Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MYLOTARG 5MG VIAL

Facility

$12,661.00

Hospital Charge Code	60635573
Hospital Revenue Code	636
Min. Negotiated Rate	$1,899.15
Max. Negotiated Rate	$3,063.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,063.96
Rate for Payer: Qualcare PPO/HMO/WC	$1,899.15

MYLOTARG 5MG VIAL 20ML

Facility

$5,574.00

Hospital Charge Code	60635359
Hospital Revenue Code	636
Min. Negotiated Rate	$134.33
Max. Negotiated Rate	$2,787.00
Rate for Payer: Aetna Commercial	$2,118.12
Rate for Payer: Aetna Medicare Advantage	$1,672.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,421.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,421.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,421.37
Rate for Payer: Cigna Commercial	$2,787.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,348.91
Rate for Payer: Qualcare PPO/HMO/WC	$836.10
Rate for Payer: UnitedHealthcare Community & State	$134.33
Rate for Payer: Wellpoint Medicaid Managed Care	$147.71

MYLOTARG 5MG VIAL 20ML

Facility

$5,574.00

Hospital Charge Code	60635359
Hospital Revenue Code	636
Min. Negotiated Rate	$836.10
Max. Negotiated Rate	$1,348.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,348.91
Rate for Payer: Qualcare PPO/HMO/WC	$836.10

MYNGTM INCL ASP/EUSTACH INFLAT

Facility

$14,464.70

Service Code	HCPCS 69421
Hospital Charge Code	16001046
Hospital Revenue Code	360
Min. Negotiated Rate	$2,169.70
Max. Negotiated Rate	$2,169.70
Rate for Payer: Qualcare PPO/HMO/WC	$2,169.70

MYNGTM INCL ASP/EUSTACH INFLAT

Facility

$14,464.70

Service Code	HCPCS 69421
Hospital Charge Code	16001046
Hospital Revenue Code	360
Min. Negotiated Rate	$348.60
Max. Negotiated Rate	$14,218.07
Rate for Payer: Aetna Commercial	$10,713.67
Rate for Payer: Aetna Medicare Advantage	$12,761.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,218.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,218.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,938.85
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	$14,218.07
Rate for Payer: Cigna Commercial	$7,895.42
Rate for Payer: Cigna Medicare Advantage	$3,938.85
Rate for Payer: Clover Medicare Advantage	$3,741.91
Rate for Payer: EmblemHealth Commercial	$11,816.55
Rate for Payer: Humana Medicare Advantage	$4,057.02
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,938.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,339.41
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,169.70
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$348.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,938.85
Rate for Payer: Wellcare Medicare Advantage	$3,938.85
Rate for Payer: Wellpoint Medicaid Managed Care	$383.31

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,185.00

Service Code	HCPCS C1760
Hospital Charge Code	270662371S
Hospital Revenue Code	278
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$592.50
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare Advantage	$355.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$302.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$302.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$237.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$302.18
Rate for Payer: Cigna Commercial	$592.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$286.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$260.70
Rate for Payer: Qualcare PPO/HMO/WC	$177.75
Rate for Payer: UnitedHealthcare Community & State	$28.56
Rate for Payer: Wellpoint Medicaid Managed Care	$31.40

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,416.25

Service Code	HCPCS C1760
Hospital Charge Code	270662371N
Hospital Revenue Code	278
Min. Negotiated Rate	$34.13
Max. Negotiated Rate	$708.12
Rate for Payer: Aetna Commercial	$538.17
Rate for Payer: Aetna Medicare Advantage	$424.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$361.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$361.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$283.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$361.14
Rate for Payer: Cigna Commercial	$708.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$342.73
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$311.57
Rate for Payer: Qualcare PPO/HMO/WC	$212.44
Rate for Payer: UnitedHealthcare Community & State	$34.13
Rate for Payer: Wellpoint Medicaid Managed Care	$37.53

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,185.00

Service Code	HCPCS C1760
Hospital Charge Code	270662371
Hospital Revenue Code	278
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$592.50
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare Advantage	$355.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$302.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$302.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$237.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$302.18
Rate for Payer: Cigna Commercial	$592.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$286.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$260.70
Rate for Payer: Qualcare PPO/HMO/WC	$177.75
Rate for Payer: UnitedHealthcare Community & State	$28.56
Rate for Payer: Wellpoint Medicaid Managed Care	$31.40

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,416.25

Service Code	HCPCS C1760
Hospital Charge Code	270662371N
Hospital Revenue Code	278
Min. Negotiated Rate	$212.44
Max. Negotiated Rate	$342.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$283.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$342.73
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$311.57
Rate for Payer: Qualcare PPO/HMO/WC	$212.44

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,185.00

Service Code	HCPCS C1760
Hospital Charge Code	270662371
Hospital Revenue Code	278
Min. Negotiated Rate	$177.75
Max. Negotiated Rate	$286.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$237.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$286.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$260.70
Rate for Payer: Qualcare PPO/HMO/WC	$177.75

MYNX GRIP VASCULAR CL DEV 5F

Facility

$1,185.00

Service Code	HCPCS C1760
Hospital Charge Code	270662371S
Hospital Revenue Code	278
Min. Negotiated Rate	$177.75
Max. Negotiated Rate	$286.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$237.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$286.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$260.70
Rate for Payer: Qualcare PPO/HMO/WC	$177.75

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74116003
Hospital Revenue Code	341
Min. Negotiated Rate	$478.35
Max. Negotiated Rate	$478.35
Rate for Payer: Qualcare PPO/HMO/WC	$478.35

MYOCARDIAL PERF RESTING

Facility

$6,289.55

Service Code	HCPCS 78453
Hospital Charge Code	94053010
Hospital Revenue Code	341
Min. Negotiated Rate	$943.43
Max. Negotiated Rate	$943.43
Rate for Payer: Qualcare PPO/HMO/WC	$943.43

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74117003
Hospital Revenue Code	341
Min. Negotiated Rate	$76.85
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$139.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$956.70
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$478.35
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$76.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$84.51

MYOCARDIAL PERF RESTING

Facility

$6,289.55

Service Code	HCPCS 78453
Hospital Charge Code	94053010
Hospital Revenue Code	341
Min. Negotiated Rate	$139.39
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$139.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,886.87
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$943.43
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$151.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$166.67

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74117003
Hospital Revenue Code	341
Min. Negotiated Rate	$478.35
Max. Negotiated Rate	$478.35
Rate for Payer: Qualcare PPO/HMO/WC	$478.35

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74115003
Hospital Revenue Code	341
Min. Negotiated Rate	$478.35
Max. Negotiated Rate	$478.35
Rate for Payer: Qualcare PPO/HMO/WC	$478.35

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74115003
Hospital Revenue Code	341
Min. Negotiated Rate	$76.85
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$139.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$956.70
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$478.35
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$76.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$84.51

MYOCARDIAL PERF RESTING

Facility

$3,189.00

Service Code	HCPCS 78453
Hospital Charge Code	74116003
Hospital Revenue Code	341
Min. Negotiated Rate	$76.85
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$139.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$956.70
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$478.35
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$76.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$84.51

MYOCARDIAL PERF SPECT

Facility

$4,418.87

Service Code	HCPCS 78454
Hospital Charge Code	74117004
Hospital Revenue Code	341
Min. Negotiated Rate	$106.49
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$232.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,325.66
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$662.83
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$106.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$117.10

MYOCARDIAL PERF SPECT

Facility

$4,418.87

Service Code	HCPCS 78454
Hospital Charge Code	74115004
Hospital Revenue Code	341
Min. Negotiated Rate	$106.49
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$232.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,325.66
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$662.83
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$106.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$117.10

MYOCARDIAL PERF SPECT

Facility

$2,643.25

Service Code	HCPCS 78454
Hospital Charge Code	94053015
Hospital Revenue Code	341
Min. Negotiated Rate	$396.49
Max. Negotiated Rate	$396.49
Rate for Payer: Qualcare PPO/HMO/WC	$396.49

MYOCARDIAL PERF SPECT

Facility

$4,418.87

Service Code	HCPCS 78454
Hospital Charge Code	74116004
Hospital Revenue Code	341
Min. Negotiated Rate	$106.49
Max. Negotiated Rate	$5,552.01
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,552.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$232.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,552.01
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,325.66
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$662.83
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$106.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$117.10

MYOCARDIAL PERF SPECT

Facility

$4,418.87

Service Code	HCPCS 78454
Hospital Charge Code	74116004
Hospital Revenue Code	341
Min. Negotiated Rate	$662.83
Max. Negotiated Rate	$662.83
Rate for Payer: Qualcare PPO/HMO/WC	$662.83

MYOCARDIAL PERF SPECT

Facility

$4,418.87

Service Code	HCPCS 78454
Hospital Charge Code	74115004
Hospital Revenue Code	341
Min. Negotiated Rate	$662.83
Max. Negotiated Rate	$662.83
Rate for Payer: Qualcare PPO/HMO/WC	$662.83

Know your out-of-pocket cost for care.

All Charges