Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

NM BONE MARROW LIMITED

Facility

$12,000.00

Service Code	HCPCS 78102
Hospital Charge Code	4500559
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM BONE MARROW LIMITED

Facility

$12,000.00

Service Code	HCPCS 78102
Hospital Charge Code	4500559
Hospital Revenue Code	341
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$108.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,722.84
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM BONE MARROW MULTIPLE

Facility

$2,056.80

Service Code	HCPCS 78103
Hospital Charge Code	4500567
Hospital Revenue Code	341
Min. Negotiated Rate	$308.52
Max. Negotiated Rate	$308.52
Rate for Payer: Qualcare PPO/HMO/WC	$308.52

NM BONE MARROW MULTIPLE

Facility

$2,056.80

Service Code	HCPCS 78103
Hospital Charge Code	4500567
Hospital Revenue Code	341
Min. Negotiated Rate	$58.41
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$136.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,722.84
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$534.77
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$308.52
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$64.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$58.41

NM BONE MARROW WHOLE BODY

Facility

$2,056.80

Service Code	HCPCS 78104
Hospital Charge Code	4500575
Hospital Revenue Code	341
Min. Negotiated Rate	$308.52
Max. Negotiated Rate	$308.52
Rate for Payer: Qualcare PPO/HMO/WC	$308.52

NM BONE MARROW WHOLE BODY

Facility

$2,056.80

Service Code	HCPCS 78104
Hospital Charge Code	4500575
Hospital Revenue Code	341
Min. Negotiated Rate	$58.41
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$154.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,722.84
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$534.77
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$308.52
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$64.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$58.41

NM-BONE SCAN MULTIPLE AREAS

Facility

$1,802.00

Service Code	HCPCS 78305
Hospital Charge Code	4508015
Hospital Revenue Code	341
Min. Negotiated Rate	$51.18
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,722.84
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$468.52
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$270.30
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$56.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,205.13
Rate for Payer: Wellpoint Medicaid Managed Care	$51.18

NM-BONE SCAN MULTIPLE AREAS

Facility

$1,802.00

Service Code	HCPCS 78305
Hospital Charge Code	4508015
Hospital Revenue Code	341
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$270.30
Rate for Payer: Qualcare PPO/HMO/WC	$270.30

NM BONE SCAN WHOLE BODY

Facility

$12,000.00

Service Code	HCPCS 78306
Hospital Charge Code	4500088
Hospital Revenue Code	341
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,291.84
Rate for Payer: Aetna Medicare Advantage	$1,538.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,722.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$474.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,722.84
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: Cigna Medicare Advantage	$332.46
Rate for Payer: Clover Medicare Advantage	$451.19
Rate for Payer: EmblemHealth Commercial	$1,424.82
Rate for Payer: Humana Medicare Advantage	$489.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$474.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM BONE SCAN WHOLE BODY

Facility

$12,000.00

Service Code	HCPCS 78306
Hospital Charge Code	4500088
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM BONE SPECT

Facility

$12,000.00

Service Code	HCPCS 78320
Hospital Charge Code	4500468
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM BONE SPECT

Facility

$12,000.00

Service Code	HCPCS 78320
Hospital Charge Code	4500468
Hospital Revenue Code	341
Min. Negotiated Rate	$340.80
Max. Negotiated Rate	$6,000.00
Rate for Payer: Aetna Commercial	$4,560.00
Rate for Payer: Aetna Medicare Advantage	$3,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,060.00
Rate for Payer: Cigna Commercial	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM BRAIN & FLOW

Facility

$12,000.00

Service Code	HCPCS 78606
Hospital Charge Code	4500138
Hospital Revenue Code	341
Min. Negotiated Rate	$154.28
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,754.56
Rate for Payer: Aetna Medicare Advantage	$2,089.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$645.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$154.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,339.96
Rate for Payer: Cigna Commercial	$1,293.03
Rate for Payer: Cigna Medicare Advantage	$451.54
Rate for Payer: Clover Medicare Advantage	$612.81
Rate for Payer: EmblemHealth Commercial	$1,935.18
Rate for Payer: Humana Medicare Advantage	$664.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$645.06
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$645.06
Rate for Payer: Wellcare Medicare Advantage	$645.06
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM BRAIN & FLOW

Facility

$12,000.00

Service Code	HCPCS 78606
Hospital Charge Code	4500138
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM BRAIN SPECT

Facility

$3,540.00

Service Code	HCPCS 78607
Hospital Charge Code	4500492
Hospital Revenue Code	341
Min. Negotiated Rate	$100.54
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,345.20
Rate for Payer: Aetna Medicare Advantage	$1,062.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$902.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$902.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$902.70
Rate for Payer: Cigna Commercial	$1,770.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$920.40
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$531.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$111.86
Rate for Payer: Wellpoint Medicaid Managed Care	$100.54

NM BRAIN SPECT

Facility

$3,540.00

Service Code	HCPCS 78607
Hospital Charge Code	4500492
Hospital Revenue Code	341
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$531.00
Rate for Payer: Qualcare PPO/HMO/WC	$531.00

NM-CARDIAC SPECT SNGL ACQ

Facility

$6,851.00

Service Code	HCPCS 78451
Hospital Charge Code	4509005
Hospital Revenue Code	341
Min. Negotiated Rate	$1,027.65
Max. Negotiated Rate	$1,027.65
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.65

NM-CARDIAC SPECT SNGL ACQ

Facility

$6,851.00

Service Code	HCPCS 78451
Hospital Charge Code	4509005
Hospital Revenue Code	341
Min. Negotiated Rate	$194.57
Max. Negotiated Rate	$5,579.39
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,579.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,579.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$198.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,579.39
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,781.26
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.65
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$216.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$194.57

NM CEREBRAL FLOW

Facility

$12,000.00

Service Code	HCPCS 78610
Hospital Charge Code	4500153
Hospital Revenue Code	341
Min. Negotiated Rate	$27.93
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,754.56
Rate for Payer: Aetna Medicare Advantage	$2,089.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$645.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$27.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,339.96
Rate for Payer: Cigna Commercial	$1,293.03
Rate for Payer: Cigna Medicare Advantage	$451.54
Rate for Payer: Clover Medicare Advantage	$612.81
Rate for Payer: EmblemHealth Commercial	$1,935.18
Rate for Payer: Humana Medicare Advantage	$664.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$645.06
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$645.06
Rate for Payer: Wellcare Medicare Advantage	$645.06
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM CEREBRAL FLOW

Facility

$12,000.00

Service Code	HCPCS 78610
Hospital Charge Code	4500153
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM CEREBROSPINAL FLD LKGE DTCT

Facility

$3,540.00

Service Code	HCPCS 78650
Hospital Charge Code	4500951
Hospital Revenue Code	341
Min. Negotiated Rate	$100.54
Max. Negotiated Rate	$5,579.39
Rate for Payer: Aetna Commercial	$4,183.58
Rate for Payer: Aetna Medicare Advantage	$4,983.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,579.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,579.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,538.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$136.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,579.39
Rate for Payer: Cigna Commercial	$3,083.08
Rate for Payer: Cigna Medicare Advantage	$1,076.66
Rate for Payer: Clover Medicare Advantage	$1,461.18
Rate for Payer: EmblemHealth Commercial	$4,614.24
Rate for Payer: Humana Medicare Advantage	$1,584.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,538.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$920.40
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$531.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$111.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$100.54

NM CEREBROSPINAL FLD LKGE DTCT

Facility

$3,540.00

Service Code	HCPCS 78650
Hospital Charge Code	4500951
Hospital Revenue Code	341
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$531.00
Rate for Payer: Qualcare PPO/HMO/WC	$531.00

NM CISTERNOGRAM

Facility

$12,000.00

Service Code	HCPCS 78630
Hospital Charge Code	4500229
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

NM CISTERNOGRAM

Facility

$12,000.00

Service Code	HCPCS 78630
Hospital Charge Code	4500229
Hospital Revenue Code	341
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$4,820.00
Rate for Payer: Aetna Commercial	$1,754.56
Rate for Payer: Aetna Medicare Advantage	$2,089.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,339.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$645.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$173.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,339.96
Rate for Payer: Cigna Commercial	$1,293.03
Rate for Payer: Cigna Medicare Advantage	$451.54
Rate for Payer: Clover Medicare Advantage	$612.81
Rate for Payer: EmblemHealth Commercial	$1,935.18
Rate for Payer: Humana Medicare Advantage	$664.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$645.06
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,120.00
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$379.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$645.06
Rate for Payer: Wellcare Medicare Advantage	$645.06
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NMDA RECEPTOR AB TEST

Facility

$2,650.00

Service Code	HCPCS 86255
Hospital Charge Code	39990240
Hospital Revenue Code	302
Min. Negotiated Rate	$397.50
Max. Negotiated Rate	$397.50
Rate for Payer: Qualcare PPO/HMO/WC	$397.50

Know your out-of-pocket cost for care.

All Charges