St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

RIFAXIMIN 550 MG PO TABS [104604]

Facility

$65.35

Service Code	NDC 65649030303
Hospital Charge Code	65649030303
Hospital Revenue Code	250
Min. Negotiated Rate	$22.87
Max. Negotiated Rate	$52.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$35.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$32.67
Rate for Payer: Aetna Government	$32.67
Rate for Payer: Brighton Health Commercial	$49.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$52.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$44.43
Rate for Payer: Group Health Inc Commercial	$32.67
Rate for Payer: Group Health Inc Medicare	$22.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$32.67
Rate for Payer: Hamaspik Choice Inc Medicare	$32.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$42.47

RIFAXIMIN 550 MG TAB

Facility

$26.51

Hospital Charge Code	41645597
Hospital Revenue Code	250
Min. Negotiated Rate	$9.28
Max. Negotiated Rate	$21.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.26
Rate for Payer: Aetna Government	$13.26
Rate for Payer: Brighton Health Commercial	$19.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.03
Rate for Payer: Group Health Inc Commercial	$13.26
Rate for Payer: Group Health Inc Medicare	$9.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.26
Rate for Payer: Hamaspik Choice Inc Medicare	$13.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17.23

RIGHT HORSESHOE GEL PAD

Facility

$867.50

Hospital Charge Code	64905099
Hospital Revenue Code	270
Min. Negotiated Rate	$303.62
Max. Negotiated Rate	$694.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$477.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$433.75
Rate for Payer: Aetna Government	$433.75
Rate for Payer: Brighton Health Commercial	$650.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$694.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$589.90
Rate for Payer: Group Health Inc Commercial	$433.75
Rate for Payer: Group Health Inc Medicare	$303.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$433.75
Rate for Payer: Hamaspik Choice Inc Medicare	$433.75

RIGHT LUMBAR SYMPATHECTOMY

Facility

$2,139.86

Service Code	HCPCS 64818
Hospital Charge Code	40011105
Hospital Revenue Code	360
Min. Negotiated Rate	$712.70
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,176.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$712.70
Rate for Payer: Aetna Government	$712.70
Rate for Payer: Brighton Health Commercial	$1,604.90
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: EmblemHealth Commercial	$1,505.00
Rate for Payer: Group Health Inc Commercial	$1,069.93
Rate for Payer: Group Health Inc Medicare	$748.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,069.93
Rate for Payer: Hamaspik Choice Inc Medicare	$1,069.93
Rate for Payer: United Healthcare Commercial	$1,496.00

RIGHT POPLITEPL FORCEP

Facility

$599.75

Hospital Charge Code	64903648
Hospital Revenue Code	270
Min. Negotiated Rate	$209.91
Max. Negotiated Rate	$479.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$329.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$299.88
Rate for Payer: Aetna Government	$299.88
Rate for Payer: Brighton Health Commercial	$449.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$479.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$407.83
Rate for Payer: Group Health Inc Commercial	$299.88
Rate for Payer: Group Health Inc Medicare	$209.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$299.88
Rate for Payer: Hamaspik Choice Inc Medicare	$299.88

RIGID BL BSSO 6 H PLATE

Facility

$521.38

Service Code	HCPCS C1713
Hospital Charge Code	64903281
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$547.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$286.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$312.83
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$260.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$299.79
Rate for Payer: EmblemHealth Commercial	$260.69
Rate for Payer: Fidelis Medicare Advantage	$547.45
Rate for Payer: Group Health Inc Commercial	$260.69
Rate for Payer: Group Health Inc Medicare	$182.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$260.69
Rate for Payer: Hamaspik Choice Inc Medicare	$260.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$338.90

RIGID BL BSSO 6 H PLATE

Facility

$521.38

Service Code	HCPCS C1713
Hospital Charge Code	64903281
Hospital Revenue Code	278
Min. Negotiated Rate	$260.69
Max. Negotiated Rate	$260.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$260.69
Rate for Payer: Hamaspik Choice Inc Medicare	$260.69

RIGID LEG CAST

Facility

$674.00

Service Code	HCPCS 29445
Hospital Charge Code	42500112
Hospital Revenue Code	510
Rate for Payer: Cash Price	$310.57

RIGID LEG CAST

Facility

$674.00

Service Code	HCPCS 29445
Hospital Charge Code	42500112
Hospital Revenue Code	510
Min. Negotiated Rate	$217.40
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$310.57
Rate for Payer: Aetna Government	$310.57
Rate for Payer: Affinity Essential Plan 1&2	$217.40
Rate for Payer: Affinity Essential Plan 3&4	$217.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$217.40
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$310.57
Rate for Payer: Cash Price	$310.57
Rate for Payer: Cash Price	$310.57
Rate for Payer: Cash Price	$310.57
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$310.57
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	$310.57
Rate for Payer: Fidelis Essential Plan Aliesa	$263.98
Rate for Payer: Fidelis Essential Plan QHP	$276.41
Rate for Payer: Fidelis Medicare Advantage	$310.57
Rate for Payer: Fidelis Qualified Health Plan	$276.41
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$337.00
Rate for Payer: Hamaspik Choice Inc Medicare	$310.57
Rate for Payer: Healthfirst Medicare Advantage	$263.98
Rate for Payer: Healthfirst QHP	$310.57
Rate for Payer: Humana Medicare	$316.78
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$310.57
Rate for Payer: Senior Whole Health Medicare Advantage	$310.57
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$310.57
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$310.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$248.46
Rate for Payer: Wellcare Medicare	$295.04

RILPIVIRINE HCL 25 MG PO TABS [109909]

Facility

$58.11

Service Code	NDC 59676027801
Hospital Charge Code	59676027801
Hospital Revenue Code	250
Min. Negotiated Rate	$20.34
Max. Negotiated Rate	$46.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$29.06
Rate for Payer: Aetna Government	$29.06
Rate for Payer: Brighton Health Commercial	$43.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$46.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$39.52
Rate for Payer: Group Health Inc Commercial	$29.06
Rate for Payer: Group Health Inc Medicare	$20.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$29.06
Rate for Payer: Hamaspik Choice Inc Medicare	$29.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37.77

RILPIVIRNE 25 MG TABLET

Facility

$44.29

Hospital Charge Code	41657013
Hospital Revenue Code	250
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$35.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$22.14
Rate for Payer: Aetna Government	$22.14
Rate for Payer: Brighton Health Commercial	$33.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$35.43
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.12
Rate for Payer: Group Health Inc Commercial	$22.14
Rate for Payer: Group Health Inc Medicare	$15.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.14
Rate for Payer: Hamaspik Choice Inc Medicare	$22.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28.79

RILPIVIRNE 25MG TABLET

Facility

$44.29

Hospital Charge Code	41647013
Hospital Revenue Code	250
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$35.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$22.14
Rate for Payer: Aetna Government	$22.14
Rate for Payer: Brighton Health Commercial	$33.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$35.43
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.12
Rate for Payer: Group Health Inc Commercial	$22.14
Rate for Payer: Group Health Inc Medicare	$15.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.14
Rate for Payer: Hamaspik Choice Inc Medicare	$22.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28.79

RILUZOLE 50 MG PO TABS [16124]

Facility

$36.94

Service Code	NDC 67877028660
Hospital Charge Code	67877028660
Hospital Revenue Code	250
Min. Negotiated Rate	$12.93
Max. Negotiated Rate	$29.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.47
Rate for Payer: Aetna Government	$18.47
Rate for Payer: Brighton Health Commercial	$27.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.12
Rate for Payer: Group Health Inc Commercial	$18.47
Rate for Payer: Group Health Inc Medicare	$12.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.47
Rate for Payer: Hamaspik Choice Inc Medicare	$18.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$24.01

RILUZOLE 50 MG TAB

Facility

$26.00

Hospital Charge Code	41651012
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$20.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.00
Rate for Payer: Aetna Government	$13.00
Rate for Payer: Brighton Health Commercial	$19.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.68
Rate for Payer: Group Health Inc Commercial	$13.00
Rate for Payer: Group Health Inc Medicare	$9.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.00
Rate for Payer: Hamaspik Choice Inc Medicare	$13.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.90

RILUZOLE 50 MG TAB

Facility

$26.00

Hospital Charge Code	41641012
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$20.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.00
Rate for Payer: Aetna Government	$13.00
Rate for Payer: Brighton Health Commercial	$19.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.68
Rate for Payer: Group Health Inc Commercial	$13.00
Rate for Payer: Group Health Inc Medicare	$9.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.00
Rate for Payer: Hamaspik Choice Inc Medicare	$13.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.90

RIMANTADINE 100 MG TAB - NF

Facility

$4.00

Hospital Charge Code	41645142
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

RIMANTADINE 100 MG TAB - NF

Facility

$4.00

Hospital Charge Code	41655142
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$3.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.72
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

RIMANTADINE HCL 100 MG PO TABS [15440]

Facility

$3.25

Service Code	NDC 00115191101
Hospital Charge Code	00115191101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.62
Rate for Payer: Aetna Government	$1.62
Rate for Payer: Brighton Health Commercial	$2.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.21
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.11

RING ADAPT, OVAL CONVEX

Facility

$5.49

Hospital Charge Code	40201973
Hospital Revenue Code	270
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$4.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.74
Rate for Payer: Aetna Government	$2.74
Rate for Payer: Brighton Health Commercial	$4.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.73
Rate for Payer: Group Health Inc Commercial	$2.74
Rate for Payer: Group Health Inc Medicare	$1.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.74
Rate for Payer: Hamaspik Choice Inc Medicare	$2.74

RING, ADPT, OVAL, CVX, 7/8 X 1

Facility

$54.88

Hospital Charge Code	64903932
Hospital Revenue Code	270
Min. Negotiated Rate	$19.21
Max. Negotiated Rate	$43.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.44
Rate for Payer: Aetna Government	$27.44
Rate for Payer: Brighton Health Commercial	$41.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.32
Rate for Payer: Group Health Inc Commercial	$27.44
Rate for Payer: Group Health Inc Medicare	$19.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.44
Rate for Payer: Hamaspik Choice Inc Medicare	$27.44

RING, CONVEX, OVAL

Facility

$5.49

Hospital Charge Code	40201975
Hospital Revenue Code	270
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$4.39
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.74
Rate for Payer: Aetna Government	$2.74
Rate for Payer: Brighton Health Commercial	$4.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.73
Rate for Payer: Group Health Inc Commercial	$2.74
Rate for Payer: Group Health Inc Medicare	$1.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.74
Rate for Payer: Hamaspik Choice Inc Medicare	$2.74

RING, CONVEX, OVAL, 1-3/16X1-7/8

Facility

$54.88

Hospital Charge Code	64903934
Hospital Revenue Code	270
Min. Negotiated Rate	$19.21
Max. Negotiated Rate	$43.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$30.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.44
Rate for Payer: Aetna Government	$27.44
Rate for Payer: Brighton Health Commercial	$41.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$43.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$37.32
Rate for Payer: Group Health Inc Commercial	$27.44
Rate for Payer: Group Health Inc Medicare	$19.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$27.44
Rate for Payer: Hamaspik Choice Inc Medicare	$27.44

RING EXTERNAL FIXATION ILIZARO

Facility

$3,493.88

Service Code	HCPCS C1713
Hospital Charge Code	64904104
Hospital Revenue Code	278
Min. Negotiated Rate	$1,746.94
Max. Negotiated Rate	$1,746.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,746.94
Rate for Payer: Hamaspik Choice Inc Medicare	$1,746.94

RING EXTERNAL FIXATION ILIZARO

Facility

$3,493.88

Service Code	HCPCS C1713
Hospital Charge Code	64904104
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,668.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,921.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,096.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,746.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,008.98
Rate for Payer: EmblemHealth Commercial	$1,746.94
Rate for Payer: Fidelis Medicare Advantage	$3,668.57
Rate for Payer: Group Health Inc Commercial	$1,746.94
Rate for Payer: Group Health Inc Medicare	$1,222.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,746.94
Rate for Payer: Hamaspik Choice Inc Medicare	$1,746.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,271.02

RING EXT FIXATION 180MM ID

Facility

$4,000.00

Service Code	HCPCS C1713
Hospital Charge Code	64903339
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$2,000.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,000.00

Know your out-of-pocket cost for care.

All Charges