St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PENICILLIN V POTASSIUM 250 MG/5 ML SUSP

Facility

$0.05

Hospital Charge Code	41643399
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PENICILLIN V POTASSIUM 250 MG PO TABS [6092]

Facility

$1.13

Service Code	NDC 00093117210
Hospital Charge Code	00093117210
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.57
Rate for Payer: Aetna Government	$0.57
Rate for Payer: Brighton Health Commercial	$0.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.77
Rate for Payer: Group Health Inc Commercial	$0.57
Rate for Payer: Group Health Inc Medicare	$0.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.57
Rate for Payer: Hamaspik Choice Inc Medicare	$0.57
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.73

PENICILLIN V POTASSIUM 250 MG PO TABS [6092]

Facility

$0.85

Service Code	NDC 00143983701
Hospital Charge Code	00143983701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.43
Rate for Payer: Aetna Government	$0.43
Rate for Payer: Brighton Health Commercial	$0.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
Rate for Payer: Group Health Inc Commercial	$0.43
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.43
Rate for Payer: Hamaspik Choice Inc Medicare	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

PENICILLIN V POTASSIUM 250 MG TAB

Facility

$0.05

Hospital Charge Code	41654587
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PENICILLIN V POTASSIUM 250 MG TAB

Facility

$0.05

Hospital Charge Code	41644587
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PENICILLIN V POTASSIUM 500 MG PO TABS [6093]

Facility

$2.02

Service Code	NDC 00093117401
Hospital Charge Code	00093117401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.01
Rate for Payer: Aetna Government	$1.01
Rate for Payer: Brighton Health Commercial	$1.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.37
Rate for Payer: Group Health Inc Commercial	$1.01
Rate for Payer: Group Health Inc Medicare	$0.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.01
Rate for Payer: Hamaspik Choice Inc Medicare	$1.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.31

PENICILLIN V POTASSIUM 500 MG PO TABS [6093]

Facility

$0.78

Service Code	NDC 00143983601
Hospital Charge Code	00143983601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.39
Rate for Payer: Aetna Government	$0.39
Rate for Payer: Brighton Health Commercial	$0.58
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.53
Rate for Payer: Group Health Inc Commercial	$0.39
Rate for Payer: Group Health Inc Medicare	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39
Rate for Payer: Hamaspik Choice Inc Medicare	$0.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.51

PENICILLIN V POTASSIUM 500 MG TAB

Facility

$0.04

Hospital Charge Code	41644032
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PENICILLIN V POTASSIUM 500 MG TAB

Facility

$0.04

Hospital Charge Code	41654032
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PENILE IMPLANT, INFLATABLE

Facility

$14,410.00

Service Code	HCPCS C1813
Hospital Charge Code	40203160
Hospital Revenue Code	278
Min. Negotiated Rate	$7,205.00
Max. Negotiated Rate	$7,205.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,205.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,205.00

PENILE IMPLANT, INFLATABLE

Facility

$14,410.00

Service Code	HCPCS C1813
Hospital Charge Code	40203160
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$15,130.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7,925.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$8,646.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,205.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,285.75
Rate for Payer: EmblemHealth Commercial	$7,205.00
Rate for Payer: Fidelis Medicare Advantage	$15,130.50
Rate for Payer: Group Health Inc Commercial	$7,205.00
Rate for Payer: Group Health Inc Medicare	$5,043.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,205.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,205.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,366.50

PENILE INJECTION

Facility

$711.45

Service Code	HCPCS 54235
Hospital Charge Code	30105871
Hospital Revenue Code	450
Rate for Payer: Cash Price	$285.81

PENILE INJECTION

Facility

$711.45

Service Code	HCPCS 54235
Hospital Charge Code	30105871
Hospital Revenue Code	450
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$285.81
Rate for Payer: Aetna Government	$285.81
Rate for Payer: Affinity Essential Plan 1&2	$200.07
Rate for Payer: Affinity Essential Plan 3&4	$200.07
Rate for Payer: Affinity Medicaid/CHP/HARP	$200.07
Rate for Payer: Brighton Health Commercial	$874.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$285.81
Rate for Payer: Carelon Behavioral Health Medicare Advantage	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Cash Price	$285.81
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$285.81
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	$285.81
Rate for Payer: EmblemHealth Commercial	$525.00
Rate for Payer: Fidelis Essential Plan Aliesa	$242.94
Rate for Payer: Fidelis Essential Plan QHP	$254.37
Rate for Payer: Fidelis Medicare Advantage	$285.81
Rate for Payer: Fidelis Qualified Health Plan	$254.37
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$525.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$355.72
Rate for Payer: Hamaspik Choice Inc Medicare	$285.81
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$165.00
Rate for Payer: Healthfirst Medicare Advantage	$225.00
Rate for Payer: Healthfirst QHP	$285.81
Rate for Payer: Humana Medicare	$291.53
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$285.81
Rate for Payer: Senior Whole Health Medicare Advantage	$285.81
Rate for Payer: United Healthcare Commercial	$569.00
Rate for Payer: United Healthcare Medicare Advantage	$285.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$285.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$228.65
Rate for Payer: Wellcare Medicare	$271.52

PENILE PROSTH, 13MM - COLOPLAST

Facility

$8,900.00

Service Code	HCPCS C2622
Hospital Charge Code	40203030
Hospital Revenue Code	278
Min. Negotiated Rate	$3,115.00
Max. Negotiated Rate	$9,345.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,895.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,768.95
Rate for Payer: Aetna Government	$3,768.95
Rate for Payer: Brighton Health Commercial	$5,340.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,450.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,117.50
Rate for Payer: EmblemHealth Commercial	$4,450.00
Rate for Payer: Fidelis Medicare Advantage	$9,345.00
Rate for Payer: Group Health Inc Commercial	$4,450.00
Rate for Payer: Group Health Inc Medicare	$3,115.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,450.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,785.00

PENILE PROSTH, 13MM - COLOPLAST

Facility

$8,900.00

Service Code	HCPCS C2622
Hospital Charge Code	40203030
Hospital Revenue Code	278
Min. Negotiated Rate	$4,450.00
Max. Negotiated Rate	$4,450.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,450.00

PENILE PROSTHES 12MM DIA 21C

Facility

$21,992.50

Service Code	HCPCS C1813
Hospital Charge Code	64903512
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$23,092.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12,095.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$13,195.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10,996.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,645.69
Rate for Payer: EmblemHealth Commercial	$10,996.25
Rate for Payer: Fidelis Medicare Advantage	$23,092.12
Rate for Payer: Group Health Inc Commercial	$10,996.25
Rate for Payer: Group Health Inc Medicare	$7,697.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,996.25
Rate for Payer: Hamaspik Choice Inc Medicare	$10,996.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14,295.12

PENILE PROSTHES 12MM DIA 21C

Facility

$21,992.50

Service Code	HCPCS C1813
Hospital Charge Code	64903512
Hospital Revenue Code	278
Min. Negotiated Rate	$10,996.25
Max. Negotiated Rate	$10,996.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,996.25
Rate for Payer: Hamaspik Choice Inc Medicare	$10,996.25

PENILE PROSTHES 15CML SALINE

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64903142
Hospital Revenue Code	278
Min. Negotiated Rate	$10,792.50
Max. Negotiated Rate	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50

PENILE PROSTHES 15CML SALINE

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64903142
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$22,664.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11,871.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$12,951.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10,792.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,411.38
Rate for Payer: EmblemHealth Commercial	$10,792.50
Rate for Payer: Fidelis Medicare Advantage	$22,664.25
Rate for Payer: Group Health Inc Commercial	$10,792.50
Rate for Payer: Group Health Inc Medicare	$7,554.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14,030.25

PENILE PROSTHES 18CML SALINE

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64903275
Hospital Revenue Code	278
Min. Negotiated Rate	$10,792.50
Max. Negotiated Rate	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50

PENILE PROSTHES 18CML SALINE

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64903275
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$22,664.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11,871.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$12,951.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10,792.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,411.38
Rate for Payer: EmblemHealth Commercial	$10,792.50
Rate for Payer: Fidelis Medicare Advantage	$22,664.25
Rate for Payer: Group Health Inc Commercial	$10,792.50
Rate for Payer: Group Health Inc Medicare	$7,554.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14,030.25

PENILE PROSTHES 3.5CML SCRO

Facility

$12,862.50

Service Code	HCPCS C1813
Hospital Charge Code	64904155
Hospital Revenue Code	278
Min. Negotiated Rate	$6,431.25
Max. Negotiated Rate	$6,431.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,431.25
Rate for Payer: Hamaspik Choice Inc Medicare	$6,431.25

PENILE PROSTHES 3.5CML SCRO

Facility

$12,862.50

Service Code	HCPCS C1813
Hospital Charge Code	64904155
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$13,505.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7,074.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$7,717.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6,431.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,395.94
Rate for Payer: EmblemHealth Commercial	$6,431.25
Rate for Payer: Fidelis Medicare Advantage	$13,505.62
Rate for Payer: Group Health Inc Commercial	$6,431.25
Rate for Payer: Group Health Inc Medicare	$4,501.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,431.25
Rate for Payer: Hamaspik Choice Inc Medicare	$6,431.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8,360.62

PENILE PROSTHES 700 18C

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905209
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$22,664.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11,871.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$12,951.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10,792.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$12,411.38
Rate for Payer: EmblemHealth Commercial	$10,792.50
Rate for Payer: Fidelis Medicare Advantage	$22,664.25
Rate for Payer: Group Health Inc Commercial	$10,792.50
Rate for Payer: Group Health Inc Medicare	$7,554.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$14,030.25

PENILE PROSTHES 700 18C

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905209
Hospital Revenue Code	278
Min. Negotiated Rate	$10,792.50
Max. Negotiated Rate	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10,792.50
Rate for Payer: Hamaspik Choice Inc Medicare	$10,792.50

Know your out-of-pocket cost for care.

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