St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OMALIZUMAB 150 MG SC SOLR

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024204062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$45.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.60
Rate for Payer: Aetna Government	$44.60
Rate for Payer: Affinity Essential Plan 1&2	$31.22
Rate for Payer: Affinity Essential Plan 3&4	$31.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$31.22
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$44.60
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	$44.60
Rate for Payer: EmblemHealth Commercial	$44.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40.14
Rate for Payer: Fidelis Essential Plan Aliesa	$37.91
Rate for Payer: Fidelis Essential Plan QHP	$39.69
Rate for Payer: Fidelis Medicare Advantage	$44.60
Rate for Payer: Fidelis Qualified Health Plan	$39.69
Rate for Payer: Group Health Inc Commercial	$44.60
Rate for Payer: Group Health Inc Medicare	$44.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.60
Rate for Payer: Hamaspik Choice Inc Medicare	$44.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$44.60
Rate for Payer: Healthfirst Medicare Advantage	$37.91
Rate for Payer: Healthfirst QHP	$44.60
Rate for Payer: Humana Medicare	$45.49
Rate for Payer: Senior Whole Health Medicare Advantage	$44.60
Rate for Payer: United Healthcare Medicare Advantage	$44.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$42.37
Rate for Payer: Wellcare Medicare	$42.37

OMALIZUMAB 150 MG SC SOLR

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024204062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

OMALIZUMAB 300 MG/2ML SC SOAJ

Facility

$1.00

Service Code	NDC 5024222755
Hospital Charge Code	5024222755
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

OMALIZUMAB 300 MG/2ML SC SOAJ

Facility

$1.00

Service Code	NDC 5024222755
Hospital Charge Code	5024222755
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

OMALIZUMAB 300 MG/2 ML SC SOSY

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024222701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$45.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.60
Rate for Payer: Aetna Government	$44.60
Rate for Payer: Affinity Essential Plan 1&2	$31.22
Rate for Payer: Affinity Essential Plan 3&4	$31.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$31.22
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$44.60
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	$44.60
Rate for Payer: EmblemHealth Commercial	$44.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40.14
Rate for Payer: Fidelis Essential Plan Aliesa	$37.91
Rate for Payer: Fidelis Essential Plan QHP	$39.69
Rate for Payer: Fidelis Medicare Advantage	$44.60
Rate for Payer: Fidelis Qualified Health Plan	$39.69
Rate for Payer: Group Health Inc Commercial	$44.60
Rate for Payer: Group Health Inc Medicare	$44.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.60
Rate for Payer: Hamaspik Choice Inc Medicare	$44.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$44.60
Rate for Payer: Healthfirst Medicare Advantage	$37.91
Rate for Payer: Healthfirst QHP	$44.60
Rate for Payer: Humana Medicare	$45.49
Rate for Payer: Senior Whole Health Medicare Advantage	$44.60
Rate for Payer: United Healthcare Medicare Advantage	$44.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$42.37
Rate for Payer: Wellcare Medicare	$42.37

OMALIZUMAB 300 MG/2 ML SC SOSY

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024222701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

OMALIZUMAB 75 MG/0.5ML SC SOAJ

Facility

$1.00

Service Code	NDC 5024221455
Hospital Charge Code	5024221455
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

OMALIZUMAB 75 MG/0.5ML SC SOAJ

Facility

$1.00

Service Code	NDC 5024221455
Hospital Charge Code	5024221455
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

OMALIZUMAB 75 MG/0.5ML SC SOSY

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024221401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$45.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.60
Rate for Payer: Aetna Government	$44.60
Rate for Payer: Affinity Essential Plan 1&2	$31.22
Rate for Payer: Affinity Essential Plan 3&4	$31.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$31.22
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$44.60
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	$44.60
Rate for Payer: EmblemHealth Commercial	$44.60
Rate for Payer: Fidelis CHP/HARP/Medicaid	$40.14
Rate for Payer: Fidelis Essential Plan Aliesa	$37.91
Rate for Payer: Fidelis Essential Plan QHP	$39.69
Rate for Payer: Fidelis Medicare Advantage	$44.60
Rate for Payer: Fidelis Qualified Health Plan	$39.69
Rate for Payer: Group Health Inc Commercial	$44.60
Rate for Payer: Group Health Inc Medicare	$44.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.60
Rate for Payer: Hamaspik Choice Inc Medicare	$44.60
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$44.60
Rate for Payer: Healthfirst Medicare Advantage	$37.91
Rate for Payer: Healthfirst QHP	$44.60
Rate for Payer: Humana Medicare	$45.49
Rate for Payer: Senior Whole Health Medicare Advantage	$44.60
Rate for Payer: United Healthcare Medicare Advantage	$44.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$42.37
Rate for Payer: Wellcare Medicare	$42.37

OMALIZUMAB 75 MG/0.5ML SC SOSY

Facility

$1.00

Service Code	HCPCS J2357
Hospital Charge Code	5024221401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

ONABOTULINUMTOXINA 100 UNITS IJ SOLR

Facility

$760.80

Service Code	HCPCS J0585
Hospital Charge Code	0023114501
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$608.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$418.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Affinity Essential Plan 1&2	$4.55
Rate for Payer: Affinity Essential Plan 3&4	$4.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$4.55
Rate for Payer: Brighton Health Commercial	$570.60
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$608.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$517.34
Rate for Payer: Elderplan Medicare Advantage	$6.50
Rate for Payer: EmblemHealth Commercial	$6.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$5.85
Rate for Payer: Fidelis Essential Plan Aliesa	$5.53
Rate for Payer: Fidelis Essential Plan QHP	$5.79
Rate for Payer: Fidelis Medicare Advantage	$6.50
Rate for Payer: Fidelis Qualified Health Plan	$5.79
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$6.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$6.50
Rate for Payer: Healthfirst Medicare Advantage	$5.53
Rate for Payer: Healthfirst QHP	$6.50
Rate for Payer: Humana Medicare	$6.63
Rate for Payer: Senior Whole Health Medicare Advantage	$6.50
Rate for Payer: United Healthcare Medicare Advantage	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$494.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$6.17
Rate for Payer: Wellcare Medicare	$6.17

ONABOTULINUMTOXINA 100 UNITS IJ SOLR

Facility

$760.80

Service Code	HCPCS J0585
Hospital Charge Code	0023114501
Hospital Revenue Code	250
Min. Negotiated Rate	$380.40
Max. Negotiated Rate	$380.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$380.40

ONABOTULINUMTOXINA 200 UNITS IJ SOLR

Facility

$1.00

Service Code	HCPCS J0585
Hospital Charge Code	0023392102
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

ONABOTULINUMTOXINA 200 UNITS IJ SOLR

Facility

$1.00

Service Code	HCPCS J0585
Hospital Charge Code	0023392102
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$6.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.50
Rate for Payer: Aetna Government	$6.50
Rate for Payer: Affinity Essential Plan 1&2	$4.55
Rate for Payer: Affinity Essential Plan 3&4	$4.55
Rate for Payer: Affinity Medicaid/CHP/HARP	$4.55
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6.50
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	$6.50
Rate for Payer: EmblemHealth Commercial	$6.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$5.85
Rate for Payer: Fidelis Essential Plan Aliesa	$5.53
Rate for Payer: Fidelis Essential Plan QHP	$5.79
Rate for Payer: Fidelis Medicare Advantage	$6.50
Rate for Payer: Fidelis Qualified Health Plan	$5.79
Rate for Payer: Group Health Inc Commercial	$6.50
Rate for Payer: Group Health Inc Medicare	$6.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.50
Rate for Payer: Hamaspik Choice Inc Medicare	$6.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$6.50
Rate for Payer: Healthfirst Medicare Advantage	$5.53
Rate for Payer: Healthfirst QHP	$6.50
Rate for Payer: Humana Medicare	$6.63
Rate for Payer: Senior Whole Health Medicare Advantage	$6.50
Rate for Payer: United Healthcare Medicare Advantage	$6.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$6.17
Rate for Payer: Wellcare Medicare	$6.17

ONDANSETRON 4 MG PO TBDP

Facility

$22.25

Service Code	HCPCS Q0162
Hospital Charge Code	6275624064
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$11.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.12

ONDANSETRON 4 MG PO TBDP

Facility

$22.28

Service Code	HCPCS Q0162
Hospital Charge Code	5723707710
Hospital Revenue Code	250
Min. Negotiated Rate	$11.14
Max. Negotiated Rate	$11.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.14

ONDANSETRON 4 MG PO TBDP

Facility

$22.25

Service Code	HCPCS Q0162
Hospital Charge Code	6275624064
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$17.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$16.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.13
Rate for Payer: EmblemHealth Commercial	$11.12
Rate for Payer: Group Health Inc Commercial	$11.12
Rate for Payer: Group Health Inc Medicare	$7.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.12
Rate for Payer: Hamaspik Choice Inc Medicare	$11.12
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.46

ONDANSETRON 4 MG PO TBDP

Facility

$22.28

Service Code	HCPCS Q0162
Hospital Charge Code	5723707710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$17.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$16.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.15
Rate for Payer: EmblemHealth Commercial	$11.14
Rate for Payer: Group Health Inc Commercial	$11.14
Rate for Payer: Group Health Inc Medicare	$7.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.14
Rate for Payer: Hamaspik Choice Inc Medicare	$11.14
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.48

ONDANSETRON 4 MG PO TBDP

Facility

$22.29

Service Code	HCPCS Q0162
Hospital Charge Code	6586239010
Hospital Revenue Code	250
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$11.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.15

ONDANSETRON 4 MG PO TBDP

Facility

$22.29

Service Code	HCPCS Q0162
Hospital Charge Code	6586239010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$17.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$16.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.16
Rate for Payer: EmblemHealth Commercial	$11.15
Rate for Payer: Group Health Inc Commercial	$11.15
Rate for Payer: Group Health Inc Medicare	$7.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.15
Rate for Payer: Hamaspik Choice Inc Medicare	$11.15
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14.49

ONDANSETRON 4 MG PO TBDP

Facility

$23.11

Service Code	HCPCS Q0162
Hospital Charge Code	6846215740
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$18.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$17.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.72
Rate for Payer: EmblemHealth Commercial	$11.56
Rate for Payer: Group Health Inc Commercial	$11.56
Rate for Payer: Group Health Inc Medicare	$8.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.56
Rate for Payer: Hamaspik Choice Inc Medicare	$11.56
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.02

ONDANSETRON 4 MG PO TBDP

Facility

$23.11

Service Code	HCPCS Q0162
Hospital Charge Code	6846215740
Hospital Revenue Code	250
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$11.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.56

ONDANSETRON 4 MG PO TBDP

Facility

$23.11

Service Code	HCPCS Q0162
Hospital Charge Code	6846215713
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$18.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$17.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.72
Rate for Payer: EmblemHealth Commercial	$11.56
Rate for Payer: Group Health Inc Commercial	$11.56
Rate for Payer: Group Health Inc Medicare	$8.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.56
Rate for Payer: Hamaspik Choice Inc Medicare	$11.56
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.02

ONDANSETRON 4 MG PO TBDP

Facility

$23.11

Service Code	HCPCS Q0162
Hospital Charge Code	6846215713
Hospital Revenue Code	250
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$11.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.56

ONDANSETRON HCL 4 MG/2ML IJ SOLN

Facility

$0.77

Service Code	HCPCS J2405
Hospital Charge Code	0409475518
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39

Know your out-of-pocket cost for care.

All Charges