Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

EXC BEN LES T/A/L,2.1-3.0CM

Facility

$7,918.25

Service Code	HCPCS 11403
Hospital Charge Code	16000189
Hospital Revenue Code	360
Min. Negotiated Rate	$1,187.74
Max. Negotiated Rate	$1,187.74
Rate for Payer: Qualcare PPO/HMO/WC	$1,187.74

EXC BEN LES T/A/L,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11404
Hospital Charge Code	16000204
Hospital Revenue Code	360
Min. Negotiated Rate	$478.65
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,382.03
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$532.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$478.65

EXC BEN LES T/A/L,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11404
Hospital Charge Code	16000204
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.09
Max. Negotiated Rate	$2,528.09
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09

EXC BEN LES T/A/L,> 4.0CM

Facility

$13,615.50

Service Code	HCPCS 11406
Hospital Charge Code	16000181
Hospital Revenue Code	360
Min. Negotiated Rate	$386.68
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,540.03
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$430.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$386.68

EXC BEN LES T/A/L,> 4.0CM

Facility

$13,615.50

Service Code	HCPCS 11406
Hospital Charge Code	16000181
Hospital Revenue Code	360
Min. Negotiated Rate	$2,042.33
Max. Negotiated Rate	$2,042.33
Rate for Payer: Qualcare PPO/HMO/WC	$2,042.33

EXC BLES S/N/EX G,0.5CM/<

Facility

$7,612.30

Service Code	HCPCS 11420
Hospital Charge Code	16000227
Hospital Revenue Code	360
Min. Negotiated Rate	$216.19
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,979.20
Rate for Payer: Oxford Commercial	$3,505.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,629.00
Rate for Payer: UnitedHealthcare Community & State	$240.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$216.19

EXC BLES S/N/EX G,0.5CM/<

Facility

$7,612.30

Service Code	HCPCS 11420
Hospital Charge Code	16000227
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,0.6-1.0CM

Facility

$7,612.30

Service Code	HCPCS 11421
Hospital Charge Code	16000320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,0.6-1.0CM

Facility

$7,612.30

Service Code	HCPCS 11421
Hospital Charge Code	16000320
Hospital Revenue Code	360
Min. Negotiated Rate	$216.19
Max. Negotiated Rate	$3,629.00
Rate for Payer: Aetna Commercial	$2,288.28
Rate for Payer: Aetna Medicare Advantage	$2,725.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,051.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,051.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$841.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,051.74
Rate for Payer: Cigna Commercial	$1,686.34
Rate for Payer: Cigna Medicare Advantage	$841.28
Rate for Payer: Clover Medicare Advantage	$799.22
Rate for Payer: EmblemHealth Commercial	$2,523.84
Rate for Payer: Humana Medicare Advantage	$866.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$841.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,979.20
Rate for Payer: Oxford Commercial	$3,505.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,629.00
Rate for Payer: UnitedHealthcare Community & State	$240.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$841.28
Rate for Payer: Wellcare Medicare Advantage	$841.28
Rate for Payer: Wellpoint Medicaid Managed Care	$216.19

EXC BLES S/N/EX G,1.1-2.0CM

Facility

$7,612.30

Service Code	HCPCS 11422
Hospital Charge Code	16000210
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,1.1-2.0CM

Facility

$7,612.30

Service Code	HCPCS 11422
Hospital Charge Code	16000210
Hospital Revenue Code	360
Min. Negotiated Rate	$216.19
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,979.20
Rate for Payer: Oxford Commercial	$3,505.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,629.00
Rate for Payer: UnitedHealthcare Community & State	$240.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$216.19

EXC BLES S/N/EX G,2.1-3.0CM

Facility

$16,857.75

Service Code	HCPCS 11423
Hospital Charge Code	16000219
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.66
Max. Negotiated Rate	$2,528.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66

EXC BLES S/N/EX G,2.1-3.0CM

Facility

$16,857.75

Service Code	HCPCS 11423
Hospital Charge Code	16000219
Hospital Revenue Code	360
Min. Negotiated Rate	$478.76
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,383.02
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$532.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$478.76

EXC BLES S/N/EX G,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11424
Hospital Charge Code	16000226
Hospital Revenue Code	360
Min. Negotiated Rate	$478.65
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,382.03
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$532.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$478.65

EXC BLES S/N/EX G,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11424
Hospital Charge Code	16000226
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.09
Max. Negotiated Rate	$2,528.09
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09

EXC BLES S/N/EX G,> 4.0CM

Facility

$27,889.82

Service Code	HCPCS 11426
Hospital Charge Code	16000220
Hospital Revenue Code	360
Min. Negotiated Rate	$4,183.47
Max. Negotiated Rate	$4,183.47
Rate for Payer: Qualcare PPO/HMO/WC	$4,183.47

EXC BLES S/N/EX G,> 4.0CM

Facility

$27,889.82

Service Code	HCPCS 11426
Hospital Charge Code	16000220
Hospital Revenue Code	360
Min. Negotiated Rate	$792.07
Max. Negotiated Rate	$12,518.07
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,518.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,518.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,518.07
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,251.35
Rate for Payer: Oxford Commercial	$7,525.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,183.47
Rate for Payer: UnitedHealthcare Commercial	$8,192.00
Rate for Payer: UnitedHealthcare Community & State	$881.32
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$792.07

EXC BONE BX,DEEP

Facility

$20,625.50

Service Code	HCPCS 20245
Hospital Charge Code	16000667
Hospital Revenue Code	360
Min. Negotiated Rate	$585.76
Max. Negotiated Rate	$12,518.07
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,518.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,518.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,518.07
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,362.63
Rate for Payer: Oxford Commercial	$7,525.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82
Rate for Payer: UnitedHealthcare Commercial	$8,192.00
Rate for Payer: UnitedHealthcare Community & State	$651.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$585.76

EXC BONE BX,DEEP

Facility

$20,625.50

Service Code	HCPCS 20245
Hospital Charge Code	16000667
Hospital Revenue Code	360
Min. Negotiated Rate	$3,093.82
Max. Negotiated Rate	$3,093.82
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82

EXC BREAST LES BY N LOC,SGL

Facility

$10,974.15

Service Code	HCPCS 19125
Hospital Charge Code	16000285
Hospital Revenue Code	360
Min. Negotiated Rate	$1,646.12
Max. Negotiated Rate	$1,646.12
Rate for Payer: Qualcare PPO/HMO/WC	$1,646.12

EXC BREAST LES BY N LOC,SGL

Facility

$10,974.15

Service Code	HCPCS 19125
Hospital Charge Code	16000285
Hospital Revenue Code	360
Min. Negotiated Rate	$311.67
Max. Negotiated Rate	$16,873.82
Rate for Payer: Aetna Commercial	$12,652.46
Rate for Payer: Aetna Medicare Advantage	$15,071.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,873.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,873.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,651.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,873.82
Rate for Payer: Cigna Commercial	$9,324.19
Rate for Payer: Cigna Medicare Advantage	$4,651.64
Rate for Payer: Clover Medicare Advantage	$4,419.06
Rate for Payer: EmblemHealth Commercial	$13,954.92
Rate for Payer: Humana Medicare Advantage	$4,791.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,651.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,853.28
Rate for Payer: Oxford Commercial	$7,525.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,646.12
Rate for Payer: UnitedHealthcare Commercial	$8,192.00
Rate for Payer: UnitedHealthcare Community & State	$346.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,651.64
Rate for Payer: Wellcare Medicare Advantage	$4,651.64
Rate for Payer: Wellpoint Medicaid Managed Care	$311.67

EXCEED LORDOTIC 25LX10WX11H

Facility

$25,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704714
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$6,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,050.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,750.00

EXCEED LORDOTIC 25LX10WX11H

Facility

$25,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704714
Hospital Revenue Code	278
Min. Negotiated Rate	$710.00
Max. Negotiated Rate	$12,500.00
Rate for Payer: Aetna Commercial	$9,500.00
Rate for Payer: Aetna Medicare Advantage	$7,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,375.00
Rate for Payer: Cigna Commercial	$12,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,050.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,750.00
Rate for Payer: UnitedHealthcare Community & State	$790.00
Rate for Payer: Wellpoint Medicaid Managed Care	$710.00

EXCELSIOR SL-10 STRAIGHT 2 TIP

Facility

$4,726.25

Service Code	HCPCS C1887
Hospital Charge Code	270689725
Hospital Revenue Code	272
Min. Negotiated Rate	$708.94
Max. Negotiated Rate	$708.94
Rate for Payer: Qualcare PPO/HMO/WC	$708.94

EXCELSIOR SL-10 STRAIGHT 2 TIP

Facility

$4,726.25

Service Code	HCPCS C1887
Hospital Charge Code	270689725
Hospital Revenue Code	272
Min. Negotiated Rate	$134.23
Max. Negotiated Rate	$2,363.12
Rate for Payer: Aetna Commercial	$1,795.97
Rate for Payer: Aetna Medicare Advantage	$1,417.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,205.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,205.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,205.19
Rate for Payer: Cigna Commercial	$2,363.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,228.83
Rate for Payer: Oxford Commercial	$945.25
Rate for Payer: Qualcare PPO/HMO/WC	$708.94
Rate for Payer: UnitedHealthcare Commercial	$945.25
Rate for Payer: UnitedHealthcare Community & State	$149.35
Rate for Payer: Wellpoint Medicaid Managed Care	$134.23

Know your out-of-pocket cost for care.

All Charges