St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PENILE PROSTHES 700 65 MC RES

Facility

$5,769.93

Service Code	HCPCS C1813
Hospital Charge Code	64905211
Hospital Revenue Code	278
Min. Negotiated Rate	$2,884.96
Max. Negotiated Rate	$2,884.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,884.96
Rate for Payer: Hamaspik Choice Inc Medicare	$2,884.96

PENILE PROSTHES 700 65 MC RES

Facility

$5,769.93

Service Code	HCPCS C1813
Hospital Charge Code	64905211
Hospital Revenue Code	278
Min. Negotiated Rate	$2,019.48
Max. Negotiated Rate	$6,058.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,173.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$3,461.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,884.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,317.71
Rate for Payer: EmblemHealth Commercial	$2,884.96
Rate for Payer: Fidelis Medicare Advantage	$6,058.43
Rate for Payer: Group Health Inc Commercial	$2,884.96
Rate for Payer: Group Health Inc Medicare	$2,019.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,884.96
Rate for Payer: Hamaspik Choice Inc Medicare	$2,884.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,750.45

PENILE PROSTHES CX PRECONNECT

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905458
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 CX PRECONNECT

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905458
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 PUMP 700 15CM

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905466
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 PUMP 700 15CM

Facility

$21,585.00

Service Code	HCPCS C1813
Hospital Charge Code	64905466
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 RESRVOIR 100ML

Facility

$5,505.00

Service Code	HCPCS C1813
Hospital Charge Code	64905459
Hospital Revenue Code	278
Min. Negotiated Rate	$2,752.50
Max. Negotiated Rate	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,752.50

PENILE PROSTHES RESRVOIR 100ML

Facility

$5,505.00

Service Code	HCPCS C1813
Hospital Charge Code	64905459
Hospital Revenue Code	278
Min. Negotiated Rate	$1,926.75
Max. Negotiated Rate	$5,780.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,027.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$3,303.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,752.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,165.38
Rate for Payer: EmblemHealth Commercial	$2,752.50
Rate for Payer: Fidelis Medicare Advantage	$5,780.25
Rate for Payer: Group Health Inc Commercial	$2,752.50
Rate for Payer: Group Health Inc Medicare	$1,926.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,752.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,578.25

PENILE PROSTHES SALINE FILLE

Facility

$5,505.00

Service Code	HCPCS C1813
Hospital Charge Code	64903144
Hospital Revenue Code	278
Min. Negotiated Rate	$2,752.50
Max. Negotiated Rate	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,752.50

PENILE PROSTHES SALINE FILLE

Facility

$5,505.00

Service Code	HCPCS C1813
Hospital Charge Code	64903144
Hospital Revenue Code	278
Min. Negotiated Rate	$1,926.75
Max. Negotiated Rate	$5,780.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,027.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$3,303.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,752.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,165.38
Rate for Payer: EmblemHealth Commercial	$2,752.50
Rate for Payer: Fidelis Medicare Advantage	$5,780.25
Rate for Payer: Group Health Inc Commercial	$2,752.50
Rate for Payer: Group Health Inc Medicare	$1,926.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,752.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,752.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,578.25

PENILE VASCULAR STUDY, COMPLETE

Facility

$339.45

Service Code	HCPCS 93980 TC
Hospital Charge Code	41301529
Hospital Revenue Code	921
Rate for Payer: Cash Price	$127.14

PENILE VASCULAR STUDY, COMPLETE

Facility

$339.45

Service Code	HCPCS 93980 TC
Hospital Charge Code	41301529
Hospital Revenue Code	921
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$271.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$186.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$254.59
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.83
Rate for Payer: Elderplan Medicare Advantage	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.72
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Commercial	$169.72
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

PENILE VASCULAR STUDY, F/U OR LTD

Facility

$339.45

Service Code	HCPCS 93981 TC
Hospital Charge Code	41301530
Hospital Revenue Code	921
Rate for Payer: Cash Price	$127.14

PENILE VASCULAR STUDY, F/U OR LTD

Facility

$339.45

Service Code	HCPCS 93981 TC
Hospital Charge Code	41301530
Hospital Revenue Code	921
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$271.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$186.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.14
Rate for Payer: Aetna Government	$127.14
Rate for Payer: Affinity Essential Plan 1&2	$89.00
Rate for Payer: Affinity Essential Plan 3&4	$89.00
Rate for Payer: Affinity Medicaid/CHP/HARP	$89.00
Rate for Payer: Brighton Health Commercial	$254.59
Rate for Payer: Cash Price	$127.14
Rate for Payer: Cash Price	$127.14
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$127.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.83
Rate for Payer: Elderplan Medicare Advantage	$127.14
Rate for Payer: EmblemHealth Commercial	$127.14
Rate for Payer: Fidelis Essential Plan Aliesa	$108.07
Rate for Payer: Fidelis Essential Plan QHP	$113.15
Rate for Payer: Fidelis Medicare Advantage	$127.14
Rate for Payer: Fidelis Qualified Health Plan	$113.15
Rate for Payer: Group Health Inc Commercial	$127.14
Rate for Payer: Group Health Inc Medicare	$127.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.72
Rate for Payer: Hamaspik Choice Inc Medicare	$127.14
Rate for Payer: Healthfirst Medicare Advantage	$108.07
Rate for Payer: Healthfirst QHP	$127.14
Rate for Payer: Humana Medicare	$129.68
Rate for Payer: Senior Whole Health Medicare Advantage	$127.14
Rate for Payer: United Healthcare Commercial	$169.72
Rate for Payer: United Healthcare Medicare Advantage	$127.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$127.14
Rate for Payer: Wellcare CHP/FHP/Medicaid	$101.71
Rate for Payer: Wellcare Medicare	$120.78

Penis Pouch

Facility

$17.72

Hospital Charge Code	40204845
Hospital Revenue Code	270
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$14.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.86
Rate for Payer: Aetna Government	$8.86
Rate for Payer: Brighton Health Commercial	$13.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.05
Rate for Payer: Group Health Inc Commercial	$8.86
Rate for Payer: Group Health Inc Medicare	$6.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.86
Rate for Payer: Hamaspik Choice Inc Medicare	$8.86

PENIS PROCEDURES WITH CC/MCC

Facility

$51,467.84

Service Code	MSDRG 709
Min. Negotiated Rate	$17,405.49
Max. Negotiated Rate	$51,467.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31,259.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37,431.16
Rate for Payer: Aetna Government	$37,431.16
Rate for Payer: Brighton Health Commercial	$30,740.00
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$38,179.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37,487.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$30,936.33
Rate for Payer: Elderplan Medicare Advantage	$35,559.60
Rate for Payer: EmblemHealth Commercial	$18,179.00
Rate for Payer: Fidelis Medicare Advantage	$37,431.16
Rate for Payer: Group Health Inc Commercial	$37,431.16
Rate for Payer: Group Health Inc Medicare	$37,431.16
Rate for Payer: Hamaspik Choice Inc Medicare	$37,431.16
Rate for Payer: Healthfirst Medicare Advantage	$17,405.49
Rate for Payer: Humana Medicare	$51,467.84
Rate for Payer: Senior Whole Health Medicare Advantage	$37,431.16
Rate for Payer: United Healthcare Commercial	$43,170.70
Rate for Payer: United Healthcare Medicare Advantage	$37,431.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37,431.16
Rate for Payer: Wellcare Medicare	$35,559.60

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$34,812.25

Service Code	MSDRG 710
Min. Negotiated Rate	$10,584.10
Max. Negotiated Rate	$34,812.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18,199.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$25,318.00
Rate for Payer: Aetna Government	$25,318.00
Rate for Payer: Brighton Health Commercial	$17,897.35
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$25,824.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22,403.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$18,487.98
Rate for Payer: Elderplan Medicare Advantage	$24,052.10
Rate for Payer: EmblemHealth Commercial	$10,584.10
Rate for Payer: Fidelis Medicare Advantage	$25,318.00
Rate for Payer: Group Health Inc Commercial	$25,318.00
Rate for Payer: Group Health Inc Medicare	$25,318.00
Rate for Payer: Hamaspik Choice Inc Medicare	$25,318.00
Rate for Payer: Healthfirst Medicare Advantage	$11,772.87
Rate for Payer: Humana Medicare	$34,812.25
Rate for Payer: Senior Whole Health Medicare Advantage	$25,318.00
Rate for Payer: United Healthcare Commercial	$25,799.41
Rate for Payer: United Healthcare Medicare Advantage	$25,318.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25,318.00
Rate for Payer: Wellcare Medicare	$24,052.10

PENIS PROSTHESIS, INFLT PUMP

Facility

$11,070.00

Service Code	HCPCS C1813
Hospital Charge Code	64905256
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$11,623.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,088.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$6,642.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,535.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,365.25
Rate for Payer: EmblemHealth Commercial	$5,535.00
Rate for Payer: Fidelis Medicare Advantage	$11,623.50
Rate for Payer: Group Health Inc Commercial	$5,535.00
Rate for Payer: Group Health Inc Medicare	$3,874.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,535.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,535.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,195.50

PENIS PROSTHESIS, INFLT PUMP

Facility

$11,070.00

Service Code	HCPCS C1813
Hospital Charge Code	64905256
Hospital Revenue Code	278
Min. Negotiated Rate	$5,535.00
Max. Negotiated Rate	$5,535.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,535.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,535.00

PENLIGHT DISP WHTE W/PUPIL GA

Facility

$2.06

Hospital Charge Code	64902188
Hospital Revenue Code	270
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.03
Rate for Payer: Aetna Government	$1.03
Rate for Payer: Brighton Health Commercial	$1.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.40
Rate for Payer: Group Health Inc Commercial	$1.03
Rate for Payer: Group Health Inc Medicare	$0.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.03
Rate for Payer: Hamaspik Choice Inc Medicare	$1.03

PENOSCROTAL PUMP 12CMX12MM

Facility

$15,646.00

Service Code	HCPCS C1813
Hospital Charge Code	40203163
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$16,428.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,605.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$9,387.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,823.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,996.45
Rate for Payer: EmblemHealth Commercial	$7,823.00
Rate for Payer: Fidelis Medicare Advantage	$16,428.30
Rate for Payer: Group Health Inc Commercial	$7,823.00
Rate for Payer: Group Health Inc Medicare	$5,476.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,823.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,823.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10,169.90

PENOSCROTAL PUMP 12CMX12MM

Facility

$15,646.00

Service Code	HCPCS C1813
Hospital Charge Code	40203163
Hospital Revenue Code	278
Min. Negotiated Rate	$7,823.00
Max. Negotiated Rate	$7,823.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,823.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,823.00

PENROSE

Facility

$25.52

Hospital Charge Code	40204826
Hospital Revenue Code	270
Min. Negotiated Rate	$8.93
Max. Negotiated Rate	$20.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.76
Rate for Payer: Aetna Government	$12.76
Rate for Payer: Brighton Health Commercial	$19.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.35
Rate for Payer: Group Health Inc Commercial	$12.76
Rate for Payer: Group Health Inc Medicare	$8.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.76
Rate for Payer: Hamaspik Choice Inc Medicare	$12.76

PENROSE TUBING 1/2

Facility

$6.03

Hospital Charge Code	40204827
Hospital Revenue Code	270
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$4.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.02
Rate for Payer: Aetna Government	$3.02
Rate for Payer: Brighton Health Commercial	$4.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.10
Rate for Payer: Group Health Inc Commercial	$3.02
Rate for Payer: Group Health Inc Medicare	$2.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.02
Rate for Payer: Hamaspik Choice Inc Medicare	$3.02

PENTAMIDINE 300 MG INJ

Facility

$168.10

Service Code	HCPCS J7699
Hospital Charge Code	41653430
Hospital Revenue Code	636
Min. Negotiated Rate	$84.05
Max. Negotiated Rate	$84.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$84.05
Rate for Payer: Hamaspik Choice Inc Medicare	$84.05

Know your out-of-pocket cost for care.

All Charges