Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR TIBIA & FIBULA AP & LAT RT

Facility

$6,601.19

Service Code	HCPCS 73590RT
Hospital Charge Code	2000150
Hospital Revenue Code	320
Min. Negotiated Rate	$159.09
Max. Negotiated Rate	$3,300.59
Rate for Payer: Aetna Commercial	$2,508.45
Rate for Payer: Aetna Medicare Advantage	$1,980.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,683.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,683.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,683.30
Rate for Payer: Cigna Commercial	$3,300.59
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: Wellpoint Medicaid Managed Care	$174.93

XR TIBIA/FIBULA BILATERAL

Facility

$6,601.19

Service Code	HCPCS 7359050
Hospital Charge Code	2011399
Hospital Revenue Code	320
Min. Negotiated Rate	$990.18
Max. Negotiated Rate	$990.18
Rate for Payer: Qualcare PPO/HMO/WC	$990.18

XR TIBIA/FIBULA BILATERAL

Facility

$6,601.19

Service Code	HCPCS 7359050
Hospital Charge Code	2011399
Hospital Revenue Code	320
Min. Negotiated Rate	$159.09
Max. Negotiated Rate	$3,300.59
Rate for Payer: Aetna Commercial	$2,508.45
Rate for Payer: Aetna Medicare Advantage	$1,980.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,683.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,683.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,683.30
Rate for Payer: Cigna Commercial	$3,300.59
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: Wellpoint Medicaid Managed Care	$174.93

XR TMJ JOINT BI

Facility

$5,100.00

Service Code	HCPCS 70330
Hospital Charge Code	2000479
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR TMJ JOINT BI

Facility

$5,100.00

Service Code	HCPCS 70330
Hospital Charge Code	2000479
Hospital Revenue Code	320
Min. Negotiated Rate	$38.72
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	$38.72
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	$1,530.00
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	$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	$135.15

XR TMJ OPEN AND CLOSED LEFT

Facility

$258.70

Service Code	HCPCS 70328
Hospital Charge Code	2011400
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR TMJ OPEN AND CLOSED LEFT

Facility

$258.70

Service Code	HCPCS 70328
Hospital Charge Code	2011400
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	$28.48
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	$1,236.59
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR TMJ OPEN AND CLOSED RIGHT

Facility

$258.70

Service Code	HCPCS 70328
Hospital Charge Code	2011401
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	$28.48
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	$1,236.59
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR TMJ OPEN AND CLOSED RIGHT

Facility

$258.70

Service Code	HCPCS 70328
Hospital Charge Code	2011401
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR TOE

Facility

$306.45

Service Code	HCPCS 73660
Hospital Charge Code	2000172
Hospital Revenue Code	320
Min. Negotiated Rate	$45.97
Max. Negotiated Rate	$45.97
Rate for Payer: Qualcare PPO/HMO/WC	$45.97

XR TOE

Facility

$306.45

Service Code	HCPCS 73660
Hospital Charge Code	2000172
Hospital Revenue Code	320
Min. Negotiated Rate	$7.39
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	$13.55
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	$91.94
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$45.97
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$7.39
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	$8.12

XR TOMOGRAPHY

Facility

$635.25

Service Code	HCPCS 76100
Hospital Charge Code	2000933
Hospital Revenue Code	320
Min. Negotiated Rate	$15.31
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	$67.76
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	$190.57
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$95.29
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$15.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$16.83

XR TOMOGRAPHY

Facility

$635.25

Service Code	HCPCS 76100
Hospital Charge Code	2000933
Hospital Revenue Code	320
Min. Negotiated Rate	$95.29
Max. Negotiated Rate	$95.29
Rate for Payer: Qualcare PPO/HMO/WC	$95.29

XR TOMOGRPHY CMPLX MOTION BLTL

Facility

$1,224.75

Service Code	HCPCS 76102
Hospital Charge Code	2011402
Hospital Revenue Code	320
Min. Negotiated Rate	$183.71
Max. Negotiated Rate	$183.71
Rate for Payer: Qualcare PPO/HMO/WC	$183.71

XR TOMOGRPHY CMPLX MOTION BLTL

Facility

$1,224.75

Service Code	HCPCS 76102
Hospital Charge Code	2011402
Hospital Revenue Code	320
Min. Negotiated Rate	$29.52
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$465.40
Rate for Payer: Aetna Medicare Advantage	$367.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$312.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$312.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$312.31
Rate for Payer: Cigna Commercial	$612.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$367.43
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$183.71
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$29.52
Rate for Payer: Wellpoint Medicaid Managed Care	$32.46

XR TOMOGRPHY CMPLX MOTION LEFT

Facility

$602.00

Service Code	HCPCS 76101
Hospital Charge Code	2011403
Hospital Revenue Code	320
Min. Negotiated Rate	$14.51
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$228.76
Rate for Payer: Aetna Medicare Advantage	$180.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$153.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$153.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$153.51
Rate for Payer: Cigna Commercial	$301.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$180.60
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$90.30
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$14.51
Rate for Payer: Wellpoint Medicaid Managed Care	$15.95

XR TOMOGRPHY CMPLX MOTION LEFT

Facility

$602.00

Service Code	HCPCS 76101
Hospital Charge Code	2011403
Hospital Revenue Code	320
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$90.30
Rate for Payer: Qualcare PPO/HMO/WC	$90.30

XR TOMOGRPHY CMPLX MOTION RGHT

Facility

$602.00

Service Code	HCPCS 76101
Hospital Charge Code	2011404
Hospital Revenue Code	320
Min. Negotiated Rate	$14.51
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$228.76
Rate for Payer: Aetna Medicare Advantage	$180.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$153.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$153.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$153.51
Rate for Payer: Cigna Commercial	$301.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$180.60
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$90.30
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$14.51
Rate for Payer: Wellpoint Medicaid Managed Care	$15.95

XR TOMOGRPHY CMPLX MOTION RGHT

Facility

$602.00

Service Code	HCPCS 76101
Hospital Charge Code	2011404
Hospital Revenue Code	320
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$90.30
Rate for Payer: Qualcare PPO/HMO/WC	$90.30

XR TOMOGRPHY SINGLE PLANE LEFT

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011406
Hospital Revenue Code	320
Min. Negotiated Rate	$10.61
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	$67.76
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	$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: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$11.67

XR TOMOGRPHY SINGLE PLANE LEFT

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011406
Hospital Revenue Code	320
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$66.04
Rate for Payer: Qualcare PPO/HMO/WC	$66.04

XR TOMOGRPHY SINGLE PLANE RGHT

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011407
Hospital Revenue Code	320
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$66.04
Rate for Payer: Qualcare PPO/HMO/WC	$66.04

XR TOMOGRPHY SINGLE PLANE RGHT

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011407
Hospital Revenue Code	320
Min. Negotiated Rate	$10.61
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	$67.76
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	$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: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$11.67

XR TOMOGRPHY SNGL PLANE BILTRL

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011405
Hospital Revenue Code	320
Min. Negotiated Rate	$10.61
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	$67.76
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	$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: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$11.67

XR TOMOGRPHY SNGL PLANE BILTRL

Facility

$440.25

Service Code	HCPCS 76100
Hospital Charge Code	2011405
Hospital Revenue Code	320
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$66.04
Rate for Payer: Qualcare PPO/HMO/WC	$66.04

Know your out-of-pocket cost for care.

All Charges