Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PORACTANT ALFA 80 MG/ML(3ML)

Facility

$9,495.91

Service Code	NDC 10122051003
Hospital Charge Code	6063943233
Hospital Revenue Code	250
Min. Negotiated Rate	$1,424.39
Max. Negotiated Rate	$1,424.39
Rate for Payer: Qualcare PPO/HMO/WC	$1,424.39

POROUS COATED INTERBODY 10X27X

Facility

$20,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704666
Hospital Revenue Code	278
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$4,840.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,840.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,400.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,000.00

POROUS COATED INTERBODY 10X27X

Facility

$20,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704666
Hospital Revenue Code	278
Min. Negotiated Rate	$482.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$7,600.00
Rate for Payer: Aetna Medicare Advantage	$6,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,100.00
Rate for Payer: Cigna Commercial	$10,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,840.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,400.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,000.00
Rate for Payer: UnitedHealthcare Community & State	$482.00
Rate for Payer: Wellpoint Medicaid Managed Care	$530.00

POROUS IM STEM 15.5X150

Facility

$11,820.00

Service Code	HCPCS C1776
Hospital Charge Code	270673873
Hospital Revenue Code	278
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$5,910.00
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) NJ Health	$2,364.00
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	$2,860.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,600.40
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00
Rate for Payer: UnitedHealthcare Community & State	$284.86
Rate for Payer: Wellpoint Medicaid Managed Care	$313.23

POROUS IM STEM 15.5X150

Facility

$11,820.00

Service Code	HCPCS C1776
Hospital Charge Code	270673873
Hospital Revenue Code	278
Min. Negotiated Rate	$1,773.00
Max. Negotiated Rate	$2,860.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,364.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,860.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,600.40
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00

PORPHOBILINOGEN****

Facility

$27.00

Hospital Charge Code	3012135
Hospital Revenue Code	309
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Aetna Medicare Advantage	$8.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.88
Rate for Payer: Cigna Commercial	$13.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$0.65
Rate for Payer: Wellpoint Medicaid Managed Care	$0.72

PORPHOBILINOGEN****

Facility

$27.00

Hospital Charge Code	3012135
Hospital Revenue Code	309
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.05
Rate for Payer: Qualcare PPO/HMO/WC	$4.05

PORPHOBILINOGEN,24HR

Facility

$85.00

Service Code	HCPCS 84110
Hospital Charge Code	38479121
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$22.96
Rate for Payer: Aetna Medicare Advantage	$27.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.47
Rate for Payer: Cigna Commercial	$42.50
Rate for Payer: Cigna Medicare Advantage	$8.44
Rate for Payer: Clover Medicare Advantage	$8.02
Rate for Payer: EmblemHealth Commercial	$25.32
Rate for Payer: Humana Medicare Advantage	$8.69
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.44
Rate for Payer: Wellcare Medicare Advantage	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$2.25

PORPHOBILINOGEN,24HR

Facility

$85.00

Service Code	HCPCS 84110
Hospital Charge Code	38479121
Hospital Revenue Code	301
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Qualcare PPO/HMO/WC	$12.75

PORPHOBILINOGEN, URINE

Facility

$85.00

Service Code	HCPCS 84106
Hospital Charge Code	38472545
Hospital Revenue Code	301
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Qualcare PPO/HMO/WC	$12.75

PORPHOBILINOGEN, URINE

Facility

$85.00

Service Code	HCPCS 84106
Hospital Charge Code	38472545
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Aetna Medicare Advantage	$18.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.01
Rate for Payer: Cigna Commercial	$42.50
Rate for Payer: Cigna Medicare Advantage	$5.82
Rate for Payer: Clover Medicare Advantage	$5.53
Rate for Payer: EmblemHealth Commercial	$17.46
Rate for Payer: Humana Medicare Advantage	$5.99
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.82
Rate for Payer: Wellcare Medicare Advantage	$5.82
Rate for Payer: Wellpoint Medicaid Managed Care	$2.25

PORPHOBILINOGEN,URINE I

Facility

$29.40

Service Code	HCPCS 84106
Hospital Charge Code	39990017A
Hospital Revenue Code	301
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Aetna Medicare Advantage	$18.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.01
Rate for Payer: Cigna Commercial	$14.70
Rate for Payer: Cigna Medicare Advantage	$5.82
Rate for Payer: Clover Medicare Advantage	$5.53
Rate for Payer: EmblemHealth Commercial	$17.46
Rate for Payer: Humana Medicare Advantage	$5.99
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.82
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.41
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.82
Rate for Payer: Wellcare Medicare Advantage	$5.82
Rate for Payer: Wellpoint Medicaid Managed Care	$0.78

PORPHOBILINOGEN,URINE I

Facility

$29.40

Service Code	HCPCS 84106
Hospital Charge Code	39990017A
Hospital Revenue Code	301
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$4.41
Rate for Payer: Qualcare PPO/HMO/WC	$4.41

PORPHOBILINOGEN,URINE II

Facility

$58.00

Service Code	HCPCS 84110
Hospital Charge Code	39990017B
Hospital Revenue Code	301
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$22.96
Rate for Payer: Aetna Medicare Advantage	$27.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.47
Rate for Payer: Cigna Commercial	$29.00
Rate for Payer: Cigna Medicare Advantage	$8.44
Rate for Payer: Clover Medicare Advantage	$8.02
Rate for Payer: EmblemHealth Commercial	$25.32
Rate for Payer: Humana Medicare Advantage	$8.69
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$8.70
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.44
Rate for Payer: Wellcare Medicare Advantage	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$1.54

PORPHOBILINOGEN,URINE II

Facility

$58.00

Service Code	HCPCS 84110
Hospital Charge Code	39990017B
Hospital Revenue Code	301
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$8.70

PORPHOBILINOGEN URINE QUAL

Facility

$30.00

Service Code	HCPCS 84106
Hospital Charge Code	38477028
Hospital Revenue Code	301
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Aetna Medicare Advantage	$18.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.01
Rate for Payer: Cigna Commercial	$15.00
Rate for Payer: Cigna Medicare Advantage	$5.82
Rate for Payer: Clover Medicare Advantage	$5.53
Rate for Payer: EmblemHealth Commercial	$17.46
Rate for Payer: Humana Medicare Advantage	$5.99
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.82
Rate for Payer: Wellcare Medicare Advantage	$5.82
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

PORPHOBILINOGEN URINE QUAL

Facility

$30.00

Service Code	HCPCS 84106
Hospital Charge Code	38477028
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$4.50

PORPHOBILINOGEN, URINE QUANT

Facility

$91.25

Service Code	HCPCS 84110
Hospital Charge Code	3002136
Hospital Revenue Code	301
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$22.96
Rate for Payer: Aetna Medicare Advantage	$27.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.47
Rate for Payer: Cigna Commercial	$45.62
Rate for Payer: Cigna Medicare Advantage	$8.44
Rate for Payer: Clover Medicare Advantage	$8.02
Rate for Payer: EmblemHealth Commercial	$25.32
Rate for Payer: Humana Medicare Advantage	$8.69
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.44
Rate for Payer: Wellcare Medicare Advantage	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$2.42

PORPHOBILINOGEN, URINE QUANT

Facility

$91.25

Service Code	HCPCS 84110
Hospital Charge Code	3002136
Hospital Revenue Code	301
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$13.69
Rate for Payer: Qualcare PPO/HMO/WC	$13.69

PORPHYRINS 24 HR URINE A

Facility

$390.00

Service Code	HCPCS 84120
Hospital Charge Code	397080010A
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$40.01
Rate for Payer: Aetna Medicare Advantage	$47.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$14.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.10
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.71
Rate for Payer: Clover Medicare Advantage	$13.97
Rate for Payer: EmblemHealth Commercial	$44.13
Rate for Payer: Humana Medicare Advantage	$15.15
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.71
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.71
Rate for Payer: Wellcare Medicare Advantage	$14.71
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PORPHYRINS 24 HR URINE A

Facility

$390.00

Service Code	HCPCS 84120
Hospital Charge Code	397080010A
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PORPHYRINS 24 HR URINE B

Facility

$390.00

Service Code	HCPCS 84110
Hospital Charge Code	397080010B
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PORPHYRINS 24 HR URINE B

Facility

$390.00

Service Code	HCPCS 84110
Hospital Charge Code	397080010B
Hospital Revenue Code	301
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$22.96
Rate for Payer: Aetna Medicare Advantage	$27.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.47
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$8.44
Rate for Payer: Clover Medicare Advantage	$8.02
Rate for Payer: EmblemHealth Commercial	$25.32
Rate for Payer: Humana Medicare Advantage	$8.69
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.44
Rate for Payer: Wellcare Medicare Advantage	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PORPHYRINS,FRACT,24HR UR

Facility

$390.00

Service Code	HCPCS 84120
Hospital Charge Code	401084120
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$40.01
Rate for Payer: Aetna Medicare Advantage	$47.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$14.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.10
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.71
Rate for Payer: Clover Medicare Advantage	$13.97
Rate for Payer: EmblemHealth Commercial	$44.13
Rate for Payer: Humana Medicare Advantage	$15.15
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.71
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.71
Rate for Payer: Wellcare Medicare Advantage	$14.71
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PORPHYRINS,FRACT,24HR UR

Facility

$390.00

Service Code	HCPCS 84120
Hospital Charge Code	401084120
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

Know your out-of-pocket cost for care.

All Charges