Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

GRAFT MCVL ST 24MM/30CM

Facility

$3,259.25

Hospital Charge Code	270601144
Hospital Revenue Code	278
Min. Negotiated Rate	$488.89
Max. Negotiated Rate	$788.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$651.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$788.74
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$717.03
Rate for Payer: Qualcare PPO/HMO/WC	$488.89

GRAFT MCVL ST 24MM/30CM

Facility

$3,259.25

Hospital Charge Code	270601144
Hospital Revenue Code	278
Min. Negotiated Rate	$78.55
Max. Negotiated Rate	$1,629.62
Rate for Payer: Aetna Commercial	$1,238.52
Rate for Payer: Aetna Medicare Advantage	$977.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$831.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$831.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$651.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$831.11
Rate for Payer: Cigna Commercial	$1,629.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$788.74
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$717.03
Rate for Payer: Qualcare PPO/HMO/WC	$488.89
Rate for Payer: UnitedHealthcare Community & State	$78.55
Rate for Payer: Wellpoint Medicaid Managed Care	$86.37

GRAFT MDX BIF 14/7 8CM 085147

Facility

$4,868.85

Hospital Charge Code	270601136
Hospital Revenue Code	278
Min. Negotiated Rate	$730.33
Max. Negotiated Rate	$1,178.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$973.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,178.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,071.15
Rate for Payer: Qualcare PPO/HMO/WC	$730.33

GRAFT MDX BIF 14/7 8CM 085147

Facility

$4,868.85

Hospital Charge Code	270601136
Hospital Revenue Code	278
Min. Negotiated Rate	$117.34
Max. Negotiated Rate	$2,434.43
Rate for Payer: Aetna Commercial	$1,850.16
Rate for Payer: Aetna Medicare Advantage	$1,460.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,241.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,241.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$973.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,241.56
Rate for Payer: Cigna Commercial	$2,434.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,178.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,071.15
Rate for Payer: Qualcare PPO/HMO/WC	$730.33
Rate for Payer: UnitedHealthcare Community & State	$117.34
Rate for Payer: Wellpoint Medicaid Managed Care	$129.02

GRAFT MDX VASC 26 30 175426

Facility

$3,103.25

Hospital Charge Code	270623776
Hospital Revenue Code	278
Min. Negotiated Rate	$465.49
Max. Negotiated Rate	$750.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$620.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.99
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$682.72
Rate for Payer: Qualcare PPO/HMO/WC	$465.49

GRAFT MDX VASC 26 30 175426

Facility

$3,103.25

Hospital Charge Code	270623776
Hospital Revenue Code	278
Min. Negotiated Rate	$74.79
Max. Negotiated Rate	$1,551.62
Rate for Payer: Aetna Commercial	$1,179.23
Rate for Payer: Aetna Medicare Advantage	$930.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$791.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$791.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$620.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$791.33
Rate for Payer: Cigna Commercial	$1,551.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.99
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$682.72
Rate for Payer: Qualcare PPO/HMO/WC	$465.49
Rate for Payer: UnitedHealthcare Community & State	$74.79
Rate for Payer: Wellpoint Medicaid Managed Care	$82.24

GRAFT MEMBRANE 2 x 3 MM

Facility

$2,800.00

Service Code	HCPCS Q4248
Hospital Charge Code	270696212
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$677.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$560.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$677.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$616.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00

GRAFT MEMBRANE 2 x 3 MM

Facility

$2,800.00

Service Code	HCPCS Q4248
Hospital Charge Code	270696212
Hospital Revenue Code	278
Min. Negotiated Rate	$67.48
Max. Negotiated Rate	$677.60
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	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
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	$560.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
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	$677.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$616.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00
Rate for Payer: UnitedHealthcare Community & State	$67.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$74.20

GRAFT MEMBRANE 4X6MM

Facility

$12,480.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694128
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$3,020.16
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	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
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	$2,496.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
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	$3,020.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,745.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,872.00
Rate for Payer: UnitedHealthcare Community & State	$300.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$330.72

GRAFT MEMBRANE 4X6MM

Facility

$12,480.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694128
Hospital Revenue Code	278
Min. Negotiated Rate	$1,872.00
Max. Negotiated Rate	$3,020.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,496.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,020.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,745.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,872.00

GRAFT MEMBRANE RESTORE 4X4

Facility

$5,750.00

Service Code	HCPCS C1763
Hospital Charge Code	270694127
Hospital Revenue Code	278
Min. Negotiated Rate	$138.57
Max. Negotiated Rate	$2,875.00
Rate for Payer: Aetna Commercial	$2,185.00
Rate for Payer: Aetna Medicare Advantage	$1,725.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,466.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,466.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,466.25
Rate for Payer: Cigna Commercial	$2,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,391.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,265.00
Rate for Payer: Qualcare PPO/HMO/WC	$862.50
Rate for Payer: UnitedHealthcare Community & State	$138.57
Rate for Payer: Wellpoint Medicaid Managed Care	$152.38

GRAFT MEMBRANE RESTORE 4X4

Facility

$5,750.00

Service Code	HCPCS C1763
Hospital Charge Code	270694127
Hospital Revenue Code	278
Min. Negotiated Rate	$862.50
Max. Negotiated Rate	$1,391.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,391.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,265.00
Rate for Payer: Qualcare PPO/HMO/WC	$862.50

GRAFT MEMBRANE WRAP 2X2CM

Facility

$3,960.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694504
Hospital Revenue Code	278
Min. Negotiated Rate	$95.44
Max. Negotiated Rate	$958.32
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	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
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	$792.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
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	$958.32
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$871.20
Rate for Payer: Qualcare PPO/HMO/WC	$594.00
Rate for Payer: UnitedHealthcare Community & State	$95.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$104.94

GRAFT MEMBRANE WRAP 2X2CM

Facility

$3,960.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694504
Hospital Revenue Code	278
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$958.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$792.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$958.32
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$871.20
Rate for Payer: Qualcare PPO/HMO/WC	$594.00

GRAFT MEMBRANE WRAP 4X6CM

Facility

$23,760.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694210
Hospital Revenue Code	278
Min. Negotiated Rate	$3,564.00
Max. Negotiated Rate	$5,749.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,752.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,749.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,227.20
Rate for Payer: Qualcare PPO/HMO/WC	$3,564.00

GRAFT MEMBRANE WRAP 4X6CM

Facility

$23,760.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694210
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$5,749.92
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	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
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	$4,752.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
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	$5,749.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,227.20
Rate for Payer: Qualcare PPO/HMO/WC	$3,564.00
Rate for Payer: UnitedHealthcare Community & State	$572.62
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$629.64

GRAFT MEMBRANE WRAP DUAL LAY 4

Facility

$15,840.00

Service Code	HCPCS C1762
Hospital Charge Code	270694209
Hospital Revenue Code	278
Min. Negotiated Rate	$2,376.00
Max. Negotiated Rate	$3,833.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,168.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,833.28
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,484.80
Rate for Payer: Qualcare PPO/HMO/WC	$2,376.00

GRAFT MEMBRANE WRAP DUAL LAY 4

Facility

$15,840.00

Service Code	HCPCS C1762
Hospital Charge Code	270694209
Hospital Revenue Code	278
Min. Negotiated Rate	$381.74
Max. Negotiated Rate	$7,920.00
Rate for Payer: Aetna Commercial	$6,019.20
Rate for Payer: Aetna Medicare Advantage	$4,752.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,039.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,039.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,168.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,039.20
Rate for Payer: Cigna Commercial	$7,920.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,833.28
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,484.80
Rate for Payer: Qualcare PPO/HMO/WC	$2,376.00
Rate for Payer: UnitedHealthcare Community & State	$381.74
Rate for Payer: Wellpoint Medicaid Managed Care	$419.76

GRAFT MICRO STR 14mm30cm095214

Facility

$2,191.25

Hospital Charge Code	270615621
Hospital Revenue Code	278
Min. Negotiated Rate	$328.69
Max. Negotiated Rate	$530.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$438.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$530.28
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$482.07
Rate for Payer: Qualcare PPO/HMO/WC	$328.69

GRAFT MICRO STR 14mm30cm095214

Facility

$2,191.25

Hospital Charge Code	270615621
Hospital Revenue Code	278
Min. Negotiated Rate	$52.81
Max. Negotiated Rate	$1,095.62
Rate for Payer: Aetna Commercial	$832.67
Rate for Payer: Aetna Medicare Advantage	$657.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$558.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$558.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$438.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$558.77
Rate for Payer: Cigna Commercial	$1,095.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$530.28
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$482.07
Rate for Payer: Qualcare PPO/HMO/WC	$328.69
Rate for Payer: UnitedHealthcare Community & State	$52.81
Rate for Payer: Wellpoint Medicaid Managed Care	$58.07

GRAFT MICRO STRAIT 10MMx60CM

Facility

$3,070.00

Hospital Charge Code	270630285
Hospital Revenue Code	278
Min. Negotiated Rate	$73.99
Max. Negotiated Rate	$1,535.00
Rate for Payer: Aetna Commercial	$1,166.60
Rate for Payer: Aetna Medicare Advantage	$921.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$782.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$782.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$614.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$782.85
Rate for Payer: Cigna Commercial	$1,535.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$742.94
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$675.40
Rate for Payer: Qualcare PPO/HMO/WC	$460.50
Rate for Payer: UnitedHealthcare Community & State	$73.99
Rate for Payer: Wellpoint Medicaid Managed Care	$81.36

GRAFT MICRO STRAIT 10MMx60CM

Facility

$3,070.00

Hospital Charge Code	270630285
Hospital Revenue Code	278
Min. Negotiated Rate	$460.50
Max. Negotiated Rate	$742.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$614.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$742.94
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$675.40
Rate for Payer: Qualcare PPO/HMO/WC	$460.50

GRAFT MTF TENDON 100260

Facility

$4,804.00

Hospital Charge Code	270616220
Hospital Revenue Code	278
Min. Negotiated Rate	$720.60
Max. Negotiated Rate	$1,162.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$960.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,162.57
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,056.88
Rate for Payer: Qualcare PPO/HMO/WC	$720.60

GRAFT MTF TENDON 100260

Facility

$4,804.00

Hospital Charge Code	270616220
Hospital Revenue Code	278
Min. Negotiated Rate	$115.78
Max. Negotiated Rate	$2,402.00
Rate for Payer: Aetna Commercial	$1,825.52
Rate for Payer: Aetna Medicare Advantage	$1,441.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,225.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,225.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$960.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,225.02
Rate for Payer: Cigna Commercial	$2,402.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,162.57
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,056.88
Rate for Payer: Qualcare PPO/HMO/WC	$720.60
Rate for Payer: UnitedHealthcare Community & State	$115.78
Rate for Payer: Wellpoint Medicaid Managed Care	$127.31

GRAFT NANOPUTTY OSTEOFLO 10CC

Facility

$27,625.00

Service Code	HCPCS C1713
Hospital Charge Code	270692931
Hospital Revenue Code	278
Min. Negotiated Rate	$4,143.75
Max. Negotiated Rate	$6,685.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,525.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,685.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,077.50
Rate for Payer: Qualcare PPO/HMO/WC	$4,143.75

Know your out-of-pocket cost for care.

All Charges