St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DOCUSATE SODIUM 100 MG PO CAPS [2566]

Facility

$0.05

Service Code	NDC 63739047802
Hospital Charge Code	63739047802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
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	$0.04
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	$0.02
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	$0.03

DOCUSATE SODIUM 150 MG/15ML PO LIQD [2569]

Facility

$0.20

Service Code	NDC 48433022040
Hospital Charge Code	48433022040
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
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	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
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	$0.13

DOCUSATE SODIUM 150 MG/15ML PO LIQD [2569]

Facility

$0.20

Service Code	NDC 48433022010
Hospital Charge Code	48433022010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
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	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
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	$0.13

DOLUTEGRAVIR 50MG TAB

Facility

$59.30

Hospital Charge Code	41655861
Hospital Revenue Code	250
Min. Negotiated Rate	$20.76
Max. Negotiated Rate	$47.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$32.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.65
Rate for Payer: Aetna Government	$29.65
Rate for Payer: Brighton Health Commercial	$44.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$40.32
Rate for Payer: Group Health Inc Commercial	$29.65
Rate for Payer: Group Health Inc Medicare	$20.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.65
Rate for Payer: Hamaspik Choice Inc Medicare	$29.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$38.54

DOLUTEGRAVIR 50MG TAB

Facility

$59.30

Hospital Charge Code	41645861
Hospital Revenue Code	250
Min. Negotiated Rate	$20.76
Max. Negotiated Rate	$47.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$32.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.65
Rate for Payer: Aetna Government	$29.65
Rate for Payer: Brighton Health Commercial	$44.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$47.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$40.32
Rate for Payer: Group Health Inc Commercial	$29.65
Rate for Payer: Group Health Inc Medicare	$20.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.65
Rate for Payer: Hamaspik Choice Inc Medicare	$29.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$38.54

DOLUTEGRAVIR-LAMIVUDINE 50-300 MG PO TABS [167846]

Facility

$119.07

Service Code	NDC 49702024633
Hospital Charge Code	49702024633
Hospital Revenue Code	250
Min. Negotiated Rate	$41.67
Max. Negotiated Rate	$95.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$65.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$59.53
Rate for Payer: Aetna Government	$59.53
Rate for Payer: Brighton Health Commercial	$89.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$95.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$80.96
Rate for Payer: Group Health Inc Commercial	$59.53
Rate for Payer: Group Health Inc Medicare	$41.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$59.53
Rate for Payer: Hamaspik Choice Inc Medicare	$59.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$77.39

DOLUTEGRAVIR-LAMIVUDINE 50-300 MG PO TABS [167846]

Facility

$119.07

Service Code	NDC 49702024613
Hospital Charge Code	49702024613
Hospital Revenue Code	250
Min. Negotiated Rate	$41.67
Max. Negotiated Rate	$95.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$65.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$59.53
Rate for Payer: Aetna Government	$59.53
Rate for Payer: Brighton Health Commercial	$89.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$95.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$80.96
Rate for Payer: Group Health Inc Commercial	$59.53
Rate for Payer: Group Health Inc Medicare	$41.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$59.53
Rate for Payer: Hamaspik Choice Inc Medicare	$59.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$77.39

DOLUTEGRAVIR/RILPIVIRINE 50-25MG

Facility

$225.43

Hospital Charge Code	41648890
Hospital Revenue Code	250
Min. Negotiated Rate	$78.90
Max. Negotiated Rate	$180.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$123.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$112.72
Rate for Payer: Aetna Government	$112.72
Rate for Payer: Brighton Health Commercial	$169.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$180.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$153.29
Rate for Payer: Group Health Inc Commercial	$112.72
Rate for Payer: Group Health Inc Medicare	$78.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$112.72
Rate for Payer: Hamaspik Choice Inc Medicare	$112.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$146.53

DOLUTEGRAVIR/RILPIVIRINE 50-25MG

Facility

$225.43

Hospital Charge Code	41658890
Hospital Revenue Code	250
Min. Negotiated Rate	$78.90
Max. Negotiated Rate	$180.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$123.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$112.72
Rate for Payer: Aetna Government	$112.72
Rate for Payer: Brighton Health Commercial	$169.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$180.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$153.29
Rate for Payer: Group Health Inc Commercial	$112.72
Rate for Payer: Group Health Inc Medicare	$78.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$112.72
Rate for Payer: Hamaspik Choice Inc Medicare	$112.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$146.53

DOLUTEGRAVIR-RILPIVIRINE 50-25 MG PO TABS [150930]

Facility

$140.49

Service Code	NDC 49702024213
Hospital Charge Code	49702024213
Hospital Revenue Code	250
Min. Negotiated Rate	$49.17
Max. Negotiated Rate	$112.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$77.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$70.24
Rate for Payer: Aetna Government	$70.24
Rate for Payer: Brighton Health Commercial	$105.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$112.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$95.53
Rate for Payer: Group Health Inc Commercial	$70.24
Rate for Payer: Group Health Inc Medicare	$49.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$70.24
Rate for Payer: Hamaspik Choice Inc Medicare	$70.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$91.32

DOLUTEGRAVIR SODIUM 50 MG PO TABS [122784]

Facility

$90.30

Service Code	NDC 49702022813
Hospital Charge Code	49702022813
Hospital Revenue Code	250
Min. Negotiated Rate	$31.60
Max. Negotiated Rate	$72.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.15
Rate for Payer: Aetna Government	$45.15
Rate for Payer: Brighton Health Commercial	$67.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.40
Rate for Payer: Group Health Inc Commercial	$45.15
Rate for Payer: Group Health Inc Medicare	$31.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.15
Rate for Payer: Hamaspik Choice Inc Medicare	$45.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$58.69

DOME PASTE BANDAGE 3 INCH DRESSING

Facility

$14.00

Hospital Charge Code	41650109
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

DOME PASTE BANDAGE 3 INCH DRESSING

Facility

$14.00

Hospital Charge Code	41640109
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

DOME PASTE BANDAGE 4 INCH DRESSING

Facility

$16.00

Hospital Charge Code	41640108
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$12.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.00
Rate for Payer: Aetna Government	$8.00
Rate for Payer: Brighton Health Commercial	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.88
Rate for Payer: Group Health Inc Commercial	$8.00
Rate for Payer: Group Health Inc Medicare	$5.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.00
Rate for Payer: Hamaspik Choice Inc Medicare	$8.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.40

DOME PASTE BANDAGE 4 INCH DRESSING

Facility

$16.00

Hospital Charge Code	41650108
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$12.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.00
Rate for Payer: Aetna Government	$8.00
Rate for Payer: Brighton Health Commercial	$12.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.88
Rate for Payer: Group Health Inc Commercial	$8.00
Rate for Payer: Group Health Inc Medicare	$5.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.00
Rate for Payer: Hamaspik Choice Inc Medicare	$8.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.40

DOMES

Facility

$19.14

Hospital Charge Code	40200680
Hospital Revenue Code	270
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$15.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.57
Rate for Payer: Aetna Government	$9.57
Rate for Payer: Brighton Health Commercial	$14.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.02
Rate for Payer: Group Health Inc Commercial	$9.57
Rate for Payer: Group Health Inc Medicare	$6.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.57
Rate for Payer: Hamaspik Choice Inc Medicare	$9.57

DONEPEZIL 10 MG TAB

Facility

$0.23

Hospital Charge Code	41653124
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
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	$0.18
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	$0.15

DONEPEZIL 10 MG TAB

Facility

$0.23

Hospital Charge Code	41643124
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
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	$0.18
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	$0.15

DONEPEZIL 5 MG TAB

Facility

$0.23

Hospital Charge Code	41641900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
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	$0.18
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	$0.15

DONEPEZIL 5 MG TAB

Facility

$0.23

Hospital Charge Code	41651900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
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	$0.18
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	$0.15

DONEPEZIL HCL 10 MG PO TABS [18787]

Facility

$0.16

Service Code	NDC 00904647861
Hospital Charge Code	00904647861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.11

DONEPEZIL HCL 10 MG PO TABS [18787]

Facility

$8.66

Service Code	NDC 43547027603
Hospital Charge Code	43547027603
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$6.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.33
Rate for Payer: Aetna Government	$4.33
Rate for Payer: Brighton Health Commercial	$6.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.92
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.89
Rate for Payer: Group Health Inc Commercial	$4.33
Rate for Payer: Group Health Inc Medicare	$3.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.33
Rate for Payer: Hamaspik Choice Inc Medicare	$4.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.63

DONEPEZIL HCL 10 MG PO TABS [18787]

Facility

$0.78

Service Code	NDC 60687030311
Hospital Charge Code	60687030311
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.39
Rate for Payer: Aetna Government	$0.39
Rate for Payer: Brighton Health Commercial	$0.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.53
Rate for Payer: Group Health Inc Commercial	$0.39
Rate for Payer: Group Health Inc Medicare	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39
Rate for Payer: Hamaspik Choice Inc Medicare	$0.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.50

DONEPEZIL HCL 5 MG PO TABS [18786]

Facility

$0.16

Service Code	NDC 00904647761
Hospital Charge Code	00904647761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.11

DONEPEZIL HCL 5 MG PO TABS [18786]

Facility

$8.65

Service Code	NDC 31722073730
Hospital Charge Code	31722073730
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$6.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.33
Rate for Payer: Aetna Government	$4.33
Rate for Payer: Brighton Health Commercial	$6.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.92
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.88
Rate for Payer: Group Health Inc Commercial	$4.33
Rate for Payer: Group Health Inc Medicare	$3.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.33
Rate for Payer: Hamaspik Choice Inc Medicare	$4.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.62

Know your out-of-pocket cost for care.

All Charges