|
IR BX LYMPH NODE LT
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505LT
|
| Hospital Charge Code |
23001106
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$930.30 |
| Max. Negotiated Rate |
$930.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
|
|
IR BX LYMPH NODE LT
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505LT
|
| Hospital Charge Code |
2250431
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$2,356.76
|
| Rate for Payer: Aetna Medicare Advantage |
$1,860.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,581.51
|
| Rate for Payer: Cigna Commercial |
$3,101.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,612.52
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
| Rate for Payer: UnitedHealthcare Community & State |
$195.98
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$176.14
|
|
|
IR BX LYMPH NODE LT
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505LT
|
| Hospital Charge Code |
2250431
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$930.30 |
| Max. Negotiated Rate |
$930.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
|
|
IR BX LYMPH NODE LT
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505LT
|
| Hospital Charge Code |
23001106
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$2,356.76
|
| Rate for Payer: Aetna Medicare Advantage |
$1,860.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,581.51
|
| Rate for Payer: Cigna Commercial |
$3,101.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,612.52
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
| Rate for Payer: UnitedHealthcare Community & State |
$195.98
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$176.14
|
|
|
IR BX LYMPH NODE RT
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505RT
|
| Hospital Charge Code |
23001105
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$930.30 |
| Max. Negotiated Rate |
$930.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
|
|
IR BX LYMPH NODE RT
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505RT
|
| Hospital Charge Code |
2250430
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$930.30 |
| Max. Negotiated Rate |
$930.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
|
|
IR BX LYMPH NODE RT
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505RT
|
| Hospital Charge Code |
2250430
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$2,356.76
|
| Rate for Payer: Aetna Medicare Advantage |
$1,860.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,581.51
|
| Rate for Payer: Cigna Commercial |
$3,101.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,612.52
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
| Rate for Payer: UnitedHealthcare Community & State |
$195.98
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$176.14
|
|
|
IR BX LYMPH NODE RT
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS 38505RT
|
| Hospital Charge Code |
23001105
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$2,356.76
|
| Rate for Payer: Aetna Medicare Advantage |
$1,860.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,581.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,581.51
|
| Rate for Payer: Cigna Commercial |
$3,101.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,612.52
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$930.30
|
| Rate for Payer: UnitedHealthcare Community & State |
$195.98
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$176.14
|
|
|
IR BX PROCEDURE TRAY
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
4800960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.55
|
|
|
IR BX PROCEDURE TRAY
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
4800960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$18.50 |
| Rate for Payer: Aetna Commercial |
$14.06
|
| Rate for Payer: Aetna Medicare Advantage |
$11.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$9.44
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$9.44
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$9.44
|
| Rate for Payer: Cigna Commercial |
$18.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$9.62
|
| Rate for Payer: Oxford Commercial |
$7.40
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.40
|
| Rate for Payer: UnitedHealthcare Community & State |
$1.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.05
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
IP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 55705
|
| Hospital Charge Code |
321055700
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,528.17 |
| Max. Negotiated Rate |
$1,528.17 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
IP
|
$7,457.80
|
|
|
Service Code
|
HCPCS 55700
|
| Hospital Charge Code |
7411634
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,118.67 |
| Max. Negotiated Rate |
$1,118.67 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,118.67
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
OP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 55705
|
| Hospital Charge Code |
321055700
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$289.33 |
| Max. Negotiated Rate |
$15,191.14 |
| Rate for Payer: Aetna Commercial |
$11,390.73
|
| Rate for Payer: Aetna Medicare Advantage |
$13,568.37
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15,191.14
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15,191.14
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$4,187.77
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15,191.14
|
| Rate for Payer: Cigna Commercial |
$8,394.37
|
| Rate for Payer: Cigna Medicare Advantage |
$4,187.77
|
| Rate for Payer: Clover Medicare Advantage |
$3,978.38
|
| Rate for Payer: EmblemHealth Commercial |
$12,563.31
|
| Rate for Payer: Humana Medicare Advantage |
$4,313.40
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$4,187.77
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,648.83
|
| Rate for Payer: Oxford Commercial |
$5,018.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,347.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$321.93
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4,187.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$4,187.77
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$289.33
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
OP
|
$7,457.80
|
|
|
Service Code
|
HCPCS 55700
|
| Hospital Charge Code |
7411634
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$211.80 |
| Max. Negotiated Rate |
$5,347.00 |
| Rate for Payer: Aetna Commercial |
$2,833.96
|
| Rate for Payer: Aetna Medicare Advantage |
$2,237.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,901.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,901.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,901.74
|
| Rate for Payer: Cigna Commercial |
$3,728.90
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,939.03
|
| Rate for Payer: Oxford Commercial |
$5,018.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,118.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,347.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$235.67
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$211.80
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
IP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 55700
|
| Hospital Charge Code |
2670130
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,528.17 |
| Max. Negotiated Rate |
$1,528.17 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
|
|
IR BX PROSTATE,NEEDLE OR PUNCH
|
Facility
|
OP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 55700
|
| Hospital Charge Code |
2670130
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$289.33 |
| Max. Negotiated Rate |
$5,347.00 |
| Rate for Payer: Aetna Commercial |
$3,871.36
|
| Rate for Payer: Aetna Medicare Advantage |
$3,056.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,597.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,597.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,597.89
|
| Rate for Payer: Cigna Commercial |
$5,093.90
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,648.83
|
| Rate for Payer: Oxford Commercial |
$5,018.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,347.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$321.93
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$289.33
|
|
|
IR BX SPINAL CORD,PERCUTNS NEE
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 62269
|
| Hospital Charge Code |
2670120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$7,117.66 |
| 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 |
$7,117.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$7,117.66
|
| 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 |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$7,117.66
|
| 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 |
$416.00
|
| Rate for Payer: Oxford Commercial |
$5,018.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$240.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,347.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$50.56
|
| 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 |
$45.44
|
|
|
IR BX SPINAL CORD,PERCUTNS NEE
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 62269
|
| Hospital Charge Code |
7411649
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$7,117.66 |
| 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 |
$7,117.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$7,117.66
|
| 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 |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$7,117.66
|
| 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 |
$416.00
|
| Rate for Payer: Oxford Commercial |
$5,018.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$240.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,347.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$50.56
|
| 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 |
$45.44
|
|
|
IR BX SPINAL CORD,PERCUTNS NEE
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 62269
|
| Hospital Charge Code |
7411649
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$240.00
|
|
|
IR BX SPINAL CORD,PERCUTNS NEE
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 62269
|
| Hospital Charge Code |
2670120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$240.00
|
|
|
IR CATH IN ART INIT 2ND BILAT
|
Facility
|
IP
|
$8,697.00
|
|
|
Service Code
|
HCPCS 3624650
|
| Hospital Charge Code |
321036246B
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,304.55 |
| Max. Negotiated Rate |
$1,304.55 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,304.55
|
|
|
IR CATH IN ART INIT 2ND BILAT
|
Facility
|
OP
|
$8,697.00
|
|
|
Service Code
|
HCPCS 3624650
|
| Hospital Charge Code |
321036246B
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$246.99 |
| Max. Negotiated Rate |
$4,348.50 |
| Rate for Payer: Aetna Commercial |
$3,304.86
|
| Rate for Payer: Aetna Medicare Advantage |
$2,609.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,217.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,217.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,217.74
|
| Rate for Payer: Cigna Commercial |
$4,348.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,261.22
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,304.55
|
| Rate for Payer: UnitedHealthcare Community & State |
$274.83
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$246.99
|
|
|
IR CATH IN ART INIT 2ND BILAT
|
Facility
|
OP
|
$17,394.00
|
|
|
Service Code
|
HCPCS 3624650
|
| Hospital Charge Code |
7411796
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$493.99 |
| Max. Negotiated Rate |
$8,697.00 |
| Rate for Payer: Aetna Commercial |
$6,609.72
|
| Rate for Payer: Aetna Medicare Advantage |
$5,218.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4,435.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4,435.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,536.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$4,435.47
|
| Rate for Payer: Cigna Commercial |
$8,697.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,522.44
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,609.10
|
| Rate for Payer: UnitedHealthcare Community & State |
$549.65
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$493.99
|
|
|
IR CATH IN ART INIT 2ND BILAT
|
Facility
|
IP
|
$17,394.00
|
|
|
Service Code
|
HCPCS 3624650
|
| Hospital Charge Code |
7411796
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,609.10 |
| Max. Negotiated Rate |
$2,609.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,609.10
|
|
|
IR CATH IN ART INIT 2ND BILAT
|
Facility
|
IP
|
$8,697.00
|
|
|
Service Code
|
HCPCS 3624650
|
| Hospital Charge Code |
2101167
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,304.55 |
| Max. Negotiated Rate |
$1,304.55 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,304.55
|
|
