Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

GRAFT NANOPUTTY OSTEOFLO 10CC

Facility

$27,625.00

Service Code	HCPCS C1713
Hospital Charge Code	270692931
Hospital Revenue Code	278
Min. Negotiated Rate	$665.76
Max. Negotiated Rate	$13,812.50
Rate for Payer: Aetna Commercial	$10,497.50
Rate for Payer: Aetna Medicare Advantage	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,044.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,044.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,525.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,044.38
Rate for Payer: Cigna Commercial	$13,812.50
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
Rate for Payer: UnitedHealthcare Community & State	$665.76
Rate for Payer: Wellpoint Medicaid Managed Care	$732.06

GRAFT NEOX

Facility

$5,975.00

Service Code	HCPCS Q4156
Hospital Charge Code	270683169
Hospital Revenue Code	636
Min. Negotiated Rate	$896.25
Max. Negotiated Rate	$1,445.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,445.95
Rate for Payer: Qualcare PPO/HMO/WC	$896.25

GRAFT NEOX

Facility

$5,975.00

Service Code	HCPCS Q4156
Hospital Charge Code	270683169
Hospital Revenue Code	636
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$1,445.95
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	$156.71
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	$1,445.95
Rate for Payer: Qualcare PPO/HMO/WC	$896.25
Rate for Payer: UnitedHealthcare Community & State	$144.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$158.34

GRAFT NEOX 100MG

Facility

$5,750.00

Service Code	HCPCS Q4156
Hospital Charge Code	270683170
Hospital Revenue Code	636
Min. Negotiated Rate	$138.57
Max. Negotiated Rate	$1,391.50
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	$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	$156.71
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	$1,391.50
Rate for Payer: Qualcare PPO/HMO/WC	$862.50
Rate for Payer: UnitedHealthcare Community & State	$138.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$152.38

GRAFT NEOX 100MG

Facility

$5,750.00

Service Code	HCPCS Q4156
Hospital Charge Code	270683170
Hospital Revenue Code	636
Min. Negotiated Rate	$862.50
Max. Negotiated Rate	$1,391.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,391.50
Rate for Payer: Qualcare PPO/HMO/WC	$862.50

GRAFT NERVE 2-3X70 AVANCE

Facility

$23,000.00

Hospital Charge Code	270663369
Hospital Revenue Code	278
Min. Negotiated Rate	$554.30
Max. Negotiated Rate	$11,500.00
Rate for Payer: Aetna Commercial	$8,740.00
Rate for Payer: Aetna Medicare Advantage	$6,900.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,865.00
Rate for Payer: Cigna Commercial	$11,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,566.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,060.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,450.00
Rate for Payer: UnitedHealthcare Community & State	$554.30
Rate for Payer: Wellpoint Medicaid Managed Care	$609.50

GRAFT NERVE 2-3X70 AVANCE

Facility

$23,000.00

Hospital Charge Code	270663369
Hospital Revenue Code	278
Min. Negotiated Rate	$3,450.00
Max. Negotiated Rate	$5,566.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,566.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,060.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,450.00

GRAFT NERVE PROTECTOR 7x40MM

Facility

$12,600.00

Hospital Charge Code	270661365
Hospital Revenue Code	278
Min. Negotiated Rate	$1,890.00
Max. Negotiated Rate	$3,049.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,520.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,049.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,772.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,890.00

GRAFT NERVE PROTECTOR 7x40MM

Facility

$12,600.00

Hospital Charge Code	270661365
Hospital Revenue Code	278
Min. Negotiated Rate	$303.66
Max. Negotiated Rate	$6,300.00
Rate for Payer: Aetna Commercial	$4,788.00
Rate for Payer: Aetna Medicare Advantage	$3,780.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,213.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,213.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,520.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,213.00
Rate for Payer: Cigna Commercial	$6,300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,049.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,772.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,890.00
Rate for Payer: UnitedHealthcare Community & State	$303.66
Rate for Payer: Wellpoint Medicaid Managed Care	$333.90

GRAFT NEURAGEN 3MMX2CM NERVE

Facility

$4,732.50

Service Code	HCPCS C9352
Hospital Charge Code	270684066
Hospital Revenue Code	278
Min. Negotiated Rate	$709.88
Max. Negotiated Rate	$1,145.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$946.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,145.27
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,041.15
Rate for Payer: Qualcare PPO/HMO/WC	$709.88

GRAFT NEURAGEN 3MMX2CM NERVE

Facility

$4,732.50

Service Code	HCPCS C9352
Hospital Charge Code	270684066
Hospital Revenue Code	278
Min. Negotiated Rate	$114.05
Max. Negotiated Rate	$2,366.25
Rate for Payer: Aetna Commercial	$1,798.35
Rate for Payer: Aetna Medicare Advantage	$1,419.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,206.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,206.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$946.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,206.79
Rate for Payer: Cigna Commercial	$2,366.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,145.27
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,041.15
Rate for Payer: Qualcare PPO/HMO/WC	$709.88
Rate for Payer: UnitedHealthcare Community & State	$114.05
Rate for Payer: Wellpoint Medicaid Managed Care	$125.41

GRAFT NEURAGEN GUIDE 2MMX2CM

Facility

$4,732.50

Service Code	HCPCS C9352
Hospital Charge Code	270684068
Hospital Revenue Code	278
Min. Negotiated Rate	$114.05
Max. Negotiated Rate	$2,366.25
Rate for Payer: Aetna Commercial	$1,798.35
Rate for Payer: Aetna Medicare Advantage	$1,419.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,206.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,206.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$946.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,206.79
Rate for Payer: Cigna Commercial	$2,366.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,145.27
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,041.15
Rate for Payer: Qualcare PPO/HMO/WC	$709.88
Rate for Payer: UnitedHealthcare Community & State	$114.05
Rate for Payer: Wellpoint Medicaid Managed Care	$125.41

GRAFT NEURAGEN GUIDE 2MMX2CM

Facility

$4,732.50

Service Code	HCPCS C9352
Hospital Charge Code	270684068
Hospital Revenue Code	278
Min. Negotiated Rate	$709.88
Max. Negotiated Rate	$1,145.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$946.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,145.27
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,041.15
Rate for Payer: Qualcare PPO/HMO/WC	$709.88

GRAFT NEURAWRAP 10MMX4CM NERVE

Facility

$6,542.50

Service Code	HCPCS C9353
Hospital Charge Code	270684067
Hospital Revenue Code	278
Min. Negotiated Rate	$981.38
Max. Negotiated Rate	$1,583.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,308.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,583.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,439.35
Rate for Payer: Qualcare PPO/HMO/WC	$981.38

GRAFT NEURAWRAP 10MMX4CM NERVE

Facility

$6,542.50

Service Code	HCPCS C9353
Hospital Charge Code	270684067
Hospital Revenue Code	278
Min. Negotiated Rate	$157.67
Max. Negotiated Rate	$3,271.25
Rate for Payer: Aetna Commercial	$2,486.15
Rate for Payer: Aetna Medicare Advantage	$1,962.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,668.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,668.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,308.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,668.34
Rate for Payer: Cigna Commercial	$3,271.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,583.29
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,439.35
Rate for Payer: Qualcare PPO/HMO/WC	$981.38
Rate for Payer: UnitedHealthcare Community & State	$157.67
Rate for Payer: Wellpoint Medicaid Managed Care	$173.38

GRAFT NEUROWRAP 3MM X 20CM

Facility

$4,777.50

Service Code	HCPCS C9361
Hospital Charge Code	270688282
Hospital Revenue Code	278
Min. Negotiated Rate	$716.62
Max. Negotiated Rate	$1,156.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$955.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,156.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,051.05
Rate for Payer: Qualcare PPO/HMO/WC	$716.62

GRAFT NEUROWRAP 3MM X 20CM

Facility

$4,777.50

Service Code	HCPCS C9361
Hospital Charge Code	270688282
Hospital Revenue Code	278
Min. Negotiated Rate	$115.14
Max. Negotiated Rate	$2,388.75
Rate for Payer: Aetna Commercial	$1,815.45
Rate for Payer: Aetna Medicare Advantage	$1,433.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,218.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,218.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$955.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,218.26
Rate for Payer: Cigna Commercial	$2,388.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,156.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,051.05
Rate for Payer: Qualcare PPO/HMO/WC	$716.62
Rate for Payer: UnitedHealthcare Community & State	$115.14
Rate for Payer: Wellpoint Medicaid Managed Care	$126.60

GRAFT NEVOS SPONGE 50X20X5MM

Facility

$13,750.00

Service Code	HCPCS C1713
Hospital Charge Code	270692930
Hospital Revenue Code	278
Min. Negotiated Rate	$331.38
Max. Negotiated Rate	$6,875.00
Rate for Payer: Aetna Commercial	$5,225.00
Rate for Payer: Aetna Medicare Advantage	$4,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,506.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,506.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,506.25
Rate for Payer: Cigna Commercial	$6,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,327.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,062.50
Rate for Payer: UnitedHealthcare Community & State	$331.38
Rate for Payer: Wellpoint Medicaid Managed Care	$364.38

GRAFT NEVOS SPONGE 50X20X5MM

Facility

$13,750.00

Service Code	HCPCS C1713
Hospital Charge Code	270692930
Hospital Revenue Code	278
Min. Negotiated Rate	$2,062.50
Max. Negotiated Rate	$3,327.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,327.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,062.50

GRAFT NU SHIELD 6 SQ CM

Facility

$3,975.00

Service Code	HCPCS Q4160
Hospital Charge Code	270686858
Hospital Revenue Code	278
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$961.95
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	$795.00
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	$961.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$874.50
Rate for Payer: Qualcare PPO/HMO/WC	$596.25
Rate for Payer: UnitedHealthcare Community & State	$95.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$105.34

GRAFT NU SHIELD 6 SQ CM

Facility

$3,975.00

Service Code	HCPCS Q4160
Hospital Charge Code	270686858
Hospital Revenue Code	278
Min. Negotiated Rate	$596.25
Max. Negotiated Rate	$961.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$795.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$961.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$874.50
Rate for Payer: Qualcare PPO/HMO/WC	$596.25

GRAFT OMNIGRAFT 2.5CM X 2.5 CM

Facility

$2,975.00

Service Code	HCPCS Q4105
Hospital Charge Code	270684011
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$719.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$719.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$654.50
Rate for Payer: Qualcare PPO/HMO/WC	$446.25

GRAFT OMNIGRAFT 2.5CM X 2.5 CM

Facility

$2,975.00

Service Code	HCPCS Q4105
Hospital Charge Code	270684011
Hospital Revenue Code	278
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$719.95
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	$595.00
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	$719.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$654.50
Rate for Payer: Qualcare PPO/HMO/WC	$446.25
Rate for Payer: UnitedHealthcare Community & State	$71.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$78.84

GRAFT OMNIGRAFT 4CM X 4 CM

Facility

$4,375.00

Service Code	HCPCS Q4105
Hospital Charge Code	270684012
Hospital Revenue Code	278
Min. Negotiated Rate	$656.25
Max. Negotiated Rate	$1,058.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,058.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$962.50
Rate for Payer: Qualcare PPO/HMO/WC	$656.25

GRAFT OMNIGRAFT 4CM X 4 CM

Facility

$4,375.00

Service Code	HCPCS Q4105
Hospital Charge Code	270684012
Hospital Revenue Code	278
Min. Negotiated Rate	$105.44
Max. Negotiated Rate	$1,058.75
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	$875.00
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	$1,058.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$962.50
Rate for Payer: Qualcare PPO/HMO/WC	$656.25
Rate for Payer: UnitedHealthcare Community & State	$105.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$115.94

Know your out-of-pocket cost for care.

All Charges