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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PACK CUSTOM CATH AVIBMBM00112

Facility

IP

$392.70

Hospital Charge Code	270642262
Hospital Revenue Code	272
Min. Negotiated Rate	$58.91
Max. Negotiated Rate	$58.91
Rate for Payer: Qualcare PPO/HMO/WC	$58.91

PACK CUSTOM CATH AVIBMBM00112

Facility

OP

$392.70

Hospital Charge Code	270642262
Hospital Revenue Code	272
Min. Negotiated Rate	$51.05
Max. Negotiated Rate	$196.35
Rate for Payer: Aetna Commercial	$117.81
Rate for Payer: Aetna Medicare Advantage	$117.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$100.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$100.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$100.14
Rate for Payer: Cigna Commercial	$196.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$51.05
Rate for Payer: Oxford Commercial	$196.35
Rate for Payer: Qualcare PPO/HMO/WC	$58.91
Rate for Payer: UnitedHealthcare Commercial	$196.35

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

IP

$391.25

Hospital Charge Code	270677786S
Hospital Revenue Code	272
Min. Negotiated Rate	$58.69
Max. Negotiated Rate	$58.69
Rate for Payer: Qualcare PPO/HMO/WC	$58.69

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

IP

$352.90

Hospital Charge Code	270677786N
Hospital Revenue Code	272
Min. Negotiated Rate	$52.94
Max. Negotiated Rate	$52.94
Rate for Payer: Qualcare PPO/HMO/WC	$52.94

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

IP

$391.25

Hospital Charge Code	270677786
Hospital Revenue Code	272
Min. Negotiated Rate	$58.69
Max. Negotiated Rate	$58.69
Rate for Payer: Qualcare PPO/HMO/WC	$58.69

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

OP

$391.25

Hospital Charge Code	270677786
Hospital Revenue Code	272
Min. Negotiated Rate	$50.86
Max. Negotiated Rate	$195.62
Rate for Payer: Aetna Commercial	$117.38
Rate for Payer: Aetna Medicare Advantage	$117.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.77
Rate for Payer: Cigna Commercial	$195.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.86
Rate for Payer: Oxford Commercial	$195.62
Rate for Payer: Qualcare PPO/HMO/WC	$58.69
Rate for Payer: UnitedHealthcare Commercial	$195.62

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

OP

$391.25

Hospital Charge Code	270677786S
Hospital Revenue Code	272
Min. Negotiated Rate	$50.86
Max. Negotiated Rate	$195.62
Rate for Payer: Aetna Commercial	$117.38
Rate for Payer: Aetna Medicare Advantage	$117.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.77
Rate for Payer: Cigna Commercial	$195.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.86
Rate for Payer: Oxford Commercial	$195.62
Rate for Payer: Qualcare PPO/HMO/WC	$58.69
Rate for Payer: UnitedHealthcare Commercial	$195.62

PACK CUSTOM CATHLAB W/CHLORAPR

Facility

OP

$352.90

Hospital Charge Code	270677786N
Hospital Revenue Code	272
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$176.45
Rate for Payer: Aetna Commercial	$105.87
Rate for Payer: Aetna Medicare Advantage	$105.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$89.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$89.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$89.99
Rate for Payer: Cigna Commercial	$176.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.88
Rate for Payer: Oxford Commercial	$176.45
Rate for Payer: Qualcare PPO/HMO/WC	$52.94
Rate for Payer: UnitedHealthcare Commercial	$176.45

PACK CUSTOM CENTURION SYSTEM

Facility

OP

$1,532.15

Hospital Charge Code	270683573
Hospital Revenue Code	272
Min. Negotiated Rate	$199.18
Max. Negotiated Rate	$766.08
Rate for Payer: Aetna Commercial	$459.64
Rate for Payer: Aetna Medicare Advantage	$459.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$390.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$390.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$390.70
Rate for Payer: Cigna Commercial	$766.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$199.18
Rate for Payer: Oxford Commercial	$766.08
Rate for Payer: Qualcare PPO/HMO/WC	$229.82
Rate for Payer: UnitedHealthcare Commercial	$766.08

PACK CUSTOM CENTURION SYSTEM

Facility

IP

$1,532.15

Hospital Charge Code	270683573
Hospital Revenue Code	272
Min. Negotiated Rate	$229.82
Max. Negotiated Rate	$229.82
Rate for Payer: Qualcare PPO/HMO/WC	$229.82

PACK CUSTOM CENTURION VISION

Facility

OP

$743.75

Hospital Charge Code	270684100
Hospital Revenue Code	272
Min. Negotiated Rate	$96.69
Max. Negotiated Rate	$371.88
Rate for Payer: Aetna Commercial	$223.12
Rate for Payer: Aetna Medicare Advantage	$223.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$189.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$189.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$189.66
Rate for Payer: Cigna Commercial	$371.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.69
Rate for Payer: Oxford Commercial	$371.88
Rate for Payer: Qualcare PPO/HMO/WC	$111.56
Rate for Payer: UnitedHealthcare Commercial	$371.88

PACK CUSTOM CENTURION VISION

Facility

IP

$743.75

Hospital Charge Code	270684100
Hospital Revenue Code	272
Min. Negotiated Rate	$111.56
Max. Negotiated Rate	$111.56
Rate for Payer: Qualcare PPO/HMO/WC	$111.56

PACK CUSTOM D&C AVIBMBM008-12

Facility

IP

$143.05

Hospital Charge Code	270642267
Hospital Revenue Code	272
Min. Negotiated Rate	$21.46
Max. Negotiated Rate	$21.46
Rate for Payer: Qualcare PPO/HMO/WC	$21.46

PACK CUSTOM D&C AVIBMBM008-12

Facility

OP

$143.05

Hospital Charge Code	270642267
Hospital Revenue Code	272
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$71.53
Rate for Payer: Aetna Commercial	$42.91
Rate for Payer: Aetna Medicare Advantage	$42.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36.48
Rate for Payer: Cigna Commercial	$71.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.60
Rate for Payer: Oxford Commercial	$71.53
Rate for Payer: Qualcare PPO/HMO/WC	$21.46
Rate for Payer: UnitedHealthcare Commercial	$71.53

PACK CUSTOM D&C SMA11DCBYA

Facility

OP

$153.50

Hospital Charge Code	270632134
Hospital Revenue Code	272
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$76.75
Rate for Payer: Aetna Commercial	$46.05
Rate for Payer: Aetna Medicare Advantage	$46.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.14
Rate for Payer: Cigna Commercial	$76.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.95
Rate for Payer: Oxford Commercial	$76.75
Rate for Payer: Qualcare PPO/HMO/WC	$23.02
Rate for Payer: UnitedHealthcare Commercial	$76.75

PACK CUSTOM D&C SMA11DCBYA

Facility

IP

$153.50

Hospital Charge Code	270632134
Hospital Revenue Code	272
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$23.02
Rate for Payer: Qualcare PPO/HMO/WC	$23.02

PACK CUSTOM ENDOVAS SCV11EVBYA

Facility

OP

$371.05

Hospital Charge Code	270626895
Hospital Revenue Code	270
Min. Negotiated Rate	$48.24
Max. Negotiated Rate	$185.53
Rate for Payer: Aetna Commercial	$111.31
Rate for Payer: Aetna Medicare Advantage	$111.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$94.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$94.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$94.62
Rate for Payer: Cigna Commercial	$185.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.24
Rate for Payer: Oxford Commercial	$185.53
Rate for Payer: Qualcare PPO/HMO/WC	$55.66
Rate for Payer: UnitedHealthcare Commercial	$185.53

PACK CUSTOM ENDOVAS SCV11EVBYA

Facility

IP

$371.05

Hospital Charge Code	270626895
Hospital Revenue Code	270
Min. Negotiated Rate	$55.66
Max. Negotiated Rate	$55.66
Rate for Payer: Qualcare PPO/HMO/WC	$55.66

PACK CUSTOM EYE AVIBMBM00706

Facility

OP

$192.50

Hospital Charge Code	270642266
Hospital Revenue Code	272
Min. Negotiated Rate	$25.02
Max. Negotiated Rate	$96.25
Rate for Payer: Aetna Commercial	$57.75
Rate for Payer: Aetna Medicare Advantage	$57.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.09
Rate for Payer: Cigna Commercial	$96.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.02
Rate for Payer: Oxford Commercial	$96.25
Rate for Payer: Qualcare PPO/HMO/WC	$28.88
Rate for Payer: UnitedHealthcare Commercial	$96.25

PACK CUSTOM EYE AVIBMBM00706

Facility

IP

$192.50

Hospital Charge Code	270642266
Hospital Revenue Code	272
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$28.88
Rate for Payer: Qualcare PPO/HMO/WC	$28.88

PACK CUSTOM EYE PPK1468-02

Facility

OP

$1,069.65

Hospital Charge Code	270623323
Hospital Revenue Code	272
Min. Negotiated Rate	$139.05
Max. Negotiated Rate	$534.83
Rate for Payer: Aetna Commercial	$320.89
Rate for Payer: Aetna Medicare Advantage	$320.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$272.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$272.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$272.76
Rate for Payer: Cigna Commercial	$534.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$139.05
Rate for Payer: Oxford Commercial	$534.83
Rate for Payer: Qualcare PPO/HMO/WC	$160.45
Rate for Payer: UnitedHealthcare Commercial	$534.83

PACK CUSTOM EYE PPK1468-02

Facility

IP

$1,069.65

Hospital Charge Code	270623323
Hospital Revenue Code	272
Min. Negotiated Rate	$160.45
Max. Negotiated Rate	$160.45
Rate for Payer: Qualcare PPO/HMO/WC	$160.45

PACK CUSTOM EYE PPK1469-02

Facility

OP

$959.00

Hospital Charge Code	270623324
Hospital Revenue Code	272
Min. Negotiated Rate	$124.67
Max. Negotiated Rate	$479.50
Rate for Payer: Aetna Commercial	$287.70
Rate for Payer: Aetna Medicare Advantage	$287.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$244.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$244.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$244.54
Rate for Payer: Cigna Commercial	$479.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$124.67
Rate for Payer: Oxford Commercial	$479.50
Rate for Payer: Qualcare PPO/HMO/WC	$143.85
Rate for Payer: UnitedHealthcare Commercial	$479.50

PACK CUSTOM EYE PPK1469-02

Facility

IP

$959.00

Hospital Charge Code	270623324
Hospital Revenue Code	272
Min. Negotiated Rate	$143.85
Max. Negotiated Rate	$143.85
Rate for Payer: Qualcare PPO/HMO/WC	$143.85

PACK CUSTOM EYE SEY11EYBYA

Facility

OP

$248.00

Hospital Charge Code	270622793
Hospital Revenue Code	272
Min. Negotiated Rate	$32.24
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$74.40
Rate for Payer: Aetna Medicare Advantage	$74.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$63.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$63.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$63.24
Rate for Payer: Cigna Commercial	$124.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.24
Rate for Payer: Oxford Commercial	$124.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.20
Rate for Payer: UnitedHealthcare Commercial	$124.00