Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MRI - OPEN SENT OUTSIDE

Facility

$9,109.53

Service Code	HCPCS 70551
Hospital Charge Code	2400415
Hospital Revenue Code	611
Min. Negotiated Rate	$219.54
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$638.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,732.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$629.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,366.43
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$219.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$241.40

MRI ORBIT

Facility

$13,500.00

Service Code	HCPCS 70540
Hospital Charge Code	94061023
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI ORBIT

Facility

$13,500.00

Service Code	HCPCS 70540
Hospital Charge Code	94061023
Hospital Revenue Code	614
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$580.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$618.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI ORBIT FACE AND NECK W/O

Facility

$13,500.00

Service Code	HCPCS 70540
Hospital Charge Code	2400059
Hospital Revenue Code	614
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$580.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$618.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI ORBIT FACE AND NECK W/O

Facility

$13,500.00

Service Code	HCPCS 70540
Hospital Charge Code	2400059
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI ORBIT W/ CONTRAST

Facility

$5,866.80

Service Code	HCPCS 70542
Hospital Charge Code	2400604
Hospital Revenue Code	614
Min. Negotiated Rate	$880.02
Max. Negotiated Rate	$880.02
Rate for Payer: Qualcare PPO/HMO/WC	$880.02

MRI ORBIT W/ CONTRAST

Facility

$5,866.80

Service Code	HCPCS 70542
Hospital Charge Code	2400604
Hospital Revenue Code	614
Min. Negotiated Rate	$141.39
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$660.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,760.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$678.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$880.02
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$141.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$155.47

MRI ORBIT W/O CONTRAST

Facility

$5,866.80

Service Code	HCPCS 70540
Hospital Charge Code	2400605
Hospital Revenue Code	614
Min. Negotiated Rate	$141.39
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$580.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,760.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$618.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$880.02
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$141.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$155.47

MRI ORBIT W/O CONTRAST

Facility

$5,866.80

Service Code	HCPCS 70540
Hospital Charge Code	2400605
Hospital Revenue Code	614
Min. Negotiated Rate	$880.02
Max. Negotiated Rate	$880.02
Rate for Payer: Qualcare PPO/HMO/WC	$880.02

MRI ORBIT W/ & W/O CONTRAST

Facility

$13,500.00

Service Code	HCPCS 70543
Hospital Charge Code	2400603
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$947.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$917.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI ORBIT W/ & W/O CONTRAST

Facility

$13,500.00

Service Code	HCPCS 70543
Hospital Charge Code	2400603
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI - PELVIS

Facility

$13,500.00

Service Code	HCPCS 72195
Hospital Charge Code	94061093
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI - PELVIS

Facility

$13,500.00

Service Code	HCPCS 72195
Hospital Charge Code	94061093
Hospital Revenue Code	614
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$532.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI PELVIS W/ CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72196
Hospital Charge Code	2400224
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI PELVIS W/ CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72196
Hospital Charge Code	2400224
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$580.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI PELVIS W/WO CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72197
Hospital Charge Code	94061095
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$949.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,543.21
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI PELVIS W/WO CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72197
Hospital Charge Code	94061095
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI PULSE OXIMETRY-MULTI DETER

Facility

$312.85

Service Code	HCPCS 94761
Hospital Charge Code	2400414
Hospital Revenue Code	460
Min. Negotiated Rate	$46.93
Max. Negotiated Rate	$46.93
Rate for Payer: Qualcare PPO/HMO/WC	$46.93

MRI PULSE OXIMETRY-MULTI DETER

Facility

$312.85

Service Code	HCPCS 94761
Hospital Charge Code	2400414
Hospital Revenue Code	460
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$118.88
Rate for Payer: Aetna Medicare Advantage	$93.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$54.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.78
Rate for Payer: Cigna Commercial	$156.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$93.86
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$46.93
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$7.54
Rate for Payer: Wellpoint Medicaid Managed Care	$8.29

MRI PULSE OXIMETRY-SING.DETER

Facility

$158.45

Service Code	HCPCS 94760
Hospital Charge Code	2400406
Hospital Revenue Code	460
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$60.21
Rate for Payer: Aetna Medicare Advantage	$47.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$40.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$40.40
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	$40.40
Rate for Payer: Cigna Commercial	$79.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$47.53
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.77
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$3.82
Rate for Payer: Wellpoint Medicaid Managed Care	$4.20

MRI PULSE OXIMETRY-SING.DETER

Facility

$158.45

Service Code	HCPCS 94760
Hospital Charge Code	2400406
Hospital Revenue Code	460
Min. Negotiated Rate	$23.77
Max. Negotiated Rate	$23.77
Rate for Payer: Qualcare PPO/HMO/WC	$23.77

MRI SHLDER W/&W/O CNTRST BILTL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400514
Hospital Revenue Code	614
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$4,491.60
Rate for Payer: Aetna Medicare Advantage	$3,546.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,014.10
Rate for Payer: Cigna Commercial	$5,910.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,546.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$284.86
Rate for Payer: Wellpoint Medicaid Managed Care	$313.23

MRI SHLDER W/&W/O CNTRST BILTL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400514
Hospital Revenue Code	614
Min. Negotiated Rate	$1,773.00
Max. Negotiated Rate	$1,773.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00

MRI SHLDER W/&W/O CONTRST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223LT
Hospital Charge Code	2400515
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI SHLDER W/&W/O CONTRST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223LT
Hospital Charge Code	2400515
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

Know your out-of-pocket cost for care.

All Charges