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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510G
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

OP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510M
Hospital Revenue Code	300
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
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	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510F
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510I
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510H
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510N
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

OP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510H
Hospital Revenue Code	300
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
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	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

OP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510K
Hospital Revenue Code	300
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
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	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

OP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510N
Hospital Revenue Code	300
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
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	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

PNEUMOCOCCAL IMMUNITY 14 TYPES

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510L
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14TYP II

Facility

IP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510B
Hospital Revenue Code	300
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

PNEUMOCOCCAL IMMUNITY 14TYP II

Facility

OP

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3038510B
Hospital Revenue Code	300
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
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	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

PNEUMOCOCCAL VACCINE INJ

Facility

OP

$581.96

Service Code	HCPCS 90732
Hospital Charge Code	6009021P
Hospital Revenue Code	636
Min. Negotiated Rate	$14.03
Max. Negotiated Rate	$290.98
Rate for Payer: Aetna Commercial	$221.14
Rate for Payer: Aetna Medicare Advantage	$174.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$148.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$148.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$148.40
Rate for Payer: Cigna Commercial	$290.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$140.83
Rate for Payer: Qualcare PPO/HMO/WC	$87.29
Rate for Payer: UnitedHealthcare Community & State	$14.03
Rate for Payer: Wellpoint Medicaid Managed Care	$15.42

PNEUMOCOCCAL VACCINE INJ

Facility

IP

$581.96

Service Code	NDC 6494300
Hospital Charge Code	6009021
Hospital Revenue Code	259
Min. Negotiated Rate	$87.29
Max. Negotiated Rate	$87.29
Rate for Payer: Qualcare PPO/HMO/WC	$87.29

PNEUMOCOCCAL VACCINE INJ

Facility

OP

$581.96

Service Code	NDC 6494300
Hospital Charge Code	6009021
Hospital Revenue Code	259
Min. Negotiated Rate	$14.03
Max. Negotiated Rate	$290.98
Rate for Payer: Aetna Commercial	$221.14
Rate for Payer: Aetna Medicare Advantage	$174.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$148.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$148.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$148.40
Rate for Payer: Cigna Commercial	$290.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$174.59
Rate for Payer: Oxford Commercial	$116.39
Rate for Payer: Qualcare PPO/HMO/WC	$87.29
Rate for Payer: UnitedHealthcare Commercial	$116.39
Rate for Payer: UnitedHealthcare Community & State	$14.03
Rate for Payer: Wellpoint Medicaid Managed Care	$15.42

PNEUMOCOCCAL VACCINE INJ

Facility

IP

$581.96

Service Code	HCPCS 90732
Hospital Charge Code	6009021P
Hospital Revenue Code	636
Min. Negotiated Rate	$87.29
Max. Negotiated Rate	$140.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$140.83
Rate for Payer: Qualcare PPO/HMO/WC	$87.29

PNEUMOCYSTIS JROVECII DFA A

Facility

IP

$390.00

Service Code	HCPCS 87015
Hospital Charge Code	39708006A
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PNEUMOCYSTIS JROVECII DFA A

Facility

OP

$390.00

Service Code	HCPCS 87015
Hospital Charge Code	39708006A
Hospital Revenue Code	309
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.11
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
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	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PNEUMOCYSTIS JROVECII DFA B

Facility

IP

$390.00

Service Code	HCPCS 87281
Hospital Charge Code	39708006B
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PNEUMOCYSTIS JROVECII DFA B

Facility

OP

$390.00

Service Code	HCPCS 87281
Hospital Charge Code	39708006B
Hospital Revenue Code	309
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

PNEUMOGRAM

Facility

IP

$1,233.00

Service Code	HCPCS 94772
Hospital Charge Code	83092025
Hospital Revenue Code	460
Min. Negotiated Rate	$184.95
Max. Negotiated Rate	$184.95
Rate for Payer: Qualcare PPO/HMO/WC	$184.95

PNEUMOGRAM

Facility

IP

$1,233.00

Service Code	HCPCS 94772
Hospital Charge Code	83080040
Hospital Revenue Code	460
Min. Negotiated Rate	$184.95
Max. Negotiated Rate	$184.95
Rate for Payer: Qualcare PPO/HMO/WC	$184.95

PNEUMOGRAM

Facility

OP

$1,233.00

Service Code	HCPCS 94772
Hospital Charge Code	83080040
Hospital Revenue Code	460
Min. Negotiated Rate	$29.72
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$1,205.83
Rate for Payer: Aetna Medicare Advantage	$1,436.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$443.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$232.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,600.25
Rate for Payer: Cigna Commercial	$888.63
Rate for Payer: Cigna Medicare Advantage	$443.32
Rate for Payer: Clover Medicare Advantage	$421.15
Rate for Payer: EmblemHealth Commercial	$1,329.96
Rate for Payer: Humana Medicare Advantage	$456.62
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$443.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$369.90
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$184.95
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$29.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$443.32
Rate for Payer: Wellcare Medicare Advantage	$443.32
Rate for Payer: Wellpoint Medicaid Managed Care	$32.67

PNEUMOGRAM

Facility

OP

$1,233.00

Service Code	HCPCS 94772
Hospital Charge Code	83092025
Hospital Revenue Code	460
Min. Negotiated Rate	$29.72
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$1,205.83
Rate for Payer: Aetna Medicare Advantage	$1,436.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$443.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$232.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,600.25
Rate for Payer: Cigna Commercial	$888.63
Rate for Payer: Cigna Medicare Advantage	$443.32
Rate for Payer: Clover Medicare Advantage	$421.15
Rate for Payer: EmblemHealth Commercial	$1,329.96
Rate for Payer: Humana Medicare Advantage	$456.62
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$443.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$369.90
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$184.95
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$29.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$443.32
Rate for Payer: Wellcare Medicare Advantage	$443.32
Rate for Payer: Wellpoint Medicaid Managed Care	$32.67

PNEUMOGRAM 24 HR/2 CHAN*****

Facility

OP

$1,020.00

Hospital Charge Code	270606216
Hospital Revenue Code	270
Min. Negotiated Rate	$24.58
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare Advantage	$306.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$260.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$260.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$260.10
Rate for Payer: Cigna Commercial	$510.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$306.00
Rate for Payer: Oxford Commercial	$204.00
Rate for Payer: Qualcare PPO/HMO/WC	$153.00
Rate for Payer: UnitedHealthcare Commercial	$204.00
Rate for Payer: UnitedHealthcare Community & State	$24.58
Rate for Payer: Wellpoint Medicaid Managed Care	$27.03