Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

INTRO CATH DIALYSIS CIRCUIT

Facility

$6,404.20

Service Code	HCPCS 36901
Hospital Charge Code	321036901
Hospital Revenue Code	361
Min. Negotiated Rate	$154.34
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,921.26
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$960.63
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$154.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$169.71

INTRO CATH DIALYSIS CIRCUIT

Facility

$6,404.20

Service Code	HCPCS 36901
Hospital Charge Code	2692127
Hospital Revenue Code	361
Min. Negotiated Rate	$154.34
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,921.26
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$960.63
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$154.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$169.71

INTRO CATH DIALYSIS CIRCUIT

Facility

$3,419.20

Service Code	HCPCS 36901
Hospital Charge Code	2709022
Hospital Revenue Code	361
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,025.76
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$512.88
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$82.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$90.61

INTRO CATH DIALYSIS CIRCUIT

Facility

$3,419.20

Service Code	HCPCS 36901
Hospital Charge Code	5100835
Hospital Revenue Code	361
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,025.76
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$512.88
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$82.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$90.61

INTRO CATH DIALYSIS CIRCUIT

Facility

$3,419.20

Service Code	HCPCS 36901
Hospital Charge Code	5100835
Hospital Revenue Code	361
Min. Negotiated Rate	$512.88
Max. Negotiated Rate	$512.88
Rate for Payer: Qualcare PPO/HMO/WC	$512.88

INTRO CATH DIALYSIS CIRCUIT

Facility

$3,419.20

Service Code	HCPCS 36901
Hospital Charge Code	7412056
Hospital Revenue Code	361
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,025.76
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$512.88
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$82.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$90.61

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	404636140
Hospital Revenue Code	481
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$6,600.00
Rate for Payer: Aetna Commercial	$125.99
Rate for Payer: Aetna Medicare Advantage	$99.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,194.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$84.55
Rate for Payer: Cigna Commercial	$165.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$99.47
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$49.73
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$7.99
Rate for Payer: Wellpoint Medicaid Managed Care	$8.79

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	5100500
Hospital Revenue Code	761
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$165.78
Rate for Payer: Aetna Commercial	$125.99
Rate for Payer: Aetna Medicare Advantage	$99.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$84.55
Rate for Payer: Cigna Commercial	$165.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$99.47
Rate for Payer: Oxford Commercial	$66.31
Rate for Payer: Qualcare PPO/HMO/WC	$49.73
Rate for Payer: UnitedHealthcare Commercial	$66.31
Rate for Payer: UnitedHealthcare Community & State	$7.99
Rate for Payer: Wellpoint Medicaid Managed Care	$8.79

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	5100500
Hospital Revenue Code	761
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$49.73
Rate for Payer: Qualcare PPO/HMO/WC	$49.73

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	74110053
Hospital Revenue Code	761
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$165.78
Rate for Payer: Aetna Commercial	$125.99
Rate for Payer: Aetna Medicare Advantage	$99.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$84.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$84.55
Rate for Payer: Cigna Commercial	$165.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$99.47
Rate for Payer: Oxford Commercial	$66.31
Rate for Payer: Qualcare PPO/HMO/WC	$49.73
Rate for Payer: UnitedHealthcare Commercial	$66.31
Rate for Payer: UnitedHealthcare Community & State	$7.99
Rate for Payer: Wellpoint Medicaid Managed Care	$8.79

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	74110053
Hospital Revenue Code	761
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$49.73
Rate for Payer: Qualcare PPO/HMO/WC	$49.73

INTRO CATH RETROG EXTR ARTERY

Facility

$331.55

Service Code	HCPCS 36140
Hospital Charge Code	404636140
Hospital Revenue Code	481
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$49.73
Rate for Payer: Qualcare PPO/HMO/WC	$49.73

INTRODCER 9F PLVN903824VAD5CVI

Facility

$301.40

Hospital Charge Code	270632179
Hospital Revenue Code	272
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$150.70
Rate for Payer: Aetna Commercial	$114.53
Rate for Payer: Aetna Medicare Advantage	$90.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$76.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$76.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$76.86
Rate for Payer: Cigna Commercial	$150.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.42
Rate for Payer: Oxford Commercial	$60.28
Rate for Payer: Qualcare PPO/HMO/WC	$45.21
Rate for Payer: UnitedHealthcare Commercial	$60.28
Rate for Payer: UnitedHealthcare Community & State	$7.26
Rate for Payer: Wellpoint Medicaid Managed Care	$7.99

INTRODCER 9F PLVN903824VAD5CVI

Facility

$301.40

Hospital Charge Code	270632179
Hospital Revenue Code	272
Min. Negotiated Rate	$45.21
Max. Negotiated Rate	$45.21
Rate for Payer: Qualcare PPO/HMO/WC	$45.21

INTRODCR ARROWFLEX 9x6 CL07965

Facility

$394.90

Hospital Charge Code	270634388
Hospital Revenue Code	272
Min. Negotiated Rate	$59.23
Max. Negotiated Rate	$59.23
Rate for Payer: Qualcare PPO/HMO/WC	$59.23

INTRODCR ARROWFLEX 9x6 CL07965

Facility

$394.90

Hospital Charge Code	270634388
Hospital Revenue Code	272
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$197.45
Rate for Payer: Aetna Commercial	$150.06
Rate for Payer: Aetna Medicare Advantage	$118.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$100.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$100.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$100.70
Rate for Payer: Cigna Commercial	$197.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$118.47
Rate for Payer: Oxford Commercial	$78.98
Rate for Payer: Qualcare PPO/HMO/WC	$59.23
Rate for Payer: UnitedHealthcare Commercial	$78.98
Rate for Payer: UnitedHealthcare Community & State	$9.52
Rate for Payer: Wellpoint Medicaid Managed Care	$10.46

INTRO DIALYSIS CIRCUIT

Facility

$2,873.16

Service Code	HCPCS 36901
Hospital Charge Code	16000484
Hospital Revenue Code	360
Min. Negotiated Rate	$430.97
Max. Negotiated Rate	$430.97
Rate for Payer: Qualcare PPO/HMO/WC	$430.97

INTRO DIALYSIS CIRCUIT

Facility

$2,873.16

Service Code	HCPCS 36901
Hospital Charge Code	16000484
Hospital Revenue Code	360
Min. Negotiated Rate	$69.24
Max. Negotiated Rate	$6,750.64
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,750.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,750.64
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,870.14
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$861.95
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$430.97
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$69.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$76.14

INTRODR 8F VLESS PLESS 504608V

Facility

$44.85

Hospital Charge Code	270619639
Hospital Revenue Code	278
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$10.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$9.87
Rate for Payer: Qualcare PPO/HMO/WC	$6.73

INTRODR 8F VLESS PLESS 504608V

Facility

$44.85

Hospital Charge Code	270619639
Hospital Revenue Code	278
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$22.43
Rate for Payer: Aetna Commercial	$17.04
Rate for Payer: Aetna Medicare Advantage	$13.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.44
Rate for Payer: Cigna Commercial	$22.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$9.87
Rate for Payer: Qualcare PPO/HMO/WC	$6.73
Rate for Payer: UnitedHealthcare Community & State	$1.08
Rate for Payer: Wellpoint Medicaid Managed Care	$1.19

INTROD RAABE 7FR 70CM G11635

Facility

$220.50

Service Code	HCPCS C1894
Hospital Charge Code	270636699C
Hospital Revenue Code	278
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$110.25
Rate for Payer: Aetna Commercial	$83.79
Rate for Payer: Aetna Medicare Advantage	$66.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$56.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$56.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$44.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$56.23
Rate for Payer: Cigna Commercial	$110.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$48.51
Rate for Payer: Qualcare PPO/HMO/WC	$33.08
Rate for Payer: UnitedHealthcare Community & State	$5.31
Rate for Payer: Wellpoint Medicaid Managed Care	$5.84

INTROD RAABE 7FR 70CM G11635

Facility

$220.50

Service Code	HCPCS C1894
Hospital Charge Code	270636699C
Hospital Revenue Code	278
Min. Negotiated Rate	$33.08
Max. Negotiated Rate	$53.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$44.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$48.51
Rate for Payer: Qualcare PPO/HMO/WC	$33.08

INTRODR BRT TIP 5F 11c 401511M

Facility

$178.45

Hospital Charge Code	270624372
Hospital Revenue Code	272
Min. Negotiated Rate	$26.77
Max. Negotiated Rate	$26.77
Rate for Payer: Qualcare PPO/HMO/WC	$26.77

INTRODR BRT TIP 5F 11c 401511M

Facility

$178.45

Hospital Charge Code	270624372
Hospital Revenue Code	272
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$89.22
Rate for Payer: Aetna Commercial	$67.81
Rate for Payer: Aetna Medicare Advantage	$53.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$45.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$45.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$45.50
Rate for Payer: Cigna Commercial	$89.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.53
Rate for Payer: Oxford Commercial	$35.69
Rate for Payer: Qualcare PPO/HMO/WC	$26.77
Rate for Payer: UnitedHealthcare Commercial	$35.69
Rate for Payer: UnitedHealthcare Community & State	$4.30
Rate for Payer: Wellpoint Medicaid Managed Care	$4.73

INTRODR GUIDE 8F 55c 4038553A

Facility

$620.00

Service Code	HCPCS C1887
Hospital Charge Code	270624374
Hospital Revenue Code	272
Min. Negotiated Rate	$93.00
Max. Negotiated Rate	$93.00
Rate for Payer: Qualcare PPO/HMO/WC	$93.00

Know your out-of-pocket cost for care.

All Charges