Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

NM LYMPHATIC UNLISTED PROCEDUR

Facility

$1,388.55

Service Code	HCPCS 78199
Hospital Charge Code	4500969
Hospital Revenue Code	341
Min. Negotiated Rate	$208.28
Max. Negotiated Rate	$208.28
Rate for Payer: Qualcare PPO/HMO/WC	$208.28

NM LYMPHATIC UNLISTED PROCEDUR

Facility

$1,388.55

Service Code	HCPCS 78199
Hospital Charge Code	4500969
Hospital Revenue Code	341
Min. Negotiated Rate	$33.46
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$416.56
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$208.28
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$33.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$36.80

NM MECKLES BOWEL IMAGING

Facility

$12,000.00

Service Code	HCPCS 78290
Hospital Charge Code	4500385
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM MECKLES BOWEL IMAGING

Facility

$12,000.00

Service Code	HCPCS 78290
Hospital Charge Code	4500385
Hospital Revenue Code	341
Min. Negotiated Rate	$138.81
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$138.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$318.00

NM METASTRON PER MCI

Facility

$15,184.00

Hospital Charge Code	4509040
Hospital Revenue Code	344
Min. Negotiated Rate	$2,277.60
Max. Negotiated Rate	$2,277.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,277.60

NM METASTRON PER MCI

Facility

$15,184.00

Hospital Charge Code	4509040
Hospital Revenue Code	344
Min. Negotiated Rate	$365.93
Max. Negotiated Rate	$7,592.00
Rate for Payer: Aetna Commercial	$5,769.92
Rate for Payer: Aetna Medicare Advantage	$4,555.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,871.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,871.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,871.92
Rate for Payer: Cigna Commercial	$7,592.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,555.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,277.60
Rate for Payer: UnitedHealthcare Community & State	$365.93
Rate for Payer: Wellpoint Medicaid Managed Care	$402.38

NM MISC DIAGNOSTIC PROCEDURE

Facility

$506.20

Service Code	HCPCS 78999
Hospital Charge Code	4500970
Hospital Revenue Code	341
Min. Negotiated Rate	$75.93
Max. Negotiated Rate	$75.93
Rate for Payer: Qualcare PPO/HMO/WC	$75.93

NM MISC DIAGNOSTIC PROCEDURE

Facility

$506.20

Service Code	HCPCS 78999
Hospital Charge Code	4500970
Hospital Revenue Code	341
Min. Negotiated Rate	$12.20
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.86
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.93
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$12.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$13.41

NM MODERATE SEDATION

Facility

$1,937.60

Service Code	HCPCS 99144
Hospital Charge Code	4508035
Hospital Revenue Code	370
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$290.64
Rate for Payer: Qualcare PPO/HMO/WC	$290.64

NM MODERATE SEDATION

Facility

$1,937.60

Service Code	HCPCS 99144
Hospital Charge Code	4508035
Hospital Revenue Code	370
Min. Negotiated Rate	$46.70
Max. Negotiated Rate	$968.80
Rate for Payer: Aetna Commercial	$736.29
Rate for Payer: Aetna Medicare Advantage	$581.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$494.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$494.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$494.09
Rate for Payer: Cigna Commercial	$968.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$581.28
Rate for Payer: Oxford Commercial	$387.52
Rate for Payer: Qualcare PPO/HMO/WC	$290.64
Rate for Payer: UnitedHealthcare Commercial	$387.52
Rate for Payer: UnitedHealthcare Community & State	$46.70
Rate for Payer: Wellpoint Medicaid Managed Care	$51.35

NM MUGA (MULTIGATED SCAN)

Facility

$12,000.00

Service Code	HCPCS 78472
Hospital Charge Code	4500393
Hospital Revenue Code	341
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$193.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$318.00

NM MUGA (MULTIGATED SCAN)

Facility

$12,000.00

Service Code	HCPCS 78472
Hospital Charge Code	4500393
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM MUGA MULTI REST STRESS WO

Facility

$3,975.25

Service Code	HCPCS 78473
Hospital Charge Code	4500922
Hospital Revenue Code	341
Min. Negotiated Rate	$596.29
Max. Negotiated Rate	$596.29
Rate for Payer: Qualcare PPO/HMO/WC	$596.29

NM MUGA MULTI REST STRESS WO

Facility

$3,975.25

Service Code	HCPCS 78473
Hospital Charge Code	4500922
Hospital Revenue Code	341
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$251.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,192.58
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$596.29
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$95.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$105.34

NM MUSCULOSKELETAL OTHER

Facility

$1,415.50

Service Code	HCPCS 78399
Hospital Charge Code	4500971
Hospital Revenue Code	341
Min. Negotiated Rate	$34.11
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$424.65
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$212.32
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$34.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$37.51

NM MUSCULOSKELETAL OTHER

Facility

$1,415.50

Service Code	HCPCS 78399
Hospital Charge Code	4500971
Hospital Revenue Code	341
Min. Negotiated Rate	$212.32
Max. Negotiated Rate	$212.32
Rate for Payer: Qualcare PPO/HMO/WC	$212.32

NM MYOCARDIAL HOT SPOT

Facility

$869.65

Service Code	HCPCS 78466
Hospital Charge Code	4500344
Hospital Revenue Code	341
Min. Negotiated Rate	$130.45
Max. Negotiated Rate	$130.45
Rate for Payer: Qualcare PPO/HMO/WC	$130.45

NM MYOCARDIAL HOT SPOT

Facility

$869.65

Service Code	HCPCS 78466
Hospital Charge Code	4500344
Hospital Revenue Code	341
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,714.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
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	$1,714.39
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$260.89
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$130.45
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$23.05

NM MYOCARDIAL PERF W EJEC FRA

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500872
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM MYOCARDIAL PERF W EJEC FRA

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500872
Hospital Revenue Code	341
Min. Negotiated Rate	$289.20
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	$325.25
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	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
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	$318.00

NM MYOCARDIAL PERF W WALL MOTI

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500880
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM MYOCARDIAL PERF W WALL MOTI

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500880
Hospital Revenue Code	341
Min. Negotiated Rate	$289.20
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	$325.25
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	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
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	$318.00

NM MYOCARDIAL PLANAR REST OR E

Facility

$12,000.00

Service Code	HCPCS 78454
Hospital Charge Code	4500526
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM MYOCARDIAL PLANAR REST OR E

Facility

$12,000.00

Service Code	HCPCS 78454
Hospital Charge Code	4500526
Hospital Revenue Code	341
Min. Negotiated Rate	$232.32
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	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
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	$318.00

NM MYOCARDIAL PLANAR STREE &

Facility

$12,000.00

Service Code	HCPCS 78454
Hospital Charge Code	4500351
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

Know your out-of-pocket cost for care.

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