Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

LEVEL I SP GROSS&MICROSCOPIC

Facility

$390.00

Service Code	HCPCS 88300
Hospital Charge Code	3005281
Hospital Revenue Code	312
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LEVEL I SP GROSS&MICROSCOPIC

Facility

$390.00

Service Code	HCPCS 88300
Hospital Charge Code	3005281
Hospital Revenue Code	312
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$93.46
Rate for Payer: Aetna Medicare Advantage	$111.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$124.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$124.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$34.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$124.64
Rate for Payer: Cigna Commercial	$68.87
Rate for Payer: Cigna Medicare Advantage	$34.36
Rate for Payer: Clover Medicare Advantage	$32.64
Rate for Payer: EmblemHealth Commercial	$103.08
Rate for Payer: Humana Medicare Advantage	$35.39
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$34.36
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	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.36
Rate for Payer: Wellcare Medicare Advantage	$34.36
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

LEVEL I SP GROSS&MICROSCOPIC

Facility

$465.00

Service Code	HCPCS 88300
Hospital Charge Code	3005280
Hospital Revenue Code	310
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$93.46
Rate for Payer: Aetna Medicare Advantage	$111.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$124.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$124.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$34.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$124.64
Rate for Payer: Cigna Commercial	$68.87
Rate for Payer: Cigna Medicare Advantage	$34.36
Rate for Payer: Clover Medicare Advantage	$32.64
Rate for Payer: EmblemHealth Commercial	$103.08
Rate for Payer: Humana Medicare Advantage	$35.39
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$34.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$120.90
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$69.75
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.36
Rate for Payer: Wellcare Medicare Advantage	$34.36
Rate for Payer: Wellpoint Medicaid Managed Care	$13.21

LEVEL IV SP GROSS&MICROSCOPIC

Facility

$1,358.00

Service Code	HCPCS 88305TC
Hospital Charge Code	3005294
Hospital Revenue Code	310
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$203.70
Rate for Payer: Qualcare PPO/HMO/WC	$203.70

LEVEL IV SP GROSS&MICROSCOPIC

Facility

$1,358.00

Service Code	HCPCS 88305TC
Hospital Charge Code	3005294
Hospital Revenue Code	310
Min. Negotiated Rate	$38.57
Max. Negotiated Rate	$679.00
Rate for Payer: Aetna Commercial	$516.04
Rate for Payer: Aetna Medicare Advantage	$407.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$346.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$346.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$346.29
Rate for Payer: Cigna Commercial	$679.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$353.08
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$203.70
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$42.91
Rate for Payer: Wellpoint Medicaid Managed Care	$38.57

LEVEL VI SP GROSS&MICROSCOPIC

Facility

$2,184.00

Service Code	HCPCS 88309TC
Hospital Charge Code	3005310
Hospital Revenue Code	310
Min. Negotiated Rate	$62.03
Max. Negotiated Rate	$1,092.00
Rate for Payer: Aetna Commercial	$829.92
Rate for Payer: Aetna Medicare Advantage	$655.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$556.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$556.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$556.92
Rate for Payer: Cigna Commercial	$1,092.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$567.84
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$327.60
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$69.01
Rate for Payer: Wellpoint Medicaid Managed Care	$62.03

LEVEL VI SP GROSS&MICROSCOPIC

Facility

$2,184.00

Service Code	HCPCS 88309TC
Hospital Charge Code	3005310
Hospital Revenue Code	310
Min. Negotiated Rate	$327.60
Max. Negotiated Rate	$327.60
Rate for Payer: Qualcare PPO/HMO/WC	$327.60

LEVEL V SP GROSS&MICROSCOPIC

Facility

$390.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005301
Hospital Revenue Code	312
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

LEVEL V SP GROSS&MICROSCOPIC

Facility

$1,099.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005300
Hospital Revenue Code	310
Min. Negotiated Rate	$164.85
Max. Negotiated Rate	$164.85
Rate for Payer: Qualcare PPO/HMO/WC	$164.85

LEVEL V SP GROSS&MICROSCOPIC

Facility

$1,099.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005300
Hospital Revenue Code	310
Min. Negotiated Rate	$31.21
Max. Negotiated Rate	$549.50
Rate for Payer: Aetna Commercial	$417.62
Rate for Payer: Aetna Medicare Advantage	$329.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$280.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$280.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$280.25
Rate for Payer: Cigna Commercial	$549.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$285.74
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$164.85
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$34.73
Rate for Payer: Wellpoint Medicaid Managed Care	$31.21

LEVEL V SP GROSS&MICROSCOPIC

Facility

$390.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005301
Hospital Revenue Code	312
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LEVETIRACETAM

Facility

$390.00

Service Code	HCPCS 80177
Hospital Charge Code	39900013
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LEVETIRACETAM

Facility

$390.00

Service Code	HCPCS 80177
Hospital Charge Code	39900013
Hospital Revenue Code	301
Min. Negotiated Rate	$10.60
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$36.04
Rate for Payer: Aetna Medicare Advantage	$42.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.06
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.25
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.25
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	$10.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Medicare Advantage	$13.25
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$59.83
Max. Negotiated Rate	$96.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$199.43
Rate for Payer: Aetna Commercial	$151.56
Rate for Payer: Aetna Medicare Advantage	$119.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$101.71
Rate for Payer: Cigna Commercial	$199.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83
Rate for Payer: UnitedHealthcare Community & State	$12.60
Rate for Payer: Wellpoint Medicaid Managed Care	$11.33

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$87.83
Rate for Payer: Aetna Commercial	$66.75
Rate for Payer: Aetna Medicare Advantage	$52.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.80
Rate for Payer: Cigna Commercial	$87.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35
Rate for Payer: UnitedHealthcare Community & State	$5.55
Rate for Payer: Wellpoint Medicaid Managed Care	$4.99

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$42.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$2.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.60

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$8.68
Rate for Payer: Aetna Commercial	$6.59
Rate for Payer: Aetna Medicare Advantage	$5.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.42
Rate for Payer: Cigna Commercial	$8.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.51
Rate for Payer: Oxford Commercial	$3.47
Rate for Payer: Qualcare PPO/HMO/WC	$2.60
Rate for Payer: UnitedHealthcare Commercial	$3.47
Rate for Payer: UnitedHealthcare Community & State	$0.55
Rate for Payer: Wellpoint Medicaid Managed Care	$0.49

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$119.66
Rate for Payer: Aetna Commercial	$90.94
Rate for Payer: Aetna Medicare Advantage	$71.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$61.03
Rate for Payer: Cigna Commercial	$119.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90
Rate for Payer: UnitedHealthcare Community & State	$7.56
Rate for Payer: Wellpoint Medicaid Managed Care	$6.80

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$35.90
Max. Negotiated Rate	$57.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$46.63
Max. Negotiated Rate	$75.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$155.44
Rate for Payer: Aetna Commercial	$118.13
Rate for Payer: Aetna Medicare Advantage	$93.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.27
Rate for Payer: Cigna Commercial	$155.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63
Rate for Payer: UnitedHealthcare Community & State	$9.82
Rate for Payer: Wellpoint Medicaid Managed Care	$8.83

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$27.84
Rate for Payer: Aetna Commercial	$21.16
Rate for Payer: Aetna Medicare Advantage	$16.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.20
Rate for Payer: Cigna Commercial	$27.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.48
Rate for Payer: Oxford Commercial	$11.14
Rate for Payer: Qualcare PPO/HMO/WC	$8.35
Rate for Payer: UnitedHealthcare Commercial	$11.14
Rate for Payer: UnitedHealthcare Community & State	$1.76
Rate for Payer: Wellpoint Medicaid Managed Care	$1.58

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$8.35
Rate for Payer: Qualcare PPO/HMO/WC	$8.35

Know your out-of-pocket cost for care.

All Charges