Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

HPV DNA LOW/HIGH RISK II

Facility

$241.20

Service Code	HCPCS 87621
Hospital Charge Code	39990137B
Hospital Revenue Code	306
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$36.18
Rate for Payer: Qualcare PPO/HMO/WC	$36.18

HPV DNA LOW/HIGH RISK II

Facility

$241.20

Service Code	HCPCS 87621
Hospital Charge Code	39990137B
Hospital Revenue Code	306
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$91.66
Rate for Payer: Aetna Medicare Advantage	$72.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$61.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$61.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$61.51
Rate for Payer: Cigna Commercial	$120.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$72.36
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.18
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$5.81
Rate for Payer: Wellpoint Medicaid Managed Care	$6.39

HPV GENOTYPE 16/18 I

Facility

$390.00

Service Code	HCPCS 87625
Hospital Charge Code	39990136A
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HPV GENOTYPE 16/18 I

Facility

$390.00

Service Code	HCPCS 87625
Hospital Charge Code	39990136A
Hospital Revenue Code	306
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$110.30
Rate for Payer: Aetna Medicare Advantage	$131.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$40.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$146.37
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$40.55
Rate for Payer: Clover Medicare Advantage	$38.52
Rate for Payer: EmblemHealth Commercial	$121.65
Rate for Payer: Humana Medicare Advantage	$41.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$40.55
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	$32.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.55
Rate for Payer: Wellcare Medicare Advantage	$40.55
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HPV GENOTYPE 16/18 II

Facility

$390.00

Service Code	HCPCS 87625
Hospital Charge Code	39990136B
Hospital Revenue Code	306
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$110.30
Rate for Payer: Aetna Medicare Advantage	$131.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$40.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$146.37
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$40.55
Rate for Payer: Clover Medicare Advantage	$38.52
Rate for Payer: EmblemHealth Commercial	$121.65
Rate for Payer: Humana Medicare Advantage	$41.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$40.55
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	$32.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.55
Rate for Payer: Wellcare Medicare Advantage	$40.55
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HPV GENOTYPE 16/18 II

Facility

$390.00

Service Code	HCPCS 87625
Hospital Charge Code	39990136B
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HPV HIGH-RISK TYPES

Facility

$241.20

Service Code	HCPCS 87624
Hospital Charge Code	39990235
Hospital Revenue Code	306
Min. Negotiated Rate	$6.39
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$120.60
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	$72.36
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.18
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	$6.39

HPV HIGH-RISK TYPES

Facility

$390.00

Service Code	HCPCS 87624
Hospital Charge Code	38430035
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HPV HIGH-RISK TYPES

Facility

$390.00

Service Code	HCPCS 87624
Hospital Charge Code	38430035
Hospital Revenue Code	306
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$195.00
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	$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	$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	$10.34

HPV HIGH-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87624
Hospital Charge Code	397061379
Hospital Revenue Code	306
Min. Negotiated Rate	$5.05
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$95.22
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	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
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	$5.05

HPV HIGH-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87624
Hospital Charge Code	397061379
Hospital Revenue Code	306
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

HPV HIGH-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87624
Hospital Charge Code	3039035
Hospital Revenue Code	301
Min. Negotiated Rate	$5.05
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$95.22
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	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
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	$5.05

HPV HIGH-RISK TYPES

Facility

$241.20

Service Code	HCPCS 87624
Hospital Charge Code	39990235
Hospital Revenue Code	306
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$36.18
Rate for Payer: Qualcare PPO/HMO/WC	$36.18

HPV HIGH-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87624
Hospital Charge Code	3039035
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

HPV HI RISK TYPES

Facility

$390.00

Service Code	HCPCS 87624
Hospital Charge Code	39990117A
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HPV HI RISK TYPES

Facility

$390.00

Service Code	HCPCS 87624
Hospital Charge Code	39990117A
Hospital Revenue Code	306
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$195.00
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	$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	$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	$10.34

HPV LOW-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87623
Hospital Charge Code	397061378
Hospital Revenue Code	306
Min. Negotiated Rate	$5.05
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$95.22
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	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
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	$5.05

HPV LOW-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87623
Hospital Charge Code	3039034
Hospital Revenue Code	301
Min. Negotiated Rate	$5.05
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$95.22
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	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
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	$5.05

HPV LOW-RISK TYPES

Facility

$241.20

Service Code	HCPCS 87623
Hospital Charge Code	39990234
Hospital Revenue Code	306
Min. Negotiated Rate	$6.39
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$120.60
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	$72.36
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.18
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	$6.39

HPV LOW-RISK TYPES

Facility

$241.20

Service Code	HCPCS 87623
Hospital Charge Code	39990234
Hospital Revenue Code	306
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$36.18
Rate for Payer: Qualcare PPO/HMO/WC	$36.18

HPV LOW-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87623
Hospital Charge Code	3039034
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

HPV LOW-RISK TYPES

Facility

$390.00

Service Code	HCPCS 87623
Hospital Charge Code	38430034
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HPV LOW-RISK TYPES

Facility

$390.00

Service Code	HCPCS 87623
Hospital Charge Code	38430034
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
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	$36.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.66
Rate for Payer: Cigna Commercial	$195.00
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	$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	$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	$10.34

HPV LOW-RISK TYPES

Facility

$190.45

Service Code	HCPCS 87623
Hospital Charge Code	397061378
Hospital Revenue Code	306
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

HPV mRNA E6/E7, RECTAL

Facility

$175.45

Service Code	HCPCS 87624
Hospital Charge Code	401387624
Hospital Revenue Code	306
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$26.32
Rate for Payer: Qualcare PPO/HMO/WC	$26.32

Know your out-of-pocket cost for care.

All Charges