St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MITOMYCIN 40 MG IV SOLR

Facility

$1.00

Service Code	HCPCS J9280
Hospital Charge Code	6745752040
Hospital Revenue Code	258
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$20.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.35
Rate for Payer: Aetna Government	$20.35
Rate for Payer: Affinity Essential Plan 1&2	$14.24
Rate for Payer: Affinity Essential Plan 3&4	$14.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.24
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Elderplan Medicare Advantage	$20.35
Rate for Payer: EmblemHealth Commercial	$20.35
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18.32
Rate for Payer: Fidelis Essential Plan Aliesa	$17.30
Rate for Payer: Fidelis Essential Plan QHP	$18.11
Rate for Payer: Fidelis Medicare Advantage	$20.35
Rate for Payer: Fidelis Qualified Health Plan	$18.11
Rate for Payer: Group Health Inc Commercial	$20.35
Rate for Payer: Group Health Inc Medicare	$20.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.35
Rate for Payer: Hamaspik Choice Inc Medicare	$20.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.35
Rate for Payer: Healthfirst Medicare Advantage	$17.30
Rate for Payer: Healthfirst QHP	$20.35
Rate for Payer: Humana Medicare	$20.76
Rate for Payer: Senior Whole Health Medicare Advantage	$20.35
Rate for Payer: United Healthcare Medicare Advantage	$20.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19.33
Rate for Payer: Wellcare Medicare	$19.33

MITOMYCIN 40 MG IV SOLR

Facility

$1.00

Service Code	HCPCS J9280
Hospital Charge Code	6745752040
Hospital Revenue Code	258
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

MITOMYCIN 40 MG IV SOLR

Facility

$1.00

Service Code	HCPCS J9280
Hospital Charge Code	1672911638
Hospital Revenue Code	258
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

MITOMYCIN 40 MG IV SOLR

Facility

$1.00

Service Code	HCPCS J9280
Hospital Charge Code	1672911638
Hospital Revenue Code	258
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$20.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.35
Rate for Payer: Aetna Government	$20.35
Rate for Payer: Affinity Essential Plan 1&2	$14.24
Rate for Payer: Affinity Essential Plan 3&4	$14.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.24
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Elderplan Medicare Advantage	$20.35
Rate for Payer: EmblemHealth Commercial	$20.35
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18.32
Rate for Payer: Fidelis Essential Plan Aliesa	$17.30
Rate for Payer: Fidelis Essential Plan QHP	$18.11
Rate for Payer: Fidelis Medicare Advantage	$20.35
Rate for Payer: Fidelis Qualified Health Plan	$18.11
Rate for Payer: Group Health Inc Commercial	$20.35
Rate for Payer: Group Health Inc Medicare	$20.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.35
Rate for Payer: Hamaspik Choice Inc Medicare	$20.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.35
Rate for Payer: Healthfirst Medicare Advantage	$17.30
Rate for Payer: Healthfirst QHP	$20.35
Rate for Payer: Humana Medicare	$20.76
Rate for Payer: Senior Whole Health Medicare Advantage	$20.35
Rate for Payer: United Healthcare Medicare Advantage	$20.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19.33
Rate for Payer: Wellcare Medicare	$19.33

MITOMYCIN 5 MG IV SOLR

Facility

$272.46

Service Code	HCPCS J9280
Hospital Charge Code	1672911505
Hospital Revenue Code	258
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$217.97
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$149.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.35
Rate for Payer: Aetna Government	$20.35
Rate for Payer: Affinity Essential Plan 1&2	$14.24
Rate for Payer: Affinity Essential Plan 3&4	$14.24
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.24
Rate for Payer: Brighton Health Commercial	$204.34
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$217.97
Rate for Payer: Cigna LocalPlus Benefit Plan	$185.27
Rate for Payer: Elderplan Medicare Advantage	$20.35
Rate for Payer: EmblemHealth Commercial	$20.35
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18.32
Rate for Payer: Fidelis Essential Plan Aliesa	$17.30
Rate for Payer: Fidelis Essential Plan QHP	$18.11
Rate for Payer: Fidelis Medicare Advantage	$20.35
Rate for Payer: Fidelis Qualified Health Plan	$18.11
Rate for Payer: Group Health Inc Commercial	$20.35
Rate for Payer: Group Health Inc Medicare	$20.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.35
Rate for Payer: Hamaspik Choice Inc Medicare	$20.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$20.35
Rate for Payer: Healthfirst Medicare Advantage	$17.30
Rate for Payer: Healthfirst QHP	$20.35
Rate for Payer: Humana Medicare	$20.76
Rate for Payer: Senior Whole Health Medicare Advantage	$20.35
Rate for Payer: United Healthcare Medicare Advantage	$20.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$177.10
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19.33
Rate for Payer: Wellcare Medicare	$19.33

MITOMYCIN 5 MG IV SOLR

Facility

$272.46

Service Code	HCPCS J9280
Hospital Charge Code	1672911505
Hospital Revenue Code	258
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$136.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$136.23

MITOXANTRONE HCL 20 MG/10ML IV CONC

Facility

$20.40

Service Code	HCPCS J9293
Hospital Charge Code	0703468501
Hospital Revenue Code	258
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$10.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.20

MITOXANTRONE HCL 20 MG/10ML IV CONC

Facility

$20.40

Service Code	HCPCS J9293
Hospital Charge Code	0703468501
Hospital Revenue Code	258
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$24.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.88
Rate for Payer: Aetna Government	$23.88
Rate for Payer: Affinity Essential Plan 1&2	$16.72
Rate for Payer: Affinity Essential Plan 3&4	$16.72
Rate for Payer: Affinity Medicaid/CHP/HARP	$16.72
Rate for Payer: Brighton Health Commercial	$15.30
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$23.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.87
Rate for Payer: Elderplan Medicare Advantage	$23.88
Rate for Payer: EmblemHealth Commercial	$23.88
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21.49
Rate for Payer: Fidelis Essential Plan Aliesa	$20.30
Rate for Payer: Fidelis Essential Plan QHP	$21.25
Rate for Payer: Fidelis Medicare Advantage	$23.88
Rate for Payer: Fidelis Qualified Health Plan	$21.25
Rate for Payer: Group Health Inc Commercial	$23.88
Rate for Payer: Group Health Inc Medicare	$23.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.88
Rate for Payer: Hamaspik Choice Inc Medicare	$23.88
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$23.88
Rate for Payer: Healthfirst Medicare Advantage	$20.30
Rate for Payer: Healthfirst QHP	$23.88
Rate for Payer: Humana Medicare	$24.36
Rate for Payer: Senior Whole Health Medicare Advantage	$23.88
Rate for Payer: United Healthcare Medicare Advantage	$23.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$22.69
Rate for Payer: Wellcare Medicare	$22.69

Moderately extensive procedure unrelated to principal diagnosis

Facility

$48,216.49

Service Code	APR-DRG 9511
Min. Negotiated Rate	$11,479.00
Max. Negotiated Rate	$48,216.49
Rate for Payer: Affinity Essential Plan 1&2	$48,216.49
Rate for Payer: Affinity Essential Plan 3&4	$48,216.49
Rate for Payer: Affinity Medicaid/CHP/HARP	$21,429.55
Rate for Payer: Amida Care Medicaid	$21,429.55
Rate for Payer: EmblemHealth Essential Plan 1&2	$48,216.49
Rate for Payer: EmblemHealth Essential Plan 3&4	$21,429.55
Rate for Payer: Fidelis CHP/HARP/Medicaid	$21,429.55
Rate for Payer: Fidelis Qualified Health Plan	$25,715.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,429.55
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$21,429.55
Rate for Payer: Healthfirst Commercial	$19,268.00
Rate for Payer: Healthfirst Essential Plan	$48,216.49
Rate for Payer: Healthfirst QHP	$11,479.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$21,429.55
Rate for Payer: SOMOS Essential	$48,216.49
Rate for Payer: United Healthcare Essential Plan 1&2	$48,216.49
Rate for Payer: United Healthcare Essential Plan 3&4	$48,216.49
Rate for Payer: United Healthcare Medicaid	$21,429.55
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21,429.55

Moderately extensive procedure unrelated to principal diagnosis

Facility

$56,473.79

Service Code	APR-DRG 9512
Min. Negotiated Rate	$16,709.00
Max. Negotiated Rate	$56,473.79
Rate for Payer: Affinity Essential Plan 1&2	$56,473.79
Rate for Payer: Affinity Essential Plan 3&4	$56,473.79
Rate for Payer: Affinity Medicaid/CHP/HARP	$25,099.46
Rate for Payer: Amida Care Medicaid	$25,099.46
Rate for Payer: EmblemHealth Essential Plan 1&2	$56,473.79
Rate for Payer: EmblemHealth Essential Plan 3&4	$25,099.46
Rate for Payer: Fidelis CHP/HARP/Medicaid	$25,099.46
Rate for Payer: Fidelis Qualified Health Plan	$30,119.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,099.46
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$25,099.46
Rate for Payer: Healthfirst Commercial	$28,792.00
Rate for Payer: Healthfirst Essential Plan	$56,473.79
Rate for Payer: Healthfirst QHP	$16,709.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$25,099.46
Rate for Payer: SOMOS Essential	$56,473.79
Rate for Payer: United Healthcare Essential Plan 1&2	$56,473.79
Rate for Payer: United Healthcare Essential Plan 3&4	$56,473.79
Rate for Payer: United Healthcare Medicaid	$25,099.46
Rate for Payer: Wellcare CHP/FHP/Medicaid	$25,099.46

Moderately extensive procedure unrelated to principal diagnosis

Facility

$142,379.75

Service Code	APR-DRG 9514
Min. Negotiated Rate	$63,279.89
Max. Negotiated Rate	$142,379.75
Rate for Payer: Affinity Essential Plan 1&2	$142,379.75
Rate for Payer: Affinity Essential Plan 3&4	$142,379.75
Rate for Payer: Affinity Medicaid/CHP/HARP	$63,279.89
Rate for Payer: Amida Care Medicaid	$63,279.89
Rate for Payer: EmblemHealth Essential Plan 1&2	$142,379.75
Rate for Payer: EmblemHealth Essential Plan 3&4	$63,279.89
Rate for Payer: Fidelis CHP/HARP/Medicaid	$63,279.89
Rate for Payer: Fidelis Qualified Health Plan	$75,935.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$63,279.89
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$63,279.89
Rate for Payer: Healthfirst Commercial	$116,196.00
Rate for Payer: Healthfirst Essential Plan	$142,379.75
Rate for Payer: Healthfirst QHP	$65,667.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$63,279.89
Rate for Payer: SOMOS Essential	$142,379.75
Rate for Payer: United Healthcare Essential Plan 1&2	$142,379.75
Rate for Payer: United Healthcare Essential Plan 3&4	$142,379.75
Rate for Payer: United Healthcare Medicaid	$63,279.89
Rate for Payer: Wellcare CHP/FHP/Medicaid	$63,279.89

Moderately extensive procedure unrelated to principal diagnosis

Facility

$79,710.35

Service Code	APR-DRG 9513
Min. Negotiated Rate	$30,600.00
Max. Negotiated Rate	$79,710.35
Rate for Payer: Affinity Essential Plan 1&2	$79,710.35
Rate for Payer: Affinity Essential Plan 3&4	$79,710.35
Rate for Payer: Affinity Medicaid/CHP/HARP	$35,426.82
Rate for Payer: Amida Care Medicaid	$35,426.82
Rate for Payer: EmblemHealth Essential Plan 1&2	$79,710.35
Rate for Payer: EmblemHealth Essential Plan 3&4	$35,426.82
Rate for Payer: Fidelis CHP/HARP/Medicaid	$35,426.82
Rate for Payer: Fidelis Qualified Health Plan	$42,512.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$35,426.82
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$35,426.82
Rate for Payer: Healthfirst Commercial	$54,751.00
Rate for Payer: Healthfirst Essential Plan	$79,710.35
Rate for Payer: Healthfirst QHP	$30,600.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$35,426.82
Rate for Payer: SOMOS Essential	$79,710.35
Rate for Payer: United Healthcare Essential Plan 1&2	$79,710.35
Rate for Payer: United Healthcare Essential Plan 3&4	$79,710.35
Rate for Payer: United Healthcare Medicaid	$35,426.82
Rate for Payer: Wellcare CHP/FHP/Medicaid	$35,426.82

MODIFIED MAGIC MOUTHWASH (NO LIDOCAINE) - COMPOUNDED

Facility

$0.19

Service Code	NDC 9999408453
Hospital Charge Code	9999408453
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10

MODIFIED MAGIC MOUTHWASH (NO LIDOCAINE) - COMPOUNDED

Facility

$0.19

Service Code	NDC 9999408453
Hospital Charge Code	9999408453
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
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

MOHS MICROGRAPHIC SURGERY

Facility

$1,562.15

Service Code	EAPG 00019
Min. Negotiated Rate	$1,562.15
Max. Negotiated Rate	$1,562.15
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,562.15

MOMETASONE FUROATE 110 MCG/ACT IN AEPB

Facility

$111.65

Service Code	NDC 7820611501
Hospital Charge Code	7820611501
Hospital Revenue Code	250
Min. Negotiated Rate	$55.83
Max. Negotiated Rate	$55.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.83

MOMETASONE FUROATE 110 MCG/ACT IN AEPB

Facility

$111.65

Service Code	NDC 7820611501
Hospital Charge Code	7820611501
Hospital Revenue Code	250
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$89.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$61.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.83
Rate for Payer: Aetna Government	$55.83
Rate for Payer: Brighton Health Commercial	$83.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$89.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$75.92
Rate for Payer: EmblemHealth Commercial	$55.83
Rate for Payer: Group Health Inc Commercial	$55.83
Rate for Payer: Group Health Inc Medicare	$39.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.83
Rate for Payer: Hamaspik Choice Inc Medicare	$55.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$72.57

MOMETASONE FUROATE 110 MCG/INH IN AEPB

Facility

$111.65

Service Code	NDC 7820611501
Hospital Charge Code	7820611501
Hospital Revenue Code	250
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$89.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$61.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.83
Rate for Payer: Aetna Government	$55.83
Rate for Payer: Brighton Health Commercial	$83.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$89.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$75.92
Rate for Payer: EmblemHealth Commercial	$55.83
Rate for Payer: Group Health Inc Commercial	$55.83
Rate for Payer: Group Health Inc Medicare	$39.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.83
Rate for Payer: Hamaspik Choice Inc Medicare	$55.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$72.57

MOMETASONE FUROATE 110 MCG/INH IN AEPB

Facility

$111.65

Service Code	NDC 7820611501
Hospital Charge Code	7820611501
Hospital Revenue Code	250
Min. Negotiated Rate	$55.83
Max. Negotiated Rate	$55.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.83

MOMETASONE FUROATE 220 MCG/ACT IN AEPB

Facility

$46.56

Service Code	NDC 7820611403
Hospital Charge Code	7820611403
Hospital Revenue Code	250
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$23.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.28

MOMETASONE FUROATE 220 MCG/ACT IN AEPB

Facility

$46.56

Service Code	NDC 7820611403
Hospital Charge Code	7820611403
Hospital Revenue Code	250
Min. Negotiated Rate	$16.30
Max. Negotiated Rate	$37.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.28
Rate for Payer: Aetna Government	$23.28
Rate for Payer: Brighton Health Commercial	$34.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$31.66
Rate for Payer: EmblemHealth Commercial	$23.28
Rate for Payer: Group Health Inc Commercial	$23.28
Rate for Payer: Group Health Inc Medicare	$16.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.28
Rate for Payer: Hamaspik Choice Inc Medicare	$23.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30.26

MOMETASONE FUROATE 220 MCG/INH IN AEPB

Facility

$46.56

Service Code	NDC 7820611403
Hospital Charge Code	7820611403
Hospital Revenue Code	250
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$23.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.28

MOMETASONE FUROATE 220 MCG/INH IN AEPB

Facility

$46.56

Service Code	NDC 7820611403
Hospital Charge Code	7820611403
Hospital Revenue Code	250
Min. Negotiated Rate	$16.30
Max. Negotiated Rate	$37.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.28
Rate for Payer: Aetna Government	$23.28
Rate for Payer: Brighton Health Commercial	$34.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$31.66
Rate for Payer: EmblemHealth Commercial	$23.28
Rate for Payer: Group Health Inc Commercial	$23.28
Rate for Payer: Group Health Inc Medicare	$16.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.28
Rate for Payer: Hamaspik Choice Inc Medicare	$23.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30.26

MONTELUKAST SODIUM 10 MG PO TABS

Facility

$5.65

Service Code	NDC 6586257490
Hospital Charge Code	6586257490
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$2.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83

MONTELUKAST SODIUM 10 MG PO TABS

Facility

$5.65

Service Code	NDC 6586257490
Hospital Charge Code	6586257490
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.83
Rate for Payer: Aetna Government	$2.83
Rate for Payer: Brighton Health Commercial	$4.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.84
Rate for Payer: EmblemHealth Commercial	$2.83
Rate for Payer: Group Health Inc Commercial	$2.83
Rate for Payer: Group Health Inc Medicare	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.83
Rate for Payer: Hamaspik Choice Inc Medicare	$2.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.67

Know your out-of-pocket cost for care.

All Charges