Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

CTO DEVICE TRUEPATH

Facility

$9,600.00

Service Code	HCPCS C1769
Hospital Charge Code	270672786
Hospital Revenue Code	278
Min. Negotiated Rate	$272.64
Max. Negotiated Rate	$4,800.00
Rate for Payer: Aetna Commercial	$3,648.00
Rate for Payer: Aetna Medicare Advantage	$2,880.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,448.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,448.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,920.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,448.00
Rate for Payer: Cigna Commercial	$4,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,323.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,440.00
Rate for Payer: UnitedHealthcare Community & State	$303.36
Rate for Payer: Wellpoint Medicaid Managed Care	$272.64

CTO DEVICE TRUEPATH

Facility

$9,600.00

Service Code	HCPCS C1769
Hospital Charge Code	270672786
Hospital Revenue Code	278
Min. Negotiated Rate	$1,440.00
Max. Negotiated Rate	$2,323.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,920.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,323.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,440.00

CTO DEVICE TRUEPATH

Facility

$9,600.00

Hospital Charge Code	672786
Hospital Revenue Code	278
Min. Negotiated Rate	$272.64
Max. Negotiated Rate	$4,800.00
Rate for Payer: Aetna Commercial	$3,648.00
Rate for Payer: Aetna Medicare Advantage	$2,880.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,448.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,448.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,920.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,448.00
Rate for Payer: Cigna Commercial	$4,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,323.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,440.00
Rate for Payer: UnitedHealthcare Community & State	$303.36
Rate for Payer: Wellpoint Medicaid Managed Care	$272.64

CTO DEVICE TRUEPATH

Facility

$9,600.00

Hospital Charge Code	672786
Hospital Revenue Code	278
Min. Negotiated Rate	$1,440.00
Max. Negotiated Rate	$2,323.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,920.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,323.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,440.00

CT ORBIT SELA ETC W/+W/O CNTRT

Facility

$9,500.00

Service Code	HCPCS 70482
Hospital Charge Code	2205410
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 ORBIT SELA ETC W/+W/O CNTRT

Facility

$9,500.00

Service Code	HCPCS 70482
Hospital Charge Code	2205410
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 ORBIT SELLA ETC W/ CONTRAST

Facility

$2,139.00

Service Code	HCPCS 70481
Hospital Charge Code	2205411
Hospital Revenue Code	351
Min. Negotiated Rate	$60.75
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	$556.14
Rate for Payer: Oxford Commercial	$3,774.00
Rate for Payer: Qualcare PPO/HMO/WC	$320.85
Rate for Payer: UnitedHealthcare Commercial	$3,916.00
Rate for Payer: UnitedHealthcare Community & State	$67.59
Rate for Payer: UnitedHealthcare Medicare Advantage	$208.38
Rate for Payer: Wellcare Medicare Advantage	$208.38
Rate for Payer: Wellpoint Medicaid Managed Care	$60.75

CT ORBIT SELLA ETC W/ CONTRAST

Facility

$2,139.00

Service Code	HCPCS 70481
Hospital Charge Code	2205411
Hospital Revenue Code	351
Min. Negotiated Rate	$320.85
Max. Negotiated Rate	$320.85
Rate for Payer: Qualcare PPO/HMO/WC	$320.85

CT ORBIT W/ CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70481
Hospital Charge Code	2205481
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 ORBIT W/ CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70481
Hospital Charge Code	2205481
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 ORBIT WO C

Facility

$9,500.00

Service Code	HCPCS 70480
Hospital Charge Code	2200251
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 ORBIT WO C

Facility

$9,500.00

Service Code	HCPCS 70480
Hospital Charge Code	2200251
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 ORBIT W & W/O CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70482
Hospital Charge Code	2205480
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 ORBIT W & W/O CONTRAST

Facility

$9,500.00

Service Code	HCPCS 70482
Hospital Charge Code	2205480
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 PELVIS W/CONTRAST

Facility

$9,500.00

Service Code	HCPCS 72193
Hospital Charge Code	2200145
Hospital Revenue Code	352
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT PELVIS W/CONTRAST

Facility

$9,500.00

Service Code	HCPCS 72193
Hospital Charge Code	2200145
Hospital Revenue Code	352
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	$270.75
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 PELVIS W & W/O CONTRAST

Facility

$9,500.00

Service Code	HCPCS 72194
Hospital Charge Code	2200160
Hospital Revenue Code	352
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 PELVIS W & W/O CONTRAST

Facility

$9,500.00

Service Code	HCPCS 72194
Hospital Charge Code	2200160
Hospital Revenue Code	352
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT PERC ABCESS DRAIN LIVER

Facility

$9,500.00

Service Code	HCPCS 49405
Hospital Charge Code	2200467
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 PERC ABCESS DRAIN LIVER

Facility

$9,500.00

Service Code	HCPCS 49405
Hospital Charge Code	2200467
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 PERFUSION W/CONTRAST CBF

Facility

$9,500.00

Service Code	HCPCS 0042T
Hospital Charge Code	40430042T
Hospital Revenue Code	359
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$1,425.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,425.00

CT PERFUSION W/CONTRAST CBF

Facility

$9,500.00

Service Code	HCPCS 0042T
Hospital Charge Code	40430042T
Hospital Revenue Code	359
Min. Negotiated Rate	$269.80
Max. Negotiated Rate	$4,750.00
Rate for Payer: Aetna Commercial	$3,610.00
Rate for Payer: Aetna Medicare Advantage	$2,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,422.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,422.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,422.50
Rate for Payer: Cigna Commercial	$4,750.00
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: Wellpoint Medicaid Managed Care	$269.80

CT PERITONEOCENTESIS W IMAGING

Facility

$9,500.00

Service Code	HCPCS 49083
Hospital Charge Code	2205136
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 PERITONEOCENTESIS W IMAGING

Facility

$9,500.00

Service Code	HCPCS 49083
Hospital Charge Code	2205136
Hospital Revenue Code	361
Min. Negotiated Rate	$269.80
Max. Negotiated Rate	$5,347.00
Rate for Payer: Aetna Commercial	$2,930.85
Rate for Payer: Aetna Medicare Advantage	$3,491.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,908.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,908.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,077.52
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	$3,908.70
Rate for Payer: Cigna Commercial	$2,159.89
Rate for Payer: Cigna Medicare Advantage	$1,077.52
Rate for Payer: Clover Medicare Advantage	$1,023.64
Rate for Payer: EmblemHealth Commercial	$3,232.56
Rate for Payer: Humana Medicare Advantage	$1,109.85
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,077.52
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	$1,077.52
Rate for Payer: Wellcare Medicare Advantage	$1,077.52
Rate for Payer: Wellpoint Medicaid Managed Care	$269.80

C.TRACHOMATIS AB(IGG,A,M) I

Facility

$390.00

Service Code	HCPCS 8663191
Hospital Charge Code	39990090A
Hospital Revenue Code	302
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare Advantage	$117.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$195.00
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	$12.32
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

Know your out-of-pocket cost for care.

All Charges