St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HYDROXYZINE PAMOATE 50 MG PO CAPS

Facility

$0.57

Service Code	NDC 5026839950
Hospital Charge Code	5026839950
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.29
Rate for Payer: Aetna Government	$0.29
Rate for Payer: Brighton Health Commercial	$0.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.39
Rate for Payer: EmblemHealth Commercial	$0.29
Rate for Payer: Group Health Inc Commercial	$0.29
Rate for Payer: Group Health Inc Medicare	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.29
Rate for Payer: Hamaspik Choice Inc Medicare	$0.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.37

HYDROXYZINE PAMOATE 50 MG PO CAPS

Facility

$0.61

Service Code	NDC 1453967501
Hospital Charge Code	1453967501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31

HYDROXYZINE PAMOATE 50 MG PO CAPS

Facility

$0.57

Service Code	NDC 5026839911
Hospital Charge Code	5026839911
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.29
Rate for Payer: Aetna Government	$0.29
Rate for Payer: Brighton Health Commercial	$0.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.39
Rate for Payer: EmblemHealth Commercial	$0.29
Rate for Payer: Group Health Inc Commercial	$0.29
Rate for Payer: Group Health Inc Medicare	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.29
Rate for Payer: Hamaspik Choice Inc Medicare	$0.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.37

HYDROXYZINE PAMOATE 50 MG PO CAPS

Facility

$0.61

Service Code	NDC 0555030202
Hospital Charge Code	0555030202
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31

HYLAN G-F 20 16 MG/2ML IX SOSY

Facility

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	5846800901
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$219.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$150.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.95
Rate for Payer: Aetna Government	$7.95
Rate for Payer: Affinity Essential Plan 1&2	$5.57
Rate for Payer: Affinity Essential Plan 3&4	$5.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$5.57
Rate for Payer: Brighton Health Commercial	$205.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$7.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$219.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$186.27
Rate for Payer: Elderplan Medicare Advantage	$7.95
Rate for Payer: EmblemHealth Commercial	$7.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$7.16
Rate for Payer: Fidelis Essential Plan Aliesa	$6.76
Rate for Payer: Fidelis Essential Plan QHP	$7.08
Rate for Payer: Fidelis Medicare Advantage	$7.95
Rate for Payer: Fidelis Qualified Health Plan	$7.08
Rate for Payer: Group Health Inc Commercial	$7.95
Rate for Payer: Group Health Inc Medicare	$7.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.95
Rate for Payer: Hamaspik Choice Inc Medicare	$7.95
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7.95
Rate for Payer: Healthfirst Medicare Advantage	$6.76
Rate for Payer: Healthfirst QHP	$7.95
Rate for Payer: Humana Medicare	$8.11
Rate for Payer: Senior Whole Health Medicare Advantage	$7.95
Rate for Payer: United Healthcare Medicare Advantage	$7.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$178.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$7.55
Rate for Payer: Wellcare Medicare	$7.55

HYLAN G-F 20 16 MG/2ML IX SOSY

Facility

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	5846800901
Hospital Revenue Code	250
Min. Negotiated Rate	$136.96
Max. Negotiated Rate	$136.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$136.96

HYLAN G-F 20 48 MG/6ML IX SOSY

Facility

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	5846800903
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$219.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$150.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.95
Rate for Payer: Aetna Government	$7.95
Rate for Payer: Affinity Essential Plan 1&2	$5.57
Rate for Payer: Affinity Essential Plan 3&4	$5.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$5.57
Rate for Payer: Brighton Health Commercial	$205.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$7.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$219.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$186.27
Rate for Payer: Elderplan Medicare Advantage	$7.95
Rate for Payer: EmblemHealth Commercial	$7.95
Rate for Payer: Fidelis CHP/HARP/Medicaid	$7.16
Rate for Payer: Fidelis Essential Plan Aliesa	$6.76
Rate for Payer: Fidelis Essential Plan QHP	$7.08
Rate for Payer: Fidelis Medicare Advantage	$7.95
Rate for Payer: Fidelis Qualified Health Plan	$7.08
Rate for Payer: Group Health Inc Commercial	$7.95
Rate for Payer: Group Health Inc Medicare	$7.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.95
Rate for Payer: Hamaspik Choice Inc Medicare	$7.95
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7.95
Rate for Payer: Healthfirst Medicare Advantage	$6.76
Rate for Payer: Healthfirst QHP	$7.95
Rate for Payer: Humana Medicare	$8.11
Rate for Payer: Senior Whole Health Medicare Advantage	$7.95
Rate for Payer: United Healthcare Medicare Advantage	$7.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$178.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$7.55
Rate for Payer: Wellcare Medicare	$7.55

HYLAN G-F 20 48 MG/6ML IX SOSY

Facility

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	5846800903
Hospital Revenue Code	250
Min. Negotiated Rate	$136.96
Max. Negotiated Rate	$136.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$136.96

Hypertension

Facility

$39,974.99

Service Code	APR-DRG 1991
Min. Negotiated Rate	$5,256.00
Max. Negotiated Rate	$39,974.99
Rate for Payer: Affinity Essential Plan 1&2	$39,974.99
Rate for Payer: Affinity Essential Plan 3&4	$39,974.99
Rate for Payer: Affinity Medicaid/CHP/HARP	$17,766.66
Rate for Payer: Amida Care Medicaid	$17,766.66
Rate for Payer: EmblemHealth Essential Plan 1&2	$39,974.99
Rate for Payer: EmblemHealth Essential Plan 3&4	$17,766.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$17,766.66
Rate for Payer: Fidelis Qualified Health Plan	$21,319.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$17,766.66
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$17,766.66
Rate for Payer: Healthfirst Commercial	$9,091.00
Rate for Payer: Healthfirst Essential Plan	$39,974.99
Rate for Payer: Healthfirst QHP	$5,256.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$17,766.66
Rate for Payer: SOMOS Essential	$39,974.99
Rate for Payer: United Healthcare Essential Plan 1&2	$39,974.99
Rate for Payer: United Healthcare Essential Plan 3&4	$39,974.99
Rate for Payer: United Healthcare Medicaid	$17,766.66
Rate for Payer: Wellcare CHP/FHP/Medicaid	$17,766.66

Hypertension

Facility

$42,435.47

Service Code	APR-DRG 1992
Min. Negotiated Rate	$6,463.00
Max. Negotiated Rate	$42,435.47
Rate for Payer: Affinity Essential Plan 1&2	$42,435.47
Rate for Payer: Affinity Essential Plan 3&4	$42,435.47
Rate for Payer: Affinity Medicaid/CHP/HARP	$18,860.21
Rate for Payer: Amida Care Medicaid	$18,860.21
Rate for Payer: EmblemHealth Essential Plan 1&2	$42,435.47
Rate for Payer: EmblemHealth Essential Plan 3&4	$18,860.21
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18,860.21
Rate for Payer: Fidelis Qualified Health Plan	$22,632.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$18,860.21
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18,860.21
Rate for Payer: Healthfirst Commercial	$11,035.00
Rate for Payer: Healthfirst Essential Plan	$42,435.47
Rate for Payer: Healthfirst QHP	$6,463.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$18,860.21
Rate for Payer: SOMOS Essential	$42,435.47
Rate for Payer: United Healthcare Essential Plan 1&2	$42,435.47
Rate for Payer: United Healthcare Essential Plan 3&4	$42,435.47
Rate for Payer: United Healthcare Medicaid	$18,860.21
Rate for Payer: Wellcare CHP/FHP/Medicaid	$18,860.21

Hypertension

Facility

$48,406.43

Service Code	APR-DRG 1993
Min. Negotiated Rate	$9,195.00
Max. Negotiated Rate	$48,406.43
Rate for Payer: Affinity Essential Plan 1&2	$48,406.43
Rate for Payer: Affinity Essential Plan 3&4	$48,406.43
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,513.97
Rate for Payer: Amida Care Medicaid	$21,513.97
Rate for Payer: EmblemHealth Essential Plan 1&2	$48,406.43
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,513.97
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,513.97
Rate for Payer: Fidelis Qualified Health Plan	$25,816.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,513.97
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,513.97
Rate for Payer: Healthfirst Commercial	$16,723.00
Rate for Payer: Healthfirst Essential Plan	$48,406.43
Rate for Payer: Healthfirst QHP	$9,195.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,513.97
Rate for Payer: SOMOS Essential	$48,406.43
Rate for Payer: United Healthcare Essential Plan 1&2	$48,406.43
Rate for Payer: United Healthcare Essential Plan 3&4	$48,406.43
Rate for Payer: United Healthcare Medicaid	$21,513.97
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,513.97

Hypertension

Facility

$75,216.76

Service Code	APR-DRG 1994
Min. Negotiated Rate	$17,378.00
Max. Negotiated Rate	$75,216.76
Rate for Payer: Affinity Essential Plan 1&2	$75,216.76
Rate for Payer: Affinity Essential Plan 3&4	$75,216.76
Rate for Payer: Affinity Medicaid/CHP/HARP	$33,429.67
Rate for Payer: Amida Care Medicaid	$33,429.67
Rate for Payer: EmblemHealth Essential Plan 1&2	$75,216.76
Rate for Payer: EmblemHealth Essential Plan 3&4	$33,429.67
Rate for Payer: Fidelis CHP/HARP/Medicaid	$33,429.67
Rate for Payer: Fidelis Qualified Health Plan	$40,115.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$33,429.67
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$33,429.67
Rate for Payer: Healthfirst Commercial	$43,335.00
Rate for Payer: Healthfirst Essential Plan	$75,216.76
Rate for Payer: Healthfirst QHP	$17,378.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$33,429.67
Rate for Payer: SOMOS Essential	$75,216.76
Rate for Payer: United Healthcare Essential Plan 1&2	$75,216.76
Rate for Payer: United Healthcare Essential Plan 3&4	$75,216.76
Rate for Payer: United Healthcare Medicaid	$33,429.67
Rate for Payer: Wellcare CHP/FHP/Medicaid	$33,429.67

HYPERTENSION

Facility

$206.85

Service Code	EAPG 00599
Min. Negotiated Rate	$150.43
Max. Negotiated Rate	$206.85
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$150.43
Rate for Payer: Healthfirst Commercial	$206.85

Hypovolemia & related electrolyte disorders

Facility

$41,267.68

Service Code	APR-DRG 4222
Min. Negotiated Rate	$6,327.00
Max. Negotiated Rate	$41,267.68
Rate for Payer: Affinity Essential Plan 1&2	$41,267.68
Rate for Payer: Affinity Essential Plan 3&4	$41,267.68
Rate for Payer: Affinity Medicaid/CHP/HARP	$18,341.19
Rate for Payer: Amida Care Medicaid	$18,341.19
Rate for Payer: EmblemHealth Essential Plan 1&2	$41,267.68
Rate for Payer: EmblemHealth Essential Plan 3&4	$18,341.19
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18,341.19
Rate for Payer: Fidelis Qualified Health Plan	$22,009.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$18,341.19
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18,341.19
Rate for Payer: Healthfirst Commercial	$10,591.00
Rate for Payer: Healthfirst Essential Plan	$41,267.68
Rate for Payer: Healthfirst QHP	$6,327.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$18,341.19
Rate for Payer: SOMOS Essential	$41,267.68
Rate for Payer: United Healthcare Essential Plan 1&2	$41,267.68
Rate for Payer: United Healthcare Essential Plan 3&4	$41,267.68
Rate for Payer: United Healthcare Medicaid	$18,341.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$18,341.19

Hypovolemia & related electrolyte disorders

Facility

$47,880.56

Service Code	APR-DRG 4223
Min. Negotiated Rate	$9,735.00
Max. Negotiated Rate	$47,880.56
Rate for Payer: Affinity Essential Plan 1&2	$47,880.56
Rate for Payer: Affinity Essential Plan 3&4	$47,880.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,280.25
Rate for Payer: Amida Care Medicaid	$21,280.25
Rate for Payer: EmblemHealth Essential Plan 1&2	$47,880.56
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,280.25
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,280.25
Rate for Payer: Fidelis Qualified Health Plan	$25,536.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,280.25
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,280.25
Rate for Payer: Healthfirst Commercial	$17,125.00
Rate for Payer: Healthfirst Essential Plan	$47,880.56
Rate for Payer: Healthfirst QHP	$9,735.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,280.25
Rate for Payer: SOMOS Essential	$47,880.56
Rate for Payer: United Healthcare Essential Plan 1&2	$47,880.56
Rate for Payer: United Healthcare Essential Plan 3&4	$47,880.56
Rate for Payer: United Healthcare Medicaid	$21,280.25
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,280.25

Hypovolemia & related electrolyte disorders

Facility

$71,945.48

Service Code	APR-DRG 4224
Min. Negotiated Rate	$21,720.00
Max. Negotiated Rate	$71,945.48
Rate for Payer: Affinity Essential Plan 1&2	$71,945.48
Rate for Payer: Affinity Essential Plan 3&4	$71,945.48
Rate for Payer: Affinity Medicaid/CHP/HARP	$31,975.77
Rate for Payer: Amida Care Medicaid	$31,975.77
Rate for Payer: EmblemHealth Essential Plan 1&2	$71,945.48
Rate for Payer: EmblemHealth Essential Plan 3&4	$31,975.77
Rate for Payer: Fidelis CHP/HARP/Medicaid	$31,975.77
Rate for Payer: Fidelis Qualified Health Plan	$38,370.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$31,975.77
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$31,975.77
Rate for Payer: Healthfirst Commercial	$42,388.00
Rate for Payer: Healthfirst Essential Plan	$71,945.48
Rate for Payer: Healthfirst QHP	$21,720.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$31,975.77
Rate for Payer: SOMOS Essential	$71,945.48
Rate for Payer: United Healthcare Essential Plan 1&2	$71,945.48
Rate for Payer: United Healthcare Essential Plan 3&4	$71,945.48
Rate for Payer: United Healthcare Medicaid	$31,975.77
Rate for Payer: Wellcare CHP/FHP/Medicaid	$31,975.77

Hypovolemia & related electrolyte disorders

Facility

$38,666.50

Service Code	APR-DRG 4221
Min. Negotiated Rate	$4,593.00
Max. Negotiated Rate	$38,666.50
Rate for Payer: Affinity Essential Plan 1&2	$38,666.50
Rate for Payer: Affinity Essential Plan 3&4	$38,666.50
Rate for Payer: Affinity Medicaid/CHP/HARP	$17,185.11
Rate for Payer: Amida Care Medicaid	$17,185.11
Rate for Payer: EmblemHealth Essential Plan 1&2	$38,666.50
Rate for Payer: EmblemHealth Essential Plan 3&4	$17,185.11
Rate for Payer: Fidelis CHP/HARP/Medicaid	$17,185.11
Rate for Payer: Fidelis Qualified Health Plan	$20,622.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$17,185.11
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$17,185.11
Rate for Payer: Healthfirst Commercial	$8,138.00
Rate for Payer: Healthfirst Essential Plan	$38,666.50
Rate for Payer: Healthfirst QHP	$4,593.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$17,185.11
Rate for Payer: SOMOS Essential	$38,666.50
Rate for Payer: United Healthcare Essential Plan 1&2	$38,666.50
Rate for Payer: United Healthcare Essential Plan 3&4	$38,666.50
Rate for Payer: United Healthcare Medicaid	$17,185.11
Rate for Payer: Wellcare CHP/FHP/Medicaid	$17,185.11

HYPROMELLOSE 0.3 % OP GEL

Facility

$0.86

Service Code	NDC 0065806401
Hospital Charge Code	0065806401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.43
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.43

HYPROMELLOSE 0.3 % OP GEL

Facility

$0.86

Service Code	NDC 0065806401
Hospital Charge Code	0065806401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.43
Rate for Payer: Aetna Government	$0.43
Rate for Payer: Brighton Health Commercial	$0.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
Rate for Payer: EmblemHealth Commercial	$0.43
Rate for Payer: Group Health Inc Commercial	$0.43
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.43
Rate for Payer: Hamaspik Choice Inc Medicare	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.56

HYPROMELLOSE 2.5 % OP SOLN

Facility

$2.46

Service Code	NDC 7779002215
Hospital Charge Code	7779002215
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.23
Rate for Payer: Aetna Government	$1.23
Rate for Payer: Brighton Health Commercial	$1.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.97
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.67
Rate for Payer: EmblemHealth Commercial	$1.23
Rate for Payer: Group Health Inc Commercial	$1.23
Rate for Payer: Group Health Inc Medicare	$0.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.23
Rate for Payer: Hamaspik Choice Inc Medicare	$1.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.60

HYPROMELLOSE 2.5 % OP SOLN

Facility

$2.46

Service Code	NDC 7779002215
Hospital Charge Code	7779002215
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.23

IBUPROFEN 100 MG/5ML PO SUSP

Facility

$0.17

Service Code	NDC 0121091400
Hospital Charge Code	0121091400
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.14
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	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
Rate for Payer: 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	$0.11

IBUPROFEN 100 MG/5ML PO SUSP

Facility

$0.03

Service Code	NDC 6126976394
Hospital Charge Code	6126976394
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02

IBUPROFEN 100 MG/5ML PO SUSP

Facility

$0.19

Service Code	NDC 6809449459
Hospital Charge Code	6809449459
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

IBUPROFEN 100 MG/5ML PO SUSP

Facility

$0.04

Service Code	NDC 0904530920
Hospital Charge Code	0904530920
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: EmblemHealth Commercial	$0.02
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	$0.03

Know your out-of-pocket cost for care.

All Charges