Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

HSV 1/ 2 IGG HERPESELECT II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990101B
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 1/ 2 IGG HERPESELECT II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990101B
Hospital Revenue Code	302
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$52.63
Rate for Payer: Aetna Medicare Advantage	$62.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$19.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.19
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$19.35
Rate for Payer: Clover Medicare Advantage	$18.38
Rate for Payer: EmblemHealth Commercial	$58.05
Rate for Payer: Humana Medicare Advantage	$19.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$19.35
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	$15.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.35
Rate for Payer: Wellcare Medicare Advantage	$19.35
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1/2(IGG),HSV(IGM)W/RF I

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	39990126A
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
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	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1/2(IGG),HSV(IGM)W/RF I

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	39990126A
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 1/2(IGG),HSV(IGM)W/RF II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990126B
Hospital Revenue Code	302
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$52.63
Rate for Payer: Aetna Medicare Advantage	$62.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$19.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.19
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$19.35
Rate for Payer: Clover Medicare Advantage	$18.38
Rate for Payer: EmblemHealth Commercial	$58.05
Rate for Payer: Humana Medicare Advantage	$19.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$19.35
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	$15.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.35
Rate for Payer: Wellcare Medicare Advantage	$19.35
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1/2(IGG),HSV(IGM)W/RF II

Facility

$390.00

Service Code	HCPCS 86696
Hospital Charge Code	39990126B
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 1 AB 1GM(1)

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38476117
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 1 AB 1GM(1)

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38476117
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$255.50
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 1 AB 1GM(2)

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38476118
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 1 AB 1GM(2)

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38476118
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$255.50
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 1 AB GM.1

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38479445
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 1 AB GM.1

Facility

$511.00

Service Code	HCPCS 86695
Hospital Charge Code	38479445
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$255.50
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 1 AB, IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38476114
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 1 AB, IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38476114
Hospital Revenue Code	302
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$391.36
Rate for Payer: Aetna Commercial	$35.03
Rate for Payer: Aetna Medicare Advantage	$41.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$391.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.72
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$12.88
Rate for Payer: Clover Medicare Advantage	$12.24
Rate for Payer: EmblemHealth Commercial	$38.64
Rate for Payer: Humana Medicare Advantage	$13.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.88
Rate for Payer: Wellcare Medicare Advantage	$12.88
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 1 IGG

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	39900380
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
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	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1 IGG

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	39900380
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 1 IGM TITER

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	3000378A
Hospital Revenue Code	302
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.88
Rate for Payer: Aetna Medicare Advantage	$42.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.85
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.19
Rate for Payer: Clover Medicare Advantage	$12.53
Rate for Payer: EmblemHealth Commercial	$39.57
Rate for Payer: Humana Medicare Advantage	$13.59
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.19
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	$10.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.19
Rate for Payer: Wellcare Medicare Advantage	$13.19
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1 IGM TITER

Facility

$390.00

Service Code	HCPCS 86695
Hospital Charge Code	3000378A
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 1 IGM TITER 2ND

Facility

$390.00

Service Code	HCPCS 8669591
Hospital Charge Code	3000378B
Hospital Revenue Code	302
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	$12.32
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

HSV 1 IGM TITER 2ND

Facility

$390.00

Service Code	HCPCS 8669591
Hospital Charge Code	3000378B
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HSV 2 AB IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38479446
Hospital Revenue Code	302
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$391.36
Rate for Payer: Aetna Commercial	$35.03
Rate for Payer: Aetna Medicare Advantage	$41.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$391.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.72
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$12.88
Rate for Payer: Clover Medicare Advantage	$12.24
Rate for Payer: EmblemHealth Commercial	$38.64
Rate for Payer: Humana Medicare Advantage	$13.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.88
Rate for Payer: Wellcare Medicare Advantage	$12.88
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 2 AB IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38479446
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 2 AB IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38476120
Hospital Revenue Code	302
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$391.36
Rate for Payer: Aetna Commercial	$35.03
Rate for Payer: Aetna Medicare Advantage	$41.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$391.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.72
Rate for Payer: Cigna Commercial	$255.50
Rate for Payer: Cigna Medicare Advantage	$12.88
Rate for Payer: Clover Medicare Advantage	$12.24
Rate for Payer: EmblemHealth Commercial	$38.64
Rate for Payer: Humana Medicare Advantage	$13.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.86
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$76.65
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.88
Rate for Payer: Wellcare Medicare Advantage	$12.88
Rate for Payer: Wellpoint Medicaid Managed Care	$14.51

HSV 2 AB IGG

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38476120
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

HSV 2 AB IGM

Facility

$511.00

Service Code	HCPCS 86790
Hospital Charge Code	38479447
Hospital Revenue Code	302
Min. Negotiated Rate	$76.65
Max. Negotiated Rate	$76.65
Rate for Payer: Qualcare PPO/HMO/WC	$76.65

Know your out-of-pocket cost for care.

All Charges