Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

IR VASC SEL CATH INTR 1ST T/B

Facility

$1,518.00

Service Code	HCPCS 36215
Hospital Charge Code	2004307
Hospital Revenue Code	361
Min. Negotiated Rate	$43.11
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$576.84
Rate for Payer: Aetna Medicare Advantage	$455.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$387.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$387.09
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	$387.09
Rate for Payer: Cigna Commercial	$759.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$394.68
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$227.70
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$47.97
Rate for Payer: Wellpoint Medicaid Managed Care	$43.11

IR VASC SEL CATH INTRO 2ND T/B

Facility

$2,794.00

Service Code	HCPCS 36216
Hospital Charge Code	2004315
Hospital Revenue Code	361
Min. Negotiated Rate	$79.35
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$1,061.72
Rate for Payer: Aetna Medicare Advantage	$838.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$712.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$712.47
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	$712.47
Rate for Payer: Cigna Commercial	$1,397.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$726.44
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$419.10
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$88.29
Rate for Payer: Wellpoint Medicaid Managed Care	$79.35

IR VASC SEL CATH INTRO 2ND T/B

Facility

$2,794.00

Service Code	HCPCS 36216
Hospital Charge Code	2004315
Hospital Revenue Code	361
Min. Negotiated Rate	$419.10
Max. Negotiated Rate	$419.10
Rate for Payer: Qualcare PPO/HMO/WC	$419.10

IR VASC SEL CATH INTRO 2ND T/B

Facility

$2,794.00

Service Code	HCPCS 36216
Hospital Charge Code	7411427
Hospital Revenue Code	361
Min. Negotiated Rate	$79.35
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$1,061.72
Rate for Payer: Aetna Medicare Advantage	$838.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$712.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$712.47
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	$712.47
Rate for Payer: Cigna Commercial	$1,397.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$726.44
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$419.10
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$88.29
Rate for Payer: Wellpoint Medicaid Managed Care	$79.35

IR VASC SEL CATH INTRO 2ND T/B

Facility

$2,794.00

Service Code	HCPCS 36216
Hospital Charge Code	7411427
Hospital Revenue Code	361
Min. Negotiated Rate	$419.10
Max. Negotiated Rate	$419.10
Rate for Payer: Qualcare PPO/HMO/WC	$419.10

IR VASC SEL CATH INTRO 3RD T/B

Facility

$486.00

Service Code	HCPCS 36217
Hospital Charge Code	321036217
Hospital Revenue Code	361
Min. Negotiated Rate	$72.90
Max. Negotiated Rate	$72.90
Rate for Payer: Qualcare PPO/HMO/WC	$72.90

IR VASC SEL CATH INTRO 3RD T/B

Facility

$3,316.00

Service Code	HCPCS 36217
Hospital Charge Code	7411428
Hospital Revenue Code	361
Min. Negotiated Rate	$94.17
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$1,260.08
Rate for Payer: Aetna Medicare Advantage	$994.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$845.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$845.58
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	$845.58
Rate for Payer: Cigna Commercial	$1,658.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$862.16
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$497.40
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$104.79
Rate for Payer: Wellpoint Medicaid Managed Care	$94.17

IR VASC SEL CATH INTRO 3RD T/B

Facility

$486.00

Service Code	HCPCS 36217
Hospital Charge Code	321036217
Hospital Revenue Code	361
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$184.68
Rate for Payer: Aetna Medicare Advantage	$145.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$123.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$123.93
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	$123.93
Rate for Payer: Cigna Commercial	$243.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$126.36
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$72.90
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$15.36
Rate for Payer: Wellpoint Medicaid Managed Care	$13.80

IR VASC SEL CATH INTRO 3RD T/B

Facility

$486.00

Service Code	HCPCS 36217
Hospital Charge Code	2004158
Hospital Revenue Code	361
Min. Negotiated Rate	$72.90
Max. Negotiated Rate	$72.90
Rate for Payer: Qualcare PPO/HMO/WC	$72.90

IR VASC SEL CATH INTRO 3RD T/B

Facility

$486.00

Service Code	HCPCS 36217
Hospital Charge Code	2004158
Hospital Revenue Code	361
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$3,536.00
Rate for Payer: Aetna Commercial	$184.68
Rate for Payer: Aetna Medicare Advantage	$145.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$123.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$123.93
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	$123.93
Rate for Payer: Cigna Commercial	$243.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$126.36
Rate for Payer: Oxford Commercial	$2,297.00
Rate for Payer: Qualcare PPO/HMO/WC	$72.90
Rate for Payer: UnitedHealthcare Commercial	$2,256.00
Rate for Payer: UnitedHealthcare Community & State	$15.36
Rate for Payer: Wellpoint Medicaid Managed Care	$13.80

IR VASC SEL CATH INTRO 3RD T/B

Facility

$3,316.00

Service Code	HCPCS 36217
Hospital Charge Code	7411428
Hospital Revenue Code	361
Min. Negotiated Rate	$497.40
Max. Negotiated Rate	$497.40
Rate for Payer: Qualcare PPO/HMO/WC	$497.40

IR VASOGRAPHY VESICULOGRAPHYEP

Facility

$1,046.00

Service Code	HCPCS 74440
Hospital Charge Code	7411680
Hospital Revenue Code	320
Min. Negotiated Rate	$29.71
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$39.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$198.43
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$271.96
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$156.90
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$33.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$29.71

IR VASOGRAPHY VESICULOGRAPHYEP

Facility

$1,046.00

Service Code	HCPCS 74440
Hospital Charge Code	2680305
Hospital Revenue Code	320
Min. Negotiated Rate	$29.71
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$39.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$198.43
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$271.96
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$156.90
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$33.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$29.71

IR VASOGRAPHY VESICULOGRAPHYEP

Facility

$1,046.00

Service Code	HCPCS 74440
Hospital Charge Code	7411680
Hospital Revenue Code	320
Min. Negotiated Rate	$156.90
Max. Negotiated Rate	$156.90
Rate for Payer: Qualcare PPO/HMO/WC	$156.90

IR VASOGRAPHY VESICULOGRAPHYEP

Facility

$1,046.00

Service Code	HCPCS 74440
Hospital Charge Code	2680305
Hospital Revenue Code	320
Min. Negotiated Rate	$156.90
Max. Negotiated Rate	$156.90
Rate for Payer: Qualcare PPO/HMO/WC	$156.90

IR VENA CAVAGRAM SUPERIOR

Facility

$3,630.70

Service Code	HCPCS 75827
Hospital Charge Code	321075827
Hospital Revenue Code	320
Min. Negotiated Rate	$103.11
Max. Negotiated Rate	$6,783.93
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$343.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,783.93
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,309.10
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$943.98
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$544.61
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$114.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$103.11

IR VENA CAVAGRAM SUPERIOR

Facility

$3,630.70

Service Code	HCPCS 75827
Hospital Charge Code	321075827
Hospital Revenue Code	320
Min. Negotiated Rate	$544.61
Max. Negotiated Rate	$544.61
Rate for Payer: Qualcare PPO/HMO/WC	$544.61

IR VENA CAVAGRAM SUPERIOR

Facility

$3,084.40

Service Code	HCPCS 75827
Hospital Charge Code	7411712
Hospital Revenue Code	320
Min. Negotiated Rate	$462.66
Max. Negotiated Rate	$462.66
Rate for Payer: Qualcare PPO/HMO/WC	$462.66

IR VENA CAVAGRAM SUPERIOR

Facility

$3,630.70

Service Code	HCPCS 75827
Hospital Charge Code	2002228
Hospital Revenue Code	320
Min. Negotiated Rate	$103.11
Max. Negotiated Rate	$6,783.93
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$343.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,783.93
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,309.10
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$943.98
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$544.61
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$114.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$103.11

IR VENA CAVAGRAM SUPERIOR

Facility

$3,630.70

Service Code	HCPCS 75827
Hospital Charge Code	2002228
Hospital Revenue Code	320
Min. Negotiated Rate	$544.61
Max. Negotiated Rate	$544.61
Rate for Payer: Qualcare PPO/HMO/WC	$544.61

IR VENA CAVAGRAM SUPERIOR

Facility

$3,084.40

Service Code	HCPCS 75827
Hospital Charge Code	7411712
Hospital Revenue Code	320
Min. Negotiated Rate	$87.60
Max. Negotiated Rate	$6,783.93
Rate for Payer: Aetna Commercial	$5,086.78
Rate for Payer: Aetna Medicare Advantage	$6,059.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,783.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,870.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$343.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,783.93
Rate for Payer: Cigna Commercial	$3,748.67
Rate for Payer: Cigna Medicare Advantage	$1,309.10
Rate for Payer: Clover Medicare Advantage	$1,776.63
Rate for Payer: EmblemHealth Commercial	$5,610.42
Rate for Payer: Humana Medicare Advantage	$1,926.24
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,870.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$801.94
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$462.66
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$97.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,870.14
Rate for Payer: Wellcare Medicare Advantage	$1,870.14
Rate for Payer: Wellpoint Medicaid Managed Care	$87.60

IR VENA RENAL UNILAT SELECTIVE

Facility

$15,468.50

Service Code	HCPCS 75831
Hospital Charge Code	2002230
Hospital Revenue Code	320
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

IR VENA RENAL UNILAT SELECTIVE

Facility

$15,468.50

Service Code	HCPCS 75831
Hospital Charge Code	2002230
Hospital Revenue Code	320
Min. Negotiated Rate	$269.53
Max. Negotiated Rate	$13,607.37
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	$13,607.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,607.37
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	$269.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,607.37
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	$4,021.81
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$488.80
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	$439.31

IR VENA RENAL UNILAT SELECTIVE

Facility

$15,468.50

Service Code	HCPCS 75831
Hospital Charge Code	321075831
Hospital Revenue Code	320
Min. Negotiated Rate	$269.53
Max. Negotiated Rate	$13,607.37
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	$13,607.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,607.37
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	$269.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,607.37
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	$4,021.81
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$488.80
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	$439.31

IR VENA RENAL UNILAT SELECTIVE

Facility

$15,468.50

Service Code	HCPCS 75831
Hospital Charge Code	321075831
Hospital Revenue Code	320
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

Know your out-of-pocket cost for care.

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