Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

ER EXTENDED - IV W/O MF

Facility

$9,086.55

Service Code	HCPCS 99284
Hospital Charge Code	5700090
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$2,744.00
Rate for Payer: Aetna Commercial	$1,348.36
Rate for Payer: Aetna Medicare Advantage	$1,606.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,789.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,789.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$495.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,789.40
Rate for Payer: Cigna Commercial	$993.68
Rate for Payer: Cigna Medicare Advantage	$495.72
Rate for Payer: Clover Medicare Advantage	$470.93
Rate for Payer: EmblemHealth Commercial	$1,487.16
Rate for Payer: Humana Medicare Advantage	$510.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$495.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,397.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Oxford Commercial	$2,186.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,362.98
Rate for Payer: UnitedHealthcare Commercial	$2,744.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$495.72
Rate for Payer: Wellcare Medicare Advantage	$495.72
Rate for Payer: Wellpoint Medicaid Managed Care	$450.00

ER EXTENDED - IV W/O MF

Facility

$9,086.55

Service Code	HCPCS 99284
Hospital Charge Code	5700090
Hospital Revenue Code	450
Min. Negotiated Rate	$1,362.98
Max. Negotiated Rate	$1,362.98
Rate for Payer: Qualcare PPO/HMO/WC	$1,362.98

ER EXTENDED - PP IV

Facility

$2,086.55

Service Code	HCPCS 9928425
Hospital Charge Code	5700232
Hospital Revenue Code	450
Min. Negotiated Rate	$312.98
Max. Negotiated Rate	$312.98
Rate for Payer: Qualcare PPO/HMO/WC	$312.98

ER EXTENDED - PP IV

Facility

$2,086.55

Service Code	HCPCS 9928425
Hospital Charge Code	5700232
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$2,186.00
Rate for Payer: Aetna Commercial	$792.89
Rate for Payer: Aetna Medicare Advantage	$625.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$532.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$532.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$532.07
Rate for Payer: Cigna Commercial	$1,043.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$625.97
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Oxford Commercial	$2,186.00
Rate for Payer: Qualcare PPO/HMO/WC	$312.98
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$450.00

ER EXTENDED - PP IV W/O MF

Facility

$2,086.55

Service Code	HCPCS 99284
Hospital Charge Code	5700231
Hospital Revenue Code	450
Min. Negotiated Rate	$312.98
Max. Negotiated Rate	$312.98
Rate for Payer: Qualcare PPO/HMO/WC	$312.98

ER EXTENDED - PP IV W/O MF

Facility

$2,086.55

Service Code	HCPCS 99284
Hospital Charge Code	5700231
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$2,744.00
Rate for Payer: Aetna Commercial	$1,348.36
Rate for Payer: Aetna Medicare Advantage	$1,606.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,789.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,789.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$495.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,789.40
Rate for Payer: Cigna Commercial	$993.68
Rate for Payer: Cigna Medicare Advantage	$495.72
Rate for Payer: Clover Medicare Advantage	$470.93
Rate for Payer: EmblemHealth Commercial	$1,487.16
Rate for Payer: Humana Medicare Advantage	$510.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$495.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,397.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Oxford Commercial	$2,186.00
Rate for Payer: Qualcare PPO/HMO/WC	$312.98
Rate for Payer: UnitedHealthcare Commercial	$2,744.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$495.72
Rate for Payer: Wellcare Medicare Advantage	$495.72
Rate for Payer: Wellpoint Medicaid Managed Care	$450.00

ER-EYE EXAM/VISUAL ACUITY

Facility

$315.00

Service Code	HCPCS 92002
Hospital Charge Code	5790230
Hospital Revenue Code	450
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$430.22
Rate for Payer: Aetna Medicare Advantage	$512.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$570.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$570.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$158.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$46.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$570.95
Rate for Payer: Cigna Commercial	$317.04
Rate for Payer: Cigna Medicare Advantage	$158.17
Rate for Payer: Clover Medicare Advantage	$150.26
Rate for Payer: EmblemHealth Commercial	$474.51
Rate for Payer: Humana Medicare Advantage	$162.92
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$158.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$94.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$47.25
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.17
Rate for Payer: Wellcare Medicare Advantage	$158.17
Rate for Payer: Wellpoint Medicaid Managed Care	$8.35

ER-EYE EXAM/VISUAL ACUITY

Facility

$315.00

Service Code	HCPCS 92002
Hospital Charge Code	5790230
Hospital Revenue Code	450
Min. Negotiated Rate	$47.25
Max. Negotiated Rate	$47.25
Rate for Payer: Qualcare PPO/HMO/WC	$47.25

ER FB MUSC/TENDON SHEATH DEEP

Facility

$12,792.55

Service Code	HCPCS 20525
Hospital Charge Code	5700722
Hospital Revenue Code	450
Min. Negotiated Rate	$1,918.88
Max. Negotiated Rate	$1,918.88
Rate for Payer: Qualcare PPO/HMO/WC	$1,918.88

ER FB MUSC/TENDON SHEATH DEEP

Facility

$12,792.55

Service Code	HCPCS 20525
Hospital Charge Code	5700722
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$12,456.64
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$325.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,456.64
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,837.76
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,918.88
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$339.00

ER FB MUSC/TENDON SHEATH SIMPL

Facility

$7,903.25

Service Code	HCPCS 20520
Hospital Charge Code	5700546
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$162.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,370.97
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,185.49
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$209.44

ER FB MUSC/TENDON SHEATH SIMPL

Facility

$7,903.25

Service Code	HCPCS 20520
Hospital Charge Code	5700546
Hospital Revenue Code	450
Min. Negotiated Rate	$1,185.49
Max. Negotiated Rate	$1,185.49
Rate for Payer: Qualcare PPO/HMO/WC	$1,185.49

ER-FB RECTUM

Facility

$2,316.00

Service Code	HCPCS 46608
Hospital Charge Code	5790155
Hospital Revenue Code	450
Min. Negotiated Rate	$347.40
Max. Negotiated Rate	$347.40
Rate for Payer: Qualcare PPO/HMO/WC	$347.40

ER-FB RECTUM

Facility

$2,316.00

Service Code	HCPCS 46608
Hospital Charge Code	5790155
Hospital Revenue Code	450
Min. Negotiated Rate	$61.37
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$98.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$694.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$347.40
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81
Rate for Payer: Wellpoint Medicaid Managed Care	$61.37

ER-FB REM CONJT SCLEM-BIL

Facility

$702.00

Hospital Charge Code	5790850
Hospital Revenue Code	450
Min. Negotiated Rate	$105.30
Max. Negotiated Rate	$105.30
Rate for Payer: Qualcare PPO/HMO/WC	$105.30

ER-FB REM CONJT SCLEM-BIL

Facility

$702.00

Hospital Charge Code	5790850
Hospital Revenue Code	450
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$266.76
Rate for Payer: Aetna Medicare Advantage	$210.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$179.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$179.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$179.01
Rate for Payer: Cigna Commercial	$351.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$210.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$105.30
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$18.60

ER-FB REM-CORN WOSLIT-BIL

Facility

$1,128.75

Service Code	HCPCS 65220
Hospital Charge Code	5790855
Hospital Revenue Code	450
Min. Negotiated Rate	$169.31
Max. Negotiated Rate	$169.31
Rate for Payer: Qualcare PPO/HMO/WC	$169.31

ER-FB REM-CORN WOSLIT-BIL

Facility

$1,128.75

Service Code	HCPCS 65220
Hospital Charge Code	5790855
Hospital Revenue Code	450
Min. Negotiated Rate	$29.91
Max. Negotiated Rate	$1,915.74
Rate for Payer: Aetna Commercial	$1,443.56
Rate for Payer: Aetna Medicare Advantage	$1,719.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,915.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,915.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$530.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,915.74
Rate for Payer: Cigna Commercial	$1,063.82
Rate for Payer: Cigna Medicare Advantage	$530.72
Rate for Payer: Clover Medicare Advantage	$504.18
Rate for Payer: EmblemHealth Commercial	$1,592.16
Rate for Payer: Humana Medicare Advantage	$546.64
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$530.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$338.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$169.31
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$530.72
Rate for Payer: Wellcare Medicare Advantage	$530.72
Rate for Payer: Wellpoint Medicaid Managed Care	$29.91

ER-F/B REM FECAL IMPACT

Facility

$1,377.00

Service Code	HCPCS 45915
Hospital Charge Code	5790145
Hospital Revenue Code	450
Min. Negotiated Rate	$36.49
Max. Negotiated Rate	$5,131.69
Rate for Payer: Aetna Commercial	$3,866.86
Rate for Payer: Aetna Medicare Advantage	$4,606.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,421.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$110.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,131.69
Rate for Payer: Cigna Commercial	$2,849.67
Rate for Payer: Cigna Medicare Advantage	$1,421.64
Rate for Payer: Clover Medicare Advantage	$1,350.56
Rate for Payer: EmblemHealth Commercial	$4,264.92
Rate for Payer: Humana Medicare Advantage	$1,464.29
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,421.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$413.10
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$206.55
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,421.64
Rate for Payer: Wellcare Medicare Advantage	$1,421.64
Rate for Payer: Wellpoint Medicaid Managed Care	$36.49

ER-F/B REM FECAL IMPACT

Facility

$1,377.00

Service Code	HCPCS 45915
Hospital Charge Code	5790145
Hospital Revenue Code	450
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$206.55
Rate for Payer: Qualcare PPO/HMO/WC	$206.55

ER FB REMOVAL ARM/ELBOW DEEP

Facility

$9,570.65

Service Code	HCPCS 24201
Hospital Charge Code	5700739
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$12,456.64
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$339.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,456.64
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,871.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,435.60
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$253.62

ER FB REMOVAL ARM/ELBOW DEEP

Facility

$9,570.65

Service Code	HCPCS 24201
Hospital Charge Code	5700739
Hospital Revenue Code	450
Min. Negotiated Rate	$1,435.60
Max. Negotiated Rate	$1,435.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,435.60

ER FB REMOVAL ARM/ELBOW SQ

Facility

$2,386.20

Service Code	HCPCS 24200
Hospital Charge Code	5700738
Hospital Revenue Code	450
Min. Negotiated Rate	$63.23
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$111.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$715.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$357.93
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$63.23

ER FB REMOVAL ARM/ELBOW SQ

Facility

$2,386.20

Service Code	HCPCS 24200
Hospital Charge Code	5700738
Hospital Revenue Code	450
Min. Negotiated Rate	$357.93
Max. Negotiated Rate	$357.93
Rate for Payer: Qualcare PPO/HMO/WC	$357.93

ER-FB REMOVAL EAR-LT

Facility

$203.00

Hospital Charge Code	5792160
Hospital Revenue Code	450
Min. Negotiated Rate	$30.45
Max. Negotiated Rate	$30.45
Rate for Payer: Qualcare PPO/HMO/WC	$30.45

Know your out-of-pocket cost for care.

All Charges