Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

HERPES 1&2 IGM I

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	39990100A
Hospital Revenue Code	302
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.61
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
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	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HERPES 1&2 IGM II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990100B
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HERPES 1&2 IGM II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990100B
Hospital Revenue Code	302
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$52.63
Rate for Payer: Aetna Medicare Advantage	$62.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$69.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$69.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$19.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$69.85
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$19.35
Rate for Payer: Clover Medicare Advantage	$18.38
Rate for Payer: EmblemHealth Commercial	$58.05
Rate for Payer: Humana Medicare Advantage	$19.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$19.35
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	$15.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.35
Rate for Payer: Wellcare Medicare Advantage	$19.35
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HERPES (HSV) CULTURE/TYPING

Facility

$287.25

Service Code	HCPCS 87255
Hospital Charge Code	3009249
Hospital Revenue Code	309
Min. Negotiated Rate	$43.09
Max. Negotiated Rate	$43.09
Rate for Payer: Qualcare PPO/HMO/WC	$43.09

HERPES (HSV) CULTURE/TYPING

Facility

$287.25

Service Code	HCPCS 87255
Hospital Charge Code	3009249
Hospital Revenue Code	309
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$143.62
Rate for Payer: Aetna Commercial	$92.10
Rate for Payer: Aetna Medicare Advantage	$109.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$122.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$122.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$33.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$122.22
Rate for Payer: Cigna Commercial	$143.62
Rate for Payer: Cigna Medicare Advantage	$33.86
Rate for Payer: Clover Medicare Advantage	$32.17
Rate for Payer: EmblemHealth Commercial	$101.58
Rate for Payer: Humana Medicare Advantage	$34.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$33.86
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$86.17
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$43.09
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$27.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.86
Rate for Payer: Wellcare Medicare Advantage	$33.86
Rate for Payer: Wellpoint Medicaid Managed Care	$7.61

HERPES I & II ABS IGG IGM

Facility

$388.85

Hospital Charge Code	3009254
Hospital Revenue Code	302
Min. Negotiated Rate	$58.33
Max. Negotiated Rate	$58.33
Rate for Payer: Qualcare PPO/HMO/WC	$58.33

HERPES I & II ABS IGG IGM

Facility

$388.85

Hospital Charge Code	3009254
Hospital Revenue Code	302
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$194.43
Rate for Payer: Aetna Commercial	$147.76
Rate for Payer: Aetna Medicare Advantage	$116.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.16
Rate for Payer: Cigna Commercial	$194.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$116.66
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.33
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.37
Rate for Payer: Wellpoint Medicaid Managed Care	$10.30

HERPES SIMP DIR PROBE

Facility

$248.54

Service Code	HCPCS 87529
Hospital Charge Code	38478111
Hospital Revenue Code	306
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$126.66
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$126.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$126.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$38.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$124.27
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.56
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.28
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$6.59

HERPES SIMP DIR PROBE

Facility

$248.54

Service Code	HCPCS 87529
Hospital Charge Code	38478111
Hospital Revenue Code	306
Min. Negotiated Rate	$37.28
Max. Negotiated Rate	$37.28
Rate for Payer: Qualcare PPO/HMO/WC	$37.28

HERPES SIMPLEX CULTURE & TYPIN

Facility

$296.00

Service Code	HCPCS 87252
Hospital Charge Code	38475009
Hospital Revenue Code	309
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$70.91
Rate for Payer: Aetna Medicare Advantage	$84.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$94.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$94.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$26.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$57.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$94.10
Rate for Payer: Cigna Commercial	$148.00
Rate for Payer: Cigna Medicare Advantage	$26.07
Rate for Payer: Clover Medicare Advantage	$24.77
Rate for Payer: EmblemHealth Commercial	$78.21
Rate for Payer: Humana Medicare Advantage	$26.85
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$26.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$88.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$44.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$26.07
Rate for Payer: Wellcare Medicare Advantage	$26.07
Rate for Payer: Wellpoint Medicaid Managed Care	$7.84

HERPES SIMPLEX CULTURE & TYPIN

Facility

$296.00

Service Code	HCPCS 87252
Hospital Charge Code	38475009
Hospital Revenue Code	309
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$44.40
Rate for Payer: Qualcare PPO/HMO/WC	$44.40

HERPES SIMPLEX (HSV) I/II IGG

Facility

$138.70

Service Code	HCPCS 86694
Hospital Charge Code	3009253
Hospital Revenue Code	302
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$39.14
Rate for Payer: Aetna Medicare Advantage	$46.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.94
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare Advantage	$14.39
Rate for Payer: Clover Medicare Advantage	$13.67
Rate for Payer: EmblemHealth Commercial	$43.17
Rate for Payer: Humana Medicare Advantage	$14.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$41.61
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.80
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.39
Rate for Payer: Wellcare Medicare Advantage	$14.39
Rate for Payer: Wellpoint Medicaid Managed Care	$3.68

HERPES SIMPLEX (HSV) I/II IGG

Facility

$138.70

Service Code	HCPCS 86694
Hospital Charge Code	3009253
Hospital Revenue Code	302
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$20.80

HERPES SIMPLEX I AB

Facility

$231.25

Service Code	HCPCS 86695
Hospital Charge Code	3009255
Hospital Revenue Code	302
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.61
Rate for Payer: Cigna Commercial	$115.62
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$69.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$34.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$6.13

HERPES SIMPLEX I AB

Facility

$231.25

Service Code	HCPCS 86695
Hospital Charge Code	3009255
Hospital Revenue Code	302
Min. Negotiated Rate	$34.69
Max. Negotiated Rate	$34.69
Rate for Payer: Qualcare PPO/HMO/WC	$34.69

HERPES SIMPLEX II AB

Facility

$138.70

Service Code	HCPCS 86694
Hospital Charge Code	3009248
Hospital Revenue Code	302
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$20.80

HERPES SIMPLEX II AB

Facility

$138.70

Service Code	HCPCS 86694
Hospital Charge Code	3009248
Hospital Revenue Code	302
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$39.14
Rate for Payer: Aetna Medicare Advantage	$46.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.94
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare Advantage	$14.39
Rate for Payer: Clover Medicare Advantage	$13.67
Rate for Payer: EmblemHealth Commercial	$43.17
Rate for Payer: Humana Medicare Advantage	$14.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$41.61
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.80
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.39
Rate for Payer: Wellcare Medicare Advantage	$14.39
Rate for Payer: Wellpoint Medicaid Managed Care	$3.68

HERPES SIMPLEX NES ANTBDY

Facility

$390.00

Service Code	HCPCS 86694
Hospital Charge Code	401386694
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HERPES SIMPLEX NES ANTBDY

Facility

$390.00

Service Code	HCPCS 86694
Hospital Charge Code	401386694
Hospital Revenue Code	306
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$39.14
Rate for Payer: Aetna Medicare Advantage	$46.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.94
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.39
Rate for Payer: Clover Medicare Advantage	$13.67
Rate for Payer: EmblemHealth Commercial	$43.17
Rate for Payer: Humana Medicare Advantage	$14.82
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.39
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	$11.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.39
Rate for Payer: Wellcare Medicare Advantage	$14.39
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HERPES SIMPLEX TYPE 1 TEST

Facility

$65.95

Service Code	HCPCS 86695
Hospital Charge Code	401386695C
Hospital Revenue Code	302
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$9.89
Rate for Payer: Qualcare PPO/HMO/WC	$9.89

HERPES SIMPLEX TYPE 1 TEST

Facility

$65.95

Service Code	HCPCS 86695
Hospital Charge Code	401386695C
Hospital Revenue Code	302
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.61
Rate for Payer: Cigna Commercial	$32.98
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.79
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.89
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$1.75

HERPES SIMPLEX TYPE 2 TEST

Facility

$96.75

Service Code	HCPCS 86696
Hospital Charge Code	401386696C
Hospital Revenue Code	302
Min. Negotiated Rate	$14.51
Max. Negotiated Rate	$14.51
Rate for Payer: Qualcare PPO/HMO/WC	$14.51

HERPES SIMPLEX TYPE 2 TEST

Facility

$96.75

Service Code	HCPCS 86696
Hospital Charge Code	401386696C
Hospital Revenue Code	302
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$52.63
Rate for Payer: Aetna Medicare Advantage	$62.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$69.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$69.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$19.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$69.85
Rate for Payer: Cigna Commercial	$48.38
Rate for Payer: Cigna Medicare Advantage	$19.35
Rate for Payer: Clover Medicare Advantage	$18.38
Rate for Payer: EmblemHealth Commercial	$58.05
Rate for Payer: Humana Medicare Advantage	$19.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$19.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.02
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.51
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$15.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.35
Rate for Payer: Wellcare Medicare Advantage	$19.35
Rate for Payer: Wellpoint Medicaid Managed Care	$2.56

HERPES SIMPLEX VIRUS CULT

Facility

$390.00

Service Code	HCPCS 87255
Hospital Charge Code	39900498
Hospital Revenue Code	309
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$92.10
Rate for Payer: Aetna Medicare Advantage	$109.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$122.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$122.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$33.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$122.22
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$33.86
Rate for Payer: Clover Medicare Advantage	$32.17
Rate for Payer: EmblemHealth Commercial	$101.58
Rate for Payer: Humana Medicare Advantage	$34.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$33.86
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	$27.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.86
Rate for Payer: Wellcare Medicare Advantage	$33.86
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HERPES SIMPLEX VIRUS CULT

Facility

$390.00

Service Code	HCPCS 87255
Hospital Charge Code	39900498
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

Know your out-of-pocket cost for care.

All Charges