Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR PYELOGRAM RETROGRADE

Facility

$5,100.00

Service Code	HCPCS 74420
Hospital Charge Code	2000750
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR RADIOGRAPHIC ABSORPTINMETRY

Facility

$281.80

Hospital Charge Code	2011375
Hospital Revenue Code	320
Min. Negotiated Rate	$6.79
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$107.08
Rate for Payer: Aetna Medicare Advantage	$84.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$71.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$71.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$71.86
Rate for Payer: Cigna Commercial	$140.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$84.54
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$42.27
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$6.79
Rate for Payer: Wellpoint Medicaid Managed Care	$7.47

XR RADIOGRAPHIC ABSORPTINMETRY

Facility

$281.80

Hospital Charge Code	2011375
Hospital Revenue Code	320
Min. Negotiated Rate	$42.27
Max. Negotiated Rate	$42.27
Rate for Payer: Qualcare PPO/HMO/WC	$42.27

XR RANOREX/ORTHOPANTOGRAM

Facility

$258.70

Service Code	HCPCS 70355
Hospital Charge Code	2011370
Hospital Revenue Code	320
Min. Negotiated Rate	$6.23
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	$27.10
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	$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	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR RANOREX/ORTHOPANTOGRAM

Facility

$258.70

Service Code	HCPCS 70355
Hospital Charge Code	2011370
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR REMOVAL OF KIDNEY STONE

Facility

$9,934.90

Service Code	HCPCS 50081
Hospital Charge Code	2011260
Hospital Revenue Code	361
Min. Negotiated Rate	$1,490.23
Max. Negotiated Rate	$1,490.23
Rate for Payer: Qualcare PPO/HMO/WC	$1,490.23

XR REMOVAL OF KIDNEY STONE

Facility

$9,934.90

Service Code	HCPCS 50081
Hospital Charge Code	2011260
Hospital Revenue Code	361
Min. Negotiated Rate	$239.43
Max. Negotiated Rate	$40,596.17
Rate for Payer: Aetna Commercial	$30,590.24
Rate for Payer: Aetna Medicare Advantage	$36,438.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$40,596.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$40,596.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11,246.41
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	$40,596.17
Rate for Payer: Cigna Commercial	$22,543.37
Rate for Payer: Cigna Medicare Advantage	$11,246.41
Rate for Payer: Clover Medicare Advantage	$10,684.09
Rate for Payer: EmblemHealth Commercial	$33,739.23
Rate for Payer: Humana Medicare Advantage	$11,583.80
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11,246.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,980.47
Rate for Payer: Oxford Commercial	$7,559.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,490.23
Rate for Payer: UnitedHealthcare Commercial	$12,870.00
Rate for Payer: UnitedHealthcare Community & State	$239.43
Rate for Payer: UnitedHealthcare Medicare Advantage	$11,246.41
Rate for Payer: Wellcare Medicare Advantage	$11,246.41
Rate for Payer: Wellpoint Medicaid Managed Care	$263.27

XR REMOVE RENAL TUBE W/FLUORO

Facility

$3,274.65

Service Code	HCPCS 50389
Hospital Charge Code	5600169
Hospital Revenue Code	361
Min. Negotiated Rate	$491.20
Max. Negotiated Rate	$491.20
Rate for Payer: Qualcare PPO/HMO/WC	$491.20

XR REMOVE RENAL TUBE W/FLUORO

Facility

$3,274.65

Service Code	HCPCS 50389
Hospital Charge Code	5600169
Hospital Revenue Code	361
Min. Negotiated Rate	$78.92
Max. Negotiated Rate	$3,593.00
Rate for Payer: Aetna Commercial	$2,253.28
Rate for Payer: Aetna Medicare Advantage	$2,684.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,990.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,990.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$828.41
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	$2,990.31
Rate for Payer: Cigna Commercial	$1,660.53
Rate for Payer: Cigna Medicare Advantage	$828.41
Rate for Payer: Clover Medicare Advantage	$786.99
Rate for Payer: EmblemHealth Commercial	$2,485.23
Rate for Payer: Humana Medicare Advantage	$853.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$828.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$982.39
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$491.20
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$78.92
Rate for Payer: UnitedHealthcare Medicare Advantage	$828.41
Rate for Payer: Wellcare Medicare Advantage	$828.41
Rate for Payer: Wellpoint Medicaid Managed Care	$86.78

XR REMOVE URETER STENT PERC

Facility

$8,535.00

Service Code	HCPCS 50384
Hospital Charge Code	5600168
Hospital Revenue Code	361
Min. Negotiated Rate	$1,280.25
Max. Negotiated Rate	$1,280.25
Rate for Payer: Qualcare PPO/HMO/WC	$1,280.25

XR REMOVE URETER STENT PERC

Facility

$8,535.00

Service Code	HCPCS 50384
Hospital Charge Code	5600168
Hospital Revenue Code	361
Min. Negotiated Rate	$205.69
Max. Negotiated Rate	$8,964.44
Rate for Payer: Aetna Commercial	$6,754.93
Rate for Payer: Aetna Medicare Advantage	$8,046.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,964.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,964.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,483.43
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	$8,964.44
Rate for Payer: Cigna Commercial	$4,978.04
Rate for Payer: Cigna Medicare Advantage	$2,483.43
Rate for Payer: Clover Medicare Advantage	$2,359.26
Rate for Payer: EmblemHealth Commercial	$7,450.29
Rate for Payer: Humana Medicare Advantage	$2,557.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,483.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,560.50
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,280.25
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$205.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,483.43
Rate for Payer: Wellcare Medicare Advantage	$2,483.43
Rate for Payer: Wellpoint Medicaid Managed Care	$226.18

XR REPAIR ARTERIAL BLOCK (TUB)

Facility

$14,067.00

Service Code	HCPCS 35459
Hospital Charge Code	2011283
Hospital Revenue Code	761
Min. Negotiated Rate	$2,110.05
Max. Negotiated Rate	$2,110.05
Rate for Payer: Qualcare PPO/HMO/WC	$2,110.05

XR REPAIR ARTERIAL BLOCK (TUB)

Facility

$14,067.00

Service Code	HCPCS 35459
Hospital Charge Code	2011283
Hospital Revenue Code	761
Min. Negotiated Rate	$339.01
Max. Negotiated Rate	$7,033.50
Rate for Payer: Aetna Commercial	$5,345.46
Rate for Payer: Aetna Medicare Advantage	$4,220.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,587.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,587.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,587.09
Rate for Payer: Cigna Commercial	$7,033.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,220.10
Rate for Payer: Oxford Commercial	$2,813.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,110.05
Rate for Payer: UnitedHealthcare Commercial	$2,813.40
Rate for Payer: UnitedHealthcare Community & State	$339.01
Rate for Payer: Wellpoint Medicaid Managed Care	$372.78

XR REPAIR TUNNELED CV CATH

Facility

$2,087.20

Service Code	HCPCS 36575
Hospital Charge Code	7411462
Hospital Revenue Code	361
Min. Negotiated Rate	$313.08
Max. Negotiated Rate	$313.08
Rate for Payer: Qualcare PPO/HMO/WC	$313.08

XR REPAIR TUNNELED CV CATH

Facility

$2,087.20

Service Code	HCPCS 36575
Hospital Charge Code	7411462
Hospital Revenue Code	361
Min. Negotiated Rate	$50.30
Max. Negotiated Rate	$3,593.00
Rate for Payer: Aetna Commercial	$2,027.08
Rate for Payer: Aetna Medicare Advantage	$2,414.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,690.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,690.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$745.25
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	$2,690.13
Rate for Payer: Cigna Commercial	$1,493.86
Rate for Payer: Cigna Medicare Advantage	$745.25
Rate for Payer: Clover Medicare Advantage	$707.99
Rate for Payer: EmblemHealth Commercial	$2,235.75
Rate for Payer: Humana Medicare Advantage	$767.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$745.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$626.16
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$313.08
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$50.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$745.25
Rate for Payer: Wellcare Medicare Advantage	$745.25
Rate for Payer: Wellpoint Medicaid Managed Care	$55.31

XR REPAIR TUNNELED CV CATH

Facility

$2,087.20

Service Code	HCPCS 36575
Hospital Charge Code	5600131
Hospital Revenue Code	361
Min. Negotiated Rate	$50.30
Max. Negotiated Rate	$3,593.00
Rate for Payer: Aetna Commercial	$2,027.08
Rate for Payer: Aetna Medicare Advantage	$2,414.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,690.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,690.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$745.25
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	$2,690.13
Rate for Payer: Cigna Commercial	$1,493.86
Rate for Payer: Cigna Medicare Advantage	$745.25
Rate for Payer: Clover Medicare Advantage	$707.99
Rate for Payer: EmblemHealth Commercial	$2,235.75
Rate for Payer: Humana Medicare Advantage	$767.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$745.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$626.16
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$313.08
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$50.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$745.25
Rate for Payer: Wellcare Medicare Advantage	$745.25
Rate for Payer: Wellpoint Medicaid Managed Care	$55.31

XR REPAIR TUNNELED CV CATH

Facility

$2,087.20

Service Code	HCPCS 36575
Hospital Charge Code	5600131
Hospital Revenue Code	361
Min. Negotiated Rate	$313.08
Max. Negotiated Rate	$313.08
Rate for Payer: Qualcare PPO/HMO/WC	$313.08

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	5600132
Hospital Revenue Code	361
Min. Negotiated Rate	$1,697.32
Max. Negotiated Rate	$1,697.32
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	5600132
Hospital Revenue Code	361
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,394.64
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$272.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$299.86

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	411093600
Hospital Revenue Code	481
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,194.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,394.64
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$272.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$299.86

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	411093600
Hospital Revenue Code	481
Min. Negotiated Rate	$1,697.32
Max. Negotiated Rate	$1,697.32
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	7411464
Hospital Revenue Code	361
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
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	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$3,751.17
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,394.64
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$272.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$299.86

XR REPALCE TUN CV CATH W PUMP

Facility

$11,315.45

Service Code	HCPCS 36578
Hospital Charge Code	7411464
Hospital Revenue Code	361
Min. Negotiated Rate	$1,697.32
Max. Negotiated Rate	$1,697.32
Rate for Payer: Qualcare PPO/HMO/WC	$1,697.32

XR REPEAT GB GRANULES

Facility

$463.25

Service Code	HCPCS 74291
Hospital Charge Code	2000297
Hospital Revenue Code	320
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$176.03
Rate for Payer: Aetna Medicare Advantage	$138.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$118.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$118.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$118.13
Rate for Payer: Cigna Commercial	$231.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$138.97
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$69.49
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$11.16
Rate for Payer: Wellpoint Medicaid Managed Care	$12.28

XR REPEAT GB GRANULES

Facility

$463.25

Service Code	HCPCS 74291
Hospital Charge Code	2000297
Hospital Revenue Code	320
Min. Negotiated Rate	$69.49
Max. Negotiated Rate	$69.49
Rate for Payer: Qualcare PPO/HMO/WC	$69.49

Know your out-of-pocket cost for care.

All Charges