Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TISSUE TRANSGLUTAMINASE,IGA

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38479418
Hospital Revenue Code	301
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$43.50
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$2.31

TISSUE TRANSGLUTAMINASE,IGA

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38479420
Hospital Revenue Code	301
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$43.50
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$2.31

TISSUE TRANSGLUTAMINASE,IGA

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38479418
Hospital Revenue Code	301
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$13.05
Rate for Payer: Qualcare PPO/HMO/WC	$13.05

TISSUE TRANSGLUTAMONASE, IGG

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38476797
Hospital Revenue Code	301
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$43.50
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$2.31

TISSUE TRANSGLUTAMONASE, IGG

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38476797
Hospital Revenue Code	301
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$13.05
Rate for Payer: Qualcare PPO/HMO/WC	$13.05

TISSUE TRANSGLUTAMONASE,IGG

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38479419
Hospital Revenue Code	301
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$13.05
Rate for Payer: Qualcare PPO/HMO/WC	$13.05

TISSUE TRANSGLUTAMONASE,IGG

Facility

$87.00

Service Code	HCPCS 83516
Hospital Charge Code	38479419
Hospital Revenue Code	301
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$43.50
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$2.31

TISSUE TRANSGLUTIMASE IGA

Facility

$390.00

Service Code	HCPCS 83516
Hospital Charge Code	39900331
Hospital Revenue Code	301
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
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	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

TISSUE TRANSGLUTIMASE IGA

Facility

$390.00

Service Code	HCPCS 83516
Hospital Charge Code	39900331
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

TISSUE TRAP SAFE TOUCH

Facility

$43.51

Hospital Charge Code	270652967
Hospital Revenue Code	272
Min. Negotiated Rate	$6.53
Max. Negotiated Rate	$6.53
Rate for Payer: Qualcare PPO/HMO/WC	$6.53

TISSUE TRAP SAFE TOUCH

Facility

$43.51

Hospital Charge Code	270652967
Hospital Revenue Code	272
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$21.75
Rate for Payer: Aetna Commercial	$16.53
Rate for Payer: Aetna Medicare Advantage	$13.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.10
Rate for Payer: Cigna Commercial	$21.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.05
Rate for Payer: Oxford Commercial	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$6.53
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: UnitedHealthcare Community & State	$1.05
Rate for Payer: Wellpoint Medicaid Managed Care	$1.15

TISSUE TRX ADDL 30 SQ CM

Facility

$10,841.92

Service Code	HCPCS 14302
Hospital Charge Code	16000369
Hospital Revenue Code	360
Min. Negotiated Rate	$261.29
Max. Negotiated Rate	$5,420.96
Rate for Payer: Aetna Commercial	$4,119.93
Rate for Payer: Aetna Medicare Advantage	$3,252.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,764.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,764.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,764.69
Rate for Payer: Cigna Commercial	$5,420.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,252.58
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$261.29
Rate for Payer: Wellpoint Medicaid Managed Care	$287.31

TISSUE TRX ADDL 30 SQ CM

Facility

$10,841.92

Service Code	HCPCS 14302
Hospital Charge Code	1600069
Hospital Revenue Code	360
Min. Negotiated Rate	$1,626.29
Max. Negotiated Rate	$1,626.29
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29

TISSUE TRX ADDL 30 SQ CM

Facility

$10,841.92

Service Code	HCPCS 14302
Hospital Charge Code	1600069
Hospital Revenue Code	360
Min. Negotiated Rate	$261.29
Max. Negotiated Rate	$5,420.96
Rate for Payer: Aetna Commercial	$4,119.93
Rate for Payer: Aetna Medicare Advantage	$3,252.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,764.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,764.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,764.69
Rate for Payer: Cigna Commercial	$5,420.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,252.58
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$261.29
Rate for Payer: Wellpoint Medicaid Managed Care	$287.31

TISSUE TRX ADDL 30 SQ CM

Facility

$10,841.92

Service Code	HCPCS 14302
Hospital Charge Code	16000369
Hospital Revenue Code	360
Min. Negotiated Rate	$1,626.29
Max. Negotiated Rate	$1,626.29
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29

TISSUE TRX ANY 30.1-60CM

Facility

$10,841.92

Service Code	HCPCS 14301
Hospital Charge Code	16000241
Hospital Revenue Code	360
Min. Negotiated Rate	$1,626.29
Max. Negotiated Rate	$1,626.29
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29

TISSUE TRX ANY 30.1-60CM

Facility

$10,841.92

Service Code	HCPCS 14301
Hospital Charge Code	5792297
Hospital Revenue Code	450
Min. Negotiated Rate	$1,626.29
Max. Negotiated Rate	$1,626.29
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29

TISSUE TRX ANY 30.1-60CM

Facility

$10,841.92

Service Code	HCPCS 14301
Hospital Charge Code	5792297
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$15,196.98
Rate for Payer: Aetna Commercial	$11,451.31
Rate for Payer: Aetna Medicare Advantage	$13,640.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,210.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,556.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,196.98
Rate for Payer: Cigna Commercial	$8,439.01
Rate for Payer: Cigna Medicare Advantage	$4,210.04
Rate for Payer: Clover Medicare Advantage	$3,999.54
Rate for Payer: EmblemHealth Commercial	$12,630.12
Rate for Payer: Humana Medicare Advantage	$4,336.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,210.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,252.58
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,210.04
Rate for Payer: Wellcare Medicare Advantage	$4,210.04
Rate for Payer: Wellpoint Medicaid Managed Care	$287.31

TISSUE TRX ANY 30.1-60CM

Facility

$10,841.92

Service Code	HCPCS 14301
Hospital Charge Code	16000241
Hospital Revenue Code	360
Min. Negotiated Rate	$261.29
Max. Negotiated Rate	$15,196.98
Rate for Payer: Aetna Commercial	$11,451.31
Rate for Payer: Aetna Medicare Advantage	$13,640.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,196.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,210.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,196.98
Rate for Payer: Cigna Commercial	$8,439.01
Rate for Payer: Cigna Medicare Advantage	$4,210.04
Rate for Payer: Clover Medicare Advantage	$3,999.54
Rate for Payer: EmblemHealth Commercial	$12,630.12
Rate for Payer: Humana Medicare Advantage	$4,336.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,210.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,252.58
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,626.29
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$261.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,210.04
Rate for Payer: Wellcare Medicare Advantage	$4,210.04
Rate for Payer: Wellpoint Medicaid Managed Care	$287.31

TIS TRNFR F/C/C/M/N/A/G/H/F

Facility

$19,317.68

Service Code	HCPCS 14040
Hospital Charge Code	16000201
Hospital Revenue Code	360
Min. Negotiated Rate	$2,897.65
Max. Negotiated Rate	$2,897.65
Rate for Payer: Qualcare PPO/HMO/WC	$2,897.65

TIS TRNFR F/C/C/M/N/A/G/H/F

Facility

$19,317.68

Service Code	HCPCS 14040
Hospital Charge Code	16000201
Hospital Revenue Code	360
Min. Negotiated Rate	$64.50
Max. Negotiated Rate	$8,848.20
Rate for Payer: Aetna Commercial	$6,667.35
Rate for Payer: Aetna Medicare Advantage	$7,941.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,451.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,848.20
Rate for Payer: Cigna Commercial	$4,913.48
Rate for Payer: Cigna Medicare Advantage	$2,451.23
Rate for Payer: Clover Medicare Advantage	$2,328.67
Rate for Payer: EmblemHealth Commercial	$7,353.69
Rate for Payer: Humana Medicare Advantage	$2,524.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,451.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,795.30
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,897.65
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$465.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$65.79
Rate for Payer: Wellpoint Medicaid Managed Care	$64.50

TIS TRNFR S/A/L 10.1-30 SQCM

Facility

$7,256.44

Service Code	HCPCS 14021
Hospital Charge Code	16000269
Hospital Revenue Code	360
Min. Negotiated Rate	$174.88
Max. Negotiated Rate	$8,848.20
Rate for Payer: Aetna Commercial	$6,667.35
Rate for Payer: Aetna Medicare Advantage	$7,941.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,451.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,355.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,848.20
Rate for Payer: Cigna Commercial	$4,913.48
Rate for Payer: Cigna Medicare Advantage	$2,451.23
Rate for Payer: Clover Medicare Advantage	$2,328.67
Rate for Payer: EmblemHealth Commercial	$7,353.69
Rate for Payer: Humana Medicare Advantage	$2,524.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,451.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,176.93
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,088.47
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$174.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$5,165.88
Rate for Payer: Wellpoint Medicaid Managed Care	$5,064.59

TIS TRNFR S/A/L 10.1-30 SQCM

Facility

$7,256.44

Service Code	HCPCS 14021
Hospital Charge Code	16000269
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.47
Max. Negotiated Rate	$1,088.47
Rate for Payer: Qualcare PPO/HMO/WC	$1,088.47

Tis trnfr s/a/l 10 sq cm/<

Facility

$8,616.84

Service Code	HCPCS 14020
Hospital Charge Code	241175
Hospital Revenue Code	360
Min. Negotiated Rate	$207.67
Max. Negotiated Rate	$8,848.20
Rate for Payer: Aetna Commercial	$6,667.35
Rate for Payer: Aetna Medicare Advantage	$7,941.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,848.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,451.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,355.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,848.20
Rate for Payer: Cigna Commercial	$4,913.48
Rate for Payer: Cigna Medicare Advantage	$2,451.23
Rate for Payer: Clover Medicare Advantage	$2,328.67
Rate for Payer: EmblemHealth Commercial	$7,353.69
Rate for Payer: Humana Medicare Advantage	$2,524.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,451.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,585.05
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,292.53
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$207.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare Medicare Advantage	$2,451.23
Rate for Payer: Wellpoint Medicaid Managed Care	$228.35

Tis trnfr s/a/l 10 sq cm/<

Facility

$8,616.84

Service Code	HCPCS 14020
Hospital Charge Code	241175
Hospital Revenue Code	360
Min. Negotiated Rate	$1,292.53
Max. Negotiated Rate	$1,292.53
Rate for Payer: Qualcare PPO/HMO/WC	$1,292.53

Know your out-of-pocket cost for care.

All Charges