St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

QUINIDINE SULFATE 300 MG PO TABS

Facility

$15.90

Service Code	NDC 4280651230
Hospital Charge Code	4280651230
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$12.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.95
Rate for Payer: Aetna Government	$7.95
Rate for Payer: Brighton Health Commercial	$11.93
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.81
Rate for Payer: EmblemHealth Commercial	$7.95
Rate for Payer: Group Health Inc Commercial	$7.95
Rate for Payer: Group Health Inc Medicare	$5.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.95
Rate for Payer: Hamaspik Choice Inc Medicare	$7.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.34

QUININE SULFATE 324 MG PO CAPS

Facility

$7.07

Service Code	NDC 6818056006
Hospital Charge Code	6818056006
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.54
Rate for Payer: Aetna Government	$3.54
Rate for Payer: Brighton Health Commercial	$5.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.81
Rate for Payer: EmblemHealth Commercial	$3.54
Rate for Payer: Group Health Inc Commercial	$3.54
Rate for Payer: Group Health Inc Medicare	$2.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.54
Rate for Payer: Hamaspik Choice Inc Medicare	$3.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.60

QUININE SULFATE 324 MG PO CAPS

Facility

$7.07

Service Code	NDC 6818056006
Hospital Charge Code	6818056006
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$3.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.54

RABIES IMMUNE GLOBULIN 1500 UNIT/10ML IJ SOLN

Facility

$408.39

Service Code	HCPCS 90377
Hospital Charge Code	7612515010
Hospital Revenue Code	250
Min. Negotiated Rate	$204.19
Max. Negotiated Rate	$204.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$204.19

RABIES IMMUNE GLOBULIN 1500 UNIT/10ML IJ SOLN

Facility

$408.39

Service Code	HCPCS 90377
Hospital Charge Code	7612515010
Hospital Revenue Code	250
Min. Negotiated Rate	$155.57
Max. Negotiated Rate	$326.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$224.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$222.25
Rate for Payer: Aetna Government	$222.25
Rate for Payer: Affinity Essential Plan 1&2	$155.57
Rate for Payer: Affinity Essential Plan 3&4	$155.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$155.57
Rate for Payer: Brighton Health Commercial	$306.29
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$222.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$326.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$277.70
Rate for Payer: Elderplan Medicare Advantage	$222.25
Rate for Payer: EmblemHealth Commercial	$222.25
Rate for Payer: Fidelis CHP/HARP/Medicaid	$200.03
Rate for Payer: Fidelis Essential Plan Aliesa	$188.91
Rate for Payer: Fidelis Essential Plan QHP	$197.80
Rate for Payer: Fidelis Medicare Advantage	$222.25
Rate for Payer: Fidelis Qualified Health Plan	$197.80
Rate for Payer: Group Health Inc Commercial	$222.25
Rate for Payer: Group Health Inc Medicare	$222.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$222.25
Rate for Payer: Hamaspik Choice Inc Medicare	$222.25
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$222.25
Rate for Payer: Healthfirst Medicare Advantage	$188.91
Rate for Payer: Healthfirst QHP	$222.25
Rate for Payer: Humana Medicare	$226.69
Rate for Payer: Senior Whole Health Medicare Advantage	$222.25
Rate for Payer: United Healthcare Medicare Advantage	$222.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$265.45
Rate for Payer: Wellcare CHP/FHP/Medicaid	$211.14
Rate for Payer: Wellcare Medicare	$211.14

RABIES VACCINE, PCEC IM SUSR

Facility

$392.76

Service Code	HCPCS 90675
Hospital Charge Code	5009018200
Hospital Revenue Code	250
Min. Negotiated Rate	$196.38
Max. Negotiated Rate	$196.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$196.38

RABIES VACCINE, PCEC IM SUSR

Facility

$496.69

Service Code	HCPCS 90675
Hospital Charge Code	5063201301
Hospital Revenue Code	250
Min. Negotiated Rate	$219.58
Max. Negotiated Rate	$397.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$273.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$313.68
Rate for Payer: Aetna Government	$313.68
Rate for Payer: Affinity Essential Plan 1&2	$219.58
Rate for Payer: Affinity Essential Plan 3&4	$219.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$219.58
Rate for Payer: Brighton Health Commercial	$372.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$313.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$397.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$337.75
Rate for Payer: Elderplan Medicare Advantage	$313.68
Rate for Payer: EmblemHealth Commercial	$313.68
Rate for Payer: Fidelis CHP/HARP/Medicaid	$282.31
Rate for Payer: Fidelis Essential Plan Aliesa	$266.63
Rate for Payer: Fidelis Essential Plan QHP	$279.18
Rate for Payer: Fidelis Medicare Advantage	$313.68
Rate for Payer: Fidelis Qualified Health Plan	$279.18
Rate for Payer: Group Health Inc Commercial	$313.68
Rate for Payer: Group Health Inc Medicare	$313.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$313.68
Rate for Payer: Hamaspik Choice Inc Medicare	$313.68
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$313.68
Rate for Payer: Healthfirst Medicare Advantage	$266.63
Rate for Payer: Healthfirst QHP	$313.68
Rate for Payer: Humana Medicare	$319.95
Rate for Payer: Senior Whole Health Medicare Advantage	$313.68
Rate for Payer: United Healthcare Medicare Advantage	$313.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$322.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$298.00
Rate for Payer: Wellcare Medicare	$298.00

RABIES VACCINE, PCEC IM SUSR

Facility

$496.69

Service Code	HCPCS 90675
Hospital Charge Code	5063201001
Hospital Revenue Code	250
Min. Negotiated Rate	$248.34
Max. Negotiated Rate	$248.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$248.34

RABIES VACCINE, PCEC IM SUSR

Facility

$496.69

Service Code	HCPCS 90675
Hospital Charge Code	5063201001
Hospital Revenue Code	250
Min. Negotiated Rate	$219.58
Max. Negotiated Rate	$397.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$273.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$313.68
Rate for Payer: Aetna Government	$313.68
Rate for Payer: Affinity Essential Plan 1&2	$219.58
Rate for Payer: Affinity Essential Plan 3&4	$219.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$219.58
Rate for Payer: Brighton Health Commercial	$372.52
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$313.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$397.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$337.75
Rate for Payer: Elderplan Medicare Advantage	$313.68
Rate for Payer: EmblemHealth Commercial	$313.68
Rate for Payer: Fidelis CHP/HARP/Medicaid	$282.31
Rate for Payer: Fidelis Essential Plan Aliesa	$266.63
Rate for Payer: Fidelis Essential Plan QHP	$279.18
Rate for Payer: Fidelis Medicare Advantage	$313.68
Rate for Payer: Fidelis Qualified Health Plan	$279.18
Rate for Payer: Group Health Inc Commercial	$313.68
Rate for Payer: Group Health Inc Medicare	$313.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$313.68
Rate for Payer: Hamaspik Choice Inc Medicare	$313.68
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$313.68
Rate for Payer: Healthfirst Medicare Advantage	$266.63
Rate for Payer: Healthfirst QHP	$313.68
Rate for Payer: Humana Medicare	$319.95
Rate for Payer: Senior Whole Health Medicare Advantage	$313.68
Rate for Payer: United Healthcare Medicare Advantage	$313.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$322.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$298.00
Rate for Payer: Wellcare Medicare	$298.00

RABIES VACCINE, PCEC IM SUSR

Facility

$496.69

Service Code	HCPCS 90675
Hospital Charge Code	5063201301
Hospital Revenue Code	250
Min. Negotiated Rate	$248.34
Max. Negotiated Rate	$248.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$248.34

RABIES VACCINE, PCEC IM SUSR

Facility

$392.76

Service Code	HCPCS 90675
Hospital Charge Code	5009018200
Hospital Revenue Code	250
Min. Negotiated Rate	$216.02
Max. Negotiated Rate	$319.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$216.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$313.68
Rate for Payer: Aetna Government	$313.68
Rate for Payer: Affinity Essential Plan 1&2	$219.58
Rate for Payer: Affinity Essential Plan 3&4	$219.58
Rate for Payer: Affinity Medicaid/CHP/HARP	$219.58
Rate for Payer: Brighton Health Commercial	$294.57
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$313.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$314.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$267.08
Rate for Payer: Elderplan Medicare Advantage	$313.68
Rate for Payer: EmblemHealth Commercial	$313.68
Rate for Payer: Fidelis CHP/HARP/Medicaid	$282.31
Rate for Payer: Fidelis Essential Plan Aliesa	$266.63
Rate for Payer: Fidelis Essential Plan QHP	$279.18
Rate for Payer: Fidelis Medicare Advantage	$313.68
Rate for Payer: Fidelis Qualified Health Plan	$279.18
Rate for Payer: Group Health Inc Commercial	$313.68
Rate for Payer: Group Health Inc Medicare	$313.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$313.68
Rate for Payer: Hamaspik Choice Inc Medicare	$313.68
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$313.68
Rate for Payer: Healthfirst Medicare Advantage	$266.63
Rate for Payer: Healthfirst QHP	$313.68
Rate for Payer: Humana Medicare	$319.95
Rate for Payer: Senior Whole Health Medicare Advantage	$313.68
Rate for Payer: United Healthcare Medicare Advantage	$313.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$255.29
Rate for Payer: Wellcare CHP/FHP/Medicaid	$298.00
Rate for Payer: Wellcare Medicare	$298.00

RACEPINEPHRINE HCL 2.25 % IN NEBU

Facility

$1.00

Service Code	NDC 0487278401
Hospital Charge Code	0487278401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

RACEPINEPHRINE HCL 2.25 % IN NEBU

Facility

$1.00

Service Code	NDC 0487278401
Hospital Charge Code	0487278401
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: EmblemHealth Commercial	$0.50
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

RACEPINEPHRINE HCL 2.25 % IN NEBU

Facility

$1.80

Service Code	NDC 0487590199
Hospital Charge Code	0487590199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.90

RACEPINEPHRINE HCL 2.25 % IN NEBU

Facility

$1.80

Service Code	NDC 0487590199
Hospital Charge Code	0487590199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.90
Rate for Payer: Aetna Government	$0.90
Rate for Payer: Brighton Health Commercial	$1.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.22
Rate for Payer: EmblemHealth Commercial	$0.90
Rate for Payer: Group Health Inc Commercial	$0.90
Rate for Payer: Group Health Inc Medicare	$0.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.90
Rate for Payer: Hamaspik Choice Inc Medicare	$0.90
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.17

RADIATION THERAPY MANAGEMENT

Facility

$547.35

Service Code	EAPG 00483
Min. Negotiated Rate	$398.06
Max. Negotiated Rate	$547.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$398.06
Rate for Payer: Healthfirst Commercial	$547.35

RADIOLOGICAL GUIDANCE FOR THERAPEUTIC OR DIAGNOSTIC PROCEDURES

Facility

$616.76

Service Code	EAPG 00474
Min. Negotiated Rate	$446.66
Max. Negotiated Rate	$616.76
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$446.66
Rate for Payer: Healthfirst Commercial	$616.76

RADIOSURGERY

Facility

$8,318.97

Service Code	EAPG 00346
Min. Negotiated Rate	$6,038.01
Max. Negotiated Rate	$8,318.97
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$6,038.01
Rate for Payer: Healthfirst Commercial	$8,318.97

Radiotherapy

Facility

$42,497.03

Service Code	APR-DRG 6921
Min. Negotiated Rate	$6,714.00
Max. Negotiated Rate	$42,497.03
Rate for Payer: Affinity Essential Plan 1&2	$42,497.03
Rate for Payer: Affinity Essential Plan 3&4	$42,497.03
Rate for Payer: Affinity Medicaid/CHP/HARP	$18,887.57
Rate for Payer: Amida Care Medicaid	$18,887.57
Rate for Payer: EmblemHealth Essential Plan 1&2	$42,497.03
Rate for Payer: EmblemHealth Essential Plan 3&4	$18,887.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$18,887.57
Rate for Payer: Fidelis Qualified Health Plan	$22,665.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$18,887.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18,887.57
Rate for Payer: Healthfirst Commercial	$11,685.00
Rate for Payer: Healthfirst Essential Plan	$42,497.03
Rate for Payer: Healthfirst QHP	$6,714.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$18,887.57
Rate for Payer: SOMOS Essential	$42,497.03
Rate for Payer: United Healthcare Essential Plan 1&2	$42,497.03
Rate for Payer: United Healthcare Essential Plan 3&4	$42,497.03
Rate for Payer: United Healthcare Medicaid	$18,887.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$18,887.57

Radiotherapy

Facility

$54,896.20

Service Code	APR-DRG 6922
Min. Negotiated Rate	$12,707.00
Max. Negotiated Rate	$54,896.20
Rate for Payer: Affinity Essential Plan 1&2	$54,896.20
Rate for Payer: Affinity Essential Plan 3&4	$54,896.20
Rate for Payer: Affinity Medicaid/CHP/HARP	$24,398.31
Rate for Payer: Amida Care Medicaid	$24,398.31
Rate for Payer: EmblemHealth Essential Plan 1&2	$54,896.20
Rate for Payer: EmblemHealth Essential Plan 3&4	$24,398.31
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24,398.31
Rate for Payer: Fidelis Qualified Health Plan	$29,277.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,398.31
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24,398.31
Rate for Payer: Healthfirst Commercial	$20,705.00
Rate for Payer: Healthfirst Essential Plan	$54,896.20
Rate for Payer: Healthfirst QHP	$12,707.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$24,398.31
Rate for Payer: SOMOS Essential	$54,896.20
Rate for Payer: United Healthcare Essential Plan 1&2	$54,896.20
Rate for Payer: United Healthcare Essential Plan 3&4	$54,896.20
Rate for Payer: United Healthcare Medicaid	$24,398.31
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24,398.31

Radiotherapy

Facility

$80,976.65

Service Code	APR-DRG 6923
Min. Negotiated Rate	$26,647.00
Max. Negotiated Rate	$80,976.65
Rate for Payer: Affinity Essential Plan 1&2	$80,976.65
Rate for Payer: Affinity Essential Plan 3&4	$80,976.65
Rate for Payer: Affinity Medicaid/CHP/HARP	$35,989.62
Rate for Payer: Amida Care Medicaid	$35,989.62
Rate for Payer: EmblemHealth Essential Plan 1&2	$80,976.65
Rate for Payer: EmblemHealth Essential Plan 3&4	$35,989.62
Rate for Payer: Fidelis CHP/HARP/Medicaid	$35,989.62
Rate for Payer: Fidelis Qualified Health Plan	$43,187.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$35,989.62
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$35,989.62
Rate for Payer: Healthfirst Commercial	$46,446.00
Rate for Payer: Healthfirst Essential Plan	$80,976.65
Rate for Payer: Healthfirst QHP	$26,647.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$35,989.62
Rate for Payer: SOMOS Essential	$80,976.65
Rate for Payer: United Healthcare Essential Plan 1&2	$80,976.65
Rate for Payer: United Healthcare Essential Plan 3&4	$80,976.65
Rate for Payer: United Healthcare Medicaid	$35,989.62
Rate for Payer: Wellcare CHP/FHP/Medicaid	$35,989.62

Radiotherapy

Facility

$86,954.62

Service Code	APR-DRG 6924
Min. Negotiated Rate	$30,265.00
Max. Negotiated Rate	$86,954.62
Rate for Payer: Affinity Essential Plan 1&2	$86,954.62
Rate for Payer: Affinity Essential Plan 3&4	$86,954.62
Rate for Payer: Affinity Medicaid/CHP/HARP	$38,646.50
Rate for Payer: Amida Care Medicaid	$38,646.50
Rate for Payer: EmblemHealth Essential Plan 1&2	$86,954.62
Rate for Payer: EmblemHealth Essential Plan 3&4	$38,646.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$38,646.50
Rate for Payer: Fidelis Qualified Health Plan	$46,375.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$38,646.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38,646.50
Rate for Payer: Healthfirst Commercial	$49,714.00
Rate for Payer: Healthfirst Essential Plan	$86,954.62
Rate for Payer: Healthfirst QHP	$30,265.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38,646.50
Rate for Payer: SOMOS Essential	$86,954.62
Rate for Payer: United Healthcare Essential Plan 1&2	$86,954.62
Rate for Payer: United Healthcare Essential Plan 3&4	$86,954.62
Rate for Payer: United Healthcare Medicaid	$38,646.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38,646.50

RADIOTHERAPY

Facility

$192.62

Service Code	EAPG 00802
Min. Negotiated Rate	$138.86
Max. Negotiated Rate	$192.62
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$138.86
Rate for Payer: Healthfirst Commercial	$192.62

RALTEGRAVIR POTASSIUM 400 MG PO TABS

Facility

$39.94

Service Code	NDC 0006022761
Hospital Charge Code	0006022761
Hospital Revenue Code	250
Min. Negotiated Rate	$19.97
Max. Negotiated Rate	$19.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.97

RALTEGRAVIR POTASSIUM 400 MG PO TABS

Facility

$39.94

Service Code	NDC 0006022761
Hospital Charge Code	0006022761
Hospital Revenue Code	250
Min. Negotiated Rate	$13.98
Max. Negotiated Rate	$31.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.97
Rate for Payer: Aetna Government	$19.97
Rate for Payer: Brighton Health Commercial	$29.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.16
Rate for Payer: EmblemHealth Commercial	$19.97
Rate for Payer: Group Health Inc Commercial	$19.97
Rate for Payer: Group Health Inc Medicare	$13.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.97
Rate for Payer: Hamaspik Choice Inc Medicare	$19.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.96

Know your out-of-pocket cost for care.

All Charges