St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

AXILLO FEMORAL BYPASS

Facility

$5,173.56

Service Code	HCPCS 35533
Hospital Charge Code	40031845
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.00
Max. Negotiated Rate	$3,880.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,845.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,704.40
Rate for Payer: Aetna Government	$1,704.40
Rate for Payer: Brighton Health Commercial	$3,880.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Group Health Inc Commercial	$2,586.78
Rate for Payer: Group Health Inc Medicare	$1,810.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,586.78
Rate for Payer: Hamaspik Choice Inc Medicare	$2,586.78
Rate for Payer: United Healthcare Commercial	$1,496.00

AXLE STR

Facility

$3,371.25

Service Code	HCPCS C1776
Hospital Charge Code	64907253
Hospital Revenue Code	278
Min. Negotiated Rate	$1,685.62
Max. Negotiated Rate	$1,685.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,685.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1,685.62

AXLE STR

Facility

$3,371.25

Service Code	HCPCS C1776
Hospital Charge Code	64907253
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,539.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,854.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,022.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,685.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,938.47
Rate for Payer: EmblemHealth Commercial	$1,685.62
Rate for Payer: Fidelis Medicare Advantage	$3,539.81
Rate for Payer: Group Health Inc Commercial	$1,685.62
Rate for Payer: Group Health Inc Medicare	$1,179.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,685.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1,685.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,191.31

AZACITIDINE 100 MG IJ SUSR [78420]

Facility

$120.00

Service Code	HCPCS J9025
Hospital Charge Code	43598014362
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$96.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$66.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.93
Rate for Payer: Aetna Government	$0.93
Rate for Payer: Brighton Health Commercial	$90.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$96.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$81.60
Rate for Payer: Group Health Inc Commercial	$60.00
Rate for Payer: Group Health Inc Medicare	$42.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$60.00
Rate for Payer: Hamaspik Choice Inc Medicare	$60.00
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.41
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$78.00

AZACITIDINE 100 MG IJ SUSR [78420]

Facility

$240.00

Service Code	HCPCS J9025
Hospital Charge Code	43598030562
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$192.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$132.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.93
Rate for Payer: Aetna Government	$0.93
Rate for Payer: Brighton Health Commercial	$180.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$192.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$163.20
Rate for Payer: Group Health Inc Commercial	$120.00
Rate for Payer: Group Health Inc Medicare	$84.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$120.00
Rate for Payer: Hamaspik Choice Inc Medicare	$120.00
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.41
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$156.00

AZACITIDINE 100 MG IJ SUSR [78420]

Facility

$54.00

Service Code	HCPCS J9025
Hospital Charge Code	71288011530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$43.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.93
Rate for Payer: Aetna Government	$0.93
Rate for Payer: Brighton Health Commercial	$40.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$36.72
Rate for Payer: Group Health Inc Commercial	$27.00
Rate for Payer: Group Health Inc Medicare	$18.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.00
Rate for Payer: Hamaspik Choice Inc Medicare	$27.00
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.41
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$35.10

AZATHIOPRINE 50 MG PO TABS [9183]

Facility

$6.81

Service Code	HCPCS J7500
Hospital Charge Code	60219107601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$6.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.58
Rate for Payer: Aetna Government	$6.58
Rate for Payer: Brighton Health Commercial	$5.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.63
Rate for Payer: Group Health Inc Commercial	$3.41
Rate for Payer: Group Health Inc Medicare	$2.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.41
Rate for Payer: Hamaspik Choice Inc Medicare	$3.41
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.56
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.71
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.71
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.43

AZATHIOPRINE 50 MG PO TABS [9183]

Facility

$0.85

Service Code	HCPCS J7500
Hospital Charge Code	68084022911
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$6.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.58
Rate for Payer: Aetna Government	$6.58
Rate for Payer: Brighton Health Commercial	$0.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.57
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.56
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.71
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.71
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

AZATHIOPRINE 50 MG PO TABS [9183]

Facility

$0.85

Service Code	HCPCS J7500
Hospital Charge Code	68084022901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$6.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.58
Rate for Payer: Aetna Government	$6.58
Rate for Payer: Brighton Health Commercial	$0.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.57
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.56
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.71
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.71
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

AZATHIOPRINE 50 MG TAB

Facility

$0.30

Service Code	HCPCS J7500
Hospital Charge Code	41653109
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$6.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.58
Rate for Payer: Aetna Government	$6.58
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.71
Rate for Payer: SOMOS Essential	$2.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

AZATHIOPRINE 50 MG TAB

Facility

$0.30

Service Code	HCPCS J7500
Hospital Charge Code	41643109
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$6.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.58
Rate for Payer: Aetna Government	$6.58
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.71
Rate for Payer: SOMOS Essential	$2.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

AZATHIOPRINE 50 MG TAB

Facility

$0.30

Service Code	HCPCS J7500
Hospital Charge Code	41643109
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15

AZATHIOPRINE 50 MG TAB

Facility

$0.30

Service Code	HCPCS J7500
Hospital Charge Code	41653109
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15

AZITHROMYCIN 100 MG/5ML PO SUSR [15796]

Facility

$2.33

Service Code	NDC 70710145701
Hospital Charge Code	70710145701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.16
Rate for Payer: Aetna Government	$1.16
Rate for Payer: Brighton Health Commercial	$1.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.58
Rate for Payer: Group Health Inc Commercial	$1.16
Rate for Payer: Group Health Inc Medicare	$0.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.16
Rate for Payer: Hamaspik Choice Inc Medicare	$1.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.51

AZITHROMYCIN 100 MG/5ML PO SUSR [15796]

Facility

$2.33

Service Code	NDC 00093202723
Hospital Charge Code	00093202723
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.16
Rate for Payer: Aetna Government	$1.16
Rate for Payer: Brighton Health Commercial	$1.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.58
Rate for Payer: Group Health Inc Commercial	$1.16
Rate for Payer: Group Health Inc Medicare	$0.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.16
Rate for Payer: Hamaspik Choice Inc Medicare	$1.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.51

AZITHROMYCIN 100 MG/5 ML SUSP

Facility

$1.56

Service Code	HCPCS Q0144
Hospital Charge Code	41654643
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78
Rate for Payer: Hamaspik Choice Inc Medicare	$0.78

AZITHROMYCIN 100 MG/5 ML SUSP

Facility

$1.56

Service Code	HCPCS Q0144
Hospital Charge Code	41654643
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$0.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.90
Rate for Payer: Group Health Inc Commercial	$0.78
Rate for Payer: Group Health Inc Medicare	$0.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78
Rate for Payer: Hamaspik Choice Inc Medicare	$0.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.01

AZITHROMYCIN 100 MG/5 ML SUSP

Facility

$1.56

Service Code	HCPCS Q0144
Hospital Charge Code	41644643
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78
Rate for Payer: Hamaspik Choice Inc Medicare	$0.78

AZITHROMYCIN 100 MG/5 ML SUSP

Facility

$1.56

Service Code	HCPCS Q0144
Hospital Charge Code	41644643
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$0.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.90
Rate for Payer: Group Health Inc Commercial	$0.78
Rate for Payer: Group Health Inc Medicare	$0.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78
Rate for Payer: Hamaspik Choice Inc Medicare	$0.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.01

AZITHROMYCIN 1 G PO PACK [15284]

Facility

$29.64

Service Code	NDC 00069305175
Hospital Charge Code	00069305175
Hospital Revenue Code	250
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$23.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.82
Rate for Payer: Aetna Government	$14.82
Rate for Payer: Brighton Health Commercial	$22.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.16
Rate for Payer: Group Health Inc Commercial	$14.82
Rate for Payer: Group Health Inc Medicare	$10.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.82
Rate for Payer: Hamaspik Choice Inc Medicare	$14.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$19.27

AZITHROMYCIN 1 G PO PACK [15284]

Facility

$29.13

Service Code	NDC 59762305102
Hospital Charge Code	59762305102
Hospital Revenue Code	250
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$23.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.56
Rate for Payer: Aetna Government	$14.56
Rate for Payer: Brighton Health Commercial	$21.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.81
Rate for Payer: Group Health Inc Commercial	$14.56
Rate for Payer: Group Health Inc Medicare	$10.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.56
Rate for Payer: Hamaspik Choice Inc Medicare	$14.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.93

AZITHROMYCIN 1 G PO PACK [15284]

Facility

$149.60

Service Code	NDC 00069305107
Hospital Charge Code	00069305107
Hospital Revenue Code	250
Min. Negotiated Rate	$52.36
Max. Negotiated Rate	$119.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$82.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$74.80
Rate for Payer: Aetna Government	$74.80
Rate for Payer: Brighton Health Commercial	$112.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$119.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$101.73
Rate for Payer: Group Health Inc Commercial	$74.80
Rate for Payer: Group Health Inc Medicare	$52.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$74.80
Rate for Payer: Hamaspik Choice Inc Medicare	$74.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$97.24

AZITHROMYCIN 1 GRAM SACHET POWDER

Facility

$26.28

Service Code	HCPCS Q0144
Hospital Charge Code	41652995
Hospital Revenue Code	636
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$15.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.11
Rate for Payer: Group Health Inc Commercial	$13.14
Rate for Payer: Group Health Inc Medicare	$9.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.14
Rate for Payer: Hamaspik Choice Inc Medicare	$13.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17.08

AZITHROMYCIN 1 GRAM SACHET POWDER

Facility

$26.28

Service Code	HCPCS Q0144
Hospital Charge Code	41642995
Hospital Revenue Code	636
Min. Negotiated Rate	$13.14
Max. Negotiated Rate	$13.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.14
Rate for Payer: Hamaspik Choice Inc Medicare	$13.14

AZITHROMYCIN 1 GRAM SACHET POWDER

Facility

$26.28

Service Code	HCPCS Q0144
Hospital Charge Code	41652995
Hospital Revenue Code	636
Min. Negotiated Rate	$13.14
Max. Negotiated Rate	$13.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.14
Rate for Payer: Hamaspik Choice Inc Medicare	$13.14

Know your out-of-pocket cost for care.

All Charges