St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

AMIKACIN 250 MG/ML INJ

Facility

$2.96

Service Code	HCPCS J0278
Hospital Charge Code	41654677
Hospital Revenue Code	636
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$1.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.48
Rate for Payer: Hamaspik Choice Inc Medicare	$1.48

AMIKACIN 250 MG/ML INJ

Facility

$2.96

Service Code	HCPCS J0278
Hospital Charge Code	41644677
Hospital Revenue Code	636
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$1.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.48
Rate for Payer: Hamaspik Choice Inc Medicare	$1.48

AMIKACIN 250 MG/ML INJ

Facility

$2.96

Service Code	HCPCS J0278
Hospital Charge Code	41644677
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.70
Rate for Payer: Group Health Inc Commercial	$1.48
Rate for Payer: Group Health Inc Medicare	$1.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.48
Rate for Payer: Hamaspik Choice Inc Medicare	$1.48
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.92

AMIKACIN 250 MG/ML INJ

Facility

$2.96

Service Code	HCPCS J0278
Hospital Charge Code	41654677
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$1.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.70
Rate for Payer: Group Health Inc Commercial	$1.48
Rate for Payer: Group Health Inc Medicare	$1.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.48
Rate for Payer: Hamaspik Choice Inc Medicare	$1.48
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.92

AMIKACIN 50 MG/ML INJ PEDIATRIC

Facility

$6.00

Service Code	HCPCS J0278
Hospital Charge Code	41653883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

AMIKACIN 50 MG/ML INJ PEDIATRIC

Facility

$6.00

Service Code	HCPCS J0278
Hospital Charge Code	41643883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

AMIKACIN 50 MG/ML INJ PEDIATRIC

Facility

$6.00

Service Code	HCPCS J0278
Hospital Charge Code	41643883
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

AMIKACIN 50 MG/ML INJ PEDIATRIC

Facility

$6.00

Service Code	HCPCS J0278
Hospital Charge Code	41653883
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

AMIKACIN 5 MG/ ML INJ NEONATAL

Facility

$5.00

Service Code	HCPCS J0278
Hospital Charge Code	41650683
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50

AMIKACIN 5 MG/ ML INJ NEONATAL

Facility

$5.00

Service Code	HCPCS J0278
Hospital Charge Code	41650683
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.88
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

AMIKACIN 5 MG/ ML INJ NEONATAL

Facility

$5.00

Service Code	HCPCS J0278
Hospital Charge Code	41640683
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.88
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.91
Rate for Payer: SOMOS Essential	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

AMIKACIN 5 MG/ ML INJ NEONATAL

Facility

$5.00

Service Code	HCPCS J0278
Hospital Charge Code	41640683
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50

AMIKACIN PEAK

Facility

$37.70

Service Code	HCPCS 80150
Hospital Charge Code	40602585
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$28.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.08
Rate for Payer: Aetna Government	$15.08
Rate for Payer: Affinity Essential Plan 1&2	$10.56
Rate for Payer: Affinity Essential Plan 3&4	$10.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.56
Rate for Payer: Brighton Health Commercial	$28.28
Rate for Payer: Cash Price	$15.08
Rate for Payer: Cash Price	$15.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$15.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.97
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.28
Rate for Payer: Elderplan Medicare Advantage	$15.08
Rate for Payer: EmblemHealth Commercial	$15.08
Rate for Payer: Fidelis Essential Plan Aliesa	$12.82
Rate for Payer: Fidelis Essential Plan QHP	$13.42
Rate for Payer: Fidelis Medicare Advantage	$15.08
Rate for Payer: Fidelis Qualified Health Plan	$13.42
Rate for Payer: Group Health Inc Commercial	$15.08
Rate for Payer: Group Health Inc Medicare	$15.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.85
Rate for Payer: Hamaspik Choice Inc Medicare	$15.08
Rate for Payer: Healthfirst Medicare Advantage	$15.08
Rate for Payer: Healthfirst QHP	$15.08
Rate for Payer: Humana Medicare	$15.38
Rate for Payer: Senior Whole Health Medicare Advantage	$15.08
Rate for Payer: United Healthcare Commercial	$19.09
Rate for Payer: United Healthcare Medicare Advantage	$15.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$12.06
Rate for Payer: Wellcare Medicare	$13.57

AMIKACIN PEAK

Facility

$37.70

Service Code	HCPCS 80150
Hospital Charge Code	40602585
Hospital Revenue Code	301
Rate for Payer: Cash Price	$15.08

AMIKACIN SULFATE 500 MG/2ML IJ SOLN [108131]

Facility

$7.36

Service Code	HCPCS J0278
Hospital Charge Code	23155029031
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$5.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$5.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.00
Rate for Payer: Group Health Inc Commercial	$3.68
Rate for Payer: Group Health Inc Medicare	$2.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.68
Rate for Payer: Hamaspik Choice Inc Medicare	$3.68
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.86
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.91
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.91
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.78

AMIKACIN SULFATE 500 MG/2ML IJ SOLN [108131]

Facility

$7.35

Service Code	HCPCS J0278
Hospital Charge Code	23155029041
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$5.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$5.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.00
Rate for Payer: Group Health Inc Commercial	$3.68
Rate for Payer: Group Health Inc Medicare	$2.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.68
Rate for Payer: Hamaspik Choice Inc Medicare	$3.68
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.86
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.91
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.91
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.78

AMIKACIN SULFATE 500 MG/2ML IJ SOLN [108131]

Facility

$4.65

Service Code	HCPCS J0278
Hospital Charge Code	25021017302
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$3.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.56
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.16
Rate for Payer: Group Health Inc Commercial	$2.32
Rate for Payer: Group Health Inc Medicare	$1.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.32
Rate for Payer: Hamaspik Choice Inc Medicare	$2.32
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.86
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.91
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.91
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.02

AMIKACIN SULFATE 500 MG/2ML IJ SOLN [108131]

Facility

$4.80

Service Code	HCPCS J0278
Hospital Charge Code	00641616710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$3.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.06
Rate for Payer: Aetna Government	$1.06
Rate for Payer: Brighton Health Commercial	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.26
Rate for Payer: Group Health Inc Commercial	$2.40
Rate for Payer: Group Health Inc Medicare	$1.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.40
Rate for Payer: Hamaspik Choice Inc Medicare	$2.40
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.86
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.91
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.91
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.12

AMIKACIN TROUGH

Facility

$37.70

Service Code	HCPCS 80150
Hospital Charge Code	40602590
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$28.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.08
Rate for Payer: Aetna Government	$15.08
Rate for Payer: Affinity Essential Plan 1&2	$10.56
Rate for Payer: Affinity Essential Plan 3&4	$10.56
Rate for Payer: Affinity Medicaid/CHP/HARP	$10.56
Rate for Payer: Brighton Health Commercial	$28.28
Rate for Payer: Cash Price	$15.08
Rate for Payer: Cash Price	$15.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$15.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.97
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.28
Rate for Payer: Elderplan Medicare Advantage	$15.08
Rate for Payer: EmblemHealth Commercial	$15.08
Rate for Payer: Fidelis Essential Plan Aliesa	$12.82
Rate for Payer: Fidelis Essential Plan QHP	$13.42
Rate for Payer: Fidelis Medicare Advantage	$15.08
Rate for Payer: Fidelis Qualified Health Plan	$13.42
Rate for Payer: Group Health Inc Commercial	$15.08
Rate for Payer: Group Health Inc Medicare	$15.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.85
Rate for Payer: Hamaspik Choice Inc Medicare	$15.08
Rate for Payer: Healthfirst Medicare Advantage	$15.08
Rate for Payer: Healthfirst QHP	$15.08
Rate for Payer: Humana Medicare	$15.38
Rate for Payer: Senior Whole Health Medicare Advantage	$15.08
Rate for Payer: United Healthcare Commercial	$19.09
Rate for Payer: United Healthcare Medicare Advantage	$15.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$12.06
Rate for Payer: Wellcare Medicare	$13.57

AMIKACIN TROUGH

Facility

$37.70

Service Code	HCPCS 80150
Hospital Charge Code	40602590
Hospital Revenue Code	301
Rate for Payer: Cash Price	$15.08

AMILORIDE 5MG TAB

Facility

$2.00

Hospital Charge Code	41659591
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

AMILORIDE 5MG TAB

Facility

$2.00

Hospital Charge Code	41649591
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

AMILORIDE HCL 5 MG PO TABS [391]

Facility

$0.27

Service Code	NDC 00574029201
Hospital Charge Code	00574029201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

AMINO ACID 2.75%/D5W/LYTES/CA 1L

Facility

$52.73

Service Code	HCPCS J3490
Hospital Charge Code	41648564
Hospital Revenue Code	636
Min. Negotiated Rate	$26.36
Max. Negotiated Rate	$26.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.36
Rate for Payer: Hamaspik Choice Inc Medicare	$26.36

AMINO ACID 2.75%/D5W/LYTES/CA 1L

Facility

$52.73

Service Code	HCPCS J3490
Hospital Charge Code	41648564
Hospital Revenue Code	636
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$34.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.36
Rate for Payer: Aetna Government	$26.36
Rate for Payer: Brighton Health Commercial	$31.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.32
Rate for Payer: Group Health Inc Commercial	$26.36
Rate for Payer: Group Health Inc Medicare	$18.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.36
Rate for Payer: Hamaspik Choice Inc Medicare	$26.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.27

Know your out-of-pocket cost for care.

All Charges