Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PRIM ART M-THRMBC 1ST VSL

Facility

$20,340.00

Service Code	HCPCS 37184
Hospital Charge Code	1600000735
Hospital Revenue Code	360
Min. Negotiated Rate	$3,051.00
Max. Negotiated Rate	$3,051.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,051.00

PRIM ART M-THRMBC 1ST VSL

Facility

$20,340.00

Service Code	HCPCS 37184
Hospital Charge Code	1600000735
Hospital Revenue Code	360
Min. Negotiated Rate	$490.19
Max. Negotiated Rate	$78,613.74
Rate for Payer: Aetna Commercial	$59,237.44
Rate for Payer: Aetna Medicare Advantage	$70,562.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,778.47
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	$78,613.74
Rate for Payer: Cigna Commercial	$43,654.87
Rate for Payer: Cigna Medicare Advantage	$21,778.47
Rate for Payer: Clover Medicare Advantage	$20,689.55
Rate for Payer: EmblemHealth Commercial	$65,335.41
Rate for Payer: Humana Medicare Advantage	$22,431.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,778.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,102.00
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,051.00
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$490.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,778.47
Rate for Payer: Wellcare Medicare Advantage	$21,778.47
Rate for Payer: Wellpoint Medicaid Managed Care	$539.01

PRIMARY FEMORAL PC STEM 16X152

Facility

$10,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270704518
Hospital Revenue Code	278
Min. Negotiated Rate	$253.05
Max. Negotiated Rate	$5,250.00
Rate for Payer: Aetna Commercial	$3,990.00
Rate for Payer: Aetna Medicare Advantage	$3,150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,677.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,677.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,677.50
Rate for Payer: Cigna Commercial	$5,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,541.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,310.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,575.00
Rate for Payer: UnitedHealthcare Community & State	$253.05
Rate for Payer: Wellpoint Medicaid Managed Care	$278.25

PRIMARY FEMORAL PC STEM 16X152

Facility

$10,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270704518
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$2,541.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,541.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,310.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,575.00

PRIMARY SET W/CHECK VALVE***

Facility

$21.00

Hospital Charge Code	8010001
Hospital Revenue Code	279
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.15
Rate for Payer: Qualcare PPO/HMO/WC	$3.15

PRIMARY SET W/CHECK VALVE***

Facility

$21.00

Hospital Charge Code	8010001
Hospital Revenue Code	279
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: Aetna Medicare Advantage	$6.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.36
Rate for Payer: Cigna Commercial	$10.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.30
Rate for Payer: Oxford Commercial	$4.20
Rate for Payer: Qualcare PPO/HMO/WC	$3.15
Rate for Payer: UnitedHealthcare Commercial	$4.20
Rate for Payer: UnitedHealthcare Community & State	$0.51
Rate for Payer: Wellpoint Medicaid Managed Care	$0.56

PRIMARY STEM TM 12MM STANDA

Facility

$21,430.00

Hospital Charge Code	270667177
Hospital Revenue Code	278
Min. Negotiated Rate	$516.46
Max. Negotiated Rate	$10,715.00
Rate for Payer: Aetna Commercial	$8,143.40
Rate for Payer: Aetna Medicare Advantage	$6,429.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,464.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,464.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,286.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,464.65
Rate for Payer: Cigna Commercial	$10,715.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,186.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,714.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,214.50
Rate for Payer: UnitedHealthcare Community & State	$516.46
Rate for Payer: Wellpoint Medicaid Managed Care	$567.89

PRIMARY STEM TM 12MM STANDA

Facility

$21,430.00

Hospital Charge Code	270667177
Hospital Revenue Code	278
Min. Negotiated Rate	$3,214.50
Max. Negotiated Rate	$5,186.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,286.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,186.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,714.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,214.50

PRIMARY STEM TM 14MM STANDARD

Facility

$21,427.75

Hospital Charge Code	270667174
Hospital Revenue Code	278
Min. Negotiated Rate	$516.41
Max. Negotiated Rate	$10,713.88
Rate for Payer: Aetna Commercial	$8,142.55
Rate for Payer: Aetna Medicare Advantage	$6,428.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,464.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,464.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,285.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,464.08
Rate for Payer: Cigna Commercial	$10,713.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,185.52
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,714.10
Rate for Payer: Qualcare PPO/HMO/WC	$3,214.16
Rate for Payer: UnitedHealthcare Community & State	$516.41
Rate for Payer: Wellpoint Medicaid Managed Care	$567.84

PRIMARY STEM TM 14MM STANDARD

Facility

$21,427.75

Hospital Charge Code	270667174
Hospital Revenue Code	278
Min. Negotiated Rate	$3,214.16
Max. Negotiated Rate	$5,185.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,285.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,185.52
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,714.10
Rate for Payer: Qualcare PPO/HMO/WC	$3,214.16

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	7411123
Hospital Revenue Code	361
Min. Negotiated Rate	$283.03
Max. Negotiated Rate	$78,613.74
Rate for Payer: Aetna Commercial	$59,237.44
Rate for Payer: Aetna Medicare Advantage	$70,562.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,778.47
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	$78,613.74
Rate for Payer: Cigna Commercial	$43,654.87
Rate for Payer: Cigna Medicare Advantage	$21,778.47
Rate for Payer: Clover Medicare Advantage	$20,689.55
Rate for Payer: EmblemHealth Commercial	$65,335.41
Rate for Payer: Humana Medicare Advantage	$22,431.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,778.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,523.20
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$283.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,778.47
Rate for Payer: Wellcare Medicare Advantage	$21,778.47
Rate for Payer: Wellpoint Medicaid Managed Care	$311.22

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	366837184
Hospital Revenue Code	361
Min. Negotiated Rate	$1,761.60
Max. Negotiated Rate	$1,761.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	411037184
Hospital Revenue Code	361
Min. Negotiated Rate	$1,761.60
Max. Negotiated Rate	$1,761.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	366837184
Hospital Revenue Code	361
Min. Negotiated Rate	$283.03
Max. Negotiated Rate	$78,613.74
Rate for Payer: Aetna Commercial	$59,237.44
Rate for Payer: Aetna Medicare Advantage	$70,562.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,778.47
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	$78,613.74
Rate for Payer: Cigna Commercial	$43,654.87
Rate for Payer: Cigna Medicare Advantage	$21,778.47
Rate for Payer: Clover Medicare Advantage	$20,689.55
Rate for Payer: EmblemHealth Commercial	$65,335.41
Rate for Payer: Humana Medicare Advantage	$22,431.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,778.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,523.20
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$283.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,778.47
Rate for Payer: Wellcare Medicare Advantage	$21,778.47
Rate for Payer: Wellpoint Medicaid Managed Care	$311.22

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	411037184
Hospital Revenue Code	361
Min. Negotiated Rate	$283.03
Max. Negotiated Rate	$78,613.74
Rate for Payer: Aetna Commercial	$59,237.44
Rate for Payer: Aetna Medicare Advantage	$70,562.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78,613.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,778.47
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	$78,613.74
Rate for Payer: Cigna Commercial	$43,654.87
Rate for Payer: Cigna Medicare Advantage	$21,778.47
Rate for Payer: Clover Medicare Advantage	$20,689.55
Rate for Payer: EmblemHealth Commercial	$65,335.41
Rate for Payer: Humana Medicare Advantage	$22,431.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,778.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,523.20
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$283.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,778.47
Rate for Payer: Wellcare Medicare Advantage	$21,778.47
Rate for Payer: Wellpoint Medicaid Managed Care	$311.22

PRIMARY THROMB ANY VESSEL

Facility

$11,744.00

Service Code	HCPCS 37184
Hospital Charge Code	7411123
Hospital Revenue Code	361
Min. Negotiated Rate	$1,761.60
Max. Negotiated Rate	$1,761.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,761.60

PRIMATENE MIST/0.2MG/15ML

Facility

$61.00

Hospital Charge Code	60633713
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$9.15
Rate for Payer: Qualcare PPO/HMO/WC	$9.15

PRIMATENE MIST/0.2MG/15ML

Facility

$61.00

Hospital Charge Code	60633713
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$30.50
Rate for Payer: Aetna Commercial	$23.18
Rate for Payer: Aetna Medicare Advantage	$18.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.55
Rate for Payer: Cigna Commercial	$30.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.30
Rate for Payer: Oxford Commercial	$12.20
Rate for Payer: Qualcare PPO/HMO/WC	$9.15
Rate for Payer: UnitedHealthcare Commercial	$12.20
Rate for Payer: UnitedHealthcare Community & State	$1.47
Rate for Payer: Wellpoint Medicaid Managed Care	$1.62

PRIMATRIX AG 8X8CM

Facility

$12,412.55

Service Code	HCPCS Q4110
Hospital Charge Code	270689627
Hospital Revenue Code	636
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$3,003.84
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$156.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,003.84
Rate for Payer: Qualcare PPO/HMO/WC	$1,861.88
Rate for Payer: UnitedHealthcare Community & State	$299.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$328.93

PRIMATRIX AG 8X8CM

Facility

$12,412.55

Service Code	HCPCS Q4110
Hospital Charge Code	270689627
Hospital Revenue Code	636
Min. Negotiated Rate	$1,861.88
Max. Negotiated Rate	$3,003.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,003.84
Rate for Payer: Qualcare PPO/HMO/WC	$1,861.88

PRIMATRIX MESHED 10 X 25CM

Facility

$22,370.00

Service Code	HCPCS Q4110
Hospital Charge Code	270684234
Hospital Revenue Code	278
Min. Negotiated Rate	$3,355.50
Max. Negotiated Rate	$5,413.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,474.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,413.54
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,921.40
Rate for Payer: Qualcare PPO/HMO/WC	$3,355.50

PRIMATRIX MESHED 10 X 25CM

Facility

$22,370.00

Service Code	HCPCS Q4110
Hospital Charge Code	270684234
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$5,413.54
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,474.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,413.54
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,921.40
Rate for Payer: Qualcare PPO/HMO/WC	$3,355.50
Rate for Payer: UnitedHealthcare Community & State	$539.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$592.80

PRIMATRIX PERF 4x4CM

Facility

$3,423.00

Service Code	HCPCS Q4110
Hospital Charge Code	270674002
Hospital Revenue Code	278
Min. Negotiated Rate	$513.45
Max. Negotiated Rate	$828.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$684.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$828.37
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$753.06
Rate for Payer: Qualcare PPO/HMO/WC	$513.45

PRIMATRIX PERF 4x4CM

Facility

$3,423.00

Service Code	HCPCS Q4110
Hospital Charge Code	270674002
Hospital Revenue Code	278
Min. Negotiated Rate	$82.49
Max. Negotiated Rate	$828.37
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$684.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$828.37
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$753.06
Rate for Payer: Qualcare PPO/HMO/WC	$513.45
Rate for Payer: UnitedHealthcare Community & State	$82.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$90.71

PRIMATRIX PERF 4x4CM/SQ CM JW

Facility

$855.75

Hospital Charge Code	270674002W
Hospital Revenue Code	636
Min. Negotiated Rate	$128.36
Max. Negotiated Rate	$207.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$207.09
Rate for Payer: Qualcare PPO/HMO/WC	$128.36

Know your out-of-pocket cost for care.

All Charges