Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

OPIOIDS & OPIATE ANALOGS 3/4

Facility

$190.45

Service Code	HCPCS 80363
Hospital Charge Code	39990232
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

OPIOIDS & OPIATE ANALOGS 3/4

Facility

$190.45

Service Code	HCPCS 80363
Hospital Charge Code	3039032
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

OPIOIDS & OPIATE ANALOGS 3/4

Facility

$190.45

Service Code	HCPCS 80363
Hospital Charge Code	39990232
Hospital Revenue Code	301
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$72.37
Rate for Payer: Aetna Medicare Advantage	$57.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.56
Rate for Payer: Cigna Commercial	$95.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$22.05
Rate for Payer: Wellpoint Medicaid Managed Care	$5.05

OPIUM (DEODORIZED) 10%/11

Facility

$233.00

Hospital Charge Code	60633578
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$116.50
Rate for Payer: Aetna Commercial	$88.54
Rate for Payer: Aetna Medicare Advantage	$69.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$59.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$59.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$59.41
Rate for Payer: Cigna Commercial	$116.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$69.90
Rate for Payer: Oxford Commercial	$46.60
Rate for Payer: Qualcare PPO/HMO/WC	$34.95
Rate for Payer: UnitedHealthcare Commercial	$46.60
Rate for Payer: UnitedHealthcare Community & State	$5.62
Rate for Payer: Wellpoint Medicaid Managed Care	$6.17

OPIUM (DEODORIZED) 10%/11

Facility

$233.00

Hospital Charge Code	60633578
Hospital Revenue Code	250
Min. Negotiated Rate	$34.95
Max. Negotiated Rate	$34.95
Rate for Payer: Qualcare PPO/HMO/WC	$34.95

OPIUM TINC DEOD LIQ 100MG/ML

Facility

$320.00

Hospital Charge Code	6004022
Hospital Revenue Code	251
Min. Negotiated Rate	$7.71
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$121.60
Rate for Payer: Aetna Medicare Advantage	$96.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$81.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$81.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$81.60
Rate for Payer: Cigna Commercial	$160.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.00
Rate for Payer: Oxford Commercial	$64.00
Rate for Payer: Qualcare PPO/HMO/WC	$48.00
Rate for Payer: UnitedHealthcare Commercial	$64.00
Rate for Payer: UnitedHealthcare Community & State	$7.71
Rate for Payer: Wellpoint Medicaid Managed Care	$8.48

OPIUM TINC DEOD LIQ 100MG/ML

Facility

$320.00

Hospital Charge Code	6004022
Hospital Revenue Code	251
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$48.00
Rate for Payer: Qualcare PPO/HMO/WC	$48.00

OPN BX/EXC LN,AXILLARY NODE

Facility

$24,074.90

Service Code	HCPCS 38525
Hospital Charge Code	16000206
Hospital Revenue Code	360
Min. Negotiated Rate	$3,611.24
Max. Negotiated Rate	$3,611.24
Rate for Payer: Qualcare PPO/HMO/WC	$3,611.24

OPN BX/EXC LN,AXILLARY NODE

Facility

$24,074.90

Service Code	HCPCS 38525
Hospital Charge Code	16000206
Hospital Revenue Code	360
Min. Negotiated Rate	$580.21
Max. Negotiated Rate	$16,791.02
Rate for Payer: Aetna Commercial	$12,652.46
Rate for Payer: Aetna Medicare Advantage	$15,071.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,651.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,791.02
Rate for Payer: Cigna Commercial	$9,324.19
Rate for Payer: Cigna Medicare Advantage	$4,651.64
Rate for Payer: Clover Medicare Advantage	$4,419.06
Rate for Payer: EmblemHealth Commercial	$13,954.92
Rate for Payer: Humana Medicare Advantage	$4,791.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,651.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,222.47
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,611.24
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$580.21
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,651.64
Rate for Payer: Wellcare Medicare Advantage	$4,651.64
Rate for Payer: Wellpoint Medicaid Managed Care	$637.98

OPN BX/EXC LN,DEEPCERV NODE(S)

Facility

$24,074.90

Service Code	HCPCS 38510
Hospital Charge Code	16000297
Hospital Revenue Code	360
Min. Negotiated Rate	$3,611.24
Max. Negotiated Rate	$3,611.24
Rate for Payer: Qualcare PPO/HMO/WC	$3,611.24

OPN BX/EXC LN,DEEPCERV NODE(S)

Facility

$24,074.90

Service Code	HCPCS 38510
Hospital Charge Code	16000297
Hospital Revenue Code	360
Min. Negotiated Rate	$580.21
Max. Negotiated Rate	$16,791.02
Rate for Payer: Aetna Commercial	$12,652.46
Rate for Payer: Aetna Medicare Advantage	$15,071.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,651.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,791.02
Rate for Payer: Cigna Commercial	$9,324.19
Rate for Payer: Cigna Medicare Advantage	$4,651.64
Rate for Payer: Clover Medicare Advantage	$4,419.06
Rate for Payer: EmblemHealth Commercial	$13,954.92
Rate for Payer: Humana Medicare Advantage	$4,791.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,651.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,222.47
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,611.24
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$580.21
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,651.64
Rate for Payer: Wellcare Medicare Advantage	$4,651.64
Rate for Payer: Wellpoint Medicaid Managed Care	$637.98

OPN RDL SHFT FX CLSD R/U JT

Facility

$48,992.10

Service Code	HCPCS 25525
Hospital Charge Code	16000691
Hospital Revenue Code	360
Min. Negotiated Rate	$7,348.81
Max. Negotiated Rate	$7,348.81
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81

OPN RDL SHFT FX CLSD R/U JT

Facility

$48,992.10

Service Code	HCPCS 25525
Hospital Charge Code	16000691
Hospital Revenue Code	360
Min. Negotiated Rate	$1,180.71
Max. Negotiated Rate	$31,117.67
Rate for Payer: Aetna Commercial	$23,447.95
Rate for Payer: Aetna Medicare Advantage	$27,930.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8,620.57
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	$31,117.67
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: Cigna Medicare Advantage	$8,620.57
Rate for Payer: Clover Medicare Advantage	$8,189.54
Rate for Payer: EmblemHealth Commercial	$25,861.71
Rate for Payer: Humana Medicare Advantage	$8,879.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8,620.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14,697.63
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$1,180.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$8,620.57
Rate for Payer: Wellcare Medicare Advantage	$8,620.57
Rate for Payer: Wellpoint Medicaid Managed Care	$1,298.29

OPN TX ACUTE SHOULDER DISLOCAT

Facility

$48,992.10

Service Code	HCPCS 23660
Hospital Charge Code	16000818
Hospital Revenue Code	360
Min. Negotiated Rate	$7,348.81
Max. Negotiated Rate	$7,348.81
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81

OPN TX ACUTE SHOULDER DISLOCAT

Facility

$48,992.10

Service Code	HCPCS 23660
Hospital Charge Code	16000818
Hospital Revenue Code	360
Min. Negotiated Rate	$1,180.71
Max. Negotiated Rate	$31,117.67
Rate for Payer: Aetna Commercial	$23,447.95
Rate for Payer: Aetna Medicare Advantage	$27,930.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8,620.57
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	$31,117.67
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: Cigna Medicare Advantage	$8,620.57
Rate for Payer: Clover Medicare Advantage	$8,189.54
Rate for Payer: EmblemHealth Commercial	$25,861.71
Rate for Payer: Humana Medicare Advantage	$8,879.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8,620.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14,697.63
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$1,180.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$8,620.57
Rate for Payer: Wellcare Medicare Advantage	$8,620.57
Rate for Payer: Wellpoint Medicaid Managed Care	$1,298.29

OPN TX ARTCL FRACT MCP/IP JNT

Facility

$23,899.60

Service Code	HCPCS 26746
Hospital Charge Code	16000424
Hospital Revenue Code	360
Min. Negotiated Rate	$3,584.94
Max. Negotiated Rate	$3,584.94
Rate for Payer: Qualcare PPO/HMO/WC	$3,584.94

OPN TX ARTCL FRACT MCP/IP JNT

Facility

$23,899.60

Service Code	HCPCS 26746
Hospital Charge Code	16000424
Hospital Revenue Code	360
Min. Negotiated Rate	$575.98
Max. Negotiated Rate	$14,031.70
Rate for Payer: Aetna Commercial	$10,573.24
Rate for Payer: Aetna Medicare Advantage	$12,594.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,887.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,742.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14,031.70
Rate for Payer: Cigna Commercial	$7,791.93
Rate for Payer: Cigna Medicare Advantage	$3,887.22
Rate for Payer: Clover Medicare Advantage	$3,692.86
Rate for Payer: EmblemHealth Commercial	$11,661.66
Rate for Payer: Humana Medicare Advantage	$4,003.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,887.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,169.88
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,584.94
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$575.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,887.22
Rate for Payer: Wellcare Medicare Advantage	$3,887.22
Rate for Payer: Wellpoint Medicaid Managed Care	$633.34

OPN TX BIMALLEOLAR ANKLE FRACT

Facility

$48,992.10

Service Code	HCPCS 27814
Hospital Charge Code	16000305
Hospital Revenue Code	360
Min. Negotiated Rate	$7,348.81
Max. Negotiated Rate	$7,348.81
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81

OPN TX BIMALLEOLAR ANKLE FRACT

Facility

$48,992.10

Service Code	HCPCS 27814
Hospital Charge Code	16000305
Hospital Revenue Code	360
Min. Negotiated Rate	$1,180.71
Max. Negotiated Rate	$31,117.67
Rate for Payer: Aetna Commercial	$23,447.95
Rate for Payer: Aetna Medicare Advantage	$27,930.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8,620.57
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	$31,117.67
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: Cigna Medicare Advantage	$8,620.57
Rate for Payer: Clover Medicare Advantage	$8,189.54
Rate for Payer: EmblemHealth Commercial	$25,861.71
Rate for Payer: Humana Medicare Advantage	$8,879.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8,620.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14,697.63
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$1,180.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$8,620.57
Rate for Payer: Wellcare Medicare Advantage	$8,620.57
Rate for Payer: Wellpoint Medicaid Managed Care	$1,298.29

OPN TX CRPL BN FRACT O/T SCPD

Facility

$22,174.50

Service Code	HCPCS 25645
Hospital Charge Code	16000619
Hospital Revenue Code	360
Min. Negotiated Rate	$534.41
Max. Negotiated Rate	$14,834.00
Rate for Payer: Aetna Commercial	$10,573.24
Rate for Payer: Aetna Medicare Advantage	$12,594.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,887.22
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	$14,031.70
Rate for Payer: Cigna Commercial	$7,791.93
Rate for Payer: Cigna Medicare Advantage	$3,887.22
Rate for Payer: Clover Medicare Advantage	$3,692.86
Rate for Payer: EmblemHealth Commercial	$11,661.66
Rate for Payer: Humana Medicare Advantage	$4,003.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,887.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,652.35
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,326.18
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$534.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,887.22
Rate for Payer: Wellcare Medicare Advantage	$3,887.22
Rate for Payer: Wellpoint Medicaid Managed Care	$587.62

OPN TX CRPL BN FRACT O/T SCPD

Facility

$22,174.50

Service Code	HCPCS 25645
Hospital Charge Code	16000619
Hospital Revenue Code	360
Min. Negotiated Rate	$3,326.18
Max. Negotiated Rate	$3,326.18
Rate for Payer: Qualcare PPO/HMO/WC	$3,326.18

OPN TXCRPL SCPD NAVICULAR FRAC

Facility

$48,992.10

Service Code	HCPCS 25628
Hospital Charge Code	16000553
Hospital Revenue Code	360
Min. Negotiated Rate	$1,180.71
Max. Negotiated Rate	$31,117.67
Rate for Payer: Aetna Commercial	$23,447.95
Rate for Payer: Aetna Medicare Advantage	$27,930.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8,620.57
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	$31,117.67
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: Cigna Medicare Advantage	$8,620.57
Rate for Payer: Clover Medicare Advantage	$8,189.54
Rate for Payer: EmblemHealth Commercial	$25,861.71
Rate for Payer: Humana Medicare Advantage	$8,879.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8,620.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14,697.63
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$1,180.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$8,620.57
Rate for Payer: Wellcare Medicare Advantage	$8,620.57
Rate for Payer: Wellpoint Medicaid Managed Care	$1,298.29

OPN TXCRPL SCPD NAVICULAR FRAC

Facility

$48,992.10

Service Code	HCPCS 25628
Hospital Charge Code	16000553
Hospital Revenue Code	360
Min. Negotiated Rate	$7,348.81
Max. Negotiated Rate	$7,348.81
Rate for Payer: Qualcare PPO/HMO/WC	$7,348.81

OPN TX DISTL PHLNG FRACT EA

Facility

$25,094.58

Service Code	HCPCS 26765
Hospital Charge Code	1600000425
Hospital Revenue Code	360
Min. Negotiated Rate	$604.78
Max. Negotiated Rate	$14,031.70
Rate for Payer: Aetna Commercial	$10,573.24
Rate for Payer: Aetna Medicare Advantage	$12,594.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,887.22
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	$14,031.70
Rate for Payer: Cigna Commercial	$7,791.93
Rate for Payer: Cigna Medicare Advantage	$3,887.22
Rate for Payer: Clover Medicare Advantage	$3,692.86
Rate for Payer: EmblemHealth Commercial	$11,661.66
Rate for Payer: Humana Medicare Advantage	$4,003.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,887.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,528.37
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,764.19
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$604.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,887.22
Rate for Payer: Wellcare Medicare Advantage	$3,887.22
Rate for Payer: Wellpoint Medicaid Managed Care	$665.01

OPN TX DISTL PHLNG FRACT EA

Facility

$25,094.58

Service Code	HCPCS 26765
Hospital Charge Code	1600000425
Hospital Revenue Code	360
Min. Negotiated Rate	$3,764.19
Max. Negotiated Rate	$3,764.19
Rate for Payer: Qualcare PPO/HMO/WC	$3,764.19

Know your out-of-pocket cost for care.

All Charges