Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

ER CL TX FEM FX D/M/L W/O MANI

Facility

$645.00

Service Code	HCPCS 27508
Hospital Charge Code	5700590
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX FEM FX D/M/L W/O MANI

Facility

$645.00

Service Code	HCPCS 27508
Hospital Charge Code	5700590
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$161.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX GR TOE FX W/O MAN

Facility

$645.00

Service Code	HCPCS 28490
Hospital Charge Code	5700609
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX GR TOE FX W/O MAN

Facility

$645.00

Service Code	HCPCS 28490
Hospital Charge Code	5700609
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$41.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX HIP DISL TRAUMA W/O A

Facility

$645.00

Service Code	HCPCS 27250
Hospital Charge Code	5700587
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX HIP DISL TRAUMA W/O A

Facility

$645.00

Service Code	HCPCS 27250
Hospital Charge Code	5700587
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$221.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX INTPHAL JNT DIS W/O A

Facility

$645.00

Service Code	HCPCS 28660
Hospital Charge Code	5700612
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX INTPHAL JNT DIS W/O A

Facility

$645.00

Service Code	HCPCS 28660
Hospital Charge Code	5700612
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX MED MALL FX W/MANI

Facility

$8,519.00

Service Code	HCPCS 27762
Hospital Charge Code	5700597
Hospital Revenue Code	450
Min. Negotiated Rate	$1,277.85
Max. Negotiated Rate	$1,277.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.85

ER CL TX MED MALL FX W/MANI

Facility

$8,519.00

Service Code	HCPCS 27762
Hospital Charge Code	5700597
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$6,929.76
Rate for Payer: Aetna Commercial	$5,196.12
Rate for Payer: Aetna Medicare Advantage	$6,189.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,929.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,929.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,910.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$182.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,929.76
Rate for Payer: Cigna Commercial	$3,829.26
Rate for Payer: Cigna Medicare Advantage	$1,910.34
Rate for Payer: Clover Medicare Advantage	$1,814.82
Rate for Payer: EmblemHealth Commercial	$5,731.02
Rate for Payer: Humana Medicare Advantage	$1,967.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,910.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,214.94
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.85
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,910.34
Rate for Payer: Wellcare Medicare Advantage	$1,910.34
Rate for Payer: Wellpoint Medicaid Managed Care	$241.94

ER CL TX MED MALL FX W/O MAN

Facility

$645.00

Service Code	HCPCS 27760
Hospital Charge Code	5700596
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$143.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX MED MALL FX W/O MAN

Facility

$645.00

Service Code	HCPCS 27760
Hospital Charge Code	5700596
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX METAC FX W/MAN EACH

Facility

$645.00

Service Code	HCPCS 26605
Hospital Charge Code	5700578
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX METAC FX W/MAN EACH

Facility

$645.00

Service Code	HCPCS 26605
Hospital Charge Code	5700578
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX PATELLAR FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27520
Hospital Charge Code	5700592
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX PATELLAR FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27520
Hospital Charge Code	5700592
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$143.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX PHAL SH FX W/MAN EACH

Facility

$645.00

Service Code	HCPCS 26725
Hospital Charge Code	5700582
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$110.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX PHAL SH FX W/MAN EACH

Facility

$645.00

Service Code	HCPCS 26725
Hospital Charge Code	5700582
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX POST MALL FX W/MANI

Facility

$645.00

Service Code	HCPCS 27768
Hospital Charge Code	5700599
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX POST MALL FX W/MANI

Facility

$645.00

Service Code	HCPCS 27768
Hospital Charge Code	5700599
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$6,929.76
Rate for Payer: Aetna Commercial	$5,196.12
Rate for Payer: Aetna Medicare Advantage	$6,189.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,929.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,929.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,910.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,929.76
Rate for Payer: Cigna Commercial	$3,829.26
Rate for Payer: Cigna Medicare Advantage	$1,910.34
Rate for Payer: Clover Medicare Advantage	$1,814.82
Rate for Payer: EmblemHealth Commercial	$5,731.02
Rate for Payer: Humana Medicare Advantage	$1,967.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,910.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,910.34
Rate for Payer: Wellcare Medicare Advantage	$1,910.34
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX POST MALL FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27767
Hospital Charge Code	5700598
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX POST MALL FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27767
Hospital Charge Code	5700598
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX PROX FIB FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27780
Hospital Charge Code	5700600
Hospital Revenue Code	450
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,063.04
Rate for Payer: Aetna Commercial	$797.10
Rate for Payer: Aetna Medicare Advantage	$949.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,063.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$293.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$103.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,063.04
Rate for Payer: Cigna Commercial	$587.42
Rate for Payer: Cigna Medicare Advantage	$293.05
Rate for Payer: Clover Medicare Advantage	$278.40
Rate for Payer: EmblemHealth Commercial	$879.15
Rate for Payer: Humana Medicare Advantage	$301.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$293.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$167.70
Rate for Payer: Qualcare PPO/HMO/WC	$96.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.05
Rate for Payer: Wellcare Medicare Advantage	$293.05
Rate for Payer: Wellpoint Medicaid Managed Care	$18.32

ER CL TX PROX FIB FX W/O MANI

Facility

$645.00

Service Code	HCPCS 27780
Hospital Charge Code	5700600
Hospital Revenue Code	450
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$96.75
Rate for Payer: Qualcare PPO/HMO/WC	$96.75

ER CL TX PROX HUM FX W/MAN/TRA

Facility

$11,926.60

Service Code	HCPCS 23605
Hospital Charge Code	5700556
Hospital Revenue Code	450
Min. Negotiated Rate	$1,788.99
Max. Negotiated Rate	$1,788.99
Rate for Payer: Qualcare PPO/HMO/WC	$1,788.99

Know your out-of-pocket cost for care.

All Charges