Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

ER APPLICATION LONG LEG CAST

Facility

$1,360.45

Service Code	HCPCS 29345
Hospital Charge Code	5700355
Hospital Revenue Code	450
Min. Negotiated Rate	$36.05
Max. Negotiated Rate	$1,199.43
Rate for Payer: Aetna Commercial	$903.80
Rate for Payer: Aetna Medicare Advantage	$1,076.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,199.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,199.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$332.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$110.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,199.43
Rate for Payer: Cigna Commercial	$666.07
Rate for Payer: Cigna Medicare Advantage	$332.28
Rate for Payer: Clover Medicare Advantage	$315.67
Rate for Payer: EmblemHealth Commercial	$996.84
Rate for Payer: Humana Medicare Advantage	$342.25
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$332.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$408.13
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$204.07
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$332.28
Rate for Payer: Wellcare Medicare Advantage	$332.28
Rate for Payer: Wellpoint Medicaid Managed Care	$36.05

ER APPLICATION SHORT LEG CAST

Facility

$1,360.45

Service Code	HCPCS 29405
Hospital Charge Code	5700370
Hospital Revenue Code	450
Min. Negotiated Rate	$36.05
Max. Negotiated Rate	$1,199.43
Rate for Payer: Aetna Commercial	$903.80
Rate for Payer: Aetna Medicare Advantage	$1,076.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,199.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,199.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$332.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$81.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,199.43
Rate for Payer: Cigna Commercial	$666.07
Rate for Payer: Cigna Medicare Advantage	$332.28
Rate for Payer: Clover Medicare Advantage	$315.67
Rate for Payer: EmblemHealth Commercial	$996.84
Rate for Payer: Humana Medicare Advantage	$342.25
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$332.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$408.13
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$204.07
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$332.28
Rate for Payer: Wellcare Medicare Advantage	$332.28
Rate for Payer: Wellpoint Medicaid Managed Care	$36.05

ER APPLICATION SHORT LEG CAST

Facility

$1,360.45

Service Code	HCPCS 29405
Hospital Charge Code	5700370
Hospital Revenue Code	450
Min. Negotiated Rate	$204.07
Max. Negotiated Rate	$204.07
Rate for Payer: Qualcare PPO/HMO/WC	$204.07

ER APPLICATION SHRT LEG SPLINT

Facility

$1,250.02

Service Code	HCPCS 29515
Hospital Charge Code	5700320
Hospital Revenue Code	450
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$187.50
Rate for Payer: Qualcare PPO/HMO/WC	$187.50

ER APPLICATION SHRT LEG SPLINT

Facility

$1,250.02

Service Code	HCPCS 29515
Hospital Charge Code	5700320
Hospital Revenue Code	450
Min. Negotiated Rate	$33.13
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$525.10
Rate for Payer: Aetna Medicare Advantage	$625.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$696.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$696.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$193.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$81.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$696.85
Rate for Payer: Cigna Commercial	$386.97
Rate for Payer: Cigna Medicare Advantage	$193.05
Rate for Payer: Clover Medicare Advantage	$183.40
Rate for Payer: EmblemHealth Commercial	$579.15
Rate for Payer: Humana Medicare Advantage	$198.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$193.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$375.01
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$187.50
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$193.05
Rate for Payer: Wellcare Medicare Advantage	$193.05
Rate for Payer: Wellpoint Medicaid Managed Care	$33.13

ER-APPLI LONG LEG CAST-BI

Facility

$698.00

Hospital Charge Code	5790740
Hospital Revenue Code	450
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$265.24
Rate for Payer: Aetna Medicare Advantage	$209.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$177.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$177.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$177.99
Rate for Payer: Cigna Commercial	$349.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$209.40
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$104.70
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$18.50

ER-APPLI LONG LEG CAST-BI

Facility

$698.00

Hospital Charge Code	5790740
Hospital Revenue Code	450
Min. Negotiated Rate	$104.70
Max. Negotiated Rate	$104.70
Rate for Payer: Qualcare PPO/HMO/WC	$104.70

ER-APPLY FINGER CAST-BI

Facility

$325.00

Hospital Charge Code	5790700
Hospital Revenue Code	450
Min. Negotiated Rate	$48.75
Max. Negotiated Rate	$48.75
Rate for Payer: Qualcare PPO/HMO/WC	$48.75

ER-APPLY FINGER CAST-BI

Facility

$325.00

Hospital Charge Code	5790700
Hospital Revenue Code	450
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare Advantage	$97.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$82.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$82.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$82.88
Rate for Payer: Cigna Commercial	$162.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$48.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$8.61

ER AR/PULSE OXIMETRY SINGLE DE

Facility

$503.00

Service Code	HCPCS 94760
Hospital Charge Code	5780300
Hospital Revenue Code	460
Min. Negotiated Rate	$12.12
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$191.14
Rate for Payer: Aetna Medicare Advantage	$150.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$96.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.26
Rate for Payer: Cigna Commercial	$251.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$150.90
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.45
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$12.12
Rate for Payer: Wellpoint Medicaid Managed Care	$13.33

ER AR/PULSE OXIMETRY SINGLE DE

Facility

$503.00

Service Code	HCPCS 94760
Hospital Charge Code	5780300
Hospital Revenue Code	460
Min. Negotiated Rate	$75.45
Max. Negotiated Rate	$75.45
Rate for Payer: Qualcare PPO/HMO/WC	$75.45

ER ARTERIAL PNCTR DIAGNOSIS

Facility

$68.75

Service Code	HCPCS 36600
Hospital Charge Code	5700641
Hospital Revenue Code	450
Min. Negotiated Rate	$10.31
Max. Negotiated Rate	$10.31
Rate for Payer: Qualcare PPO/HMO/WC	$10.31

ER ARTERIAL PNCTR DIAGNOSIS

Facility

$68.75

Service Code	HCPCS 36600
Hospital Charge Code	5700641
Hospital Revenue Code	450
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$429.92
Rate for Payer: Aetna Medicare Advantage	$512.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$570.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$570.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$158.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$31.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$570.55
Rate for Payer: Cigna Commercial	$316.85
Rate for Payer: Cigna Medicare Advantage	$158.06
Rate for Payer: Clover Medicare Advantage	$150.16
Rate for Payer: EmblemHealth Commercial	$474.18
Rate for Payer: Humana Medicare Advantage	$162.80
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$158.06
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$10.31
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.06
Rate for Payer: Wellcare Medicare Advantage	$158.06
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$197.37
Rate for Payer: Wellpoint Medicaid Managed Care	$1.82

ER ARTHROCENTESIS INT JOINT

Facility

$740.00

Service Code	HCPCS 20605
Hospital Charge Code	5700549
Hospital Revenue Code	450
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$1,316.35
Rate for Payer: Aetna Commercial	$991.90
Rate for Payer: Aetna Medicare Advantage	$1,181.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$364.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$49.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,316.35
Rate for Payer: Cigna Commercial	$730.97
Rate for Payer: Cigna Medicare Advantage	$364.67
Rate for Payer: Clover Medicare Advantage	$346.44
Rate for Payer: EmblemHealth Commercial	$1,094.01
Rate for Payer: Humana Medicare Advantage	$375.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$364.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$364.67
Rate for Payer: Wellcare Medicare Advantage	$364.67
Rate for Payer: Wellpoint Medicaid Managed Care	$19.61

ER ARTHROCENTESIS INT JOINT

Facility

$740.00

Service Code	HCPCS 20605
Hospital Charge Code	5700549
Hospital Revenue Code	450
Min. Negotiated Rate	$111.00
Max. Negotiated Rate	$111.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00

ER ARTHROCENTESIS MAJOR JOINT

Facility

$740.00

Service Code	HCPCS 20610
Hospital Charge Code	5700550
Hospital Revenue Code	450
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$1,316.35
Rate for Payer: Aetna Commercial	$991.90
Rate for Payer: Aetna Medicare Advantage	$1,181.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$364.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$75.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,316.35
Rate for Payer: Cigna Commercial	$730.97
Rate for Payer: Cigna Medicare Advantage	$364.67
Rate for Payer: Clover Medicare Advantage	$346.44
Rate for Payer: EmblemHealth Commercial	$1,094.01
Rate for Payer: Humana Medicare Advantage	$375.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$364.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$364.67
Rate for Payer: Wellcare Medicare Advantage	$364.67
Rate for Payer: Wellpoint Medicaid Managed Care	$19.61

ER ARTHROCENTESIS MAJOR JOINT

Facility

$740.00

Service Code	HCPCS 20610
Hospital Charge Code	5700550
Hospital Revenue Code	450
Min. Negotiated Rate	$111.00
Max. Negotiated Rate	$111.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00

ER ARTHROCENTESIS, SMALL JOINT

Facility

$740.00

Service Code	HCPCS 20600
Hospital Charge Code	5700548
Hospital Revenue Code	450
Min. Negotiated Rate	$111.00
Max. Negotiated Rate	$111.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00

ER ARTHROCENTESIS, SMALL JOINT

Facility

$740.00

Service Code	HCPCS 20600
Hospital Charge Code	5700548
Hospital Revenue Code	450
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$1,316.35
Rate for Payer: Aetna Commercial	$991.90
Rate for Payer: Aetna Medicare Advantage	$1,181.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,316.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$364.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,316.35
Rate for Payer: Cigna Commercial	$730.97
Rate for Payer: Cigna Medicare Advantage	$364.67
Rate for Payer: Clover Medicare Advantage	$346.44
Rate for Payer: EmblemHealth Commercial	$1,094.01
Rate for Payer: Humana Medicare Advantage	$375.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$364.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$111.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$364.67
Rate for Payer: Wellcare Medicare Advantage	$364.67
Rate for Payer: Wellpoint Medicaid Managed Care	$19.61

ER ARTRIAL LINE INSERT PERCU

Facility

$959.80

Service Code	HCPCS 36620
Hospital Charge Code	5700783
Hospital Revenue Code	450
Min. Negotiated Rate	$143.97
Max. Negotiated Rate	$143.97
Rate for Payer: Qualcare PPO/HMO/WC	$143.97

ER ARTRIAL LINE INSERT PERCU

Facility

$959.80

Service Code	HCPCS 36620
Hospital Charge Code	5700783
Hospital Revenue Code	450
Min. Negotiated Rate	$25.43
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$364.72
Rate for Payer: Aetna Medicare Advantage	$287.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$244.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$244.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$45.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$244.75
Rate for Payer: Cigna Commercial	$479.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$287.94
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$143.97
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$25.43

ER ASPIR BLADDER TROCAR INTCAT

Facility

$599.40

Service Code	HCPCS 51101
Hospital Charge Code	5700797
Hospital Revenue Code	450
Min. Negotiated Rate	$15.88
Max. Negotiated Rate	$3,682.65
Rate for Payer: Aetna Commercial	$2,774.97
Rate for Payer: Aetna Medicare Advantage	$3,305.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,682.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,682.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,020.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,682.65
Rate for Payer: Cigna Commercial	$2,044.99
Rate for Payer: Cigna Medicare Advantage	$1,020.21
Rate for Payer: Clover Medicare Advantage	$969.20
Rate for Payer: EmblemHealth Commercial	$3,060.63
Rate for Payer: Humana Medicare Advantage	$1,050.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,020.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$179.82
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.91
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,020.21
Rate for Payer: Wellcare Medicare Advantage	$1,020.21
Rate for Payer: Wellpoint Medicaid Managed Care	$15.88

ER ASPIR BLADDER TROCAR INTCAT

Facility

$599.40

Service Code	HCPCS 51101
Hospital Charge Code	5700797
Hospital Revenue Code	450
Min. Negotiated Rate	$89.91
Max. Negotiated Rate	$89.91
Rate for Payer: Qualcare PPO/HMO/WC	$89.91

ER-AUTOGRAFT <=100 SQCM

Facility

$4,776.00

Service Code	HCPCS 15120
Hospital Charge Code	5790030
Hospital Revenue Code	450
Min. Negotiated Rate	$126.56
Max. Negotiated Rate	$15,196.98
Rate for Payer: Aetna Commercial	$11,451.31
Rate for Payer: Aetna Medicare Advantage	$13,640.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,210.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$941.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,196.98
Rate for Payer: Cigna Commercial	$8,439.01
Rate for Payer: Cigna Medicare Advantage	$4,210.04
Rate for Payer: Clover Medicare Advantage	$3,999.54
Rate for Payer: EmblemHealth Commercial	$12,630.12
Rate for Payer: Humana Medicare Advantage	$4,336.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,210.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,432.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$716.40
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,210.04
Rate for Payer: Wellcare Medicare Advantage	$4,210.04
Rate for Payer: Wellpoint Medicaid Managed Care	$126.56

ER-AUTOGRAFT <=100 SQCM

Facility

$4,776.00

Service Code	HCPCS 15120
Hospital Charge Code	5790030
Hospital Revenue Code	450
Min. Negotiated Rate	$716.40
Max. Negotiated Rate	$716.40
Rate for Payer: Qualcare PPO/HMO/WC	$716.40

Know your out-of-pocket cost for care.

All Charges