Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

XR ARTHROGRAM SHOULDER RT

Facility

$5,100.00

Service Code	HCPCS 73040
Hospital Charge Code	2002270
Hospital Revenue Code	322
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$290.13
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,326.00
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$161.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$144.84

XR ARTHROGRAM SHOULDER RT

Facility

$5,100.00

Service Code	HCPCS 73040
Hospital Charge Code	2002270
Hospital Revenue Code	322
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR ARTHROGRAPHY WRIST LEFT

Facility

$5,100.00

Service Code	HCPCS 73115
Hospital Charge Code	2004942
Hospital Revenue Code	322
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$290.13
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,326.00
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$161.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$144.84

XR ARTHROGRAPHY WRIST LEFT

Facility

$5,100.00

Service Code	HCPCS 73115
Hospital Charge Code	2004942
Hospital Revenue Code	322
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR ARTHROGRAPHY WRIST RIGHT

Facility

$495.00

Service Code	HCPCS 73115
Hospital Charge Code	2004940
Hospital Revenue Code	322
Min. Negotiated Rate	$74.25
Max. Negotiated Rate	$74.25
Rate for Payer: Qualcare PPO/HMO/WC	$74.25

XR ARTHROGRAPHY WRIST RIGHT

Facility

$495.00

Service Code	HCPCS 73115
Hospital Charge Code	2004940
Hospital Revenue Code	322
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$290.13
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$128.70
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$74.25
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$15.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$14.06

X-RAY AORTA LEG ARTERIES

Facility

$12,462.85

Service Code	HCPCS 75630
Hospital Charge Code	366875630
Hospital Revenue Code	323
Min. Negotiated Rate	$1,869.43
Max. Negotiated Rate	$1,869.43
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43

X-RAY AORTA LEG ARTERIES

Facility

$12,462.85

Service Code	HCPCS 75630
Hospital Charge Code	411075630
Hospital Revenue Code	323
Min. Negotiated Rate	$144.38
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	$144.38
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	$3,240.34
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$393.83
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	$353.94

X-RAY AORTA LEG ARTERIES

Facility

$12,462.85

Service Code	HCPCS 75630
Hospital Charge Code	366875630
Hospital Revenue Code	323
Min. Negotiated Rate	$144.38
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	$144.38
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	$3,240.34
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$393.83
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	$353.94

X-RAY AORTA LEG ARTERIES

Facility

$12,462.85

Service Code	HCPCS 75630
Hospital Charge Code	411075630
Hospital Revenue Code	323
Min. Negotiated Rate	$1,869.43
Max. Negotiated Rate	$1,869.43
Rate for Payer: Qualcare PPO/HMO/WC	$1,869.43

X-RAY C/T SPINE DISK

Facility

$6,593.09

Service Code	HCPCS 72285
Hospital Charge Code	2011395
Hospital Revenue Code	320
Min. Negotiated Rate	$988.96
Max. Negotiated Rate	$988.96
Rate for Payer: Qualcare PPO/HMO/WC	$988.96

X-RAY C/T SPINE DISK

Facility

$6,593.09

Service Code	HCPCS 72285
Hospital Charge Code	2011395
Hospital Revenue Code	320
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$8,415.40
Rate for Payer: Aetna Commercial	$6,310.10
Rate for Payer: Aetna Medicare Advantage	$7,516.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,415.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,415.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,319.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,415.40
Rate for Payer: Cigna Commercial	$4,650.22
Rate for Payer: Cigna Medicare Advantage	$1,623.92
Rate for Payer: Clover Medicare Advantage	$2,203.90
Rate for Payer: EmblemHealth Commercial	$6,959.67
Rate for Payer: Humana Medicare Advantage	$2,389.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,319.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,714.20
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$988.96
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$208.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,319.89
Rate for Payer: Wellcare Medicare Advantage	$2,319.89
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$5,656.68
Rate for Payer: Wellpoint Medicaid Managed Care	$187.24

XRAY ENDOVASC THOR AO REPR

Facility

$5,100.00

Service Code	HCPCS 75957
Hospital Charge Code	5701111
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XRAY ENDOVASC THOR AO REPR

Facility

$5,100.00

Service Code	HCPCS 75957
Hospital Charge Code	5701111
Hospital Revenue Code	320
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,326.00
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$161.16
Rate for Payer: Wellpoint Medicaid Managed Care	$144.84

XRAY ENDOVASC THOR AO REPR

Facility

$1,645.10

Service Code	HCPCS 75957
Hospital Charge Code	7411735
Hospital Revenue Code	320
Min. Negotiated Rate	$46.72
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$625.14
Rate for Payer: Aetna Medicare Advantage	$493.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$419.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$419.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$419.50
Rate for Payer: Cigna Commercial	$822.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$427.73
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$246.76
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$51.99
Rate for Payer: Wellpoint Medicaid Managed Care	$46.72

XRAY ENDOVASC THOR AO REPR

Facility

$1,645.10

Service Code	HCPCS 75957
Hospital Charge Code	7411735
Hospital Revenue Code	320
Min. Negotiated Rate	$246.76
Max. Negotiated Rate	$246.76
Rate for Payer: Qualcare PPO/HMO/WC	$246.76

XRAY ENDOVASC THOR AO REPR

Facility

$5,100.00

Service Code	HCPCS 75957
Hospital Charge Code	321075957
Hospital Revenue Code	320
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,326.00
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$161.16
Rate for Payer: Wellpoint Medicaid Managed Care	$144.84

XRAY ENDOVASC THOR AO REPR

Facility

$5,100.00

Service Code	HCPCS 75957
Hospital Charge Code	321075957
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

X-ray exam of forearm

Facility

$181.95

Service Code	HCPCS 73090
Hospital Charge Code	2002201
Hospital Revenue Code	320
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$2,231.00
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	$375.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$375.05
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	$23.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$375.05
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	$47.31
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.29
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$5.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellpoint Medicaid Managed Care	$5.17

X-ray exam of forearm

Facility

$181.95

Service Code	HCPCS 73090
Hospital Charge Code	2002201
Hospital Revenue Code	320
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$27.29
Rate for Payer: Qualcare PPO/HMO/WC	$27.29

X-RAY EXAM PERITONEUM S&I

Facility

$1,365.00

Service Code	HCPCS 74190
Hospital Charge Code	2408010
Hospital Revenue Code	320
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: Qualcare PPO/HMO/WC	$204.75

X-RAY EXAM PERITONEUM S&I

Facility

$1,365.00

Service Code	HCPCS 74190
Hospital Charge Code	2408010
Hospital Revenue Code	320
Min. Negotiated Rate	$38.77
Max. Negotiated Rate	$2,354.83
Rate for Payer: Aetna Commercial	$1,765.72
Rate for Payer: Aetna Medicare Advantage	$2,103.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,354.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,354.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$649.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$87.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,354.83
Rate for Payer: Cigna Commercial	$1,301.24
Rate for Payer: Cigna Medicare Advantage	$454.41
Rate for Payer: Clover Medicare Advantage	$616.70
Rate for Payer: EmblemHealth Commercial	$1,947.48
Rate for Payer: Humana Medicare Advantage	$668.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$649.16
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$354.90
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$204.75
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$43.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$649.16
Rate for Payer: Wellcare Medicare Advantage	$649.16
Rate for Payer: Wellpoint Medicaid Managed Care	$38.77

XRAY UPPER GI W CONTRAST

Facility

$5,100.00

Service Code	HCPCS 74240
Hospital Charge Code	404174240
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XRAY UPPER GI W CONTRAST

Facility

$5,100.00

Service Code	HCPCS 74240
Hospital Charge Code	404174240
Hospital Revenue Code	320
Min. Negotiated Rate	$79.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Aetna Commercial	$566.79
Rate for Payer: Aetna Medicare Advantage	$675.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$208.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$79.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$755.90
Rate for Payer: Cigna Commercial	$417.70
Rate for Payer: Cigna Medicare Advantage	$145.87
Rate for Payer: Clover Medicare Advantage	$197.96
Rate for Payer: EmblemHealth Commercial	$625.14
Rate for Payer: Humana Medicare Advantage	$214.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$208.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,326.00
Rate for Payer: Oxford Commercial	$1,955.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$2,231.00
Rate for Payer: UnitedHealthcare Community & State	$161.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$407.88
Rate for Payer: Wellpoint Medicaid Managed Care	$144.84

XR BARIUM ENEMA SINGLE CONT

Facility

$5,100.00

Service Code	HCPCS 74270
Hospital Charge Code	2000263
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

Know your out-of-pocket cost for care.

All Charges