St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

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% OPHTHALMIC SOLN

Facility

$167.92

Hospital Charge Code	41654989
Hospital Revenue Code	250
Min. Negotiated Rate	$58.77
Max. Negotiated Rate	$134.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$92.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$83.96
Rate for Payer: Aetna Government	$83.96
Rate for Payer: Brighton Health Commercial	$125.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$134.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$114.19
Rate for Payer: Group Health Inc Commercial	$83.96
Rate for Payer: Group Health Inc Medicare	$58.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.96
Rate for Payer: Hamaspik Choice Inc Medicare	$83.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$109.15

AZITHROMYCIN 1% OPHTHALMIC SOLN

Facility

$167.92

Hospital Charge Code	41644989
Hospital Revenue Code	250
Min. Negotiated Rate	$58.77
Max. Negotiated Rate	$134.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$92.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$83.96
Rate for Payer: Aetna Government	$83.96
Rate for Payer: Brighton Health Commercial	$125.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$134.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$114.19
Rate for Payer: Group Health Inc Commercial	$83.96
Rate for Payer: Group Health Inc Medicare	$58.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.96
Rate for Payer: Hamaspik Choice Inc Medicare	$83.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$109.15

AZITHROMYCIN 200 MG/5ML PO SUSR [15797]

Facility

$1.16

Service Code	NDC 42806015134
Hospital Charge Code	42806015134
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.58
Rate for Payer: Aetna Government	$0.58
Rate for Payer: Brighton Health Commercial	$0.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.76

AZITHROMYCIN 200 MG/5ML PO SUSR [15797]

Facility

$1.06

Service Code	NDC 00069314019
Hospital Charge Code	00069314019
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.53
Rate for Payer: Aetna Government	$0.53
Rate for Payer: Brighton Health Commercial	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.72
Rate for Payer: Group Health Inc Commercial	$0.53
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.53
Rate for Payer: Hamaspik Choice Inc Medicare	$0.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.69

AZITHROMYCIN 200 MG/5ML PO SUSR [15797]

Facility

$1.55

Service Code	NDC 70710145902
Hospital Charge Code	70710145902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.78
Rate for Payer: Aetna Government	$0.78
Rate for Payer: Brighton Health Commercial	$1.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.05
Rate for Payer: Group Health Inc Commercial	$0.78
Rate for Payer: Group Health Inc Medicare	$0.54
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 200 MG/5ML PO SUSR [15797]

Facility

$2.33

Service Code	NDC 70710145802
Hospital Charge Code	70710145802
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 200 MG/5ML PO SUSR [15797]

Facility

$1.16

Service Code	NDC 59762314001
Hospital Charge Code	59762314001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.58
Rate for Payer: Aetna Government	$0.58
Rate for Payer: Brighton Health Commercial	$0.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.76

AZITHROMYCIN 200 MG/5ML PO SUSR [15797]

Facility

$2.33

Service Code	NDC 59651000815
Hospital Charge Code	59651000815
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 200 MG/5ML PO SUSR [15797]

Facility

$1.16

Service Code	NDC 70710146002
Hospital Charge Code	70710146002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.58
Rate for Payer: Aetna Government	$0.58
Rate for Payer: Brighton Health Commercial	$0.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.76

AZITHROMYCIN 200 MG/5 ML SUSP

Facility

$1.00

Service Code	HCPCS Q0144
Hospital Charge Code	41644629
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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

AZITHROMYCIN 200 MG/5 ML SUSP

Facility

$1.00

Service Code	HCPCS Q0144
Hospital Charge Code	41654629
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
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

AZITHROMYCIN 200 MG/5 ML SUSP

Facility

$1.00

Service Code	HCPCS Q0144
Hospital Charge Code	41644629
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

AZITHROMYCIN 200 MG/5 ML SUSP

Facility

$1.00

Service Code	HCPCS Q0144
Hospital Charge Code	41654629
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$7.78

Service Code	NDC 65862064169
Hospital Charge Code	65862064169
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.89
Rate for Payer: Aetna Government	$3.89
Rate for Payer: Brighton Health Commercial	$5.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.29
Rate for Payer: Group Health Inc Commercial	$3.89
Rate for Payer: Group Health Inc Medicare	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.89
Rate for Payer: Hamaspik Choice Inc Medicare	$3.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.06

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$7.78

Service Code	NDC 50111078710
Hospital Charge Code	50111078710
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.89
Rate for Payer: Aetna Government	$3.89
Rate for Payer: Brighton Health Commercial	$5.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.29
Rate for Payer: Group Health Inc Commercial	$3.89
Rate for Payer: Group Health Inc Medicare	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.89
Rate for Payer: Hamaspik Choice Inc Medicare	$3.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.06

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$4.14

Service Code	NDC 00069406189
Hospital Charge Code	00069406189
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$3.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.07
Rate for Payer: Aetna Government	$2.07
Rate for Payer: Brighton Health Commercial	$3.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.82
Rate for Payer: Group Health Inc Commercial	$2.07
Rate for Payer: Group Health Inc Medicare	$1.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.07
Rate for Payer: Hamaspik Choice Inc Medicare	$2.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.69

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$7.78

Service Code	NDC 00781808931
Hospital Charge Code	00781808931
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.89
Rate for Payer: Aetna Government	$3.89
Rate for Payer: Brighton Health Commercial	$5.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.29
Rate for Payer: Group Health Inc Commercial	$3.89
Rate for Payer: Group Health Inc Medicare	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.89
Rate for Payer: Hamaspik Choice Inc Medicare	$3.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.06

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$2.59

Service Code	NDC 00069406101
Hospital Charge Code	00069406101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$2.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.29
Rate for Payer: Aetna Government	$1.29
Rate for Payer: Brighton Health Commercial	$1.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.76
Rate for Payer: Group Health Inc Commercial	$1.29
Rate for Payer: Group Health Inc Medicare	$0.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.29
Rate for Payer: Hamaspik Choice Inc Medicare	$1.29
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.68

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$1.26

Service Code	NDC 50268007413
Hospital Charge Code	50268007413
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$1.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.69
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.63
Rate for Payer: Aetna Government	$0.63
Rate for Payer: Brighton Health Commercial	$0.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.86
Rate for Payer: Group Health Inc Commercial	$0.63
Rate for Payer: Group Health Inc Medicare	$0.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.63
Rate for Payer: Hamaspik Choice Inc Medicare	$0.63
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.82

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$7.78

Service Code	NDC 51224002230
Hospital Charge Code	51224002230
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.89
Rate for Payer: Aetna Government	$3.89
Rate for Payer: Brighton Health Commercial	$5.83
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.29
Rate for Payer: Group Health Inc Commercial	$3.89
Rate for Payer: Group Health Inc Medicare	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.89
Rate for Payer: Hamaspik Choice Inc Medicare	$3.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.05

AZITHROMYCIN 250 MG PO TABS [20943]

Facility

$1.87

Service Code	NDC 60687074265
Hospital Charge Code	60687074265
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.94
Rate for Payer: Aetna Government	$0.94
Rate for Payer: Brighton Health Commercial	$1.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.27
Rate for Payer: Group Health Inc Commercial	$0.94
Rate for Payer: Group Health Inc Medicare	$0.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.94
Rate for Payer: Hamaspik Choice Inc Medicare	$0.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.22

AZITHROMYCIN 250 MG TAB

Facility

$20.60

Service Code	HCPCS Q0144
Hospital Charge Code	41654340
Hospital Revenue Code	636
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$20.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.10
Rate for Payer: Aetna Government	$20.10
Rate for Payer: Brighton Health Commercial	$12.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.84
Rate for Payer: Group Health Inc Commercial	$10.30
Rate for Payer: Group Health Inc Medicare	$7.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.30
Rate for Payer: Hamaspik Choice Inc Medicare	$10.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.39

AZITHROMYCIN 250 MG TAB

Facility

$20.60

Service Code	HCPCS Q0144
Hospital Charge Code	41654340
Hospital Revenue Code	636
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$10.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.30
Rate for Payer: Hamaspik Choice Inc Medicare	$10.30

AZITHROMYCIN 250 MG TAB

Facility

$20.60

Service Code	HCPCS Q0144
Hospital Charge Code	41644340
Hospital Revenue Code	636
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$10.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.30
Rate for Payer: Hamaspik Choice Inc Medicare	$10.30

Know your out-of-pocket cost for care.

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