Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

CT Mandible w/o Contrast

Facility

$9,500.00

Service Code	HCPCS 70486
Hospital Charge Code	2200277
Hospital Revenue Code	351
Min. Negotiated Rate	$86.94
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna Medicare Advantage	$402.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$124.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$226.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$450.54
Rate for Payer: Cigna Commercial	$248.96
Rate for Payer: Cigna Medicare Advantage	$86.94
Rate for Payer: Clover Medicare Advantage	$117.99
Rate for Payer: EmblemHealth Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$127.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$124.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT Mandible w/o Contrast

Facility

$9,500.00

Service Code	HCPCS 70486
Hospital Charge Code	2200277
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT MANDIBLE WO & W CONT

Facility

$9,500.00

Service Code	HCPCS 70488
Hospital Charge Code	2200276
Hospital Revenue Code	351
Min. Negotiated Rate	$145.87
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$566.79
Rate for Payer: Aetna Medicare Advantage	$675.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$208.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$288.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$755.90
Rate for Payer: Cigna Commercial	$417.70
Rate for Payer: Cigna Medicare Advantage	$145.87
Rate for Payer: Clover Medicare Advantage	$197.96
Rate for Payer: EmblemHealth Commercial	$625.14
Rate for Payer: Humana Medicare Advantage	$214.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$208.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT MANDIBLE WO & W CONT

Facility

$9,500.00

Service Code	HCPCS 70488
Hospital Charge Code	2200276
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT MASTOID W CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70481
Hospital Charge Code	2250421
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT MASTOID W CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70481
Hospital Charge Code	2250421
Hospital Revenue Code	351
Min. Negotiated Rate	$145.87
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$566.79
Rate for Payer: Aetna Medicare Advantage	$675.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$208.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$206.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$755.90
Rate for Payer: Cigna Commercial	$417.70
Rate for Payer: Cigna Medicare Advantage	$145.87
Rate for Payer: Clover Medicare Advantage	$197.96
Rate for Payer: EmblemHealth Commercial	$625.14
Rate for Payer: Humana Medicare Advantage	$214.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$208.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT MASTOID W/O CONTRST

Facility

$9,500.00

Service Code	HCPCS 70480
Hospital Charge Code	2250420
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT MASTOID W/O CONTRST

Facility

$9,500.00

Service Code	HCPCS 70480
Hospital Charge Code	2250420
Hospital Revenue Code	351
Min. Negotiated Rate	$86.94
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna Medicare Advantage	$402.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$124.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$226.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$450.54
Rate for Payer: Cigna Commercial	$248.96
Rate for Payer: Cigna Medicare Advantage	$86.94
Rate for Payer: Clover Medicare Advantage	$117.99
Rate for Payer: EmblemHealth Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$127.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$124.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT MAXILLO FACIAL AREA WO C

Facility

$9,500.00

Service Code	HCPCS 70486
Hospital Charge Code	2200327
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT MAXILLO FACIAL AREA WO C

Facility

$9,500.00

Service Code	HCPCS 70486
Hospital Charge Code	2200327
Hospital Revenue Code	351
Min. Negotiated Rate	$86.94
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna Medicare Advantage	$402.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$450.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$124.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$226.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$450.54
Rate for Payer: Cigna Commercial	$248.96
Rate for Payer: Cigna Medicare Advantage	$86.94
Rate for Payer: Clover Medicare Advantage	$117.99
Rate for Payer: EmblemHealth Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$127.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$124.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT MAXILLOFACIAL W/ CONTRAST

Facility

$2,037.00

Service Code	HCPCS 70487
Hospital Charge Code	2205408
Hospital Revenue Code	351
Min. Negotiated Rate	$57.85
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$566.79
Rate for Payer: Aetna Medicare Advantage	$675.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$208.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$206.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$755.90
Rate for Payer: Cigna Commercial	$417.70
Rate for Payer: Cigna Medicare Advantage	$145.87
Rate for Payer: Clover Medicare Advantage	$197.96
Rate for Payer: EmblemHealth Commercial	$625.14
Rate for Payer: Humana Medicare Advantage	$214.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$208.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$529.62
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$305.55
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$64.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellpoint Medicaid Managed Care	$57.85

CT MAXILLOFACIAL W/ CONTRAST

Facility

$2,037.00

Service Code	HCPCS 70487
Hospital Charge Code	2205408
Hospital Revenue Code	351
Min. Negotiated Rate	$305.55
Max. Negotiated Rate	$305.55
Rate for Payer: Qualcare PPO/HMO/WC	$305.55

CT MAXILLOFACIAL WO & W

Facility

$9,500.00

Service Code	HCPCS 70488
Hospital Charge Code	2200329
Hospital Revenue Code	351
Min. Negotiated Rate	$145.87
Max. Negotiated Rate	$3,916.00
Rate for Payer: Aetna Commercial	$566.79
Rate for Payer: Aetna Medicare Advantage	$675.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$755.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$208.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$288.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$755.90
Rate for Payer: Cigna Commercial	$417.70
Rate for Payer: Cigna Medicare Advantage	$145.87
Rate for Payer: Clover Medicare Advantage	$197.96
Rate for Payer: EmblemHealth Commercial	$625.14
Rate for Payer: Humana Medicare Advantage	$214.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$208.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT MAXILLOFACIAL WO & W

Facility

$9,500.00

Service Code	HCPCS 70488
Hospital Charge Code	2200329
Hospital Revenue Code	351
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CTM EXTRACELLULAR MATRIX 3X3CM

Facility

$15,015.00

Service Code	HCPCS C1762
Hospital Charge Code	270697515
Hospital Revenue Code	278
Min. Negotiated Rate	$426.43
Max. Negotiated Rate	$7,507.50
Rate for Payer: Aetna Commercial	$5,705.70
Rate for Payer: Aetna Medicare Advantage	$4,504.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,828.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,828.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,003.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,828.82
Rate for Payer: Cigna Commercial	$7,507.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,633.63
Rate for Payer: Qualcare PPO/HMO/WC	$2,252.25
Rate for Payer: UnitedHealthcare Community & State	$474.47
Rate for Payer: Wellpoint Medicaid Managed Care	$426.43

CTM EXTRACELLULAR MATRIX 3X3CM

Facility

$15,015.00

Service Code	HCPCS C1762
Hospital Charge Code	270697515
Hospital Revenue Code	278
Min. Negotiated Rate	$2,252.25
Max. Negotiated Rate	$3,633.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,003.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,633.63
Rate for Payer: Qualcare PPO/HMO/WC	$2,252.25

CTM EXTRACELLULAR MATRIX 4X7CM

Facility

$20,615.00

Service Code	HCPCS C1762
Hospital Charge Code	270696863
Hospital Revenue Code	278
Min. Negotiated Rate	$3,092.25
Max. Negotiated Rate	$4,988.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,123.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,988.83
Rate for Payer: Qualcare PPO/HMO/WC	$3,092.25

CTM EXTRACELLULAR MATRIX 4X7CM

Facility

$20,615.00

Service Code	HCPCS C1762
Hospital Charge Code	270696863
Hospital Revenue Code	278
Min. Negotiated Rate	$585.47
Max. Negotiated Rate	$10,307.50
Rate for Payer: Aetna Commercial	$7,833.70
Rate for Payer: Aetna Medicare Advantage	$6,184.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,256.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,256.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,123.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,256.82
Rate for Payer: Cigna Commercial	$10,307.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,988.83
Rate for Payer: Qualcare PPO/HMO/WC	$3,092.25
Rate for Payer: UnitedHealthcare Community & State	$651.43
Rate for Payer: Wellpoint Medicaid Managed Care	$585.47

CTM FLOW CONN TISSUE 4.0ML

Facility

$26,465.00

Service Code	HCPCS C1762
Hospital Charge Code	270697467
Hospital Revenue Code	278
Min. Negotiated Rate	$3,969.75
Max. Negotiated Rate	$6,404.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,293.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,404.53
Rate for Payer: Qualcare PPO/HMO/WC	$3,969.75

CTM FLOW CONN TISSUE 4.0ML

Facility

$26,465.00

Service Code	HCPCS C1762
Hospital Charge Code	270697467
Hospital Revenue Code	278
Min. Negotiated Rate	$751.61
Max. Negotiated Rate	$13,232.50
Rate for Payer: Aetna Commercial	$10,056.70
Rate for Payer: Aetna Medicare Advantage	$7,939.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,748.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,748.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,293.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,748.57
Rate for Payer: Cigna Commercial	$13,232.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,404.53
Rate for Payer: Qualcare PPO/HMO/WC	$3,969.75
Rate for Payer: UnitedHealthcare Community & State	$836.29
Rate for Payer: Wellpoint Medicaid Managed Care	$751.61

CTM PASTE TISSUE MATRIX LARGE

Facility

$26,465.00

Service Code	HCPCS C1762
Hospital Charge Code	270697599
Hospital Revenue Code	278
Min. Negotiated Rate	$751.61
Max. Negotiated Rate	$13,232.50
Rate for Payer: Aetna Commercial	$10,056.70
Rate for Payer: Aetna Medicare Advantage	$7,939.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,748.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,748.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,293.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,748.57
Rate for Payer: Cigna Commercial	$13,232.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,404.53
Rate for Payer: Qualcare PPO/HMO/WC	$3,969.75
Rate for Payer: UnitedHealthcare Community & State	$836.29
Rate for Payer: Wellpoint Medicaid Managed Care	$751.61

CTM PASTE TISSUE MATRIX LARGE

Facility

$26,465.00

Service Code	HCPCS C1762
Hospital Charge Code	270697599
Hospital Revenue Code	278
Min. Negotiated Rate	$3,969.75
Max. Negotiated Rate	$6,404.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,293.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,404.53
Rate for Payer: Qualcare PPO/HMO/WC	$3,969.75

CT NDL BIOPSY BONE DEEP PERC

Facility

$9,500.00

Service Code	HCPCS 20225
Hospital Charge Code	2205227
Hospital Revenue Code	361
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT NDL BIOPSY BONE DEEP PERC

Facility

$9,500.00

Service Code	HCPCS 20225
Hospital Charge Code	2205227
Hospital Revenue Code	361
Min. Negotiated Rate	$269.80
Max. Negotiated Rate	$7,117.66
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,117.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,117.66
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,470.00
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$300.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

CT NDL BIOPSY BONE SUPERFIC

Facility

$9,500.00

Service Code	HCPCS 20220
Hospital Charge Code	2205235
Hospital Revenue Code	361
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

Know your out-of-pocket cost for care.

All Charges