Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR NASAL/ORGASTRIC W/STENT

Facility

$572.10

Service Code	HCPCS 43752
Hospital Charge Code	5600150
Hospital Revenue Code	361
Min. Negotiated Rate	$13.79
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$1,443.56
Rate for Payer: Aetna Medicare Advantage	$1,719.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,915.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,915.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$530.72
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	$1,915.74
Rate for Payer: Cigna Commercial	$1,063.82
Rate for Payer: Cigna Medicare Advantage	$530.72
Rate for Payer: Clover Medicare Advantage	$504.18
Rate for Payer: EmblemHealth Commercial	$1,592.16
Rate for Payer: Humana Medicare Advantage	$546.64
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$530.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$171.63
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$85.81
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$13.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$530.72
Rate for Payer: Wellcare Medicare Advantage	$530.72
Rate for Payer: Wellpoint Medicaid Managed Care	$15.16

XR NECK SOFT TISSUE

Facility

$6,601.19

Service Code	HCPCS 70360
Hospital Charge Code	2000487
Hospital Revenue Code	320
Min. Negotiated Rate	$990.18
Max. Negotiated Rate	$990.18
Rate for Payer: Qualcare PPO/HMO/WC	$990.18

XR NECK SOFT TISSUE

Facility

$6,601.19

Service Code	HCPCS 70360
Hospital Charge Code	2000487
Hospital Revenue Code	320
Min. Negotiated Rate	$24.99
Max. Negotiated Rate	$1,980.36
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,980.36
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$990.18
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$159.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$216.59
Rate for Payer: Wellpoint Medicaid Managed Care	$174.93

XR NEEDLE BIOPSY PLEURA

Facility

$4,350.20

Service Code	HCPCS 32400
Hospital Charge Code	5600103
Hospital Revenue Code	361
Min. Negotiated Rate	$104.84
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,305.06
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$652.53
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$104.84
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$115.28

XR NEEDLE BIOPSY PLEURA

Facility

$4,350.20

Service Code	HCPCS 32400
Hospital Charge Code	5600103
Hospital Revenue Code	361
Min. Negotiated Rate	$652.53
Max. Negotiated Rate	$652.53
Rate for Payer: Qualcare PPO/HMO/WC	$652.53

XR NEEDLE BIOPSY PLEURA PER***

Facility

$162.00

Service Code	HCPCS 32400
Hospital Charge Code	2004133
Hospital Revenue Code	361
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.60
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$24.30
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$3.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$4.29

XR NEEDLE BIOPSY PLEURA PER***

Facility

$162.00

Service Code	HCPCS 32400
Hospital Charge Code	2004133
Hospital Revenue Code	361
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$24.30
Rate for Payer: Qualcare PPO/HMO/WC	$24.30

XR NEEDLE BIOPSY RENAL PERC

Facility

$7,071.40

Service Code	HCPCS 50200
Hospital Charge Code	2004547
Hospital Revenue Code	361
Min. Negotiated Rate	$1,060.71
Max. Negotiated Rate	$1,060.71
Rate for Payer: Qualcare PPO/HMO/WC	$1,060.71

XR NEEDLE BIOPSY RENAL PERC

Facility

$7,071.40

Service Code	HCPCS 50200
Hospital Charge Code	2004547
Hospital Revenue Code	361
Min. Negotiated Rate	$170.42
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,121.42
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,060.71
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$170.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$187.39

XR NEEDLE BX LIVER ADD ON

Facility

$2,500.00

Service Code	HCPCS 47001
Hospital Charge Code	7411554
Hospital Revenue Code	361
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$375.00
Rate for Payer: Qualcare PPO/HMO/WC	$375.00

XR NEEDLE BX LIVER ADD ON

Facility

$2,500.00

Service Code	HCPCS 47001
Hospital Charge Code	7411554
Hospital Revenue Code	361
Min. Negotiated Rate	$60.25
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$950.00
Rate for Payer: Aetna Medicare Advantage	$750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$637.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$637.50
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	$637.50
Rate for Payer: Cigna Commercial	$1,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.00
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$375.00
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$60.25
Rate for Payer: Wellpoint Medicaid Managed Care	$66.25

XR NEEDLE BX LIVER ADD ON

Facility

$2,500.00

Service Code	HCPCS 47001
Hospital Charge Code	5600152
Hospital Revenue Code	361
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$375.00
Rate for Payer: Qualcare PPO/HMO/WC	$375.00

XR NEEDLE BX LIVER ADD ON

Facility

$2,500.00

Service Code	HCPCS 47001
Hospital Charge Code	5600152
Hospital Revenue Code	361
Min. Negotiated Rate	$60.25
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$950.00
Rate for Payer: Aetna Medicare Advantage	$750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$637.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$637.50
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	$637.50
Rate for Payer: Cigna Commercial	$1,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.00
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$375.00
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$60.25
Rate for Payer: Wellpoint Medicaid Managed Care	$66.25

XR NEEDLE BX LYMPH NODES

Facility

$8,054.80

Service Code	HCPCS 38505
Hospital Charge Code	5700150
Hospital Revenue Code	361
Min. Negotiated Rate	$1,208.22
Max. Negotiated Rate	$1,208.22
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22

XR NEEDLE BX LYMPH NODES

Facility

$8,054.80

Service Code	HCPCS 38505
Hospital Charge Code	5700150
Hospital Revenue Code	361
Min. Negotiated Rate	$194.12
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,416.44
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$194.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$213.45

XR NEEDLE BX LYMPH NODES

Facility

$8,054.80

Service Code	HCPCS 38505
Hospital Charge Code	321038505
Hospital Revenue Code	361
Min. Negotiated Rate	$194.12
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,416.44
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$194.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$213.45

XR NEEDLE BX LYMPH NODES

Facility

$6,202.00

Service Code	HCPCS 38505
Hospital Charge Code	7411544
Hospital Revenue Code	361
Min. Negotiated Rate	$930.30
Max. Negotiated Rate	$930.30
Rate for Payer: Qualcare PPO/HMO/WC	$930.30

XR NEEDLE BX LYMPH NODES

Facility

$8,054.80

Service Code	HCPCS 38505
Hospital Charge Code	321038505
Hospital Revenue Code	361
Min. Negotiated Rate	$1,208.22
Max. Negotiated Rate	$1,208.22
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22

XR NEEDLE BX LYMPH NODES

Facility

$6,202.00

Service Code	HCPCS 38505
Hospital Charge Code	7411544
Hospital Revenue Code	361
Min. Negotiated Rate	$149.47
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,860.60
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$930.30
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$149.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$164.35

XR OPTIC FORAMINA RIGHT

Facility

$376.85

Service Code	HCPCS 70190RT
Hospital Charge Code	2011367
Hospital Revenue Code	320
Min. Negotiated Rate	$9.08
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$143.20
Rate for Payer: Aetna Medicare Advantage	$113.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$96.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$96.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$96.10
Rate for Payer: Cigna Commercial	$188.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$113.06
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$56.53
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$9.08
Rate for Payer: Wellpoint Medicaid Managed Care	$9.99

XR OPTIC FORAMINA RIGHT

Facility

$376.85

Service Code	HCPCS 70190RT
Hospital Charge Code	2011367
Hospital Revenue Code	320
Min. Negotiated Rate	$56.53
Max. Negotiated Rate	$56.53
Rate for Payer: Qualcare PPO/HMO/WC	$56.53

XR OPTIC FORAMINE

Facility

$376.85

Service Code	HCPCS 70190
Hospital Charge Code	2000446
Hospital Revenue Code	320
Min. Negotiated Rate	$9.08
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$113.06
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$56.53
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$9.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$247.19
Rate for Payer: Wellpoint Medicaid Managed Care	$9.99

XR OPTIC FORAMINE

Facility

$376.85

Service Code	HCPCS 70190
Hospital Charge Code	2000446
Hospital Revenue Code	320
Min. Negotiated Rate	$56.53
Max. Negotiated Rate	$56.53
Rate for Payer: Qualcare PPO/HMO/WC	$56.53

XR ORBITS COMPLETE BILATERAL

Facility

$258.70

Service Code	HCPCS 70200
Hospital Charge Code	2011368
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR ORBITS COMPLETE BILATERAL

Facility

$258.70

Service Code	HCPCS 70200
Hospital Charge Code	2011368
Hospital Revenue Code	320
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna Medicare Advantage	$402.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$448.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$448.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$124.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$48.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$448.32
Rate for Payer: Cigna Commercial	$248.96
Rate for Payer: Cigna Medicare Advantage	$86.94
Rate for Payer: Clover Medicare Advantage	$117.99
Rate for Payer: EmblemHealth Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$127.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$124.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.61
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$38.80
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$6.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$407.88
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

Know your out-of-pocket cost for care.

All Charges