Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

EXCALI BUR

Facility

$295.00

Hospital Charge Code	270682451
Hospital Revenue Code	272
Min. Negotiated Rate	$44.25
Max. Negotiated Rate	$44.25
Rate for Payer: Qualcare PPO/HMO/WC	$44.25

EXCALI BUR

Facility

$295.00

Hospital Charge Code	270682451
Hospital Revenue Code	272
Min. Negotiated Rate	$7.11
Max. Negotiated Rate	$147.50
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare Advantage	$88.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$75.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$75.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$75.22
Rate for Payer: Cigna Commercial	$147.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$88.50
Rate for Payer: Oxford Commercial	$59.00
Rate for Payer: Qualcare PPO/HMO/WC	$44.25
Rate for Payer: UnitedHealthcare Commercial	$59.00
Rate for Payer: UnitedHealthcare Community & State	$7.11
Rate for Payer: Wellpoint Medicaid Managed Care	$7.82

EXCALIBUR CURVED HL 4.2 MMX19C

Facility

$330.00

Hospital Charge Code	270682875
Hospital Revenue Code	272
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$125.40
Rate for Payer: Aetna Medicare Advantage	$99.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$84.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$84.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$84.15
Rate for Payer: Cigna Commercial	$165.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$99.00
Rate for Payer: Oxford Commercial	$66.00
Rate for Payer: Qualcare PPO/HMO/WC	$49.50
Rate for Payer: UnitedHealthcare Commercial	$66.00
Rate for Payer: UnitedHealthcare Community & State	$7.95
Rate for Payer: Wellpoint Medicaid Managed Care	$8.74

EXCALIBUR CURVED HL 4.2 MMX19C

Facility

$330.00

Hospital Charge Code	270682875
Hospital Revenue Code	272
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$49.50
Rate for Payer: Qualcare PPO/HMO/WC	$49.50

EXCALIBUR HL 4.2MM X19CM

Facility

$385.00

Hospital Charge Code	270687988
Hospital Revenue Code	272
Min. Negotiated Rate	$9.28
Max. Negotiated Rate	$192.50
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare Advantage	$115.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$98.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$98.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$98.17
Rate for Payer: Cigna Commercial	$192.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$115.50
Rate for Payer: Oxford Commercial	$77.00
Rate for Payer: Qualcare PPO/HMO/WC	$57.75
Rate for Payer: UnitedHealthcare Commercial	$77.00
Rate for Payer: UnitedHealthcare Community & State	$9.28
Rate for Payer: Wellpoint Medicaid Managed Care	$10.20

EXCALIBUR HL 4.2MM X19CM

Facility

$385.00

Hospital Charge Code	270687988
Hospital Revenue Code	272
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$57.75
Rate for Payer: Qualcare PPO/HMO/WC	$57.75

EXC ARM/ELBOW LES SC < 3 CM

Facility

$16,857.75

Service Code	HCPCS 24075
Hospital Charge Code	16000409
Hospital Revenue Code	360
Min. Negotiated Rate	$406.27
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	$1,016.00
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	$5,057.32
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$406.27
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	$446.73

EXC ARM/ELBOW LES SC < 3 CM

Facility

$16,857.75

Service Code	HCPCS 24075
Hospital Charge Code	16000409
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.66
Max. Negotiated Rate	$2,528.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66

EXC ARM/ELBOW LES SC 3 CM/>

Facility

$25,274.60

Service Code	HCPCS 24071
Hospital Charge Code	16000310
Hospital Revenue Code	360
Min. Negotiated Rate	$609.12
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	$1,742.00
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	$7,582.38
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,791.19
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$609.12
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	$669.78

EXC ARM/ELBOW LES SC 3 CM/>

Facility

$25,274.60

Service Code	HCPCS 24071
Hospital Charge Code	16000310
Hospital Revenue Code	360
Min. Negotiated Rate	$3,791.19
Max. Negotiated Rate	$3,791.19
Rate for Payer: Qualcare PPO/HMO/WC	$3,791.19

EXC BACK LES SC < 3 CM

Facility

$13,615.50

Service Code	HCPCS 21930
Hospital Charge Code	16000315
Hospital Revenue Code	360
Min. Negotiated Rate	$2,042.33
Max. Negotiated Rate	$2,042.33
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33

EXC BACK LES SC < 3 CM

Facility

$13,615.50

Service Code	HCPCS 21930
Hospital Charge Code	16000315
Hospital Revenue Code	360
Min. Negotiated Rate	$328.13
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	$1,016.00
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	$4,084.65
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$328.13
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	$360.81

EXC BACK LES SC 3+ CM

Facility

$22,282.25

Service Code	HCPCS 21931
Hospital Charge Code	16000194
Hospital Revenue Code	360
Min. Negotiated Rate	$537.00
Max. Negotiated Rate	$8,157.00
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	$1,742.00
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	$6,684.68
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,342.34
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$537.00
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	$590.48

EXC BACK LES SC 3+ CM

Facility

$22,282.25

Service Code	HCPCS 21931
Hospital Charge Code	16000194
Hospital Revenue Code	360
Min. Negotiated Rate	$3,342.34
Max. Negotiated Rate	$3,342.34
Rate for Payer: Qualcare PPO/HMO/WC	$3,342.34

EXC BACK TUM DEEP < 5 CM

Facility

$13,615.50

Service Code	HCPCS 21932
Hospital Charge Code	16000497
Hospital Revenue Code	360
Min. Negotiated Rate	$328.13
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	$1,355.00
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	$4,084.65
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$328.13
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	$360.81

EXC BACK TUM DEEP < 5 CM

Facility

$13,615.50

Service Code	HCPCS 21932
Hospital Charge Code	16000497
Hospital Revenue Code	360
Min. Negotiated Rate	$2,042.33
Max. Negotiated Rate	$2,042.33
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33

EXC BACK TUM DEEP 5 CM/>

Facility

$20,625.50

Service Code	HCPCS 21933
Hospital Charge Code	16000300
Hospital Revenue Code	360
Min. Negotiated Rate	$3,093.82
Max. Negotiated Rate	$3,093.82
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82

EXC BACK TUM DEEP 5 CM/>

Facility

$20,625.50

Service Code	HCPCS 21933
Hospital Charge Code	16000300
Hospital Revenue Code	360
Min. Negotiated Rate	$497.07
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	$1,742.00
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	$6,187.65
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$497.07
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	$546.58

EXC BENIGN LES DIAM 0.6-1.0 CM

Facility

$2,080.70

Service Code	HCPCS 11441
Hospital Charge Code	75190080
Hospital Revenue Code	761
Min. Negotiated Rate	$50.14
Max. Negotiated Rate	$3,036.77
Rate for Payer: Aetna Commercial	$2,288.28
Rate for Payer: Aetna Medicare Advantage	$2,725.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,036.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,036.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$841.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$87.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,036.77
Rate for Payer: Cigna Commercial	$1,686.34
Rate for Payer: Cigna Medicare Advantage	$841.28
Rate for Payer: Clover Medicare Advantage	$799.22
Rate for Payer: EmblemHealth Commercial	$2,523.84
Rate for Payer: Humana Medicare Advantage	$866.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$841.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$624.21
Rate for Payer: Oxford Commercial	$416.14
Rate for Payer: Qualcare PPO/HMO/WC	$312.11
Rate for Payer: UnitedHealthcare Commercial	$416.14
Rate for Payer: UnitedHealthcare Community & State	$50.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$841.28
Rate for Payer: Wellcare Medicare Advantage	$841.28
Rate for Payer: Wellpoint Medicaid Managed Care	$55.14

EXC BENIGN LES DIAM 0.6-1.0 CM

Facility

$2,080.70

Service Code	HCPCS 11441
Hospital Charge Code	75190080
Hospital Revenue Code	761
Min. Negotiated Rate	$312.11
Max. Negotiated Rate	$312.11
Rate for Payer: Qualcare PPO/HMO/WC	$312.11

EXC BENIGN LES DIAM 1.1-2.0 CM

Facility

$3,473.00

Service Code	HCPCS 11422
Hospital Charge Code	75190060
Hospital Revenue Code	761
Min. Negotiated Rate	$83.70
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	$190.23
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	$1,041.90
Rate for Payer: Oxford Commercial	$694.60
Rate for Payer: Qualcare PPO/HMO/WC	$520.95
Rate for Payer: UnitedHealthcare Commercial	$694.60
Rate for Payer: UnitedHealthcare Community & State	$83.70
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	$92.03

EXC BENIGN LES DIAM 1.1-2.0 CM

Facility

$3,473.00

Service Code	HCPCS 11422
Hospital Charge Code	75190060
Hospital Revenue Code	761
Min. Negotiated Rate	$520.95
Max. Negotiated Rate	$520.95
Rate for Payer: Qualcare PPO/HMO/WC	$520.95

EXC BENIGN LES DIAM 2.1-3.0 CM

Facility

$3,472.00

Service Code	HCPCS 11443
Hospital Charge Code	75190090
Hospital Revenue Code	761
Min. Negotiated Rate	$520.80
Max. Negotiated Rate	$520.80
Rate for Payer: Qualcare PPO/HMO/WC	$520.80

EXC BENIGN LES DIAM 2.1-3.0 CM

Facility

$7,392.00

Service Code	HCPCS 11423
Hospital Charge Code	75190065
Hospital Revenue Code	761
Min. Negotiated Rate	$178.15
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	$219.00
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	$2,217.60
Rate for Payer: Oxford Commercial	$1,478.40
Rate for Payer: Qualcare PPO/HMO/WC	$1,108.80
Rate for Payer: UnitedHealthcare Commercial	$1,478.40
Rate for Payer: UnitedHealthcare Community & State	$178.15
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	$195.89

EXC BENIGN LES DIAM 2.1-3.0 CM

Facility

$7,392.00

Service Code	HCPCS 11423
Hospital Charge Code	75190065
Hospital Revenue Code	761
Min. Negotiated Rate	$1,108.80
Max. Negotiated Rate	$1,108.80
Rate for Payer: Qualcare PPO/HMO/WC	$1,108.80

Know your out-of-pocket cost for care.

All Charges