Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TBA EA ADD ART (NOT DIALYSIS)

Facility

$829.85

Service Code	HCPCS 37249
Hospital Charge Code	366837249
Hospital Revenue Code	361
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$315.34
Rate for Payer: Aetna Medicare Advantage	$248.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$211.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$211.61
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	$211.61
Rate for Payer: Cigna Commercial	$414.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$248.96
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$124.48
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$20.00
Rate for Payer: Wellpoint Medicaid Managed Care	$21.99

TBA EA ADD ART (NOT DIALYSIS)

Facility

$829.85

Service Code	HCPCS 37249
Hospital Charge Code	7412068
Hospital Revenue Code	361
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$315.34
Rate for Payer: Aetna Medicare Advantage	$248.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$211.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$211.61
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	$211.61
Rate for Payer: Cigna Commercial	$414.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$248.96
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$124.48
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$20.00
Rate for Payer: Wellpoint Medicaid Managed Care	$21.99

TBA EA ADD ART (NOT DIALYSIS)

Facility

$829.85

Service Code	HCPCS 37249
Hospital Charge Code	7412068
Hospital Revenue Code	361
Min. Negotiated Rate	$124.48
Max. Negotiated Rate	$124.48
Rate for Payer: Qualcare PPO/HMO/WC	$124.48

TBA PERIPH DIALYSIS SEGMENT

Facility

$27,397.00

Service Code	HCPCS 36902
Hospital Charge Code	321036902
Hospital Revenue Code	361
Min. Negotiated Rate	$4,109.55
Max. Negotiated Rate	$4,109.55
Rate for Payer: Qualcare PPO/HMO/WC	$4,109.55

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	366836902
Hospital Revenue Code	361
Min. Negotiated Rate	$3,617.37
Max. Negotiated Rate	$3,617.37
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37

TBA PERIPH DIALYSIS SEGMENT

Facility

$27,397.00

Service Code	HCPCS 36902
Hospital Charge Code	321036902
Hospital Revenue Code	361
Min. Negotiated Rate	$660.27
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,219.10
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,109.55
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$660.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$726.02

TBA PERIPH DIALYSIS SEGMENT

Facility

$27,397.00

Service Code	HCPCS 36902
Hospital Charge Code	2692128
Hospital Revenue Code	361
Min. Negotiated Rate	$4,109.55
Max. Negotiated Rate	$4,109.55
Rate for Payer: Qualcare PPO/HMO/WC	$4,109.55

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	366836902
Hospital Revenue Code	361
Min. Negotiated Rate	$581.19
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,234.74
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$581.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$639.07

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	2709023
Hospital Revenue Code	361
Min. Negotiated Rate	$3,617.37
Max. Negotiated Rate	$3,617.37
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	7412057
Hospital Revenue Code	361
Min. Negotiated Rate	$581.19
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,234.74
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$581.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$639.07

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	2709023
Hospital Revenue Code	361
Min. Negotiated Rate	$581.19
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,234.74
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$581.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$639.07

TBA PERIPH DIALYSIS SEGMENT

Facility

$27,397.00

Service Code	HCPCS 36902
Hospital Charge Code	2692128
Hospital Revenue Code	361
Min. Negotiated Rate	$660.27
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,219.10
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,109.55
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$660.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$726.02

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	7412057
Hospital Revenue Code	361
Min. Negotiated Rate	$3,617.37
Max. Negotiated Rate	$3,617.37
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	5100836
Hospital Revenue Code	361
Min. Negotiated Rate	$3,617.37
Max. Negotiated Rate	$3,617.37
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37

TBA PERIPH DIALYSIS SEGMENT

Facility

$24,115.80

Service Code	HCPCS 36902
Hospital Charge Code	5100836
Hospital Revenue Code	361
Min. Negotiated Rate	$581.19
Max. Negotiated Rate	$24,407.82
Rate for Payer: Aetna Commercial	$18,391.91
Rate for Payer: Aetna Medicare Advantage	$21,908.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24,407.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6,761.73
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	$24,407.82
Rate for Payer: Cigna Commercial	$13,553.85
Rate for Payer: Cigna Medicare Advantage	$6,761.73
Rate for Payer: Clover Medicare Advantage	$6,423.64
Rate for Payer: EmblemHealth Commercial	$20,285.19
Rate for Payer: Humana Medicare Advantage	$6,964.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6,761.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,234.74
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,617.37
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$581.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$6,761.73
Rate for Payer: Wellcare Medicare Advantage	$6,761.73
Rate for Payer: Wellpoint Medicaid Managed Care	$639.07

T-BAR***

Facility

$27.00

Hospital Charge Code	9500455
Hospital Revenue Code	279
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$13.50
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	$5.40
Rate for Payer: Qualcare PPO/HMO/WC	$4.05
Rate for Payer: UnitedHealthcare Commercial	$5.40
Rate for Payer: UnitedHealthcare Community & State	$0.65
Rate for Payer: Wellpoint Medicaid Managed Care	$0.72

T-BAR***

Facility

$27.00

Hospital Charge Code	9500455
Hospital Revenue Code	279
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.05
Rate for Payer: Qualcare PPO/HMO/WC	$4.05

TBG

Facility

$390.00

Service Code	HCPCS 84442
Hospital Charge Code	39900140
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$40.20
Rate for Payer: Aetna Medicare Advantage	$47.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$23.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.35
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.78
Rate for Payer: Clover Medicare Advantage	$14.04
Rate for Payer: EmblemHealth Commercial	$44.34
Rate for Payer: Humana Medicare Advantage	$15.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.78
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	$11.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.78
Rate for Payer: Wellcare Medicare Advantage	$14.78
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

TBG

Facility

$390.00

Service Code	HCPCS 84442
Hospital Charge Code	39900140
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

TBII

Facility

$390.00

Service Code	HCPCS 83519
Hospital Charge Code	39900097
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$50.05
Rate for Payer: Aetna Medicare Advantage	$59.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$66.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$66.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$14.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$66.42
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$18.40
Rate for Payer: Clover Medicare Advantage	$17.48
Rate for Payer: EmblemHealth Commercial	$55.20
Rate for Payer: Humana Medicare Advantage	$18.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$18.40
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	$14.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.40
Rate for Payer: Wellcare Medicare Advantage	$18.40
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

TBII

Facility

$390.00

Service Code	HCPCS 83519
Hospital Charge Code	39900097
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

TBI N6 TRIATH TS PL X3 N6 9MM

Facility

$5,821.00

Service Code	HCPCS C1776
Hospital Charge Code	270694173
Hospital Revenue Code	278
Min. Negotiated Rate	$140.29
Max. Negotiated Rate	$2,910.50
Rate for Payer: Aetna Commercial	$2,211.98
Rate for Payer: Aetna Medicare Advantage	$1,746.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,484.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,484.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,164.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,484.36
Rate for Payer: Cigna Commercial	$2,910.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,408.68
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,280.62
Rate for Payer: Qualcare PPO/HMO/WC	$873.15
Rate for Payer: UnitedHealthcare Community & State	$140.29
Rate for Payer: Wellpoint Medicaid Managed Care	$154.26

TBI N6 TRIATH TS PL X3 N6 9MM

Facility

$5,821.00

Service Code	HCPCS C1776
Hospital Charge Code	270694173
Hospital Revenue Code	278
Min. Negotiated Rate	$873.15
Max. Negotiated Rate	$1,408.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,164.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,408.68
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,280.62
Rate for Payer: Qualcare PPO/HMO/WC	$873.15

TBI PS SZ3 10MM

Facility

$5,212.45

Service Code	HCPCS C1776
Hospital Charge Code	270699195
Hospital Revenue Code	278
Min. Negotiated Rate	$781.87
Max. Negotiated Rate	$1,261.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,042.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,261.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,146.74
Rate for Payer: Qualcare PPO/HMO/WC	$781.87

TBI PS SZ3 10MM

Facility

$5,212.45

Service Code	HCPCS C1776
Hospital Charge Code	270699195
Hospital Revenue Code	278
Min. Negotiated Rate	$125.62
Max. Negotiated Rate	$2,606.22
Rate for Payer: Aetna Commercial	$1,980.73
Rate for Payer: Aetna Medicare Advantage	$1,563.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,329.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,329.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,042.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,329.17
Rate for Payer: Cigna Commercial	$2,606.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,261.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,146.74
Rate for Payer: Qualcare PPO/HMO/WC	$781.87
Rate for Payer: UnitedHealthcare Community & State	$125.62
Rate for Payer: Wellpoint Medicaid Managed Care	$138.13

Know your out-of-pocket cost for care.

All Charges