St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PANITUMUMAB 400 MG/20ML INJ

Facility

$177.40

Service Code	HCPCS J9303
Hospital Charge Code	41646056
Hospital Revenue Code	636
Min. Negotiated Rate	$88.70
Max. Negotiated Rate	$160.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$97.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$150.66
Rate for Payer: Aetna Government	$150.66
Rate for Payer: Affinity Essential Plan 1&2	$105.46
Rate for Payer: Affinity Essential Plan 3&4	$105.46
Rate for Payer: Affinity Medicaid/CHP/HARP	$105.46
Rate for Payer: Brighton Health Commercial	$106.44
Rate for Payer: Cash Price	$150.66
Rate for Payer: Cash Price	$150.66
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$150.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$88.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$102.00
Rate for Payer: Elderplan Medicare Advantage	$150.66
Rate for Payer: EmblemHealth Commercial	$150.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$150.66
Rate for Payer: Fidelis Essential Plan Aliesa	$150.66
Rate for Payer: Fidelis Essential Plan QHP	$158.19
Rate for Payer: Fidelis Medicare Advantage	$150.66
Rate for Payer: Fidelis Qualified Health Plan	$158.19
Rate for Payer: Group Health Inc Commercial	$150.66
Rate for Payer: Group Health Inc Medicare	$150.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$88.70
Rate for Payer: Hamaspik Choice Inc Medicare	$88.70
Rate for Payer: Healthfirst Medicare Advantage	$128.06
Rate for Payer: Healthfirst QHP	$150.66
Rate for Payer: Humana Medicare	$153.67
Rate for Payer: Senior Whole Health Medicare Advantage	$150.66
Rate for Payer: SOMOS CHP/HARP/Medicaid	$160.31
Rate for Payer: SOMOS Essential	$160.31
Rate for Payer: United Healthcare Commercial	$143.51
Rate for Payer: United Healthcare Medicare Advantage	$150.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$115.31
Rate for Payer: Wellcare CHP/FHP/Medicaid	$120.53
Rate for Payer: Wellcare Medicare	$143.13

PANITUMUMAB 400 MG/20ML INJ

Facility

$177.40

Service Code	HCPCS J9303
Hospital Charge Code	41656056
Hospital Revenue Code	636
Min. Negotiated Rate	$88.70
Max. Negotiated Rate	$88.70
Rate for Payer: Cash Price	$150.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$88.70
Rate for Payer: Hamaspik Choice Inc Medicare	$88.70

PANITUMUMAB 400 MG/20ML INJ

Facility

$177.40

Service Code	HCPCS J9303
Hospital Charge Code	41646056
Hospital Revenue Code	636
Min. Negotiated Rate	$88.70
Max. Negotiated Rate	$88.70
Rate for Payer: Cash Price	$150.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$88.70
Rate for Payer: Hamaspik Choice Inc Medicare	$88.70

PANITUMUMAB 400 MG/20ML INJ

Facility

$177.40

Service Code	HCPCS J9303
Hospital Charge Code	41656056
Hospital Revenue Code	636
Min. Negotiated Rate	$88.70
Max. Negotiated Rate	$160.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$97.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$150.66
Rate for Payer: Aetna Government	$150.66
Rate for Payer: Affinity Essential Plan 1&2	$105.46
Rate for Payer: Affinity Essential Plan 3&4	$105.46
Rate for Payer: Affinity Medicaid/CHP/HARP	$105.46
Rate for Payer: Brighton Health Commercial	$106.44
Rate for Payer: Cash Price	$150.66
Rate for Payer: Cash Price	$150.66
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$150.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$88.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$102.00
Rate for Payer: Elderplan Medicare Advantage	$150.66
Rate for Payer: EmblemHealth Commercial	$150.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$150.66
Rate for Payer: Fidelis Essential Plan Aliesa	$150.66
Rate for Payer: Fidelis Essential Plan QHP	$158.19
Rate for Payer: Fidelis Medicare Advantage	$150.66
Rate for Payer: Fidelis Qualified Health Plan	$158.19
Rate for Payer: Group Health Inc Commercial	$150.66
Rate for Payer: Group Health Inc Medicare	$150.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$88.70
Rate for Payer: Hamaspik Choice Inc Medicare	$88.70
Rate for Payer: Healthfirst Medicare Advantage	$128.06
Rate for Payer: Healthfirst QHP	$150.66
Rate for Payer: Humana Medicare	$153.67
Rate for Payer: Senior Whole Health Medicare Advantage	$150.66
Rate for Payer: SOMOS CHP/HARP/Medicaid	$160.31
Rate for Payer: SOMOS Essential	$160.31
Rate for Payer: United Healthcare Commercial	$143.51
Rate for Payer: United Healthcare Medicare Advantage	$150.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$115.31
Rate for Payer: Wellcare CHP/FHP/Medicaid	$120.53
Rate for Payer: Wellcare Medicare	$143.13

PANITUMUMAB 400 MG/20ML IV SOLN [108057]

Facility

$395.50

Service Code	HCPCS J9303
Hospital Charge Code	55513095601
Hospital Revenue Code	278
Min. Negotiated Rate	$120.53
Max. Negotiated Rate	$257.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$150.66
Rate for Payer: Aetna Government	$150.66
Rate for Payer: Brighton Health Commercial	$237.30
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$150.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$197.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$227.41
Rate for Payer: Elderplan Medicare Advantage	$150.66
Rate for Payer: EmblemHealth Commercial	$197.75
Rate for Payer: Fidelis Medicare Advantage	$150.66
Rate for Payer: Group Health Inc Commercial	$150.66
Rate for Payer: Group Health Inc Medicare	$150.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.75
Rate for Payer: Hamaspik Choice Inc Medicare	$197.75
Rate for Payer: Healthfirst Medicare Advantage	$128.06
Rate for Payer: Healthfirst QHP	$150.66
Rate for Payer: Humana Medicare	$153.67
Rate for Payer: Senior Whole Health Medicare Advantage	$150.66
Rate for Payer: United Healthcare Medicare Advantage	$150.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$257.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$120.53

PANITUMUMAB 400 MG/20ML IV SOLN [108057]

Facility

$395.50

Service Code	HCPCS J9303
Hospital Charge Code	55513095601
Hospital Revenue Code	278
Min. Negotiated Rate	$197.75
Max. Negotiated Rate	$197.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.75
Rate for Payer: Hamaspik Choice Inc Medicare	$197.75

PANORAMIC FILM

Facility

$87.50

Service Code	HCPCS D0330
Hospital Charge Code	42300185
Hospital Revenue Code	361
Rate for Payer: Cash Price	$283.37

PANORAMIC FILM

Facility

$87.50

Service Code	HCPCS D0330
Hospital Charge Code	42300185
Hospital Revenue Code	361
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$283.37
Rate for Payer: Aetna Government	$283.37
Rate for Payer: Affinity Essential Plan 1&2	$198.36
Rate for Payer: Affinity Essential Plan 3&4	$198.36
Rate for Payer: Affinity Medicaid/CHP/HARP	$198.36
Rate for Payer: Brighton Health Commercial	$65.62
Rate for Payer: Cash Price	$283.37
Rate for Payer: Cash Price	$283.37
Rate for Payer: Cash Price	$283.37
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$283.37
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: Elderplan Medicare Advantage	$283.37
Rate for Payer: EmblemHealth Commercial	$283.37
Rate for Payer: Fidelis Essential Plan Aliesa	$240.86
Rate for Payer: Fidelis Essential Plan QHP	$252.20
Rate for Payer: Fidelis Medicare Advantage	$283.37
Rate for Payer: Fidelis Qualified Health Plan	$252.20
Rate for Payer: Group Health Inc Commercial	$283.37
Rate for Payer: Group Health Inc Medicare	$283.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.75
Rate for Payer: Hamaspik Choice Inc Medicare	$283.37
Rate for Payer: Healthfirst Medicare Advantage	$240.86
Rate for Payer: Healthfirst QHP	$283.37
Rate for Payer: Humana Medicare	$289.04
Rate for Payer: Senior Whole Health Medicare Advantage	$283.37
Rate for Payer: United Healthcare Medicare Advantage	$283.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$283.37
Rate for Payer: Wellcare CHP/FHP/Medicaid	$226.70
Rate for Payer: Wellcare Medicare	$269.20

PANT,KNIT,MATERNITY, L/XL

Facility

$1.34

Hospital Charge Code	64906202
Hospital Revenue Code	270
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$1.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.67
Rate for Payer: Aetna Government	$0.67
Rate for Payer: Brighton Health Commercial	$1.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.91
Rate for Payer: Group Health Inc Commercial	$0.67
Rate for Payer: Group Health Inc Medicare	$0.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.67
Rate for Payer: Hamaspik Choice Inc Medicare	$0.67

PANT,KNIT,MATERNITY,XXL

Facility

$1.39

Hospital Charge Code	64906203
Hospital Revenue Code	270
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.70
Rate for Payer: Aetna Government	$0.70
Rate for Payer: Brighton Health Commercial	$1.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.95
Rate for Payer: Group Health Inc Commercial	$0.70
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70

PANTOPRAZOLE 40MG INJ

Facility

$5.90

Service Code	HCPCS J3490
Hospital Charge Code	41658131
Hospital Revenue Code	636
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$2.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.95
Rate for Payer: Hamaspik Choice Inc Medicare	$2.95

PANTOPRAZOLE 40MG INJ

Facility

$5.90

Service Code	HCPCS J3490
Hospital Charge Code	41648131
Hospital Revenue Code	636
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$2.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.95
Rate for Payer: Hamaspik Choice Inc Medicare	$2.95

PANTOPRAZOLE 40MG INJ

Facility

$5.90

Service Code	HCPCS J3490
Hospital Charge Code	41648131
Hospital Revenue Code	636
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$3.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.95
Rate for Payer: Aetna Government	$2.95
Rate for Payer: Brighton Health Commercial	$3.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.39
Rate for Payer: Group Health Inc Commercial	$2.95
Rate for Payer: Group Health Inc Medicare	$2.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.95
Rate for Payer: Hamaspik Choice Inc Medicare	$2.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.84

PANTOPRAZOLE 40MG INJ

Facility

$5.90

Service Code	HCPCS J3490
Hospital Charge Code	41658131
Hospital Revenue Code	636
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$3.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.95
Rate for Payer: Aetna Government	$2.95
Rate for Payer: Brighton Health Commercial	$3.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.39
Rate for Payer: Group Health Inc Commercial	$2.95
Rate for Payer: Group Health Inc Medicare	$2.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.95
Rate for Payer: Hamaspik Choice Inc Medicare	$2.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.84

PANTOPRAZOLE 40MG TAB

Facility

$0.09

Hospital Charge Code	41658129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.05
Rate for Payer: Aetna Government	$0.05
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.06
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

PANTOPRAZOLE 40MG TAB

Facility

$0.09

Hospital Charge Code	41648129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.05
Rate for Payer: Aetna Government	$0.05
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.06
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$8.50

Service Code	NDC 55150020210
Hospital Charge Code	55150020210
Hospital Revenue Code	278
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4.25

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$6.09

Service Code	NDC 00008092355
Hospital Charge Code	00008092355
Hospital Revenue Code	278
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$6.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.04
Rate for Payer: Aetna Government	$3.04
Rate for Payer: Brighton Health Commercial	$3.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.50
Rate for Payer: EmblemHealth Commercial	$3.04
Rate for Payer: Fidelis Medicare Advantage	$6.39
Rate for Payer: Group Health Inc Commercial	$3.04
Rate for Payer: Group Health Inc Medicare	$2.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.04
Rate for Payer: Hamaspik Choice Inc Medicare	$3.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.96

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$6.09

Service Code	NDC 00008092355
Hospital Charge Code	00008092355
Hospital Revenue Code	278
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$3.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.04
Rate for Payer: Hamaspik Choice Inc Medicare	$3.04

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$6.13

Service Code	NDC 00781323295
Hospital Charge Code	00781323295
Hospital Revenue Code	278
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$3.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.06
Rate for Payer: Hamaspik Choice Inc Medicare	$3.06

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$8.50

Service Code	NDC 62756012944
Hospital Charge Code	62756012944
Hospital Revenue Code	278
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$8.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.25
Rate for Payer: Aetna Government	$4.25
Rate for Payer: Brighton Health Commercial	$5.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.89
Rate for Payer: EmblemHealth Commercial	$4.25
Rate for Payer: Fidelis Medicare Advantage	$8.92
Rate for Payer: Group Health Inc Commercial	$4.25
Rate for Payer: Group Health Inc Medicare	$2.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.52

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$8.50

Service Code	NDC 55150020210
Hospital Charge Code	55150020210
Hospital Revenue Code	278
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$8.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.25
Rate for Payer: Aetna Government	$4.25
Rate for Payer: Brighton Health Commercial	$5.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.89
Rate for Payer: EmblemHealth Commercial	$4.25
Rate for Payer: Fidelis Medicare Advantage	$8.92
Rate for Payer: Group Health Inc Commercial	$4.25
Rate for Payer: Group Health Inc Medicare	$2.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.52

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$6.13

Service Code	NDC 00781323295
Hospital Charge Code	00781323295
Hospital Revenue Code	278
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$6.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.06
Rate for Payer: Aetna Government	$3.06
Rate for Payer: Brighton Health Commercial	$3.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.52
Rate for Payer: EmblemHealth Commercial	$3.06
Rate for Payer: Fidelis Medicare Advantage	$6.43
Rate for Payer: Group Health Inc Commercial	$3.06
Rate for Payer: Group Health Inc Medicare	$2.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.06
Rate for Payer: Hamaspik Choice Inc Medicare	$3.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.98

PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]

Facility

$8.50

Service Code	NDC 62756012944
Hospital Charge Code	62756012944
Hospital Revenue Code	278
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4.25

PANTOPRAZOLE SODIUM 40 MG IV SOLR [26226]

Facility

$8.50

Service Code	NDC 55150020200
Hospital Charge Code	55150020200
Hospital Revenue Code	278
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.25
Rate for Payer: Hamaspik Choice Inc Medicare	$4.25

Know your out-of-pocket cost for care.

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