Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

AMISTEM STEM # 5

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270686064
Hospital Revenue Code	278
Min. Negotiated Rate	$227.20
Max. Negotiated Rate	$4,000.00
Rate for Payer: Aetna Commercial	$3,040.00
Rate for Payer: Aetna Medicare Advantage	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,040.00
Rate for Payer: Cigna Commercial	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00
Rate for Payer: UnitedHealthcare Community & State	$252.80
Rate for Payer: Wellpoint Medicaid Managed Care	$227.20

AMISTEM STEM # 5

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270686064
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,936.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00

AMITRIP/NORTRIP SERUM TRICYCLI

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3006988
Hospital Revenue Code	301
Min. Negotiated Rate	$4.36
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$58.39
Rate for Payer: Aetna Medicare Advantage	$46.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$76.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.95
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$4.36

AMITRIP/NORTRIP SERUM TRICYCLI

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3006988
Hospital Revenue Code	301
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$23.05
Rate for Payer: Qualcare PPO/HMO/WC	$23.05

AMITRIPTYLINE

Facility

$390.00

Service Code	HCPCS 80335
Hospital Charge Code	39900478
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

AMITRIPTYLINE

Facility

$390.00

Service Code	HCPCS 80335
Hospital Charge Code	39900478
Hospital Revenue Code	301
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare Advantage	$117.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

AMITRIPTYLINE 10 MG TAB

Facility

$4.00

Service Code	NDC 51079013120
Hospital Charge Code	60627753
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

AMITRIPTYLINE 10 MG TAB

Facility

$4.00

Service Code	NDC 51079013120
Hospital Charge Code	60627753
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

AMITRIPTYLINE 1-2

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3001211
Hospital Revenue Code	301
Min. Negotiated Rate	$4.36
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$58.39
Rate for Payer: Aetna Medicare Advantage	$46.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$76.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.95
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$4.36

AMITRIPTYLINE 1-2

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3001211
Hospital Revenue Code	301
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$23.05
Rate for Payer: Qualcare PPO/HMO/WC	$23.05

AMITRIPTYLINE 25 MG TAB

Facility

$4.29

Service Code	NDC 51079010720
Hospital Charge Code	60627754
Hospital Revenue Code	250
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.64
Rate for Payer: Qualcare PPO/HMO/WC	$0.64

AMITRIPTYLINE 25 MG TAB

Facility

$4.29

Service Code	NDC 51079010720
Hospital Charge Code	60627754
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare Advantage	$1.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.09
Rate for Payer: Cigna Commercial	$2.15
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.12
Rate for Payer: Oxford Commercial	$0.86
Rate for Payer: Qualcare PPO/HMO/WC	$0.64
Rate for Payer: UnitedHealthcare Commercial	$0.86
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

AMITRIPTYLINE 50 MG TAB

Facility

$7.10

Service Code	NDC 51079013320
Hospital Charge Code	60627755
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.06
Rate for Payer: Qualcare PPO/HMO/WC	$1.06

AMITRIPTYLINE 50 MG TAB

Facility

$7.10

Service Code	NDC 51079013320
Hospital Charge Code	60627755
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$3.55
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Aetna Medicare Advantage	$2.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.81
Rate for Payer: Cigna Commercial	$3.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.85
Rate for Payer: Oxford Commercial	$1.42
Rate for Payer: Qualcare PPO/HMO/WC	$1.06
Rate for Payer: UnitedHealthcare Commercial	$1.42
Rate for Payer: UnitedHealthcare Community & State	$0.22
Rate for Payer: Wellpoint Medicaid Managed Care	$0.20

AMITRIPTYLINE (ELAVIL)

Facility

$360.00

Service Code	HCPCS 80335
Hospital Charge Code	38472673
Hospital Revenue Code	301
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Qualcare PPO/HMO/WC	$54.00

AMITRIPTYLINE (ELAVIL)

Facility

$360.00

Service Code	HCPCS 80335
Hospital Charge Code	38472673
Hospital Revenue Code	301
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare Advantage	$108.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$91.80
Rate for Payer: Cigna Commercial	$180.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$93.60
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$54.00
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$10.22

AMITRIPTYLINE & METABOLITE

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3035122
Hospital Revenue Code	301
Min. Negotiated Rate	$4.36
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$58.39
Rate for Payer: Aetna Medicare Advantage	$46.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$76.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.95
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$4.36

AMITRIPTYLINE & METABOLITE

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3035122
Hospital Revenue Code	301
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$23.05
Rate for Payer: Qualcare PPO/HMO/WC	$23.05

AMITRIPTYLINE/NORTRIP, URINE

Facility

$190.45

Service Code	HCPCS 80335
Hospital Charge Code	3006996
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

AMITRIPTYLINE/NORTRIP, URINE

Facility

$190.45

Service Code	HCPCS 80335
Hospital Charge Code	3006996
Hospital Revenue Code	301
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$72.37
Rate for Payer: Aetna Medicare Advantage	$57.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.56
Rate for Payer: Cigna Commercial	$95.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$49.52
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$5.41

AML MMA FEMORAL STEM

Facility

$14,441.00

Hospital Charge Code	270335033
Hospital Revenue Code	278
Min. Negotiated Rate	$410.12
Max. Negotiated Rate	$7,220.50
Rate for Payer: Aetna Commercial	$5,487.58
Rate for Payer: Aetna Medicare Advantage	$4,332.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,682.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,682.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,888.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,682.45
Rate for Payer: Cigna Commercial	$7,220.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,494.72
Rate for Payer: Qualcare PPO/HMO/WC	$2,166.15
Rate for Payer: UnitedHealthcare Community & State	$456.34
Rate for Payer: Wellpoint Medicaid Managed Care	$410.12

AML MMA FEMORAL STEM

Facility

$14,441.00

Hospital Charge Code	270335033
Hospital Revenue Code	278
Min. Negotiated Rate	$2,166.15
Max. Negotiated Rate	$3,494.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,888.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,494.72
Rate for Payer: Qualcare PPO/HMO/WC	$2,166.15

AMLODIPINE 10 MG TAB

Facility

$41.74

Service Code	NDC 69154041
Hospital Charge Code	60029064
Hospital Revenue Code	250
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$6.26
Rate for Payer: Qualcare PPO/HMO/WC	$6.26

AMLODIPINE 10 MG TAB

Facility

$41.74

Service Code	NDC 69154041
Hospital Charge Code	60029064
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$20.87
Rate for Payer: Aetna Commercial	$15.86
Rate for Payer: Aetna Medicare Advantage	$12.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.64
Rate for Payer: Cigna Commercial	$20.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.85
Rate for Payer: Oxford Commercial	$8.35
Rate for Payer: Qualcare PPO/HMO/WC	$6.26
Rate for Payer: UnitedHealthcare Commercial	$8.35
Rate for Payer: UnitedHealthcare Community & State	$1.32
Rate for Payer: Wellpoint Medicaid Managed Care	$1.19

AMLODIPINE 2.5 MG TAB

Facility

$30.42

Service Code	NDC 58151035377
Hospital Charge Code	6008841
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$15.21
Rate for Payer: Aetna Commercial	$11.56
Rate for Payer: Aetna Medicare Advantage	$9.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.76
Rate for Payer: Cigna Commercial	$15.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.91
Rate for Payer: Oxford Commercial	$6.08
Rate for Payer: Qualcare PPO/HMO/WC	$4.56
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: UnitedHealthcare Community & State	$0.96
Rate for Payer: Wellpoint Medicaid Managed Care	$0.86

Know your out-of-pocket cost for care.

All Charges