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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

GWIRE MIRACLEBR 12X300 8290302

Facility

IP

$625.00

Service Code	HCPCS C1769
Hospital Charge Code	270642967C
Hospital Revenue Code	278
Min. Negotiated Rate	$93.75
Max. Negotiated Rate	$151.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$137.50
Rate for Payer: Qualcare PPO/HMO/WC	$93.75

GWIRE NEURO SS .014X300

Facility

OP

$4,022.50

Service Code	HCPCS C1769
Hospital Charge Code	270697470S
Hospital Revenue Code	278
Min. Negotiated Rate	$96.94
Max. Negotiated Rate	$2,011.25
Rate for Payer: Aetna Commercial	$1,528.55
Rate for Payer: Aetna Medicare Advantage	$1,206.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,025.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,025.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$804.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,025.74
Rate for Payer: Cigna Commercial	$2,011.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$973.45
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$884.95
Rate for Payer: Qualcare PPO/HMO/WC	$603.38
Rate for Payer: UnitedHealthcare Community & State	$96.94
Rate for Payer: Wellpoint Medicaid Managed Care	$106.60

GWIRE NEURO SS .014X300

Facility

IP

$4,022.50

Service Code	HCPCS C1769
Hospital Charge Code	270697470S
Hospital Revenue Code	278
Min. Negotiated Rate	$603.38
Max. Negotiated Rate	$973.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$804.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$973.45
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$884.95
Rate for Payer: Qualcare PPO/HMO/WC	$603.38

GWIRE NIT PLAT 18X40 MAK001N40

Facility

OP

$113.25

Service Code	HCPCS C1769
Hospital Charge Code	270660311
Hospital Revenue Code	278
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$56.62
Rate for Payer: Aetna Commercial	$43.03
Rate for Payer: Aetna Medicare Advantage	$33.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.88
Rate for Payer: Cigna Commercial	$56.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.91
Rate for Payer: Qualcare PPO/HMO/WC	$16.99
Rate for Payer: UnitedHealthcare Community & State	$2.73
Rate for Payer: Wellpoint Medicaid Managed Care	$3.00

GWIRE NIT PLAT 18X40 MAK001N40

Facility

IP

$137.00

Service Code	HCPCS C1769
Hospital Charge Code	270660311N
Hospital Revenue Code	278
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$33.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$27.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$30.14
Rate for Payer: Qualcare PPO/HMO/WC	$20.55

GWIRE NIT PLAT 18X40 MAK001N40

Facility

OP

$137.00

Service Code	HCPCS C1769
Hospital Charge Code	270660311N
Hospital Revenue Code	278
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$68.50
Rate for Payer: Aetna Commercial	$52.06
Rate for Payer: Aetna Medicare Advantage	$41.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$27.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.94
Rate for Payer: Cigna Commercial	$68.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$30.14
Rate for Payer: Qualcare PPO/HMO/WC	$20.55
Rate for Payer: UnitedHealthcare Community & State	$3.30
Rate for Payer: Wellpoint Medicaid Managed Care	$3.63

GWIRE NIT PLAT 18X40 MAK001N40

Facility

IP

$113.25

Service Code	HCPCS C1769
Hospital Charge Code	270660311
Hospital Revenue Code	278
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$27.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.91
Rate for Payer: Qualcare PPO/HMO/WC	$16.99

GWIRE NIT PLAT 18X40 MAK001N40

Facility

IP

$113.25

Service Code	HCPCS C1769
Hospital Charge Code	270660311S
Hospital Revenue Code	278
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$27.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.91
Rate for Payer: Qualcare PPO/HMO/WC	$16.99

GWIRE NIT PLAT 18X40 MAK001N40

Facility

OP

$113.25

Service Code	HCPCS C1769
Hospital Charge Code	270660311S
Hospital Revenue Code	278
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$56.62
Rate for Payer: Aetna Commercial	$43.03
Rate for Payer: Aetna Medicare Advantage	$33.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.88
Rate for Payer: Cigna Commercial	$56.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.91
Rate for Payer: Qualcare PPO/HMO/WC	$16.99
Rate for Payer: UnitedHealthcare Community & State	$2.73
Rate for Payer: Wellpoint Medicaid Managed Care	$3.00

GWIRE PROWTR 180CM 1277601

Facility

OP

$2,108.00

Service Code	HCPCS C1769
Hospital Charge Code	270636741N
Hospital Revenue Code	278
Min. Negotiated Rate	$50.80
Max. Negotiated Rate	$1,054.00
Rate for Payer: Aetna Commercial	$801.04
Rate for Payer: Aetna Medicare Advantage	$632.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$537.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$537.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$421.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$537.54
Rate for Payer: Cigna Commercial	$1,054.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$510.14
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$463.76
Rate for Payer: Qualcare PPO/HMO/WC	$316.20
Rate for Payer: UnitedHealthcare Community & State	$50.80
Rate for Payer: Wellpoint Medicaid Managed Care	$55.86

GWIRE PROWTR 180CM 1277601

Facility

OP

$375.00

Service Code	HCPCS C1769
Hospital Charge Code	270636741
Hospital Revenue Code	278
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$187.50
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare Advantage	$112.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$95.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$95.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$75.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$95.62
Rate for Payer: Cigna Commercial	$187.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$82.50
Rate for Payer: Qualcare PPO/HMO/WC	$56.25
Rate for Payer: UnitedHealthcare Community & State	$9.04
Rate for Payer: Wellpoint Medicaid Managed Care	$9.94

GWIRE PROWTR 180CM 1277601

Facility

IP

$2,108.00

Service Code	HCPCS C1769
Hospital Charge Code	270636741N
Hospital Revenue Code	278
Min. Negotiated Rate	$316.20
Max. Negotiated Rate	$510.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$421.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$510.14
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$463.76
Rate for Payer: Qualcare PPO/HMO/WC	$316.20

GWIRE PROWTR 180CM 1277601

Facility

IP

$375.00

Service Code	HCPCS C1769
Hospital Charge Code	270636741
Hospital Revenue Code	278
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$90.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$75.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$82.50
Rate for Payer: Qualcare PPO/HMO/WC	$56.25

G WIRE TIP THD .062X 9.25 MM

Facility

OP

$150.00

Service Code	HCPCS C1769
Hospital Charge Code	270691073
Hospital Revenue Code	278
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare Advantage	$45.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$30.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.25
Rate for Payer: Cigna Commercial	$75.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$33.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.50
Rate for Payer: UnitedHealthcare Community & State	$3.62
Rate for Payer: Wellpoint Medicaid Managed Care	$3.98

G WIRE TIP THD .062X 9.25 MM

Facility

IP

$150.00

Service Code	HCPCS C1769
Hospital Charge Code	270691073
Hospital Revenue Code	278
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$36.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$30.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$33.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.50

GWIRE TROC TP 18 IN

Facility

IP

$437.50

Hospital Charge Code	270703007
Hospital Revenue Code	278
Min. Negotiated Rate	$65.62
Max. Negotiated Rate	$105.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$87.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$105.88
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$96.25
Rate for Payer: Qualcare PPO/HMO/WC	$65.62

GWIRE TROC TP 18 IN

Facility

OP

$437.50

Hospital Charge Code	270703007
Hospital Revenue Code	278
Min. Negotiated Rate	$10.54
Max. Negotiated Rate	$218.75
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare Advantage	$131.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$111.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$111.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$87.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$111.56
Rate for Payer: Cigna Commercial	$218.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$105.88
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$96.25
Rate for Payer: Qualcare PPO/HMO/WC	$65.62
Rate for Payer: UnitedHealthcare Community & State	$10.54
Rate for Payer: Wellpoint Medicaid Managed Care	$11.59

GWIRE VIPERWIRE .014DIA 335CM

Facility

IP

$750.00

Service Code	HCPCS C1769
Hospital Charge Code	270693012
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

GWIRE VIPERWIRE .014DIA 335CM

Facility

OP

$750.00

Service Code	HCPCS C1769
Hospital Charge Code	270693012
Hospital Revenue Code	278
Min. Negotiated Rate	$18.07
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: UnitedHealthcare Community & State	$18.07
Rate for Payer: Wellpoint Medicaid Managed Care	$19.88

G-WIRE W/TRCR TIP.NON THD

Facility

IP

$110.00

Service Code	HCPCS C1769
Hospital Charge Code	270685924
Hospital Revenue Code	278
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$26.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.20
Rate for Payer: Qualcare PPO/HMO/WC	$16.50

G-WIRE W/TRCR TIP.NON THD

Facility

OP

$110.00

Service Code	HCPCS C1769
Hospital Charge Code	270685924
Hospital Revenue Code	278
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare Advantage	$33.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.05
Rate for Payer: Cigna Commercial	$55.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$24.20
Rate for Payer: Qualcare PPO/HMO/WC	$16.50
Rate for Payer: UnitedHealthcare Community & State	$2.65
Rate for Payer: Wellpoint Medicaid Managed Care	$2.92

GW WHISPER .014 190 1005357H

Facility

IP

$375.00

Service Code	HCPCS C1769
Hospital Charge Code	270638396C
Hospital Revenue Code	278
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$90.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$75.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$82.50
Rate for Payer: Qualcare PPO/HMO/WC	$56.25

GW WHISPER .014 190 1005357H

Facility

OP

$375.00

Service Code	HCPCS C1769
Hospital Charge Code	270638396C
Hospital Revenue Code	278
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$187.50
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare Advantage	$112.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$95.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$95.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$75.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$95.62
Rate for Payer: Cigna Commercial	$187.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$82.50
Rate for Payer: Qualcare PPO/HMO/WC	$56.25
Rate for Payer: UnitedHealthcare Community & State	$9.04
Rate for Payer: Wellpoint Medicaid Managed Care	$9.94

GYNE-LOTRIMIN/100MG/TAB

Facility

IP

$56.00

Hospital Charge Code	60633061
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$8.40

GYNE-LOTRIMIN/100MG/TAB

Facility

OP

$56.00

Hospital Charge Code	60633061
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$21.28
Rate for Payer: Aetna Medicare Advantage	$16.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.28
Rate for Payer: Cigna Commercial	$28.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.80
Rate for Payer: Oxford Commercial	$11.20
Rate for Payer: Qualcare PPO/HMO/WC	$8.40
Rate for Payer: UnitedHealthcare Commercial	$11.20
Rate for Payer: UnitedHealthcare Community & State	$1.35
Rate for Payer: Wellpoint Medicaid Managed Care	$1.48