Heights University Hospital

All Charges

Charge

Type

Setting

Price

COMPLEMENT,C1Q

Facility

$235.00

Service Code	HCPCS 86160
Hospital Charge Code	38476217
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$30.55
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$35.25
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C1Q QUANTITATIVE

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006153
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.55
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.71
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C1Q QUANTITATIVE

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006153
Hospital Revenue Code	302
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$23.71
Rate for Payer: Qualcare PPO/HMO/WC	$23.71

COMPLEMENT C2

Facility

$341.00

Service Code	HCPCS 86160
Hospital Charge Code	38476252
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$44.33
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$51.15
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C2

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900462
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.72
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.38
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C2

Facility

$341.00

Service Code	HCPCS 86160
Hospital Charge Code	38476252
Hospital Revenue Code	302
Min. Negotiated Rate	$51.15
Max. Negotiated Rate	$51.15
Rate for Payer: Qualcare PPO/HMO/WC	$51.15

COMPLEMENT C2

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900462
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$12.38
Rate for Payer: Qualcare PPO/HMO/WC	$12.38

COMPLEMENT C2 AG

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3007317
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.55
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.71
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C2 AG

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3007317
Hospital Revenue Code	302
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$23.71
Rate for Payer: Qualcare PPO/HMO/WC	$23.71

COMPLEMENT C3

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900423
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.72
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.38
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C3

Facility

$228.00

Service Code	HCPCS 86160
Hospital Charge Code	38476081
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.64
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$34.20
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C3

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900423
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$12.38
Rate for Payer: Qualcare PPO/HMO/WC	$12.38

COMPLEMENT C3

Facility

$228.00

Service Code	HCPCS 86160
Hospital Charge Code	38476081
Hospital Revenue Code	302
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$34.20
Rate for Payer: Qualcare PPO/HMO/WC	$34.20

COMPLEMENT C3,FLUID

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006152
Hospital Revenue Code	302
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$23.71
Rate for Payer: Qualcare PPO/HMO/WC	$23.71

COMPLEMENT C3,FLUID

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006152
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.55
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.71
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

Complement C3, Serum

Facility

$667.59

Service Code	HCPCS 86160
Hospital Charge Code	39888018
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$86.79
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

Complement C3, Serum

Facility

$667.59

Service Code	HCPCS 86160
Hospital Charge Code	39888018
Hospital Revenue Code	302
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

COMPLEMENT C4

Facility

$228.00

Service Code	HCPCS 86160
Hospital Charge Code	38476084
Hospital Revenue Code	302
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$34.20
Rate for Payer: Qualcare PPO/HMO/WC	$34.20

COMPLEMENT C4

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900424
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.72
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.38
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C4

Facility

$82.50

Service Code	HCPCS 86160
Hospital Charge Code	39900424
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$12.38
Rate for Payer: Qualcare PPO/HMO/WC	$12.38

COMPLEMENT C4

Facility

$228.00

Service Code	HCPCS 86160
Hospital Charge Code	38476084
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.64
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$34.20
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C4,FLUID

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006160
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.55
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.71
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

COMPLEMENT C4,FLUID

Facility

$158.05

Service Code	HCPCS 86160
Hospital Charge Code	3006160
Hospital Revenue Code	302
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$23.71
Rate for Payer: Qualcare PPO/HMO/WC	$23.71

Complement C4, Serum

Facility

$667.59

Service Code	HCPCS 86160
Hospital Charge Code	39888019
Hospital Revenue Code	302
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.97
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$6.00
Rate for Payer: Clover Medicare Advantage	$11.40
Rate for Payer: EmblemHealth Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$86.79
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12.72
Rate for Payer: Wellcare Medicare Advantage	$12.00

Complement C4, Serum

Facility

$667.59

Service Code	HCPCS 86160
Hospital Charge Code	39888019
Hospital Revenue Code	302
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

Know your out-of-pocket cost for care.

All Charges