Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

MYCOBACTERIA CULTURE

Facility

$390.00

Service Code	HCPCS 87116
Hospital Charge Code	401087116
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

MYCOBACTERIA CULTURE

Facility

$390.00

Service Code	HCPCS 87116
Hospital Charge Code	401087116
Hospital Revenue Code	306
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
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) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
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	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

MYCOBACTERIA ID

Facility

$235.00

Service Code	HCPCS 87118
Hospital Charge Code	38475101
Hospital Revenue Code	309
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$39.74
Rate for Payer: Aetna Medicare Advantage	$47.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.00
Rate for Payer: Cigna Commercial	$117.50
Rate for Payer: Cigna Medicare Advantage	$14.61
Rate for Payer: Clover Medicare Advantage	$13.88
Rate for Payer: EmblemHealth Commercial	$43.83
Rate for Payer: Humana Medicare Advantage	$15.05
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$61.10
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$35.25
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.61
Rate for Payer: Wellcare Medicare Advantage	$14.61
Rate for Payer: Wellpoint Medicaid Managed Care	$6.67

MYCOBACTERIA ID

Facility

$235.00

Service Code	HCPCS 87118
Hospital Charge Code	38475101
Hospital Revenue Code	309
Min. Negotiated Rate	$35.25
Max. Negotiated Rate	$35.25
Rate for Payer: Qualcare PPO/HMO/WC	$35.25

MYCOBACTERIA,PCR,RESP

Facility

$390.00

Service Code	HCPCS 87556
Hospital Charge Code	39900500
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

MYCOBACTERIA,PCR,RESP

Facility

$390.00

Service Code	HCPCS 87556
Hospital Charge Code	39900500
Hospital Revenue Code	306
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$113.37
Rate for Payer: Aetna Medicare Advantage	$135.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$41.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$32.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$151.19
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$41.68
Rate for Payer: Clover Medicare Advantage	$39.60
Rate for Payer: EmblemHealth Commercial	$125.04
Rate for Payer: Humana Medicare Advantage	$42.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$41.68
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	$33.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.68
Rate for Payer: Wellcare Medicare Advantage	$41.68
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

MYCOBACTERIA,PCR,SPUTUM

Facility

$241.20

Service Code	HCPCS 87556
Hospital Charge Code	39900301
Hospital Revenue Code	306
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$36.18
Rate for Payer: Qualcare PPO/HMO/WC	$36.18

MYCOBACTERIA,PCR,SPUTUM

Facility

$241.20

Service Code	HCPCS 87556
Hospital Charge Code	39900301
Hospital Revenue Code	306
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$113.37
Rate for Payer: Aetna Medicare Advantage	$135.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$41.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$32.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$151.19
Rate for Payer: Cigna Commercial	$120.60
Rate for Payer: Cigna Medicare Advantage	$41.68
Rate for Payer: Clover Medicare Advantage	$39.60
Rate for Payer: EmblemHealth Commercial	$125.04
Rate for Payer: Humana Medicare Advantage	$42.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$41.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$62.71
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.18
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$33.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.68
Rate for Payer: Wellcare Medicare Advantage	$41.68
Rate for Payer: Wellpoint Medicaid Managed Care	$6.85

MYCOBACTERIA TB PCR

Facility

$241.20

Service Code	HCPCS 87556
Hospital Charge Code	39900499
Hospital Revenue Code	306
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$113.37
Rate for Payer: Aetna Medicare Advantage	$135.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$41.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$32.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$151.19
Rate for Payer: Cigna Commercial	$120.60
Rate for Payer: Cigna Medicare Advantage	$41.68
Rate for Payer: Clover Medicare Advantage	$39.60
Rate for Payer: EmblemHealth Commercial	$125.04
Rate for Payer: Humana Medicare Advantage	$42.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$41.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$62.71
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.18
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$33.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.68
Rate for Payer: Wellcare Medicare Advantage	$41.68
Rate for Payer: Wellpoint Medicaid Managed Care	$6.85

MYCOBACTERIA TB PCR

Facility

$241.20

Service Code	HCPCS 87556
Hospital Charge Code	39900499
Hospital Revenue Code	306
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$36.18
Rate for Payer: Qualcare PPO/HMO/WC	$36.18

MYCOBACTERIUM, BROC CULUT III

Facility

$36.70

Service Code	HCPCS 87206
Hospital Charge Code	3990155C
Hospital Revenue Code	309
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$14.66
Rate for Payer: Aetna Medicare Advantage	$17.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.55
Rate for Payer: Cigna Commercial	$18.35
Rate for Payer: Cigna Medicare Advantage	$5.39
Rate for Payer: Clover Medicare Advantage	$5.12
Rate for Payer: EmblemHealth Commercial	$16.17
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.54
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$4.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.39
Rate for Payer: Wellcare Medicare Advantage	$5.39
Rate for Payer: Wellpoint Medicaid Managed Care	$1.04

MYCOBACTERIUM, BROC CULUT III

Facility

$36.70

Service Code	HCPCS 87206
Hospital Charge Code	3990155C
Hospital Revenue Code	309
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$5.50
Rate for Payer: Qualcare PPO/HMO/WC	$5.50

MYCOBACTERIUM, BROCH CULT I

Facility

$45.90

Service Code	HCPCS 87015
Hospital Charge Code	3990155A
Hospital Revenue Code	309
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$6.88
Rate for Payer: Qualcare PPO/HMO/WC	$6.88

MYCOBACTERIUM, BROCH CULT I

Facility

$45.90

Service Code	HCPCS 87015
Hospital Charge Code	3990155A
Hospital Revenue Code	309
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$22.95
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.93
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.88
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$1.30

MYCOBACTERIUM, BROCHCULUT II

Facility

$73.70

Service Code	HCPCS 87116
Hospital Charge Code	3990155B
Hospital Revenue Code	309
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$11.05
Rate for Payer: Qualcare PPO/HMO/WC	$11.05

MYCOBACTERIUM, BROCHCULUT II

Facility

$73.70

Service Code	HCPCS 87116
Hospital Charge Code	3990155B
Hospital Revenue Code	309
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
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) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$36.85
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.16
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$2.09

MYCOBACTERIUM ID

Facility

$390.00

Service Code	HCPCS 87118
Hospital Charge Code	39900270
Hospital Revenue Code	309
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

MYCOBACTERIUM ID

Facility

$75.20

Service Code	HCPCS 87118
Hospital Charge Code	39900492
Hospital Revenue Code	309
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$11.28
Rate for Payer: Qualcare PPO/HMO/WC	$11.28

MYCOBACTERIUM ID

Facility

$75.20

Service Code	HCPCS 87118
Hospital Charge Code	39900492
Hospital Revenue Code	309
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$39.74
Rate for Payer: Aetna Medicare Advantage	$47.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.00
Rate for Payer: Cigna Commercial	$37.60
Rate for Payer: Cigna Medicare Advantage	$14.61
Rate for Payer: Clover Medicare Advantage	$13.88
Rate for Payer: EmblemHealth Commercial	$43.83
Rate for Payer: Humana Medicare Advantage	$15.05
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.55
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.28
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.61
Rate for Payer: Wellcare Medicare Advantage	$14.61
Rate for Payer: Wellpoint Medicaid Managed Care	$2.14

MYCOBACTERIUM ID

Facility

$390.00

Service Code	HCPCS 87118
Hospital Charge Code	39900270
Hospital Revenue Code	309
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$39.74
Rate for Payer: Aetna Medicare Advantage	$47.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.00
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.61
Rate for Payer: Clover Medicare Advantage	$13.88
Rate for Payer: EmblemHealth Commercial	$43.83
Rate for Payer: Humana Medicare Advantage	$15.05
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.61
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	$11.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.61
Rate for Payer: Wellcare Medicare Advantage	$14.61
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

MYCOB AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479504
Hospital Revenue Code	309
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$14.66
Rate for Payer: Aetna Medicare Advantage	$17.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.55
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare Advantage	$5.39
Rate for Payer: Clover Medicare Advantage	$5.12
Rate for Payer: EmblemHealth Commercial	$16.17
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.52
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.80
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$4.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.39
Rate for Payer: Wellcare Medicare Advantage	$5.39
Rate for Payer: Wellpoint Medicaid Managed Care	$4.32

MYCOB AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479504
Hospital Revenue Code	309
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$22.80
Rate for Payer: Qualcare PPO/HMO/WC	$22.80

MYCOPHENOLATE 500 MG INJ

Facility

$730.70

Service Code	NDC 4029809
Hospital Charge Code	60635437
Hospital Revenue Code	250
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$365.35
Rate for Payer: Aetna Commercial	$277.67
Rate for Payer: Aetna Medicare Advantage	$219.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$186.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$186.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$186.33
Rate for Payer: Cigna Commercial	$365.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$189.98
Rate for Payer: Oxford Commercial	$146.14
Rate for Payer: Qualcare PPO/HMO/WC	$109.61
Rate for Payer: UnitedHealthcare Commercial	$146.14
Rate for Payer: UnitedHealthcare Community & State	$23.09
Rate for Payer: Wellpoint Medicaid Managed Care	$20.75

MYCOPHENOLATE 500 MG INJ

Facility

$730.70

Service Code	NDC 4029809
Hospital Charge Code	60635437
Hospital Revenue Code	250
Min. Negotiated Rate	$109.61
Max. Negotiated Rate	$109.61
Rate for Payer: Qualcare PPO/HMO/WC	$109.61

MYCOPHENOLATE CAP 250MG

Facility

$57.42

Service Code	HCPCS J7517
Hospital Charge Code	60628535
Hospital Revenue Code	636
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$13.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.90
Rate for Payer: Qualcare PPO/HMO/WC	$8.61

Know your out-of-pocket cost for care.

All Charges