Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

IGG INDEX AND SYNTHESIS RATE I

Facility

$390.00

Service Code	HCPCS 82784
Hospital Charge Code	39990147D
Hospital Revenue Code	301
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Medicare Advantage	$30.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.74
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$9.30
Rate for Payer: Clover Medicare Advantage	$8.84
Rate for Payer: EmblemHealth Commercial	$27.90
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.30
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	$7.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.30
Rate for Payer: Wellcare Medicare Advantage	$9.30
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

IGG SUBCLASSES, EACH

Facility

$574.00

Service Code	HCPCS 82787
Hospital Charge Code	38472028
Hospital Revenue Code	301
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$86.10
Rate for Payer: Qualcare PPO/HMO/WC	$86.10

IGG SUBCLASSES, EACH

Facility

$574.00

Service Code	HCPCS 82787
Hospital Charge Code	38472028
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$21.81
Rate for Payer: Aetna Medicare Advantage	$25.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$112.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.09
Rate for Payer: Cigna Commercial	$287.00
Rate for Payer: Cigna Medicare Advantage	$8.02
Rate for Payer: Clover Medicare Advantage	$7.62
Rate for Payer: EmblemHealth Commercial	$24.06
Rate for Payer: Humana Medicare Advantage	$8.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$149.24
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$86.10
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$6.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.02
Rate for Payer: Wellcare Medicare Advantage	$8.02
Rate for Payer: Wellpoint Medicaid Managed Care	$16.30

IGG SUBCLASSES PANEL I

Facility

$667.59

Service Code	HCPCS 82784
Hospital Charge Code	39990068A
Hospital Revenue Code	301
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

IGG SUBCLASSES PANEL I

Facility

$667.59

Service Code	HCPCS 82784
Hospital Charge Code	39990068A
Hospital Revenue Code	301
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Medicare Advantage	$30.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.74
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$9.30
Rate for Payer: Clover Medicare Advantage	$8.84
Rate for Payer: EmblemHealth Commercial	$27.90
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$173.57
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$7.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.30
Rate for Payer: Wellcare Medicare Advantage	$9.30
Rate for Payer: Wellpoint Medicaid Managed Care	$18.96

IGG SUBCLASSES PANEL II

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068B
Hospital Revenue Code	301
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

IGG SUBCLASSES PANEL II

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068B
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$21.81
Rate for Payer: Aetna Medicare Advantage	$25.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$112.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.09
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$8.02
Rate for Payer: Clover Medicare Advantage	$7.62
Rate for Payer: EmblemHealth Commercial	$24.06
Rate for Payer: Humana Medicare Advantage	$8.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$173.57
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$6.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.02
Rate for Payer: Wellcare Medicare Advantage	$8.02
Rate for Payer: Wellpoint Medicaid Managed Care	$18.96

IGG SUBCLASSES PANEL III

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068C
Hospital Revenue Code	301
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

IGG SUBCLASSES PANEL III

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068C
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$21.81
Rate for Payer: Aetna Medicare Advantage	$25.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$112.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.09
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$8.02
Rate for Payer: Clover Medicare Advantage	$7.62
Rate for Payer: EmblemHealth Commercial	$24.06
Rate for Payer: Humana Medicare Advantage	$8.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$173.57
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$6.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.02
Rate for Payer: Wellcare Medicare Advantage	$8.02
Rate for Payer: Wellpoint Medicaid Managed Care	$18.96

IGG SUBCLASSES PANEL IV

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068D
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$21.81
Rate for Payer: Aetna Medicare Advantage	$25.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$112.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.09
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$8.02
Rate for Payer: Clover Medicare Advantage	$7.62
Rate for Payer: EmblemHealth Commercial	$24.06
Rate for Payer: Humana Medicare Advantage	$8.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$173.57
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$6.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.02
Rate for Payer: Wellcare Medicare Advantage	$8.02
Rate for Payer: Wellpoint Medicaid Managed Care	$18.96

IGG SUBCLASSES PANEL IV

Facility

$667.59

Service Code	HCPCS 82787
Hospital Charge Code	39990068D
Hospital Revenue Code	301
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

IGG SUBCLASSES PANEL V

Facility

$390.00

Service Code	HCPCS 82787
Hospital Charge Code	39990068E
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

IGG SUBCLASSES PANEL V

Facility

$390.00

Service Code	HCPCS 82787
Hospital Charge Code	39990068E
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$21.81
Rate for Payer: Aetna Medicare Advantage	$25.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$112.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.09
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$8.02
Rate for Payer: Clover Medicare Advantage	$7.62
Rate for Payer: EmblemHealth Commercial	$24.06
Rate for Payer: Humana Medicare Advantage	$8.26
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.02
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	$6.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.02
Rate for Payer: Wellcare Medicare Advantage	$8.02
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

IGIV HUMAN FOR INTRAVENEOS USE

Facility

$180.00

Service Code	HCPCS 90283
Hospital Charge Code	3408005
Hospital Revenue Code	636
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare Advantage	$54.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$45.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$45.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$73.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$45.90
Rate for Payer: Cigna Commercial	$90.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.56
Rate for Payer: Qualcare PPO/HMO/WC	$27.00
Rate for Payer: UnitedHealthcare Community & State	$5.69
Rate for Payer: Wellpoint Medicaid Managed Care	$5.11

IGIV HUMAN FOR INTRAVENEOS USE

Facility

$180.00

Service Code	HCPCS 90283
Hospital Charge Code	3408005
Hospital Revenue Code	636
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$43.56
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.56
Rate for Payer: Qualcare PPO/HMO/WC	$27.00

IGK REARRANGEABN CLONAL POP

Facility

$760.50

Service Code	HCPCS 81264
Hospital Charge Code	401081264
Hospital Revenue Code	310
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$626.58
Rate for Payer: Aetna Commercial	$469.83
Rate for Payer: Aetna Medicare Advantage	$559.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$626.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$626.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$172.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$626.58
Rate for Payer: Cigna Commercial	$380.25
Rate for Payer: Cigna Medicare Advantage	$172.73
Rate for Payer: Clover Medicare Advantage	$164.09
Rate for Payer: EmblemHealth Commercial	$518.19
Rate for Payer: Humana Medicare Advantage	$177.91
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$172.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$197.73
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$114.08
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$138.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$172.73
Rate for Payer: Wellcare Medicare Advantage	$172.73
Rate for Payer: Wellpoint Medicaid Managed Care	$21.60

IGK REARRANGEABN CLONAL POP

Facility

$760.50

Service Code	HCPCS 81264
Hospital Charge Code	401081264
Hospital Revenue Code	310
Min. Negotiated Rate	$114.08
Max. Negotiated Rate	$114.08
Rate for Payer: Qualcare PPO/HMO/WC	$114.08

IgM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38472413
Hospital Revenue Code	301
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$37.95
Rate for Payer: Qualcare PPO/HMO/WC	$37.95

IgM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38472413
Hospital Revenue Code	301
Min. Negotiated Rate	$7.19
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Medicare Advantage	$30.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.74
Rate for Payer: Cigna Commercial	$126.50
Rate for Payer: Cigna Medicare Advantage	$9.30
Rate for Payer: Clover Medicare Advantage	$8.84
Rate for Payer: EmblemHealth Commercial	$27.90
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.78
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.95
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$7.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.30
Rate for Payer: Wellcare Medicare Advantage	$9.30
Rate for Payer: Wellpoint Medicaid Managed Care	$7.19

IGM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38479449
Hospital Revenue Code	301
Min. Negotiated Rate	$7.19
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Medicare Advantage	$30.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.74
Rate for Payer: Cigna Commercial	$126.50
Rate for Payer: Cigna Medicare Advantage	$9.30
Rate for Payer: Clover Medicare Advantage	$8.84
Rate for Payer: EmblemHealth Commercial	$27.90
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.78
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.95
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$7.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.30
Rate for Payer: Wellcare Medicare Advantage	$9.30
Rate for Payer: Wellpoint Medicaid Managed Care	$7.19

IGM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38479417
Hospital Revenue Code	301
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$37.95
Rate for Payer: Qualcare PPO/HMO/WC	$37.95

IGM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38479417
Hospital Revenue Code	301
Min. Negotiated Rate	$7.19
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Medicare Advantage	$30.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.74
Rate for Payer: Cigna Commercial	$126.50
Rate for Payer: Cigna Medicare Advantage	$9.30
Rate for Payer: Clover Medicare Advantage	$8.84
Rate for Payer: EmblemHealth Commercial	$27.90
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.78
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.95
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$7.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.30
Rate for Payer: Wellcare Medicare Advantage	$9.30
Rate for Payer: Wellpoint Medicaid Managed Care	$7.19

IGM

Facility

$253.00

Service Code	HCPCS 82784
Hospital Charge Code	38479449
Hospital Revenue Code	301
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$37.95
Rate for Payer: Qualcare PPO/HMO/WC	$37.95

IgM, Mycoplasma pneumoniae

Facility

$79.19

Service Code	HCPCS 21130
Hospital Charge Code	3000079
Hospital Revenue Code	306
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$30.09
Rate for Payer: Aetna Medicare Advantage	$23.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.19
Rate for Payer: Cigna Commercial	$39.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.59
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.88
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$2.50
Rate for Payer: Wellpoint Medicaid Managed Care	$2.25

IgM, Mycoplasma pneumoniae

Facility

$79.19

Service Code	HCPCS 21130
Hospital Charge Code	3000079
Hospital Revenue Code	306
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$11.88
Rate for Payer: Qualcare PPO/HMO/WC	$11.88

Know your out-of-pocket cost for care.

All Charges