellcare Medicare	$89.73

ALTEPLASE 100 MG IV SOLR

Facility

$88.00

Service Code	HCPCS J2997
Hospital Charge Code	5024208525
Hospital Revenue Code	258
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$44.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.00

ALTEPLASE 100 MG IV SOLR

Facility

$10.00

Service Code	HCPCS J2997
Hospital Charge Code	5024208527
Hospital Revenue Code	258
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00

ALTEPLASE 100 MG IV SOLR

Facility

$10.00

Service Code	HCPCS J2997
Hospital Charge Code	5024208527
Hospital Revenue Code	258
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7,378.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$94.45
Rate for Payer: Aetna Government	$94.45
Rate for Payer: Affinity Essential Plan 1&2	$166.00
Rate for Payer: Affinity Essential Plan 3&4	$166.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.78
Rate for Payer: Amida Care Medicaid	$73.78
Rate for Payer: Brighton Health Commercial	$7.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$94.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.80
Rate for Payer: Elderplan Medicare Advantage	$94.45
Rate for Payer: EmblemHealth Commercial	$94.45
Rate for Payer: EmblemHealth Essential Plan 1&2	$166.00
Rate for Payer: EmblemHealth Essential Plan 3&4	$73.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$73.78
Rate for Payer: Fidelis Essential Plan Aliesa	$166.00
Rate for Payer: Fidelis Essential Plan QHP	$166.00
Rate for Payer: Fidelis Medicare Advantage	$94.45
Rate for Payer: Fidelis Qualified Health Plan	$77.47
Rate for Payer: Group Health Inc Commercial	$94.45
Rate for Payer: Group Health Inc Medicare	$94.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.78
Rate for Payer: Hamaspik Choice Inc Medicare	$94.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7,378.00
Rate for Payer: Healthfirst Essential Plan	$166.00
Rate for Payer: Healthfirst Medicare Advantage	$80.28
Rate for Payer: Healthfirst QHP	$120.26
Rate for Payer: Humana Medicare	$96.34
Rate for Payer: Senior Whole Health Medicare Advantage	$94.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$73.78
Rate for Payer: SOMOS Essential	$166.00
Rate for Payer: United Healthcare Essential Plan 1&2	$166.00
Rate for Payer: United Healthcare Essential Plan 3&4	$81.16
Rate for Payer: United Healthcare Medicaid	$73.78
Rate for Payer: United Healthcare Medicare Advantage	$94.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$73.78
Rate for Payer: Wellcare Medicare	$89.73

ALTEPLASE 2 MG IJ SOLR

Facility

$211.62

Service Code	HCPCS J2997
Hospital Charge Code	5024204164
Hospital Revenue Code	250
Min. Negotiated Rate	$105.81
Max. Negotiated Rate	$105.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.81

ALTEPLASE 2 MG IJ SOLR

Facility

$211.62

Service Code	HCPCS J2997
Hospital Charge Code	5024204164
Hospital Revenue Code	250
Min. Negotiated Rate	$73.78
Max. Negotiated Rate	$7,378.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$116.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$94.45
Rate for Payer: Aetna Government	$94.45
Rate for Payer: Affinity Essential Plan 1&2	$166.00
Rate for Payer: Affinity Essential Plan 3&4	$166.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.78
Rate for Payer: Amida Care Medicaid	$73.78
Rate for Payer: Brighton Health Commercial	$158.72
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$94.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$169.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$143.90
Rate for Payer: Elderplan Medicare Advantage	$94.45
Rate for Payer: EmblemHealth Commercial	$94.45
Rate for Payer: EmblemHealth Essential Plan 1&2	$166.00
Rate for Payer: EmblemHealth Essential Plan 3&4	$73.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$73.78
Rate for Payer: Fidelis Essential Plan Aliesa	$166.00
Rate for Payer: Fidelis Essential Plan QHP	$166.00
Rate for Payer: Fidelis Medicare Advantage	$94.45
Rate for Payer: Fidelis Qualified Health Plan	$77.47
Rate for Payer: Group Health Inc Commercial	$94.45
Rate for Payer: Group Health Inc Medicare	$94.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.78
Rate for Payer: Hamaspik Choice Inc Medicare	$94.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7,378.00
Rate for Payer: Healthfirst Essential Plan	$166.00
Rate for Payer: Healthfirst Medicare Advantage	$80.28
Rate for Payer: Healthfirst QHP	$120.26
Rate for Payer: Humana Medicare	$96.34
Rate for Payer: Senior Whole Health Medicare Advantage	$94.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$73.78
Rate for Payer: SOMOS Essential	$166.00
Rate for Payer: United Healthcare Essential Plan 1&2	$166.00
Rate for Payer: United Healthcare Essential Plan 3&4	$81.16
Rate for Payer: United Healthcare Medicaid	$73.78
Rate for Payer: United Healthcare Medicare Advantage	$94.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$137.55
Rate for Payer: Wellcare CHP/FHP/Medicaid	$73.78
Rate for Payer: Wellcare Medicare	$89.73

ALTEPLASE 50 MG IV SOLR

Facility

$5.00

Service Code	HCPCS J2997
Hospital Charge Code	5024204413
Hospital Revenue Code	258
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50

ALTEPLASE 50 MG IV SOLR

Facility

$5.00

Service Code	HCPCS J2997
Hospital Charge Code	5024204413
Hospital Revenue Code	258
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$7,378.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$94.45
Rate for Payer: Aetna Government	$94.45
Rate for Payer: Affinity Essential Plan 1&2	$166.00
Rate for Payer: Affinity Essential Plan 3&4	$166.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$73.78
Rate for Payer: Amida Care Medicaid	$73.78
Rate for Payer: Brighton Health Commercial	$3.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$94.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.40
Rate for Payer: Elderplan Medicare Advantage	$94.45
Rate for Payer: EmblemHealth Commercial	$94.45
Rate for Payer: EmblemHealth Essential Plan 1&2	$166.00
Rate for Payer: EmblemHealth Essential Plan 3&4	$73.78
Rate for Payer: Fidelis CHP/HARP/Medicaid	$73.78
Rate for Payer: Fidelis Essential Plan Aliesa	$166.00
Rate for Payer: Fidelis Essential Plan QHP	$166.00
Rate for Payer: Fidelis Medicare Advantage	$94.45
Rate for Payer: Fidelis Qualified Health Plan	$77.47
Rate for Payer: Group Health Inc Commercial	$94.45
Rate for Payer: Group Health Inc Medicare	$94.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.78
Rate for Payer: Hamaspik Choice Inc Medicare	$94.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7,378.00
Rate for Payer: Healthfirst Essential Plan	$166.00
Rate for Payer: Healthfirst Medicare Advantage	$80.28
Rate for Payer: Healthfirst QHP	$120.26
Rate for Payer: Humana Medicare	$96.34
Rate for Payer: Senior Whole Health Medicare Advantage	$94.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$73.78
Rate for Payer: SOMOS Essential	$166.00
Rate for Payer: United Healthcare Essential Plan 1&2	$166.00
Rate for Payer: United Healthcare Essential Plan 3&4	$81.16
Rate for Payer: United Healthcare Medicaid	$73.78
Rate for Payer: United Healthcare Medicare Advantage	$94.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25
Rate for Payer: Wellcare CHP/FHP/Medicaid	$73.78
Rate for Payer: Wellcare Medicare	$89.73

ALTERATION IN CONSCIOUSNESS

Facility

$192.09

Service Code	EAPG 00883
Min. Negotiated Rate	$192.09
Max. Negotiated Rate	$192.09
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$192.09

ALUMINUM CHLORIDE 20 % EX SOLN

Facility

$0.29

Service Code	NDC 0096070735
Hospital Charge Code	0096070735
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: EmblemHealth Commercial	$0.15
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.19

ALUMINUM CHLORIDE 20 % EX SOLN

Facility

$0.23

Service Code	NDC 0096070760
Hospital Charge Code	0096070760
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: EmblemHealth Commercial	$0.12
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.15

ALUMINUM CHLORIDE 20 % EX SOLN

Facility

$0.23

Service Code	NDC 0096070760
Hospital Charge Code	0096070760
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12

ALUMINUM CHLORIDE 20 % EX SOLN

Facility

$0.29

Service Code	NDC 0096070735
Hospital Charge Code	0096070735
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15

ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP

Facility

$0.09

Service Code	NDC 1785609103
Hospital Charge Code	1785609103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04

ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP

Facility

$0.02

Service Code	NDC 0536009185
Hospital Charge Code	0536009185
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: EmblemHealth Commercial	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP

Facility

$0.02

Service Code	NDC 0536009185
Hospital Charge Code	0536009185
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01

ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP

Facility

$0.09

Service Code	NDC 1785609103
Hospital Charge Code	1785609103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.06
Rate for Payer: EmblemHealth Commercial	$0.04
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

Know your out-of-pocket cost for care.

All Charges