Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

IR CATH IN ART INIT 3RD RIGHT

Facility

IP

$484.00

Service Code	HCPCS 36247RT
Hospital Charge Code	2101173
Hospital Revenue Code	361
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$72.60
Rate for Payer: Qualcare PPO/HMO/WC	$72.60

IR CATH PLCMNT RENAL ARTRY BIL

Facility

IP

$15,468.50

Service Code	HCPCS 36254
Hospital Charge Code	2670105
Hospital Revenue Code	361
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

IR CATH PLCMNT RENAL ARTRY BIL

Facility

OP

$15,468.50

Service Code	HCPCS 36254
Hospital Charge Code	2670105
Hospital Revenue Code	361
Min. Negotiated Rate	$372.79
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,640.55
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$372.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$409.92

IR CATH PLCMNT RENAL ARTRY BIL

Facility

IP

$12,462.85

Service Code	HCPCS 36254
Hospital Charge Code	411036254
Hospital Revenue Code	361
Min. Negotiated Rate	$1,869.43
Max. Negotiated Rate	$1,869.43
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43

IR CATH PLCMNT RENAL ARTRY BIL

Facility

IP

$12,400.74

Service Code	HCPCS 36254
Hospital Charge Code	7411435
Hospital Revenue Code	361
Min. Negotiated Rate	$1,860.11
Max. Negotiated Rate	$1,860.11
Rate for Payer: Qualcare PPO/HMO/WC	$1,860.11

IR CATH PLCMNT RENAL ARTRY BIL

Facility

OP

$12,462.85

Service Code	HCPCS 36254
Hospital Charge Code	366836254
Hospital Revenue Code	361
Min. Negotiated Rate	$300.35
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,738.86
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$300.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$330.27

IR CATH PLCMNT RENAL ARTRY BIL

Facility

IP

$15,468.50

Service Code	HCPCS 36254
Hospital Charge Code	321036254
Hospital Revenue Code	361
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

IR CATH PLCMNT RENAL ARTRY BIL

Facility

IP

$12,462.85

Service Code	HCPCS 36254
Hospital Charge Code	366836254
Hospital Revenue Code	361
Min. Negotiated Rate	$1,869.43
Max. Negotiated Rate	$1,869.43
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43

IR CATH PLCMNT RENAL ARTRY BIL

Facility

OP

$12,462.85

Service Code	HCPCS 36254
Hospital Charge Code	411036254
Hospital Revenue Code	361
Min. Negotiated Rate	$300.35
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,738.86
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$300.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$330.27

IR CATH PLCMNT RENAL ARTRY BIL

Facility

OP

$15,468.50

Service Code	HCPCS 36254
Hospital Charge Code	321036254
Hospital Revenue Code	361
Min. Negotiated Rate	$372.79
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,640.55
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$372.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$409.92

IR CATH PLCMNT RENAL ARTRY BIL

Facility

OP

$12,400.74

Service Code	HCPCS 36254
Hospital Charge Code	7411435
Hospital Revenue Code	361
Min. Negotiated Rate	$298.86
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,720.22
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,860.11
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$298.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$328.62

IR-CECO/COLONIC TUBE

Facility

OP

$5,489.85

Service Code	HCPCS 49442
Hospital Charge Code	366849442
Hospital Revenue Code	361
Min. Negotiated Rate	$132.31
Max. Negotiated Rate	$5,311.00
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	$1,626.00
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	$1,646.95
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$823.48
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$132.31
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	$145.48

IR-CECO/COLONIC TUBE

Facility

OP

$5,489.85

Service Code	HCPCS 49442
Hospital Charge Code	7411595
Hospital Revenue Code	361
Min. Negotiated Rate	$132.31
Max. Negotiated Rate	$5,311.00
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	$1,626.00
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	$1,646.95
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$823.48
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$132.31
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	$145.48

IR-CECO/COLONIC TUBE

Facility

IP

$5,489.85

Service Code	HCPCS 49442
Hospital Charge Code	366849442
Hospital Revenue Code	361
Min. Negotiated Rate	$823.48
Max. Negotiated Rate	$823.48
Rate for Payer: Qualcare PPO/HMO/WC	$823.48

IR-CECO/COLONIC TUBE

Facility

IP

$4,185.00

Service Code	HCPCS 49442
Hospital Charge Code	2690155
Hospital Revenue Code	361
Min. Negotiated Rate	$627.75
Max. Negotiated Rate	$627.75
Rate for Payer: Qualcare PPO/HMO/WC	$627.75

IR-CECO/COLONIC TUBE

Facility

IP

$5,489.85

Service Code	HCPCS 49442
Hospital Charge Code	7411595
Hospital Revenue Code	361
Min. Negotiated Rate	$823.48
Max. Negotiated Rate	$823.48
Rate for Payer: Qualcare PPO/HMO/WC	$823.48

IR-CECO/COLONIC TUBE

Facility

OP

$4,185.00

Service Code	HCPCS 49442
Hospital Charge Code	2690155
Hospital Revenue Code	361
Min. Negotiated Rate	$100.86
Max. Negotiated Rate	$5,311.00
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	$1,626.00
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	$1,255.50
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$627.75
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$100.86
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	$110.90

IR-CERV PUNCT FOR MYELOGRAM

Facility

IP

$3,107.20

Service Code	HCPCS 61055
Hospital Charge Code	7411641
Hospital Revenue Code	361
Min. Negotiated Rate	$466.08
Max. Negotiated Rate	$466.08
Rate for Payer: Qualcare PPO/HMO/WC	$466.08

IR-CERV PUNCT FOR MYELOGRAM

Facility

IP

$3,107.20

Service Code	HCPCS 61055
Hospital Charge Code	2680235
Hospital Revenue Code	361
Min. Negotiated Rate	$466.08
Max. Negotiated Rate	$466.08
Rate for Payer: Qualcare PPO/HMO/WC	$466.08

IR-CERV PUNCT FOR MYELOGRAM

Facility

OP

$3,107.20

Service Code	HCPCS 61055
Hospital Charge Code	7411641
Hospital Revenue Code	361
Min. Negotiated Rate	$74.88
Max. Negotiated Rate	$2,220.00
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	$862.00
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	$932.16
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$466.08
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$74.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$364.67
Rate for Payer: Wellcare Medicare Advantage	$364.67
Rate for Payer: Wellpoint Medicaid Managed Care	$82.34

IR-CERV PUNCT FOR MYELOGRAM

Facility

OP

$3,107.20

Service Code	HCPCS 61055
Hospital Charge Code	2680235
Hospital Revenue Code	361
Min. Negotiated Rate	$74.88
Max. Negotiated Rate	$2,220.00
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	$862.00
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	$932.16
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$466.08
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$74.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$364.67
Rate for Payer: Wellcare Medicare Advantage	$364.67
Rate for Payer: Wellpoint Medicaid Managed Care	$82.34

IR CHANGE GASTROSTOMY TUBE

Facility

IP

$776.45

Service Code	HCPCS 43760
Hospital Charge Code	7411547
Hospital Revenue Code	361
Min. Negotiated Rate	$116.47
Max. Negotiated Rate	$116.47
Rate for Payer: Qualcare PPO/HMO/WC	$116.47

IR CHANGE GASTROSTOMY TUBE

Facility

OP

$1,147.55

Service Code	HCPCS 43760
Hospital Charge Code	411043760
Hospital Revenue Code	361
Min. Negotiated Rate	$27.66
Max. Negotiated Rate	$862.00
Rate for Payer: Aetna Commercial	$436.07
Rate for Payer: Aetna Medicare Advantage	$344.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$292.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$292.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$292.63
Rate for Payer: Cigna Commercial	$573.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$344.26
Rate for Payer: Qualcare PPO/HMO/WC	$172.13
Rate for Payer: UnitedHealthcare Community & State	$27.66
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$781.67
Rate for Payer: Wellpoint Medicaid Managed Care	$766.34

IR CHANGE GASTROSTOMY TUBE

Facility

IP

$776.45

Service Code	HCPCS 43760
Hospital Charge Code	2101175
Hospital Revenue Code	361
Min. Negotiated Rate	$116.47
Max. Negotiated Rate	$116.47
Rate for Payer: Qualcare PPO/HMO/WC	$116.47

IR CHANGE GASTROSTOMY TUBE

Facility

IP

$1,147.55

Service Code	HCPCS 43760
Hospital Charge Code	411043760
Hospital Revenue Code	361
Min. Negotiated Rate	$172.13
Max. Negotiated Rate	$172.13
Rate for Payer: Qualcare PPO/HMO/WC	$172.13