St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ALLOPURINOL 1 MG/ML SUSP

Facility

$2.00

Hospital Charge Code	41642019
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

ALLOPURINOL 300 MG PO TABS [311]

Facility

$0.92

Service Code	NDC 00603211621
Hospital Charge Code	00603211621
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.60

ALLOPURINOL 300 MG PO TABS [311]

Facility

$0.94

Service Code	NDC 62584071311
Hospital Charge Code	62584071311
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.47
Rate for Payer: Aetna Government	$0.47
Rate for Payer: Brighton Health Commercial	$0.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.64
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

ALLOPURINOL 300 MG PO TABS [311]

Facility

$0.92

Service Code	NDC 53489015701
Hospital Charge Code	53489015701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.60

ALLOPURINOL 300 MG PO TABS [311]

Facility

$0.94

Service Code	NDC 62584071301
Hospital Charge Code	62584071301
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.47
Rate for Payer: Aetna Government	$0.47
Rate for Payer: Brighton Health Commercial	$0.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.64
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

ALLOPURINOL 300 MG PO TABS [311]

Facility

$0.92

Service Code	NDC 00591554401
Hospital Charge Code	00591554401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.60

ALLOPURINOL 300 MG TAB

Facility

$1.00

Hospital Charge Code	41650757
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

ALLOPURINOL 300 MG TAB

Facility

$1.00

Hospital Charge Code	41640757
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

ALLOPURINOL SUSPENSION 10 MG/ML [400552]

Facility

$0.92

Service Code	NDC 09999123456
Hospital Charge Code	00591554401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.60

ALL POLY BUTTON PATELLA

Facility

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209577
Hospital Revenue Code	278
Min. Negotiated Rate	$614.00
Max. Negotiated Rate	$614.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00

ALL POLY BUTTON PATELLA

Facility

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209577
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,289.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$675.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$736.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$614.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$706.10
Rate for Payer: EmblemHealth Commercial	$614.00
Rate for Payer: Fidelis Medicare Advantage	$1,289.40
Rate for Payer: Group Health Inc Commercial	$614.00
Rate for Payer: Group Health Inc Medicare	$429.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$798.20

ALL POLY BUTTON PATELLA STD #11-1

Facility

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209578
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,289.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$675.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$736.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$614.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$706.10
Rate for Payer: EmblemHealth Commercial	$614.00
Rate for Payer: Fidelis Medicare Advantage	$1,289.40
Rate for Payer: Group Health Inc Commercial	$614.00
Rate for Payer: Group Health Inc Medicare	$429.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$798.20

ALL POLY BUTTON PATELLA STD #11-1

Facility

$1,228.00

Service Code	HCPCS C1776
Hospital Charge Code	40209578
Hospital Revenue Code	278
Min. Negotiated Rate	$614.00
Max. Negotiated Rate	$614.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$614.00
Rate for Payer: Hamaspik Choice Inc Medicare	$614.00

ALOGRFT ILICREST/WDGE24-26MMX31MM

Facility

$181.90

Service Code	HCPCS C1762
Hospital Charge Code	40209425
Hospital Revenue Code	278
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$90.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.95
Rate for Payer: Hamaspik Choice Inc Medicare	$90.95

ALOGRFT ILICREST/WDGE24-26MMX31MM

Facility

$181.90

Service Code	HCPCS C1762
Hospital Charge Code	40209425
Hospital Revenue Code	278
Min. Negotiated Rate	$63.66
Max. Negotiated Rate	$1,879.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$100.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,879.82
Rate for Payer: Aetna Government	$1,879.82
Rate for Payer: Brighton Health Commercial	$109.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$104.59
Rate for Payer: EmblemHealth Commercial	$90.95
Rate for Payer: Fidelis Medicare Advantage	$191.00
Rate for Payer: Group Health Inc Commercial	$90.95
Rate for Payer: Group Health Inc Medicare	$63.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.95
Rate for Payer: Hamaspik Choice Inc Medicare	$90.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$118.24

ALPHA-1-ANTITRYPSIN DEFICIENCY

Facility

$109.13

Service Code	HCPCS 81332
Hospital Charge Code	40609030
Hospital Revenue Code	310
Min. Negotiated Rate	$30.56
Max. Negotiated Rate	$87.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$43.65
Rate for Payer: Aetna Government	$43.65
Rate for Payer: Affinity Essential Plan 1&2	$30.56
Rate for Payer: Affinity Essential Plan 3&4	$30.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$30.56
Rate for Payer: Brighton Health Commercial	$43.65
Rate for Payer: Cash Price	$43.65
Rate for Payer: Cash Price	$43.65
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$43.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$87.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$74.21
Rate for Payer: Elderplan Medicare Advantage	$43.65
Rate for Payer: EmblemHealth Commercial	$43.65
Rate for Payer: Fidelis Essential Plan Aliesa	$37.10
Rate for Payer: Fidelis Essential Plan QHP	$38.85
Rate for Payer: Fidelis Medicare Advantage	$43.65
Rate for Payer: Fidelis Qualified Health Plan	$38.85
Rate for Payer: Group Health Inc Commercial	$43.65
Rate for Payer: Group Health Inc Medicare	$43.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.56
Rate for Payer: Hamaspik Choice Inc Medicare	$43.65
Rate for Payer: Healthfirst Medicare Advantage	$43.65
Rate for Payer: Healthfirst QHP	$43.65
Rate for Payer: Humana Medicare	$44.52
Rate for Payer: Senior Whole Health Medicare Advantage	$43.65
Rate for Payer: United Healthcare Medicare Advantage	$43.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$34.92
Rate for Payer: Wellcare Medicare	$39.28

ALPHA-1-ANTITRYPSIN DEFICIENCY

Facility

$109.13

Service Code	HCPCS 81332
Hospital Charge Code	40609030
Hospital Revenue Code	310
Rate for Payer: Cash Price	$43.65

ALPHA-1-ANTITRYPSIN, SERUM

Facility

$33.60

Service Code	HCPCS 82103
Hospital Charge Code	40609036
Hospital Revenue Code	300
Min. Negotiated Rate	$9.41
Max. Negotiated Rate	$25.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.44
Rate for Payer: Aetna Government	$13.44
Rate for Payer: Affinity Essential Plan 1&2	$9.41
Rate for Payer: Affinity Essential Plan 3&4	$9.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$9.41
Rate for Payer: Brighton Health Commercial	$25.20
Rate for Payer: Cash Price	$13.44
Rate for Payer: Cash Price	$13.44
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$13.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.07
Rate for Payer: Elderplan Medicare Advantage	$13.44
Rate for Payer: EmblemHealth Commercial	$13.44
Rate for Payer: Fidelis Essential Plan Aliesa	$11.42
Rate for Payer: Fidelis Essential Plan QHP	$11.96
Rate for Payer: Fidelis Medicare Advantage	$13.44
Rate for Payer: Fidelis Qualified Health Plan	$11.96
Rate for Payer: Group Health Inc Commercial	$13.44
Rate for Payer: Group Health Inc Medicare	$13.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.80
Rate for Payer: Hamaspik Choice Inc Medicare	$13.44
Rate for Payer: Healthfirst Medicare Advantage	$13.44
Rate for Payer: Healthfirst QHP	$13.44
Rate for Payer: Humana Medicare	$13.71
Rate for Payer: Senior Whole Health Medicare Advantage	$13.44
Rate for Payer: United Healthcare Commercial	$17.02
Rate for Payer: United Healthcare Medicare Advantage	$13.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.44
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10.75
Rate for Payer: Wellcare Medicare	$12.10

ALPHA-1-ANTITRYPSIN, SERUM

Facility

$33.60

Service Code	HCPCS 82103
Hospital Charge Code	40609036
Hospital Revenue Code	300
Rate for Payer: Cash Price	$13.44

ALPHA-THALASSEMIA

Facility

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	40629206
Hospital Revenue Code	310
Min. Negotiated Rate	$71.58
Max. Negotiated Rate	$204.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$102.26
Rate for Payer: Aetna Government	$102.26
Rate for Payer: Affinity Essential Plan 1&2	$71.58
Rate for Payer: Affinity Essential Plan 3&4	$71.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$71.58
Rate for Payer: Brighton Health Commercial	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$102.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.84
Rate for Payer: Elderplan Medicare Advantage	$102.26
Rate for Payer: EmblemHealth Commercial	$102.26
Rate for Payer: Fidelis Essential Plan Aliesa	$86.92
Rate for Payer: Fidelis Essential Plan QHP	$91.01
Rate for Payer: Fidelis Medicare Advantage	$102.26
Rate for Payer: Fidelis Qualified Health Plan	$91.01
Rate for Payer: Group Health Inc Commercial	$102.26
Rate for Payer: Group Health Inc Medicare	$102.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.82
Rate for Payer: Hamaspik Choice Inc Medicare	$102.26
Rate for Payer: Healthfirst Medicare Advantage	$102.26
Rate for Payer: Healthfirst QHP	$102.26
Rate for Payer: Humana Medicare	$104.31
Rate for Payer: Senior Whole Health Medicare Advantage	$102.26
Rate for Payer: United Healthcare Medicare Advantage	$102.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$102.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$81.81
Rate for Payer: Wellcare Medicare	$92.03

ALPHA-THALASSEMIA

Facility

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	40629206
Hospital Revenue Code	310
Rate for Payer: Cash Price	$102.26

ALPHA THALASSEMIA, DNA N

Facility

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	30305803
Hospital Revenue Code	310
Rate for Payer: Cash Price	$102.26

ALPHA THALASSEMIA, DNA N

Facility

$255.65

Service Code	HCPCS 81257
Hospital Charge Code	30305803
Hospital Revenue Code	310
Min. Negotiated Rate	$71.58
Max. Negotiated Rate	$204.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$102.26
Rate for Payer: Aetna Government	$102.26
Rate for Payer: Affinity Essential Plan 1&2	$71.58
Rate for Payer: Affinity Essential Plan 3&4	$71.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$71.58
Rate for Payer: Brighton Health Commercial	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Cash Price	$102.26
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$102.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.84
Rate for Payer: Elderplan Medicare Advantage	$102.26
Rate for Payer: EmblemHealth Commercial	$102.26
Rate for Payer: Fidelis Essential Plan Aliesa	$86.92
Rate for Payer: Fidelis Essential Plan QHP	$91.01
Rate for Payer: Fidelis Medicare Advantage	$102.26
Rate for Payer: Fidelis Qualified Health Plan	$91.01
Rate for Payer: Group Health Inc Commercial	$102.26
Rate for Payer: Group Health Inc Medicare	$102.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.82
Rate for Payer: Hamaspik Choice Inc Medicare	$102.26
Rate for Payer: Healthfirst Medicare Advantage	$102.26
Rate for Payer: Healthfirst QHP	$102.26
Rate for Payer: Humana Medicare	$104.31
Rate for Payer: Senior Whole Health Medicare Advantage	$102.26
Rate for Payer: United Healthcare Medicare Advantage	$102.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$102.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$81.81
Rate for Payer: Wellcare Medicare	$92.03

ALPRAZOLAM 0.25 MG PO TABS [324]

Facility

$0.70

Service Code	NDC 00781106101
Hospital Charge Code	00781106101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.45

ALPRAZOLAM 0.25 MG TAB

Facility

$1.00

Hospital Charge Code	41640899
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.

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