Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR SPINE CRVCAL W/FLXT& OR/EXT

Facility

$440.25

Service Code	HCPCS 72052
Hospital Charge Code	2011389
Hospital Revenue Code	320
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$66.04
Rate for Payer: Qualcare PPO/HMO/WC	$66.04

XR SPINE ENTIRE

Facility

$1,051.25

Hospital Charge Code	2000644
Hospital Revenue Code	320
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$399.48
Rate for Payer: Aetna Medicare Advantage	$315.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$268.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$268.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$268.07
Rate for Payer: Cigna Commercial	$525.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$315.38
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$157.69
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$25.34
Rate for Payer: Wellpoint Medicaid Managed Care	$27.86

XR SPINE ENTIRE

Facility

$1,051.25

Hospital Charge Code	2000644
Hospital Revenue Code	320
Min. Negotiated Rate	$157.69
Max. Negotiated Rate	$157.69
Rate for Payer: Qualcare PPO/HMO/WC	$157.69

XR SPINE LS AP & LAT

Facility

$6,601.19

Service Code	HCPCS 72100
Hospital Charge Code	2000677
Hospital Revenue Code	320
Min. Negotiated Rate	$42.59
Max. Negotiated Rate	$1,980.36
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	$42.59
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	$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	$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	$174.93

XR SPINE LS AP & LAT

Facility

$6,601.19

Service Code	HCPCS 72100
Hospital Charge Code	2000677
Hospital Revenue Code	320
Min. Negotiated Rate	$990.18
Max. Negotiated Rate	$990.18
Rate for Payer: Qualcare PPO/HMO/WC	$990.18

XR SPINE LS BENDING ONLY MIN 4

Facility

$760.00

Service Code	HCPCS 72120
Hospital Charge Code	2011115
Hospital Revenue Code	320
Min. Negotiated Rate	$18.32
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	$38.72
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	$228.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$114.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$18.32
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$20.14

XR SPINE LS BENDING ONLY MIN 4

Facility

$760.00

Service Code	HCPCS 72120
Hospital Charge Code	2011115
Hospital Revenue Code	320
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$114.00
Rate for Payer: Qualcare PPO/HMO/WC	$114.00

XR SPINE LS COMPLETE INC BEND

Facility

$5,100.00

Service Code	HCPCS 72114
Hospital Charge Code	2011110
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SPINE LS COMPLETE INC BEND

Facility

$5,100.00

Service Code	HCPCS 72114
Hospital Charge Code	2011110
Hospital Revenue Code	320
Min. Negotiated Rate	$54.21
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	$54.21
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	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
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	$135.15

XR SPINE SCOLIOSIS SPNE & STND

Facility

$440.25

Hospital Charge Code	2011390
Hospital Revenue Code	320
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$66.04
Rate for Payer: Qualcare PPO/HMO/WC	$66.04

XR SPINE SCOLIOSIS SPNE & STND

Facility

$440.25

Hospital Charge Code	2011390
Hospital Revenue Code	320
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$167.29
Rate for Payer: Aetna Medicare Advantage	$132.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.26
Rate for Payer: Cigna Commercial	$220.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.07
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$66.04
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$10.61
Rate for Payer: Wellpoint Medicaid Managed Care	$11.67

XR SPINE THORACIC AP & LAB SWI

Facility

$704.00

Service Code	HCPCS 72072
Hospital Charge Code	2011105
Hospital Revenue Code	320
Min. Negotiated Rate	$105.60
Max. Negotiated Rate	$105.60
Rate for Payer: Qualcare PPO/HMO/WC	$105.60

XR SPINE THORACIC AP & LAB SWI

Facility

$704.00

Service Code	HCPCS 72072
Hospital Charge Code	2011105
Hospital Revenue Code	320
Min. Negotiated Rate	$16.97
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	$38.72
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	$211.20
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$105.60
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$16.97
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	$18.66

XR SPINE THORACOLUMBAR 2 VIEWS

Facility

$258.70

Service Code	HCPCS 72080
Hospital Charge Code	2011393
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR SPINE THORACOLUMBAR 2 VIEWS

Facility

$258.70

Service Code	HCPCS 72080
Hospital Charge Code	2011393
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	$36.80
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: Wellcare New Jersey Medicaid/Family Care	$216.59
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR SPINE THOR/LUM CHILD MIN 2V

Facility

$5,100.00

Service Code	HCPCS 72082
Hospital Charge Code	2002186
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SPINE THOR/LUM CHILD MIN 2V

Facility

$5,100.00

Service Code	HCPCS 72082
Hospital Charge Code	2002186
Hospital Revenue Code	320
Min. Negotiated Rate	$67.12
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	$67.12
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	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
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	$135.15

XR SPLENOPORTOGRAM

Facility

$3,084.40

Service Code	HCPCS 75810
Hospital Charge Code	2011394
Hospital Revenue Code	320
Min. Negotiated Rate	$74.33
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	$121.00
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	$2,625.82
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	$925.32
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$462.66
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$74.33
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	$81.74

XR SPLENOPORTOGRAM

Facility

$3,084.40

Service Code	HCPCS 75810
Hospital Charge Code	2011394
Hospital Revenue Code	320
Min. Negotiated Rate	$462.66
Max. Negotiated Rate	$462.66
Rate for Payer: Qualcare PPO/HMO/WC	$462.66

XR SPNE CERVCAL CRSS-TBLE LTRL

Facility

$430.45

Service Code	HCPCS 72020
Hospital Charge Code	2011388
Hospital Revenue Code	320
Min. Negotiated Rate	$10.37
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	$23.60
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	$129.13
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$64.57
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$10.37
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	$11.41

XR SPNE CERVCAL CRSS-TBLE LTRL

Facility

$430.45

Service Code	HCPCS 72020
Hospital Charge Code	2011388
Hospital Revenue Code	320
Min. Negotiated Rate	$64.57
Max. Negotiated Rate	$64.57
Rate for Payer: Qualcare PPO/HMO/WC	$64.57

XR SPNE SNGLE VIEW SPECIFY LVL

Facility

$258.70

Service Code	HCPCS 72020
Hospital Charge Code	2011391
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	$23.60
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: Wellcare New Jersey Medicaid/Family Care	$216.59
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR SPNE SNGLE VIEW SPECIFY LVL

Facility

$258.70

Service Code	HCPCS 72020
Hospital Charge Code	2011391
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR SPNE THORACIC MINIMUM 4 VWS

Facility

$258.70

Service Code	HCPCS 72074
Hospital Charge Code	2011392
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

XR SPNE THORACIC MINIMUM 4 VWS

Facility

$258.70

Service Code	HCPCS 72074
Hospital Charge Code	2011392
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

Know your out-of-pocket cost for care.

All Charges