Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

FUNGAL ISOLATED IDENTIFICATION

Facility

$183.60

Service Code	HCPCS 87107
Hospital Charge Code	397080010
Hospital Revenue Code	309
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$28.07
Rate for Payer: Aetna Medicare Advantage	$33.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$37.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$37.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$37.25
Rate for Payer: Cigna Commercial	$91.80
Rate for Payer: Cigna Medicare Advantage	$10.32
Rate for Payer: Clover Medicare Advantage	$9.80
Rate for Payer: EmblemHealth Commercial	$30.96
Rate for Payer: Humana Medicare Advantage	$10.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.08
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.54
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$8.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.32
Rate for Payer: Wellcare Medicare Advantage	$10.32
Rate for Payer: Wellpoint Medicaid Managed Care	$4.87

FUNGAL ISOLATED IDENTIFICATION

Facility

$183.60

Service Code	HCPCS 87107
Hospital Charge Code	397080010
Hospital Revenue Code	309
Min. Negotiated Rate	$27.54
Max. Negotiated Rate	$27.54
Rate for Payer: Qualcare PPO/HMO/WC	$27.54

FUNGAL SCREEN IMMUNODIFFUSION

Facility

$139.25

Service Code	HCPCS 86606
Hospital Charge Code	3009644
Hospital Revenue Code	302
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.94
Rate for Payer: Aetna Medicare Advantage	$48.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$54.33
Rate for Payer: Cigna Commercial	$69.62
Rate for Payer: Cigna Medicare Advantage	$15.05
Rate for Payer: Clover Medicare Advantage	$14.30
Rate for Payer: EmblemHealth Commercial	$45.15
Rate for Payer: Humana Medicare Advantage	$15.50
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$41.77
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.89
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.05
Rate for Payer: Wellcare Medicare Advantage	$15.05
Rate for Payer: Wellpoint Medicaid Managed Care	$3.69

FUNGAL SCREEN IMMUNODIFFUSION

Facility

$139.25

Service Code	HCPCS 86606
Hospital Charge Code	3009644
Hospital Revenue Code	302
Min. Negotiated Rate	$20.89
Max. Negotiated Rate	$20.89
Rate for Payer: Qualcare PPO/HMO/WC	$20.89

FUNGITELL

Facility

$125.00

Service Code	HCPCS 87449
Hospital Charge Code	3038151
Hospital Revenue Code	306
Min. Negotiated Rate	$18.75
Max. Negotiated Rate	$18.75
Rate for Payer: Qualcare PPO/HMO/WC	$18.75

FUNGITELL

Facility

$125.00

Service Code	HCPCS 87449
Hospital Charge Code	3038151
Hospital Revenue Code	306
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$32.59
Rate for Payer: Aetna Medicare Advantage	$38.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.24
Rate for Payer: Cigna Commercial	$62.50
Rate for Payer: Cigna Medicare Advantage	$11.98
Rate for Payer: Clover Medicare Advantage	$11.38
Rate for Payer: EmblemHealth Commercial	$35.94
Rate for Payer: Humana Medicare Advantage	$12.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.98
Rate for Payer: Wellcare Medicare Advantage	$11.98
Rate for Payer: Wellpoint Medicaid Managed Care	$3.31

FUNGITELL

Facility

$390.00

Service Code	HCPCS 87449
Hospital Charge Code	3038125
Hospital Revenue Code	300
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

FUNGITELL

Facility

$390.00

Service Code	HCPCS 87449
Hospital Charge Code	3038125
Hospital Revenue Code	300
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$32.59
Rate for Payer: Aetna Medicare Advantage	$38.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.24
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$11.98
Rate for Payer: Clover Medicare Advantage	$11.38
Rate for Payer: EmblemHealth Commercial	$35.94
Rate for Payer: Humana Medicare Advantage	$12.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.98
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	$9.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.98
Rate for Payer: Wellcare Medicare Advantage	$11.98
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

FUNGITELL (1-3)B-D-GLUCAN ASSA

Facility

$390.00

Service Code	HCPCS 87449
Hospital Charge Code	401187449
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

FUNGITELL (1-3)B-D-GLUCAN ASSA

Facility

$390.00

Service Code	HCPCS 87449
Hospital Charge Code	401187449
Hospital Revenue Code	306
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$32.59
Rate for Payer: Aetna Medicare Advantage	$38.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.24
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$11.98
Rate for Payer: Clover Medicare Advantage	$11.38
Rate for Payer: EmblemHealth Commercial	$35.94
Rate for Payer: Humana Medicare Advantage	$12.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.98
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	$9.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.98
Rate for Payer: Wellcare Medicare Advantage	$11.98
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

FUNGIZONE IV/50MG

Facility

$233.00

Hospital Charge Code	60633018
Hospital Revenue Code	250
Min. Negotiated Rate	$34.95
Max. Negotiated Rate	$34.95
Rate for Payer: Qualcare PPO/HMO/WC	$34.95

FUNGIZONE IV/50MG

Facility

$233.00

Hospital Charge Code	60633018
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$116.50
Rate for Payer: Aetna Commercial	$88.54
Rate for Payer: Aetna Medicare Advantage	$69.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$59.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$59.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$59.41
Rate for Payer: Cigna Commercial	$116.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$69.90
Rate for Payer: Oxford Commercial	$46.60
Rate for Payer: Qualcare PPO/HMO/WC	$34.95
Rate for Payer: UnitedHealthcare Commercial	$46.60
Rate for Payer: UnitedHealthcare Community & State	$5.62
Rate for Payer: Wellpoint Medicaid Managed Care	$6.17

FUNGUS CULTURE BLOOD

Facility

$63.85

Service Code	HCPCS 87103
Hospital Charge Code	38478095
Hospital Revenue Code	309
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$9.58
Rate for Payer: Qualcare PPO/HMO/WC	$9.58

FUNGUS CULTURE BLOOD

Facility

$63.85

Service Code	HCPCS 87103
Hospital Charge Code	38478095
Hospital Revenue Code	309
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$55.65
Rate for Payer: Aetna Medicare Advantage	$66.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$73.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$73.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$20.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$73.85
Rate for Payer: Cigna Commercial	$31.93
Rate for Payer: Cigna Medicare Advantage	$20.46
Rate for Payer: Clover Medicare Advantage	$19.44
Rate for Payer: EmblemHealth Commercial	$61.38
Rate for Payer: Humana Medicare Advantage	$21.07
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$20.46
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.16
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.58
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.46
Rate for Payer: Wellcare Medicare Advantage	$20.46
Rate for Payer: Wellpoint Medicaid Managed Care	$1.69

FUNGUS CULTURE, OTHER

Facility

$222.00

Service Code	HCPCS 87102
Hospital Charge Code	38475086
Hospital Revenue Code	309
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Qualcare PPO/HMO/WC	$33.30

FUNGUS CULTURE, OTHER

Facility

$222.00

Service Code	HCPCS 87102
Hospital Charge Code	38475086
Hospital Revenue Code	309
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$22.88
Rate for Payer: Aetna Medicare Advantage	$27.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.36
Rate for Payer: Cigna Commercial	$111.00
Rate for Payer: Cigna Medicare Advantage	$8.41
Rate for Payer: Clover Medicare Advantage	$7.99
Rate for Payer: EmblemHealth Commercial	$25.23
Rate for Payer: Humana Medicare Advantage	$8.66
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$66.60
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$33.30
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.41
Rate for Payer: Wellcare Medicare Advantage	$8.41
Rate for Payer: Wellpoint Medicaid Managed Care	$5.88

FUNGUS,DIRECT EXAMINATION (KOH

Facility

$390.00

Service Code	HCPCS 87220
Hospital Charge Code	39900495
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

FUNGUS,DIRECT EXAMINATION (KOH

Facility

$390.00

Service Code	HCPCS 87220
Hospital Charge Code	39900495
Hospital Revenue Code	309
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$11.61
Rate for Payer: Aetna Medicare Advantage	$13.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.41
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$4.27
Rate for Payer: Clover Medicare Advantage	$4.06
Rate for Payer: EmblemHealth Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$4.40
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4.27
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	$3.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.27
Rate for Payer: Wellcare Medicare Advantage	$4.27
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

Fungus (Mycology) Culture

Facility

$390.00

Service Code	HCPCS 87101
Hospital Charge Code	39888012
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

Fungus (Mycology) Culture

Facility

$390.00

Service Code	HCPCS 87101
Hospital Charge Code	39888012
Hospital Revenue Code	309
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$20.97
Rate for Payer: Aetna Medicare Advantage	$24.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$7.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.83
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$7.71
Rate for Payer: Clover Medicare Advantage	$7.32
Rate for Payer: EmblemHealth Commercial	$23.13
Rate for Payer: Humana Medicare Advantage	$7.94
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$7.71
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	$6.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.71
Rate for Payer: Wellcare Medicare Advantage	$7.71
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

FUNGUS SMEAR - INDIA INK

Facility

$189.00

Service Code	HCPCS 87210
Hospital Charge Code	38475056
Hospital Revenue Code	309
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Aetna Medicare Advantage	$18.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.01
Rate for Payer: Cigna Commercial	$94.50
Rate for Payer: Cigna Medicare Advantage	$5.82
Rate for Payer: Clover Medicare Advantage	$5.53
Rate for Payer: EmblemHealth Commercial	$17.46
Rate for Payer: Humana Medicare Advantage	$5.99
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$56.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.35
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.82
Rate for Payer: Wellcare Medicare Advantage	$5.82
Rate for Payer: Wellpoint Medicaid Managed Care	$5.01

FUNGUS SMEAR - INDIA INK

Facility

$189.00

Service Code	HCPCS 87210
Hospital Charge Code	38475056
Hospital Revenue Code	309
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$28.35
Rate for Payer: Qualcare PPO/HMO/WC	$28.35

FUNGUS SMEAR KOH

Facility

$189.00

Service Code	HCPCS 87210
Hospital Charge Code	38475008
Hospital Revenue Code	309
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Aetna Medicare Advantage	$18.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.01
Rate for Payer: Cigna Commercial	$94.50
Rate for Payer: Cigna Medicare Advantage	$5.82
Rate for Payer: Clover Medicare Advantage	$5.53
Rate for Payer: EmblemHealth Commercial	$17.46
Rate for Payer: Humana Medicare Advantage	$5.99
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$56.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.35
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.82
Rate for Payer: Wellcare Medicare Advantage	$5.82
Rate for Payer: Wellpoint Medicaid Managed Care	$5.01

FUNGUS SMEAR KOH

Facility

$189.00

Service Code	HCPCS 87210
Hospital Charge Code	38475008
Hospital Revenue Code	309
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$28.35
Rate for Payer: Qualcare PPO/HMO/WC	$28.35

FURADANTIN/25MG/5ML

Facility

$69.00

Hospital Charge Code	60633019
Hospital Revenue Code	250
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$10.35
Rate for Payer: Qualcare PPO/HMO/WC	$10.35

Know your out-of-pocket cost for care.

All Charges