Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

Theophylline ER 300mg

Facility

$24.25

Service Code	NDC 50474030001
Hospital Charge Code	606390080
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna Commercial	$9.21
Rate for Payer: Aetna Medicare Advantage	$7.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.18
Rate for Payer: Cigna Commercial	$12.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.30
Rate for Payer: Oxford Commercial	$4.85
Rate for Payer: Qualcare PPO/HMO/WC	$3.64
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: UnitedHealthcare Community & State	$0.77
Rate for Payer: Wellpoint Medicaid Managed Care	$0.69

Theophylline ER 300mg

Facility

$24.25

Service Code	NDC 50474030001
Hospital Charge Code	606390080
Hospital Revenue Code	250
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$3.64
Rate for Payer: Qualcare PPO/HMO/WC	$3.64

THEOPHYLLINE ER 400MG TAB

Facility

$9.11

Service Code	NDC 378048601
Hospital Charge Code	606361043
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Commercial	$3.46
Rate for Payer: Aetna Medicare Advantage	$2.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.32
Rate for Payer: Cigna Commercial	$4.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.37
Rate for Payer: Oxford Commercial	$1.82
Rate for Payer: Qualcare PPO/HMO/WC	$1.37
Rate for Payer: UnitedHealthcare Commercial	$1.82
Rate for Payer: UnitedHealthcare Community & State	$0.29
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

THEOPHYLLINE ER 400MG TAB

Facility

$9.11

Service Code	NDC 378048601
Hospital Charge Code	606361043
Hospital Revenue Code	250
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: Qualcare PPO/HMO/WC	$1.37

THEOPHYLLINE, SERUM

Facility

$390.00

Service Code	HCPCS 80198
Hospital Charge Code	3003969
Hospital Revenue Code	301
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$38.46
Rate for Payer: Aetna Medicare Advantage	$45.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.29
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.14
Rate for Payer: Clover Medicare Advantage	$13.43
Rate for Payer: EmblemHealth Commercial	$42.42
Rate for Payer: Humana Medicare Advantage	$14.56
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.14
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	$11.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.14
Rate for Payer: Wellcare Medicare Advantage	$14.14
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

THEOPHYLLINE, SERUM

Facility

$390.00

Service Code	HCPCS 80198
Hospital Charge Code	3003969
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

THER ACTIVITY & TRAINING 1/4 H

Facility

$434.00

Service Code	HCPCS 97110GO
Hospital Charge Code	1008210
Hospital Revenue Code	430
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$65.10
Rate for Payer: Qualcare PPO/HMO/WC	$65.10

THER ACTIVITY & TRAINING 1/4 H

Facility

$434.00

Service Code	HCPCS 97110GO
Hospital Charge Code	1008210
Hospital Revenue Code	430
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$164.92
Rate for Payer: Aetna Medicare Advantage	$130.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$110.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$110.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$69.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$110.67
Rate for Payer: Cigna Commercial	$217.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$112.84
Rate for Payer: Oxford Commercial	$933.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.10
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$13.71
Rate for Payer: Wellpoint Medicaid Managed Care	$12.33

THERAGENEMESHBILAMATRIX82X60MM

Facility

$11,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694227
Hospital Revenue Code	278
Min. Negotiated Rate	$1,650.00
Max. Negotiated Rate	$2,662.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,650.00

THERAGENEMESHBILAMATRIX82X60MM

Facility

$11,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694227
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,662.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,650.00
Rate for Payer: UnitedHealthcare Community & State	$347.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$312.40

THERAGENESISBILAMATRIX82X120MM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270694313
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.00
Max. Negotiated Rate	$3,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00

THERAGENESISBILAMATRIX82X120MM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270694313
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$3,025.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00
Rate for Payer: UnitedHealthcare Community & State	$395.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$355.00

THERAGENESISBILAYMATRIX40X60MM

Facility

$7,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270694307
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$1,875.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,550.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,875.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,162.50
Rate for Payer: UnitedHealthcare Community & State	$244.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$220.10

THERAGENESISBILAYMATRIX40X60MM

Facility

$7,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270694307
Hospital Revenue Code	278
Min. Negotiated Rate	$1,162.50
Max. Negotiated Rate	$1,875.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,875.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,162.50

THERAGENESIS BILAYMATRIX 4X6CM

Facility

$8,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270695638
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,117.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,117.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,312.50
Rate for Payer: UnitedHealthcare Community & State	$276.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$248.50

THERAGENESIS BILAYMATRIX 4X6CM

Facility

$8,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270695638
Hospital Revenue Code	278
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$2,117.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,117.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,312.50

THERAGENESISBILAYMATRIX82X60MM

Facility

$10,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694172
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,420.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,500.00

THERAGENESISBILAYMATRIX82X60MM

Facility

$10,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694172
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,420.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,420.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,500.00
Rate for Payer: UnitedHealthcare Community & State	$316.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$284.00

THERAGENSISBILAYDMATR200X240MM

Facility

$39,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270697670
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$9,619.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,619.50
Rate for Payer: Qualcare PPO/HMO/WC	$5,962.50
Rate for Payer: UnitedHealthcare Community & State	$1,256.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$1,128.90

THERAGENSISBILAYDMATR200X240MM

Facility

$39,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270697670
Hospital Revenue Code	278
Min. Negotiated Rate	$5,962.50
Max. Negotiated Rate	$9,619.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,619.50
Rate for Payer: Qualcare PPO/HMO/WC	$5,962.50

THERAGENSISBILAYDMATRIX12X24

Facility

$26,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270697008
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$6,413.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,413.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,975.00
Rate for Payer: UnitedHealthcare Community & State	$837.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$752.60

THERAGENSISBILAYDMATRIX12X24

Facility

$26,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270697008
Hospital Revenue Code	278
Min. Negotiated Rate	$3,975.00
Max. Negotiated Rate	$6,413.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,413.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,975.00

THERAGENSISBILAYMATRIX8X9CM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270695639
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.00
Max. Negotiated Rate	$3,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00

THERAGENSISBILAYMATRIX8X9CM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270695639
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$3,025.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$536.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$536.29
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00
Rate for Payer: UnitedHealthcare Community & State	$395.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$355.00

THERAPEUTIC ACT EA 15 MIN CQ

Facility

$244.50

Service Code	HCPCS 97530GP
Hospital Charge Code	409197530Q
Hospital Revenue Code	420
Min. Negotiated Rate	$36.67
Max. Negotiated Rate	$36.67
Rate for Payer: Qualcare PPO/HMO/WC	$36.67

Know your out-of-pocket cost for care.

All Charges