Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

ER SEDATION 2 MD <5 YR - 30MIN

Facility

$636.00

Service Code	HCPCS 99148
Hospital Charge Code	5700816
Hospital Revenue Code	370
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$241.68
Rate for Payer: Aetna Medicare Advantage	$190.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$162.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$162.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$162.18
Rate for Payer: Cigna Commercial	$318.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$165.36
Rate for Payer: Oxford Commercial	$127.20
Rate for Payer: Qualcare PPO/HMO/WC	$95.40
Rate for Payer: UnitedHealthcare Commercial	$127.20
Rate for Payer: UnitedHealthcare Community & State	$20.10
Rate for Payer: Wellpoint Medicaid Managed Care	$18.06

ER SEDATION 2 MD <5 YR - 30MIN

Facility

$636.00

Service Code	HCPCS 99148
Hospital Charge Code	5700816
Hospital Revenue Code	370
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$95.40
Rate for Payer: Qualcare PPO/HMO/WC	$95.40

ER SEDATION 2 MD > 5YRS - 30MI

Facility

$636.00

Service Code	HCPCS 99149
Hospital Charge Code	5700817
Hospital Revenue Code	370
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$95.40
Rate for Payer: Qualcare PPO/HMO/WC	$95.40

ER SEDATION 2 MD > 5YRS - 30MI

Facility

$636.00

Service Code	HCPCS 99149
Hospital Charge Code	5700817
Hospital Revenue Code	370
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$241.68
Rate for Payer: Aetna Medicare Advantage	$190.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$162.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$162.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$162.18
Rate for Payer: Cigna Commercial	$318.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$165.36
Rate for Payer: Oxford Commercial	$127.20
Rate for Payer: Qualcare PPO/HMO/WC	$95.40
Rate for Payer: UnitedHealthcare Commercial	$127.20
Rate for Payer: UnitedHealthcare Community & State	$20.10
Rate for Payer: Wellpoint Medicaid Managed Care	$18.06

ER SEDATION 2 MDS ECH ADD 15M

Facility

$315.00

Service Code	HCPCS 99150
Hospital Charge Code	5700818
Hospital Revenue Code	370
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare Advantage	$94.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$80.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$80.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$80.33
Rate for Payer: Cigna Commercial	$157.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$81.90
Rate for Payer: Oxford Commercial	$63.00
Rate for Payer: Qualcare PPO/HMO/WC	$47.25
Rate for Payer: UnitedHealthcare Commercial	$63.00
Rate for Payer: UnitedHealthcare Community & State	$9.95
Rate for Payer: Wellpoint Medicaid Managed Care	$8.95

ER SEDATION 2 MDS ECH ADD 15M

Facility

$315.00

Service Code	HCPCS 99150
Hospital Charge Code	5700818
Hospital Revenue Code	370
Min. Negotiated Rate	$47.25
Max. Negotiated Rate	$47.25
Rate for Payer: Qualcare PPO/HMO/WC	$47.25

ER SHORT ARM CAST

Facility

$1,391.15

Service Code	HCPCS 29075
Hospital Charge Code	5700773
Hospital Revenue Code	450
Min. Negotiated Rate	$39.51
Max. Negotiated Rate	$1,472.81
Rate for Payer: Aetna Commercial	$903.80
Rate for Payer: Aetna Medicare Advantage	$1,076.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,205.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,205.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$332.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$54.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,205.35
Rate for Payer: Cigna Commercial	$666.07
Rate for Payer: Cigna Medicare Advantage	$332.28
Rate for Payer: Clover Medicare Advantage	$315.67
Rate for Payer: EmblemHealth Commercial	$996.84
Rate for Payer: Humana Medicare Advantage	$342.25
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$332.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$361.70
Rate for Payer: Qualcare PPO/HMO/WC	$208.67
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$332.28
Rate for Payer: Wellcare Medicare Advantage	$332.28
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,472.81
Rate for Payer: Wellpoint Medicaid Managed Care	$39.51

ER SHORT ARM CAST

Facility

$1,391.15

Service Code	HCPCS 29075
Hospital Charge Code	5700773
Hospital Revenue Code	450
Min. Negotiated Rate	$208.67
Max. Negotiated Rate	$208.67
Rate for Payer: Qualcare PPO/HMO/WC	$208.67

ER SIMPLE WOUND DEHISCE REPAIR

Facility

$980.51

Service Code	HCPCS 12020
Hospital Charge Code	5700706
Hospital Revenue Code	450
Min. Negotiated Rate	$27.85
Max. Negotiated Rate	$3,185.09
Rate for Payer: Aetna Commercial	$2,388.27
Rate for Payer: Aetna Medicare Advantage	$2,844.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,185.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,185.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$878.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$113.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,185.09
Rate for Payer: Cigna Commercial	$1,760.02
Rate for Payer: Cigna Medicare Advantage	$878.04
Rate for Payer: Clover Medicare Advantage	$834.14
Rate for Payer: EmblemHealth Commercial	$2,634.12
Rate for Payer: Humana Medicare Advantage	$904.38
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$878.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$254.93
Rate for Payer: Qualcare PPO/HMO/WC	$147.08
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$878.04
Rate for Payer: Wellcare Medicare Advantage	$878.04
Rate for Payer: Wellpoint Medicaid Managed Care	$27.85

ER SIMPLE WOUND DEHISCE REPAIR

Facility

$980.51

Service Code	HCPCS 12020
Hospital Charge Code	5700706
Hospital Revenue Code	450
Min. Negotiated Rate	$147.08
Max. Negotiated Rate	$147.08
Rate for Payer: Qualcare PPO/HMO/WC	$147.08

ER SIM REP FACE 12.6-20

Facility

$3,189.20

Service Code	HCPCS 12016
Hospital Charge Code	5700524
Hospital Revenue Code	450
Min. Negotiated Rate	$478.38
Max. Negotiated Rate	$478.38
Rate for Payer: Qualcare PPO/HMO/WC	$478.38

ER SIM REP FACE 12.6-20

Facility

$3,189.20

Service Code	HCPCS 12016
Hospital Charge Code	5700524
Hospital Revenue Code	450
Min. Negotiated Rate	$90.57
Max. Negotiated Rate	$1,751.90
Rate for Payer: Aetna Commercial	$1,313.62
Rate for Payer: Aetna Medicare Advantage	$1,564.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,751.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,751.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$482.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$144.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,751.90
Rate for Payer: Cigna Commercial	$968.07
Rate for Payer: Cigna Medicare Advantage	$482.95
Rate for Payer: Clover Medicare Advantage	$458.80
Rate for Payer: EmblemHealth Commercial	$1,448.85
Rate for Payer: Humana Medicare Advantage	$497.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$482.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$829.19
Rate for Payer: Qualcare PPO/HMO/WC	$478.38
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$482.95
Rate for Payer: Wellcare Medicare Advantage	$482.95
Rate for Payer: Wellpoint Medicaid Managed Care	$90.57

ER SIM REP FACE 20.1-30

Facility

$2,700.00

Service Code	HCPCS 12017
Hospital Charge Code	5700525
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$405.00
Rate for Payer: Qualcare PPO/HMO/WC	$405.00

ER SIM REP FACE 20.1-30

Facility

$2,700.00

Service Code	HCPCS 12017
Hospital Charge Code	5700525
Hospital Revenue Code	450
Min. Negotiated Rate	$76.68
Max. Negotiated Rate	$1,751.90
Rate for Payer: Aetna Commercial	$1,313.62
Rate for Payer: Aetna Medicare Advantage	$1,564.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,751.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,751.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$482.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$127.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,751.90
Rate for Payer: Cigna Commercial	$968.07
Rate for Payer: Cigna Medicare Advantage	$482.95
Rate for Payer: Clover Medicare Advantage	$458.80
Rate for Payer: EmblemHealth Commercial	$1,448.85
Rate for Payer: Humana Medicare Advantage	$497.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$482.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$702.00
Rate for Payer: Qualcare PPO/HMO/WC	$405.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$482.95
Rate for Payer: Wellcare Medicare Advantage	$482.95
Rate for Payer: Wellpoint Medicaid Managed Care	$76.68

ER SIM REP FACE 2.6-5

Facility

$545.00

Service Code	HCPCS 12013
Hospital Charge Code	5700521
Hospital Revenue Code	450
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$864.65
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$55.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$864.65
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$141.70
Rate for Payer: Qualcare PPO/HMO/WC	$81.75
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$554.01
Rate for Payer: Wellpoint Medicaid Managed Care	$15.48

ER SIM REP FACE 2.6-5

Facility

$545.00

Service Code	HCPCS 12013
Hospital Charge Code	5700521
Hospital Revenue Code	450
Min. Negotiated Rate	$81.75
Max. Negotiated Rate	$81.75
Rate for Payer: Qualcare PPO/HMO/WC	$81.75

ER SIM REP FACE 5.1-7.5

Facility

$2,000.00

Service Code	HCPCS 12014
Hospital Charge Code	5700522
Hospital Revenue Code	450
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$864.65
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$69.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$864.65
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$520.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellpoint Medicaid Managed Care	$56.80

ER SIM REP FACE 5.1-7.5

Facility

$2,000.00

Service Code	HCPCS 12014
Hospital Charge Code	5700522
Hospital Revenue Code	450
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

ER SIM REP FACE 7.6-12.5

Facility

$2,300.00

Service Code	HCPCS 12015
Hospital Charge Code	5700523
Hospital Revenue Code	450
Min. Negotiated Rate	$65.32
Max. Negotiated Rate	$864.65
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$108.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$864.65
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$598.00
Rate for Payer: Qualcare PPO/HMO/WC	$345.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellpoint Medicaid Managed Care	$65.32

ER SIM REP FACE 7.6-12.5

Facility

$2,300.00

Service Code	HCPCS 12015
Hospital Charge Code	5700523
Hospital Revenue Code	450
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$345.00
Rate for Payer: Qualcare PPO/HMO/WC	$345.00

ER SIM REP FACE OVER 30

Facility

$3,000.00

Service Code	HCPCS 12018
Hospital Charge Code	5700526
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$450.00
Rate for Payer: Qualcare PPO/HMO/WC	$450.00

ER SIM REP FACE OVER 30

Facility

$3,000.00

Service Code	HCPCS 12018
Hospital Charge Code	5700526
Hospital Revenue Code	450
Min. Negotiated Rate	$85.20
Max. Negotiated Rate	$864.65
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$157.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$864.65
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$780.00
Rate for Payer: Qualcare PPO/HMO/WC	$450.00
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellpoint Medicaid Managed Care	$85.20

ER SIM REP FACE UPTO 2.5

Facility

$3,286.55

Service Code	HCPCS 12011
Hospital Charge Code	5700520
Hospital Revenue Code	450
Min. Negotiated Rate	$492.98
Max. Negotiated Rate	$492.98
Rate for Payer: Qualcare PPO/HMO/WC	$492.98

ER SIM REP FACE UPTO 2.5

Facility

$3,286.55

Service Code	HCPCS 12011
Hospital Charge Code	5700520
Hospital Revenue Code	450
Min. Negotiated Rate	$41.58
Max. Negotiated Rate	$864.65
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$864.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
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	$864.65
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$854.50
Rate for Payer: Qualcare PPO/HMO/WC	$492.98
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellpoint Medicaid Managed Care	$93.34

ER SIM REP NCK TO TRUN OVER 30

Facility

$1,768.00

Service Code	HCPCS 12007
Hospital Charge Code	5700519
Hospital Revenue Code	450
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$265.20
Rate for Payer: Qualcare PPO/HMO/WC	$265.20

Know your out-of-pocket cost for care.

All Charges