St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

Behavioral disorders

Facility

$12,537.00

Service Code	APR-DRG 7584
Min. Negotiated Rate	$3,379.60
Max. Negotiated Rate	$12,537.00
Rate for Payer: Affinity Essential Plan 1&2	$3,379.60
Rate for Payer: Affinity Essential Plan 3&4	$3,379.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,379.60
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,379.60
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,604.10
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,379.60
Rate for Payer: Fidelis Qualified Health Plan	$4,055.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,379.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,379.60
Rate for Payer: Healthfirst Commercial	$12,537.00
Rate for Payer: Healthfirst Essential Plan	$7,604.10
Rate for Payer: Healthfirst QHP	$6,150.87
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,379.60
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,604.10
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,604.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,379.60
Rate for Payer: SOMOS Essential	$7,604.10
Rate for Payer: United Healthcare Essential Plan 1&2	$7,604.10
Rate for Payer: United Healthcare Essential Plan 3&4	$7,604.10
Rate for Payer: United Healthcare Medicaid	$3,379.60

Behavioral disorders

Facility

$12,537.00

Service Code	APR-DRG 7583
Min. Negotiated Rate	$3,379.60
Max. Negotiated Rate	$12,537.00
Rate for Payer: Affinity Essential Plan 1&2	$3,379.60
Rate for Payer: Affinity Essential Plan 3&4	$3,379.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,379.60
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,379.60
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,604.10
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,379.60
Rate for Payer: Fidelis Qualified Health Plan	$4,055.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,379.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,379.60
Rate for Payer: Healthfirst Commercial	$12,537.00
Rate for Payer: Healthfirst Essential Plan	$7,604.10
Rate for Payer: Healthfirst QHP	$6,150.87
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,379.60
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,604.10
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,604.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,379.60
Rate for Payer: SOMOS Essential	$7,604.10
Rate for Payer: United Healthcare Essential Plan 1&2	$7,604.10
Rate for Payer: United Healthcare Essential Plan 3&4	$7,604.10
Rate for Payer: United Healthcare Medicaid	$3,379.60

Behavioral disorders

Facility

$12,537.00

Service Code	APR-DRG 7582
Min. Negotiated Rate	$3,379.60
Max. Negotiated Rate	$12,537.00
Rate for Payer: Affinity Essential Plan 1&2	$3,379.60
Rate for Payer: Affinity Essential Plan 3&4	$3,379.60
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,379.60
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,379.60
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,604.10
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,379.60
Rate for Payer: Fidelis Qualified Health Plan	$4,055.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,379.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,379.60
Rate for Payer: Healthfirst Commercial	$12,537.00
Rate for Payer: Healthfirst Essential Plan	$7,604.10
Rate for Payer: Healthfirst QHP	$6,150.87
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,379.60
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,604.10
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,604.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,379.60
Rate for Payer: SOMOS Essential	$7,604.10
Rate for Payer: United Healthcare Essential Plan 1&2	$7,604.10
Rate for Payer: United Healthcare Essential Plan 3&4	$7,604.10
Rate for Payer: United Healthcare Medicaid	$3,379.60

Behavioral disorders

Facility

$7,426.71

Service Code	APR-DRG 7581
Min. Negotiated Rate	$3,300.76
Max. Negotiated Rate	$7,426.71
Rate for Payer: Affinity Essential Plan 1&2	$3,300.76
Rate for Payer: Affinity Essential Plan 3&4	$3,300.76
Rate for Payer: Affinity Medicaid/CHP/HARP	$3,300.76
Rate for Payer: Carelon Behavioral Health HARP/QHP	$3,300.76
Rate for Payer: EmblemHealth Essential Plan 1&2	$7,426.71
Rate for Payer: EmblemHealth Essential Plan 3&4	$3,300.76
Rate for Payer: Fidelis Qualified Health Plan	$3,960.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,300.76
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3,300.76
Rate for Payer: Healthfirst Commercial	$6,944.00
Rate for Payer: Healthfirst Essential Plan	$7,426.71
Rate for Payer: Healthfirst QHP	$6,007.38
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$3,300.76
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$7,426.71
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$7,426.71
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,300.76
Rate for Payer: SOMOS Essential	$7,426.71
Rate for Payer: United Healthcare Essential Plan 1&2	$7,426.71
Rate for Payer: United Healthcare Essential Plan 3&4	$7,426.71
Rate for Payer: United Healthcare Medicaid	$3,300.76

BEHAVIORAL HEALTH RESIDENTIAL TREATMENT

Facility

$152.74

Service Code	EAPG 00333
Min. Negotiated Rate	$152.74
Max. Negotiated Rate	$152.74
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$152.74

BEHAVIORAL HEATLH ASSESSMENT

Facility

$329.78

Service Code	EAPG 00323
Min. Negotiated Rate	$238.37
Max. Negotiated Rate	$329.78
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$238.37
Rate for Payer: Healthfirst Commercial	$329.78

BELIMUMAB 120 MG IV SOLR

Facility

$735.72

Service Code	HCPCS J0490
Hospital Charge Code	4940110101
Hospital Revenue Code	258
Min. Negotiated Rate	$367.86
Max. Negotiated Rate	$367.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$367.86

BELIMUMAB 120 MG IV SOLR

Facility

$735.72

Service Code	HCPCS J0490
Hospital Charge Code	4940110101
Hospital Revenue Code	258
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$4,095.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$404.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.07
Rate for Payer: Aetna Government	$56.07
Rate for Payer: Affinity Essential Plan 1&2	$92.14
Rate for Payer: Affinity Essential Plan 3&4	$92.14
Rate for Payer: Affinity Medicaid/CHP/HARP	$40.95
Rate for Payer: Amida Care Medicaid	$40.95
Rate for Payer: Brighton Health Commercial	$551.79
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$56.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$588.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$500.29
Rate for Payer: Elderplan Medicare Advantage	$56.07
Rate for Payer: EmblemHealth Commercial	$56.07
Rate for Payer: EmblemHealth Essential Plan 1&2	$92.14
Rate for Payer: EmblemHealth Essential Plan 3&4	$40.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40.95
Rate for Payer: Fidelis Essential Plan Aliesa	$92.14
Rate for Payer: Fidelis Essential Plan QHP	$92.14
Rate for Payer: Fidelis Medicare Advantage	$56.07
Rate for Payer: Fidelis Qualified Health Plan	$43.00
Rate for Payer: Group Health Inc Commercial	$56.07
Rate for Payer: Group Health Inc Medicare	$56.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$40.95
Rate for Payer: Hamaspik Choice Inc Medicare	$56.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$4,095.00
Rate for Payer: Healthfirst Essential Plan	$92.14
Rate for Payer: Healthfirst Medicare Advantage	$47.66
Rate for Payer: Healthfirst QHP	$66.75
Rate for Payer: Humana Medicare	$57.19
Rate for Payer: Senior Whole Health Medicare Advantage	$56.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$40.95
Rate for Payer: SOMOS Essential	$92.14
Rate for Payer: United Healthcare Essential Plan 1&2	$92.14
Rate for Payer: United Healthcare Essential Plan 3&4	$45.05
Rate for Payer: United Healthcare Medicaid	$40.95
Rate for Payer: United Healthcare Medicare Advantage	$56.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$478.22
Rate for Payer: Wellcare CHP/FHP/Medicaid	$40.95
Rate for Payer: Wellcare Medicare	$53.27

BELIMUMAB 400 MG IV SOLR

Facility

$2.00

Service Code	HCPCS J0490
Hospital Charge Code	4940110201
Hospital Revenue Code	258
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$4,095.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$56.07
Rate for Payer: Aetna Government	$56.07
Rate for Payer: Affinity Essential Plan 1&2	$92.14
Rate for Payer: Affinity Essential Plan 3&4	$92.14
Rate for Payer: Affinity Medicaid/CHP/HARP	$40.95
Rate for Payer: Amida Care Medicaid	$40.95
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$56.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Elderplan Medicare Advantage	$56.07
Rate for Payer: EmblemHealth Commercial	$56.07
Rate for Payer: EmblemHealth Essential Plan 1&2	$92.14
Rate for Payer: EmblemHealth Essential Plan 3&4	$40.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40.95
Rate for Payer: Fidelis Essential Plan Aliesa	$92.14
Rate for Payer: Fidelis Essential Plan QHP	$92.14
Rate for Payer: Fidelis Medicare Advantage	$56.07
Rate for Payer: Fidelis Qualified Health Plan	$43.00
Rate for Payer: Group Health Inc Commercial	$56.07
Rate for Payer: Group Health Inc Medicare	$56.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$40.95
Rate for Payer: Hamaspik Choice Inc Medicare	$56.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$4,095.00
Rate for Payer: Healthfirst Essential Plan	$92.14
Rate for Payer: Healthfirst Medicare Advantage	$47.66
Rate for Payer: Healthfirst QHP	$66.75
Rate for Payer: Humana Medicare	$57.19
Rate for Payer: Senior Whole Health Medicare Advantage	$56.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$40.95
Rate for Payer: SOMOS Essential	$92.14
Rate for Payer: United Healthcare Essential Plan 1&2	$92.14
Rate for Payer: United Healthcare Essential Plan 3&4	$45.05
Rate for Payer: United Healthcare Medicaid	$40.95
Rate for Payer: United Healthcare Medicare Advantage	$56.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$40.95
Rate for Payer: Wellcare Medicare	$53.27

BELIMUMAB 400 MG IV SOLR

Facility

$2.00

Service Code	HCPCS J0490
Hospital Charge Code	4940110201
Hospital Revenue Code	258
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

BENDAMUSTINE HCL 100 MG IV SOLR

Facility

$3.00

Service Code	HCPCS J9033
Hospital Charge Code	6345939120
Hospital Revenue Code	258
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.88
Rate for Payer: Aetna Government	$1.88
Rate for Payer: Affinity Essential Plan 1&2	$1.32
Rate for Payer: Affinity Essential Plan 3&4	$1.32
Rate for Payer: Affinity Medicaid/CHP/HARP	$1.32
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Elderplan Medicare Advantage	$1.88
Rate for Payer: EmblemHealth Commercial	$1.88
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.69
Rate for Payer: Fidelis Essential Plan Aliesa	$1.60
Rate for Payer: Fidelis Essential Plan QHP	$1.67
Rate for Payer: Fidelis Medicare Advantage	$1.88
Rate for Payer: Fidelis Qualified Health Plan	$1.67
Rate for Payer: Group Health Inc Commercial	$1.88
Rate for Payer: Group Health Inc Medicare	$1.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.88
Rate for Payer: Hamaspik Choice Inc Medicare	$1.88
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.88
Rate for Payer: Healthfirst Medicare Advantage	$1.60
Rate for Payer: Healthfirst QHP	$1.88
Rate for Payer: Humana Medicare	$1.92
Rate for Payer: Senior Whole Health Medicare Advantage	$1.88
Rate for Payer: United Healthcare Medicare Advantage	$1.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1.79
Rate for Payer: Wellcare Medicare	$1.79

BENDAMUSTINE HCL 100 MG IV SOLR

Facility

$3.00

Service Code	HCPCS J9033
Hospital Charge Code	6345939120
Hospital Revenue Code	258
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50

BENEFIBER ON THE GO PO POWD

Facility

$0.41

Service Code	NDC 8679016280
Hospital Charge Code	8679016280
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.33
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	$0.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.28
Rate for Payer: EmblemHealth Commercial	$0.21
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.14
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

BENEFIBER ON THE GO PO POWD

Facility

$0.41

Service Code	NDC 8679016280
Hospital Charge Code	8679016280
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21

BENRALIZUMAB 30 MG/ML SC SOSY

Facility

$6.00

Service Code	HCPCS J0517
Hospital Charge Code	0310173030
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00

BENRALIZUMAB 30 MG/ML SC SOSY

Facility

$6.00

Service Code	HCPCS J0517
Hospital Charge Code	0310173030
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$167.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$164.59
Rate for Payer: Aetna Government	$164.59
Rate for Payer: Affinity Essential Plan 1&2	$115.21
Rate for Payer: Affinity Essential Plan 3&4	$115.21
Rate for Payer: Affinity Medicaid/CHP/HARP	$115.21
Rate for Payer: Brighton Health Commercial	$4.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$164.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.08
Rate for Payer: Elderplan Medicare Advantage	$164.59
Rate for Payer: EmblemHealth Commercial	$164.59
Rate for Payer: Fidelis CHP/HARP/Medicaid	$148.13
Rate for Payer: Fidelis Essential Plan Aliesa	$139.90
Rate for Payer: Fidelis Essential Plan QHP	$146.49
Rate for Payer: Fidelis Medicare Advantage	$164.59
Rate for Payer: Fidelis Qualified Health Plan	$146.49
Rate for Payer: Group Health Inc Commercial	$164.59
Rate for Payer: Group Health Inc Medicare	$164.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$164.59
Rate for Payer: Hamaspik Choice Inc Medicare	$164.59
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$164.59
Rate for Payer: Healthfirst Medicare Advantage	$139.90
Rate for Payer: Healthfirst QHP	$164.59
Rate for Payer: Humana Medicare	$167.88
Rate for Payer: Senior Whole Health Medicare Advantage	$164.59
Rate for Payer: United Healthcare Medicare Advantage	$164.59
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90
Rate for Payer: Wellcare CHP/FHP/Medicaid	$156.36
Rate for Payer: Wellcare Medicare	$156.36

BENZOCAINE-MENTHOL 15-2.6 MG MT LOZG

Facility

$0.18

Service Code	NDC 6382473216
Hospital Charge Code	6382473216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

BENZOCAINE-MENTHOL 15-2.6 MG MT LOZG

Facility

$0.18

Service Code	NDC 6382473216
Hospital Charge Code	6382473216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.12

BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG

Facility

$0.19

Service Code	NDC 0904625549
Hospital Charge Code	0904625549
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.15
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	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
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	$0.12

BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG

Facility

$0.18

Service Code	NDC 6382471516
Hospital Charge Code	6382471516
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.12

BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG

Facility

$0.18

Service Code	NDC 6382471516
Hospital Charge Code	6382471516
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG

Facility

$0.19

Service Code	NDC 0904625549
Hospital Charge Code	0904625549
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10

BENZOCAINE-MENTHOL 20-0.5 % EX AERO

Facility

$0.08

Service Code	NDC 1686468003
Hospital Charge Code	1686468003
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
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	$0.05

BENZOCAINE-MENTHOL 20-0.5 % EX AERO

Facility

$0.08

Service Code	NDC 5140900722
Hospital Charge Code	5140900722
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	$0.06
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	$0.05

BENZOCAINE-MENTHOL 20-0.5 % EX AERO

Facility

$0.08

Service Code	NDC 5140900722
Hospital Charge Code	5140900722
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04

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