Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

ALLERGY,MUGWORT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479153
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY,MUGWORT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479153
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY PANEL (CMI) DERMAL INJ

Facility

$527.40

Hospital Charge Code	6007694
Hospital Revenue Code	250
Min. Negotiated Rate	$79.11
Max. Negotiated Rate	$79.11
Rate for Payer: Qualcare PPO/HMO/WC	$79.11

ALLERGY PANEL (CMI) DERMAL INJ

Facility

$527.40

Hospital Charge Code	6007694
Hospital Revenue Code	250
Min. Negotiated Rate	$12.71
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna Commercial	$200.41
Rate for Payer: Aetna Medicare Advantage	$158.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$134.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$134.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$134.49
Rate for Payer: Cigna Commercial	$263.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$158.22
Rate for Payer: Oxford Commercial	$105.48
Rate for Payer: Qualcare PPO/HMO/WC	$79.11
Rate for Payer: UnitedHealthcare Commercial	$105.48
Rate for Payer: UnitedHealthcare Community & State	$12.71
Rate for Payer: Wellpoint Medicaid Managed Care	$13.98

ALLERGY,PEANUT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479138
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY,PEANUT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479138
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY,RAGWEED

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479152
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY,RAGWEED

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479152
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY SCALLOP

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479145
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY SCALLOP

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479145
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY,SESAME SEED

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479140
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY,SESAME SEED

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479140
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY,SHRIMP

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479143
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY,SHRIMP

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479143
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY, SOYBEAN

Facility

$596.00

Service Code	HCPCS 86001
Hospital Charge Code	38479136
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY, SOYBEAN

Facility

$596.00

Service Code	HCPCS 86001
Hospital Charge Code	38479136
Hospital Revenue Code	305
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$21.27
Rate for Payer: Aetna Medicare Advantage	$25.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$7.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.23
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$7.82
Rate for Payer: Clover Medicare Advantage	$7.43
Rate for Payer: EmblemHealth Commercial	$23.46
Rate for Payer: Humana Medicare Advantage	$8.05
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$7.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.82
Rate for Payer: Wellcare Medicare Advantage	$7.82
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY,WALNUT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479139
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLERGY,WALNUT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479139
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY, WHEAT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479137
Hospital Revenue Code	305
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$298.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$178.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$15.79

ALLERGY, WHEAT

Facility

$596.00

Service Code	HCPCS 86003
Hospital Charge Code	38479137
Hospital Revenue Code	305
Min. Negotiated Rate	$89.40
Max. Negotiated Rate	$89.40
Rate for Payer: Qualcare PPO/HMO/WC	$89.40

ALLG SPEC IGE CRUDE XTRC EA

Facility

$390.00

Service Code	HCPCS 86003
Hospital Charge Code	401086003
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

ALLG SPEC IGE CRUDE XTRC EA

Facility

$390.00

Service Code	HCPCS 86003
Hospital Charge Code	401086003
Hospital Revenue Code	302
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$14.20
Rate for Payer: Aetna Medicare Advantage	$16.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.22
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	$18.84
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$5.22
Rate for Payer: Clover Medicare Advantage	$4.96
Rate for Payer: EmblemHealth Commercial	$15.66
Rate for Payer: Humana Medicare Advantage	$5.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.22
Rate for Payer: Wellcare Medicare Advantage	$5.22
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

ALLODERM 4CM X 7 CM THINK

Facility

$5,215.00

Service Code	HCPCS Q4116
Hospital Charge Code	270682852
Hospital Revenue Code	636
Min. Negotiated Rate	$782.25
Max. Negotiated Rate	$1,262.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,262.03
Rate for Payer: Qualcare PPO/HMO/WC	$782.25

ALLODERM 4CM X 7 CM THINK

Facility

$5,215.00

Service Code	HCPCS Q4116
Hospital Charge Code	270682852
Hospital Revenue Code	636
Min. Negotiated Rate	$125.68
Max. Negotiated Rate	$1,262.03
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$156.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,262.03
Rate for Payer: Qualcare PPO/HMO/WC	$782.25
Rate for Payer: UnitedHealthcare Community & State	$125.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$138.20

ALLODERM 6 CM x12 CM

Facility

$13,535.00

Service Code	HCPCS Q4116
Hospital Charge Code	270681284
Hospital Revenue Code	278
Min. Negotiated Rate	$2,030.25
Max. Negotiated Rate	$3,275.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,707.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,275.47
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,977.70
Rate for Payer: Qualcare PPO/HMO/WC	$2,030.25

Know your out-of-pocket cost for care.

All Charges