Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

MRI PELVIS W/ CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72196
Hospital Charge Code	2400224
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI PELVIS W/WO CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72197
Hospital Charge Code	94061095
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI PELVIS W/WO CONTRAST

Facility

$13,500.00

Service Code	HCPCS 72197
Hospital Charge Code	94061095
Hospital Revenue Code	614
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$808.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,543.21
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL CERV W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72142
Hospital Charge Code	2400133
Hospital Revenue Code	612
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$582.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL CERV W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72142
Hospital Charge Code	2400133
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL CERV W/O CON

Facility

$13,500.00

Service Code	HCPCS 72141
Hospital Charge Code	2400125
Hospital Revenue Code	612
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$544.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL CERV W/O CON

Facility

$13,500.00

Service Code	HCPCS 72141
Hospital Charge Code	2400125
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL CERV W + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72156
Hospital Charge Code	2400182
Hospital Revenue Code	612
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$790.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL CERV W + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72156
Hospital Charge Code	2400182
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL LUMBAR W/O CONT

Facility

$13,500.00

Service Code	HCPCS 72148
Hospital Charge Code	2400166
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL LUMBAR W/O CONT

Facility

$13,500.00

Service Code	HCPCS 72148
Hospital Charge Code	2400166
Hospital Revenue Code	612
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$544.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$817.38
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL LUMB W/ 7 + GAD

Facility

$13,500.00

Service Code	HCPCS 72158
Hospital Charge Code	2400208
Hospital Revenue Code	612
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$897.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,543.21
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL LUMB W/ 7 + GAD

Facility

$13,500.00

Service Code	HCPCS 72158
Hospital Charge Code	2400208
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL THOR W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72147
Hospital Charge Code	2400158
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL THOR W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72147
Hospital Charge Code	2400158
Hospital Revenue Code	612
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$544.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL THOR W/O CONTR

Facility

$13,500.00

Service Code	HCPCS 72146
Hospital Charge Code	2400141
Hospital Revenue Code	612
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$544.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL THOR W/O CONTR

Facility

$13,500.00

Service Code	HCPCS 72146
Hospital Charge Code	2400141
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL THOR W/ + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72157
Hospital Charge Code	2400190
Hospital Revenue Code	612
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,503.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$790.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,503.49
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI SPINAL THOR W/ + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72157
Hospital Charge Code	2400190
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI STERILE RADIAL OSTEOTOME B

Facility

$560.00

Hospital Charge Code	270684663
Hospital Revenue Code	272
Min. Negotiated Rate	$15.90
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna Commercial	$212.80
Rate for Payer: Aetna Medicare Advantage	$168.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$142.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$142.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$142.80
Rate for Payer: Cigna Commercial	$280.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$145.60
Rate for Payer: Oxford Commercial	$112.00
Rate for Payer: Qualcare PPO/HMO/WC	$84.00
Rate for Payer: UnitedHealthcare Commercial	$112.00
Rate for Payer: UnitedHealthcare Community & State	$17.70
Rate for Payer: Wellpoint Medicaid Managed Care	$15.90

MRI STERILE RADIAL OSTEOTOME B

Facility

$560.00

Hospital Charge Code	270684663
Hospital Revenue Code	272
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$84.00
Rate for Payer: Qualcare PPO/HMO/WC	$84.00

MRI TEMPOROMANDIBULAR JOINT

Facility

$13,500.00

Service Code	HCPCS 70336
Hospital Charge Code	2400042
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI TEMPOROMANDIBULAR JOINT

Facility

$13,500.00

Service Code	HCPCS 70336
Hospital Charge Code	2400042
Hospital Revenue Code	614
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,130.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,028.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$495.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,028.29
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

MRI TIBIA/FIBULA W/&W/O CNT LF

Facility

$13,500.00

Service Code	HCPCS 73720LT
Hospital Charge Code	2400525
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI TIBIA/FIBULA W/&W/O CNT LF

Facility

$13,500.00

Service Code	HCPCS 73720LT
Hospital Charge Code	2400525
Hospital Revenue Code	614
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,510.00
Rate for Payer: Oxford Commercial	$5,427.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,130.00
Rate for Payer: UnitedHealthcare Community & State	$426.60
Rate for Payer: Wellpoint Medicaid Managed Care	$383.40

Know your out-of-pocket cost for care.

All Charges