Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

NM MYOCARDIAL SPECT REST OR EX

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500476
Hospital Revenue Code	341
Min. Negotiated Rate	$277.20
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	$277.20
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	$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	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM MYOCARDIAL SPECT REST OR EX

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500476
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 MYOCARDIAL SPECT STRESS &

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500484
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 MYOCARDIAL SPECT STRESS &

Facility

$12,000.00

Service Code	HCPCS 78452
Hospital Charge Code	4500484
Hospital Revenue Code	341
Min. Negotiated Rate	$277.20
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	$277.20
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	$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	$1,538.08
Rate for Payer: Wellcare Medicare Advantage	$1,538.08
Rate for Payer: Wellpoint Medicaid Managed Care	$340.80

NM PARATHYROID IMAGING

Facility

$12,000.00

Service Code	HCPCS 78070
Hospital Charge Code	4500591
Hospital Revenue Code	341
Min. Negotiated Rate	$61.05
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	$61.05
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 PARATHYROID IMAGING

Facility

$12,000.00

Service Code	HCPCS 78070
Hospital Charge Code	4500591
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 PERITONEAL VENOUS SHUNT PAT

Facility

$12,000.00

Service Code	HCPCS 78291
Hospital Charge Code	4500894
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 PERITONEAL VENOUS SHUNT PAT

Facility

$12,000.00

Service Code	HCPCS 78291
Hospital Charge Code	4500894
Hospital Revenue Code	341
Min. Negotiated Rate	$53.13
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	$53.13
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

NMP FIBERS (LONG)-SMALL.

Facility

$14,450.00

Service Code	HCPCS C1765
Hospital Charge Code	270703660
Hospital Revenue Code	278
Min. Negotiated Rate	$410.38
Max. Negotiated Rate	$7,225.00
Rate for Payer: Aetna Commercial	$5,491.00
Rate for Payer: Aetna Medicare Advantage	$4,335.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,684.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,684.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,890.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,684.75
Rate for Payer: Cigna Commercial	$7,225.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,496.90
Rate for Payer: Qualcare PPO/HMO/WC	$2,167.50
Rate for Payer: UnitedHealthcare Community & State	$456.62
Rate for Payer: Wellpoint Medicaid Managed Care	$410.38

NMP FIBERS (LONG)-SMALL.

Facility

$14,450.00

Service Code	HCPCS C1765
Hospital Charge Code	270703660
Hospital Revenue Code	278
Min. Negotiated Rate	$2,167.50
Max. Negotiated Rate	$3,496.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,890.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,496.90
Rate for Payer: Qualcare PPO/HMO/WC	$2,167.50

NMP FIBERS (LONG)- XSMALL

Facility

$7,225.00

Hospital Charge Code	270702965
Hospital Revenue Code	278
Min. Negotiated Rate	$1,083.75
Max. Negotiated Rate	$1,748.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,445.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,748.45
Rate for Payer: Qualcare PPO/HMO/WC	$1,083.75

NMP FIBERS (LONG)- XSMALL

Facility

$7,225.00

Hospital Charge Code	270702965
Hospital Revenue Code	278
Min. Negotiated Rate	$205.19
Max. Negotiated Rate	$3,612.50
Rate for Payer: Aetna Commercial	$2,745.50
Rate for Payer: Aetna Medicare Advantage	$2,167.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,842.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,842.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,445.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,842.38
Rate for Payer: Cigna Commercial	$3,612.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,748.45
Rate for Payer: Qualcare PPO/HMO/WC	$1,083.75
Rate for Payer: UnitedHealthcare Community & State	$228.31
Rate for Payer: Wellpoint Medicaid Managed Care	$205.19

NMP FIBERS (LONH) MEDIUM

Facility

$20,400.00

Service Code	HCPCS C1762
Hospital Charge Code	270704153
Hospital Revenue Code	278
Min. Negotiated Rate	$579.36
Max. Negotiated Rate	$10,200.00
Rate for Payer: Aetna Commercial	$7,752.00
Rate for Payer: Aetna Medicare Advantage	$6,120.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,202.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,202.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,080.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,202.00
Rate for Payer: Cigna Commercial	$10,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,936.80
Rate for Payer: Qualcare PPO/HMO/WC	$3,060.00
Rate for Payer: UnitedHealthcare Community & State	$644.64
Rate for Payer: Wellpoint Medicaid Managed Care	$579.36

NMP FIBERS (LONH) MEDIUM

Facility

$20,400.00

Service Code	HCPCS C1762
Hospital Charge Code	270704153
Hospital Revenue Code	278
Min. Negotiated Rate	$3,060.00
Max. Negotiated Rate	$4,936.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,080.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,936.80
Rate for Payer: Qualcare PPO/HMO/WC	$3,060.00

NMPMPLG (FIBERS).

Facility

$26,475.00

Service Code	HCPCS C1765
Hospital Charge Code	270703695
Hospital Revenue Code	278
Min. Negotiated Rate	$751.89
Max. Negotiated Rate	$13,237.50
Rate for Payer: Aetna Commercial	$10,060.50
Rate for Payer: Aetna Medicare Advantage	$7,942.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,751.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,751.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,751.12
Rate for Payer: Cigna Commercial	$13,237.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,406.95
Rate for Payer: Qualcare PPO/HMO/WC	$3,971.25
Rate for Payer: UnitedHealthcare Community & State	$836.61
Rate for Payer: Wellpoint Medicaid Managed Care	$751.89

NMPMPLG (FIBERS).

Facility

$26,475.00

Service Code	HCPCS C1765
Hospital Charge Code	270703695
Hospital Revenue Code	278
Min. Negotiated Rate	$3,971.25
Max. Negotiated Rate	$6,406.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,295.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,406.95
Rate for Payer: Qualcare PPO/HMO/WC	$3,971.25

NM RENOGRAM STATIC

Facility

$1,908.00

Service Code	HCPCS 78700
Hospital Charge Code	4500443
Hospital Revenue Code	341
Min. Negotiated Rate	$54.19
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	$66.00
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	$496.08
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$286.20
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$60.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$54.19

NM RENOGRAM STATIC

Facility

$1,908.00

Service Code	HCPCS 78700
Hospital Charge Code	4500443
Hospital Revenue Code	341
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Qualcare PPO/HMO/WC	$286.20

NM SALIVARY GLAND FNCTION STDY

Facility

$1,421.00

Service Code	HCPCS 78232
Hospital Charge Code	4500994
Hospital Revenue Code	341
Min. Negotiated Rate	$40.36
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	$80.85
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	$369.46
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$213.15
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$44.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$474.94
Rate for Payer: Wellcare Medicare Advantage	$474.94
Rate for Payer: Wellpoint Medicaid Managed Care	$40.36

NM SALIVARY GLAND FNCTION STDY

Facility

$1,421.00

Service Code	HCPCS 78232
Hospital Charge Code	4500994
Hospital Revenue Code	341
Min. Negotiated Rate	$213.15
Max. Negotiated Rate	$213.15
Rate for Payer: Qualcare PPO/HMO/WC	$213.15

NM SALIVARY GLND/IMAG.W SERIAL

Facility

$1,421.00

Service Code	HCPCS 78231
Hospital Charge Code	4508010
Hospital Revenue Code	341
Min. Negotiated Rate	$213.15
Max. Negotiated Rate	$213.15
Rate for Payer: Qualcare PPO/HMO/WC	$213.15

NM SALIVARY GLND/IMAG.W SERIAL

Facility

$1,421.00

Service Code	HCPCS 78231
Hospital Charge Code	4508010
Hospital Revenue Code	341
Min. Negotiated Rate	$40.36
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	$80.85
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	$369.46
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$213.15
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$44.90
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	$117.87
Rate for Payer: Wellpoint Medicaid Managed Care	$40.36

NM SHUNT CEREBRAL

Facility

$1,426.00

Service Code	HCPCS 78645
Hospital Charge Code	4500583
Hospital Revenue Code	341
Min. Negotiated Rate	$213.90
Max. Negotiated Rate	$213.90
Rate for Payer: Qualcare PPO/HMO/WC	$213.90

NM SHUNT CEREBRAL

Facility

$1,426.00

Service Code	HCPCS 78645
Hospital Charge Code	4500583
Hospital Revenue Code	341
Min. Negotiated Rate	$40.50
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	$197.64
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	$370.76
Rate for Payer: Oxford Commercial	$4,820.00
Rate for Payer: Qualcare PPO/HMO/WC	$213.90
Rate for Payer: UnitedHealthcare Commercial	$4,748.00
Rate for Payer: UnitedHealthcare Community & State	$45.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$645.06
Rate for Payer: Wellcare Medicare Advantage	$645.06
Rate for Payer: Wellpoint Medicaid Managed Care	$40.50

NM TC99 ALBUMIN 0019N350A1 DOS

Facility

$267.00

Service Code	HCPCS A9540
Hospital Charge Code	4500864
Hospital Revenue Code	343
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$133.50
Rate for Payer: Aetna Commercial	$101.46
Rate for Payer: Aetna Medicare Advantage	$80.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$68.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$68.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$33.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$68.08
Rate for Payer: Cigna Commercial	$133.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$69.42
Rate for Payer: Qualcare PPO/HMO/WC	$40.05
Rate for Payer: UnitedHealthcare Community & State	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$7.58

Know your out-of-pocket cost for care.

All Charges