Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

AETOS REVERSE LINER 34MM/SMALL

Facility

$3,745.00

Service Code	HCPCS C1713
Hospital Charge Code	270704575
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$906.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$823.90
Rate for Payer: Qualcare PPO/HMO/WC	$561.75

AETOS REVERSE LINER 34MM/SMALL

Facility

$3,745.00

Service Code	HCPCS C1713
Hospital Charge Code	270704575
Hospital Revenue Code	278
Min. Negotiated Rate	$90.25
Max. Negotiated Rate	$1,872.50
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare Advantage	$1,123.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$954.98
Rate for Payer: Cigna Commercial	$1,872.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$823.90
Rate for Payer: Qualcare PPO/HMO/WC	$561.75
Rate for Payer: UnitedHealthcare Community & State	$90.25
Rate for Payer: Wellpoint Medicaid Managed Care	$99.24

AETOS REVERSE LINER 38MM SMALL

Facility

$3,745.00

Service Code	HCPCS C1765
Hospital Charge Code	270704979
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$906.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$823.90
Rate for Payer: Qualcare PPO/HMO/WC	$561.75

AETOS REVERSE LINER 38MM SMALL

Facility

$3,745.00

Service Code	HCPCS C1765
Hospital Charge Code	270704979
Hospital Revenue Code	278
Min. Negotiated Rate	$90.25
Max. Negotiated Rate	$1,872.50
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare Advantage	$1,123.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$954.98
Rate for Payer: Cigna Commercial	$1,872.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$823.90
Rate for Payer: Qualcare PPO/HMO/WC	$561.75
Rate for Payer: UnitedHealthcare Community & State	$90.25
Rate for Payer: Wellpoint Medicaid Managed Care	$99.24

AETOS REVERSE LINER RETENT 38M

Facility

$6,531.30

Service Code	HCPCS C1713
Hospital Charge Code	270704903
Hospital Revenue Code	278
Min. Negotiated Rate	$157.40
Max. Negotiated Rate	$3,265.65
Rate for Payer: Aetna Commercial	$2,481.89
Rate for Payer: Aetna Medicare Advantage	$1,959.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,665.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,665.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,665.48
Rate for Payer: Cigna Commercial	$3,265.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.57
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,436.89
Rate for Payer: Qualcare PPO/HMO/WC	$979.70
Rate for Payer: UnitedHealthcare Community & State	$157.40
Rate for Payer: Wellpoint Medicaid Managed Care	$173.08

AETOS REVERSE LINER RETENT 38M

Facility

$6,531.30

Service Code	HCPCS C1713
Hospital Charge Code	270704903
Hospital Revenue Code	278
Min. Negotiated Rate	$979.70
Max. Negotiated Rate	$1,580.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.26
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.57
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,436.89
Rate for Payer: Qualcare PPO/HMO/WC	$979.70

AETOS SHOULDER SYSTEM 34MM

Facility

$6,530.00

Service Code	HCPCS C1713
Hospital Charge Code	270703978
Hospital Revenue Code	278
Min. Negotiated Rate	$157.37
Max. Negotiated Rate	$3,265.00
Rate for Payer: Aetna Commercial	$2,481.40
Rate for Payer: Aetna Medicare Advantage	$1,959.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,665.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,665.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,665.15
Rate for Payer: Cigna Commercial	$3,265.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,436.60
Rate for Payer: Qualcare PPO/HMO/WC	$979.50
Rate for Payer: UnitedHealthcare Community & State	$157.37
Rate for Payer: Wellpoint Medicaid Managed Care	$173.04

AETOS SHOULDER SYSTEM 34MM

Facility

$6,530.00

Service Code	HCPCS C1713
Hospital Charge Code	270703978
Hospital Revenue Code	278
Min. Negotiated Rate	$979.50
Max. Negotiated Rate	$1,580.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,436.60
Rate for Payer: Qualcare PPO/HMO/WC	$979.50

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479501
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479497
Hospital Revenue Code	309
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$4.93

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479497
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479499
Hospital Revenue Code	309
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$4.93

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479499
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479501
Hospital Revenue Code	309
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$4.93

AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479500
Hospital Revenue Code	309
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$14.66
Rate for Payer: Aetna Medicare Advantage	$17.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.46
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare Advantage	$5.39
Rate for Payer: Clover Medicare Advantage	$5.12
Rate for Payer: EmblemHealth Commercial	$16.17
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.60
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.80
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.39
Rate for Payer: Wellcare Medicare Advantage	$5.39
Rate for Payer: Wellpoint Medicaid Managed Care	$4.03

AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479500
Hospital Revenue Code	309
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$22.80
Rate for Payer: Qualcare PPO/HMO/WC	$22.80

AFB CULTURE - CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38475080
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULTURE - CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38475080
Hospital Revenue Code	309
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$4.93

AFB CULTURE-CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479465
Hospital Revenue Code	309
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$4.93

AFB CULTURE-CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479465
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULTURE DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38479467
Hospital Revenue Code	309
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.98
Rate for Payer: Cigna Commercial	$62.00
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.60
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$3.29

AFB CULTURE DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38479467
Hospital Revenue Code	309
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$18.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.60

AFB CULTURE, DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38475014
Hospital Revenue Code	309
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$18.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.60

AFB CULTURE, DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38475014
Hospital Revenue Code	309
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.98
Rate for Payer: Cigna Commercial	$62.00
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.60
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$3.29

AFB IDENTIFICATION

Facility

$96.85

Service Code	HCPCS 87118
Hospital Charge Code	3006798
Hospital Revenue Code	309
Min. Negotiated Rate	$14.53
Max. Negotiated Rate	$14.53
Rate for Payer: Qualcare PPO/HMO/WC	$14.53

Know your out-of-pocket cost for care.

All Charges