St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIAPER PREMATURE SWADDLER <4LB

Facility

$0.17

Hospital Charge Code	64901325
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
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

DIAPER RESTRAINT

Facility

$41.82

Hospital Charge Code	40201215
Hospital Revenue Code	270
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$33.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.91
Rate for Payer: Aetna Government	$20.91
Rate for Payer: Brighton Health Commercial	$31.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.44
Rate for Payer: Group Health Inc Commercial	$20.91
Rate for Payer: Group Health Inc Medicare	$14.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.91
Rate for Payer: Hamaspik Choice Inc Medicare	$20.91

Diapers (Pk)

Facility

$51.39

Hospital Charge Code	40201212
Hospital Revenue Code	270
Min. Negotiated Rate	$17.99
Max. Negotiated Rate	$41.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$28.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25.70
Rate for Payer: Aetna Government	$25.70
Rate for Payer: Brighton Health Commercial	$38.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$41.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$34.95
Rate for Payer: Group Health Inc Commercial	$25.70
Rate for Payer: Group Health Inc Medicare	$17.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$25.70
Rate for Payer: Hamaspik Choice Inc Medicare	$25.70

DIAPHRAGM/CERVICAL CAP FIT

Facility

$502.93

Service Code	HCPCS 57170
Hospital Charge Code	30301254
Hospital Revenue Code	510
Rate for Payer: Cash Price	$230.44

DIAPHRAGM/CERVICAL CAP FIT

Facility

$502.93

Service Code	HCPCS 57170
Hospital Charge Code	30301254
Hospital Revenue Code	510
Min. Negotiated Rate	$161.31
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$230.44
Rate for Payer: Aetna Government	$230.44
Rate for Payer: Affinity Essential Plan 1&2	$161.31
Rate for Payer: Affinity Essential Plan 3&4	$161.31
Rate for Payer: Affinity Medicaid/CHP/HARP	$161.31
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Cash Price	$230.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$230.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$230.44
Rate for Payer: Fidelis Essential Plan Aliesa	$195.87
Rate for Payer: Fidelis Essential Plan QHP	$205.09
Rate for Payer: Fidelis Medicare Advantage	$230.44
Rate for Payer: Fidelis Qualified Health Plan	$205.09
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.46
Rate for Payer: Hamaspik Choice Inc Medicare	$230.44
Rate for Payer: Healthfirst Medicare Advantage	$195.87
Rate for Payer: Healthfirst QHP	$230.44
Rate for Payer: Humana Medicare	$235.05
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$230.44
Rate for Payer: Senior Whole Health Medicare Advantage	$230.44
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$230.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$230.44
Rate for Payer: Wellcare CHP/FHP/Medicaid	$184.35
Rate for Payer: Wellcare Medicare	$218.92

DIAS BP LESS 90

Facility

$0.01

Service Code	HCPCS G8754
Hospital Charge Code	30307851
Hospital Revenue Code	510
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$250.00
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	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$222.00

DIAS BP > OR = 90

Facility

$0.01

Service Code	HCPCS G8755
Hospital Charge Code	30307871
Hospital Revenue Code	510
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$250.00
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	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$222.00

DIASOL 1.5% DXTRSE 1000 CC

Facility

$32.96

Hospital Charge Code	40509832
Hospital Revenue Code	260
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.48
Rate for Payer: Aetna Government	$16.48
Rate for Payer: Brighton Health Commercial	$24.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.41
Rate for Payer: Group Health Inc Commercial	$16.48
Rate for Payer: Group Health Inc Medicare	$11.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.48
Rate for Payer: Hamaspik Choice Inc Medicare	$16.48
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL 1.5 DXTRSE 3000CC

Facility

$56.70

Hospital Charge Code	40509826
Hospital Revenue Code	260
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28.35
Rate for Payer: Aetna Government	$28.35
Rate for Payer: Brighton Health Commercial	$42.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$45.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$38.56
Rate for Payer: Group Health Inc Commercial	$28.35
Rate for Payer: Group Health Inc Medicare	$19.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.35
Rate for Payer: Hamaspik Choice Inc Medicare	$28.35
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL 2.5% DXTRSE 1000CC

Facility

$33.32

Hospital Charge Code	40509830
Hospital Revenue Code	260
Min. Negotiated Rate	$11.66
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.66
Rate for Payer: Aetna Government	$16.66
Rate for Payer: Brighton Health Commercial	$24.99
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.66
Rate for Payer: Group Health Inc Commercial	$16.66
Rate for Payer: Group Health Inc Medicare	$11.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.66
Rate for Payer: Hamaspik Choice Inc Medicare	$16.66
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL 2.5% DXTRSE 2000CC

Facility

$47.13

Hospital Charge Code	40509831
Hospital Revenue Code	260
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.56
Rate for Payer: Aetna Government	$23.56
Rate for Payer: Brighton Health Commercial	$35.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.05
Rate for Payer: Group Health Inc Commercial	$23.56
Rate for Payer: Group Health Inc Medicare	$16.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.56
Rate for Payer: Hamaspik Choice Inc Medicare	$23.56
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL 4.25 DXTRSE 3000CC

Facility

$59.18

Hospital Charge Code	40509825
Hospital Revenue Code	260
Min. Negotiated Rate	$20.71
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$32.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.59
Rate for Payer: Aetna Government	$29.59
Rate for Payer: Brighton Health Commercial	$44.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$40.24
Rate for Payer: Group Health Inc Commercial	$29.59
Rate for Payer: Group Health Inc Medicare	$20.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.59
Rate for Payer: Hamaspik Choice Inc Medicare	$29.59
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL 4.5 DXTRSE 1000CC

Facility

$34.02

Hospital Charge Code	40509824
Hospital Revenue Code	260
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$17.01
Rate for Payer: Aetna Government	$17.01
Rate for Payer: Brighton Health Commercial	$25.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.13
Rate for Payer: Group Health Inc Commercial	$17.01
Rate for Payer: Group Health Inc Medicare	$11.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.01
Rate for Payer: Hamaspik Choice Inc Medicare	$17.01
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL NSN-4 120 3.43 L

Facility

$77.96

Hospital Charge Code	40509827
Hospital Revenue Code	260
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$42.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$38.98
Rate for Payer: Aetna Government	$38.98
Rate for Payer: Brighton Health Commercial	$58.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$62.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$53.01
Rate for Payer: Group Health Inc Commercial	$38.98
Rate for Payer: Group Health Inc Medicare	$27.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.98
Rate for Payer: Hamaspik Choice Inc Medicare	$38.98
Rate for Payer: United Healthcare Commercial	$76.00

DIASOL OCM POTASS. 3.43L

Facility

$20.91

Hospital Charge Code	40509828
Hospital Revenue Code	260
Min. Negotiated Rate	$7.32
Max. Negotiated Rate	$76.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.46
Rate for Payer: Aetna Government	$10.46
Rate for Payer: Brighton Health Commercial	$15.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.22
Rate for Payer: Group Health Inc Commercial	$10.46
Rate for Payer: Group Health Inc Medicare	$7.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.46
Rate for Payer: Hamaspik Choice Inc Medicare	$10.46
Rate for Payer: United Healthcare Commercial	$76.00

DIATRIZOATE 15 ML SOLN

Facility

$28.00

Hospital Charge Code	41653200
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$22.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.00
Rate for Payer: Aetna Government	$14.00
Rate for Payer: Brighton Health Commercial	$21.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.04
Rate for Payer: Group Health Inc Commercial	$14.00
Rate for Payer: Group Health Inc Medicare	$9.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.20

DIATRIZOATE 15 ML SOLN

Facility

$28.00

Hospital Charge Code	41643200
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$22.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.00
Rate for Payer: Aetna Government	$14.00
Rate for Payer: Brighton Health Commercial	$21.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.04
Rate for Payer: Group Health Inc Commercial	$14.00
Rate for Payer: Group Health Inc Medicare	$9.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.20

DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN [9828]

Facility

$0.70

Service Code	HCPCS Q9963
Hospital Charge Code	00270044540
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.47
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.22
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.23
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.23
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.45

DIAZEPAM 10 MG RE GEL [87867]

Facility

$364.06

Service Code	NDC 68682065220
Hospital Charge Code	68682065220
Hospital Revenue Code	250
Min. Negotiated Rate	$127.42
Max. Negotiated Rate	$291.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$200.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$182.03
Rate for Payer: Aetna Government	$182.03
Rate for Payer: Brighton Health Commercial	$273.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$291.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$247.56
Rate for Payer: Group Health Inc Commercial	$182.03
Rate for Payer: Group Health Inc Medicare	$127.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$182.03
Rate for Payer: Hamaspik Choice Inc Medicare	$182.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$236.64

DIAZEPAM 2.5 MG RE GEL [87865]

Facility

$354.82

Service Code	NDC 66490065020
Hospital Charge Code	66490065020
Hospital Revenue Code	250
Min. Negotiated Rate	$124.19
Max. Negotiated Rate	$283.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$195.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$177.41
Rate for Payer: Aetna Government	$177.41
Rate for Payer: Brighton Health Commercial	$266.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$283.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$241.28
Rate for Payer: Group Health Inc Commercial	$177.41
Rate for Payer: Group Health Inc Medicare	$124.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$177.41
Rate for Payer: Hamaspik Choice Inc Medicare	$177.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$230.63

DIAZEPAM 2 MG PO TABS [2404]

Facility

$0.24

Service Code	NDC 51079028420
Hospital Charge Code	51079028420
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	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
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	$0.16

DIAZEPAM 2 MG PO TABS [2404]

Facility

$0.13

Service Code	NDC 00172392560
Hospital Charge Code	00172392560
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.09
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

DIAZEPAM 2 MG PO TABS [2404]

Facility

$0.24

Service Code	NDC 51079028401
Hospital Charge Code	51079028401
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	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
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	$0.16

DIAZEPAM 2 MG TAB

Facility

$1.00

Hospital Charge Code	41651315
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

DIAZEPAM 2 MG TAB

Facility

$1.00

Hospital Charge Code	41641315
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

Know your out-of-pocket cost for care.

All Charges