Heights University Hospital

All Charges

Charge

Type

Setting

Price

GRAFT GORETEX TH/WALL 6x70

Facility

$4,980.00

Service Code	HCPCS C1768
Hospital Charge Code	270655975
Hospital Revenue Code	278
Min. Negotiated Rate	$747.00
Max. Negotiated Rate	$2,490.00
Rate for Payer: Aetna Commercial	$1,494.00
Rate for Payer: Aetna Medicare Advantage	$1,494.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,269.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,269.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$996.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,269.90
Rate for Payer: Cigna Commercial	$2,490.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,205.16
Rate for Payer: Qualcare PPO/HMO/WC	$747.00

GRAFT GORETEX TH/WALL 6x70

Facility

$4,980.00

Service Code	HCPCS C1768
Hospital Charge Code	270655975
Hospital Revenue Code	278
Min. Negotiated Rate	$747.00
Max. Negotiated Rate	$1,205.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$996.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,205.16
Rate for Payer: Qualcare PPO/HMO/WC	$747.00

GRAFT GORETEX TH/WALL 8x70

Facility

$4,980.00

Service Code	HCPCS C1768
Hospital Charge Code	270655974
Hospital Revenue Code	278
Min. Negotiated Rate	$747.00
Max. Negotiated Rate	$2,490.00
Rate for Payer: Aetna Commercial	$1,494.00
Rate for Payer: Aetna Medicare Advantage	$1,494.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,269.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,269.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$996.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,269.90
Rate for Payer: Cigna Commercial	$2,490.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,205.16
Rate for Payer: Qualcare PPO/HMO/WC	$747.00

GRAFT GORETEX TH/WALL 8x70

Facility

$4,980.00

Service Code	HCPCS C1768
Hospital Charge Code	270655974
Hospital Revenue Code	278
Min. Negotiated Rate	$747.00
Max. Negotiated Rate	$1,205.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$996.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,205.16
Rate for Payer: Qualcare PPO/HMO/WC	$747.00

GRAFT GORTEX PROPATEN 4 X 6

Facility

$6,160.00

Service Code	HCPCS C1768
Hospital Charge Code	270688741
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$3,080.00
Rate for Payer: Aetna Commercial	$1,848.00
Rate for Payer: Aetna Medicare Advantage	$1,848.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,570.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,570.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,232.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,570.80
Rate for Payer: Cigna Commercial	$3,080.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,490.72
Rate for Payer: Qualcare PPO/HMO/WC	$924.00

GRAFT GORTEX PROPATEN 4 X 6

Facility

$6,160.00

Service Code	HCPCS C1768
Hospital Charge Code	270688741
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,490.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,232.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,490.72
Rate for Payer: Qualcare PPO/HMO/WC	$924.00

GRAFT GRAFTJACKET 2 X 4 CM 1-2

Facility

$20,510.00

Service Code	HCPCS C17999
Hospital Charge Code	270700838
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.50
Max. Negotiated Rate	$4,963.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,102.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,963.42
Rate for Payer: Qualcare PPO/HMO/WC	$3,076.50

GRAFT GRAFTJACKET 2 X 4 CM 1-2

Facility

$20,510.00

Service Code	HCPCS C17999
Hospital Charge Code	270700838
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.50
Max. Negotiated Rate	$10,255.00
Rate for Payer: Aetna Commercial	$6,153.00
Rate for Payer: Aetna Medicare Advantage	$6,153.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,230.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,230.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,102.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,230.05
Rate for Payer: Cigna Commercial	$10,255.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,963.42
Rate for Payer: Qualcare PPO/HMO/WC	$3,076.50

GRAFT GTX 20 10 B201040*****

Facility

$2,866.00

Hospital Charge Code	1604172
Hospital Revenue Code	278
Min. Negotiated Rate	$429.90
Max. Negotiated Rate	$693.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$573.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$693.57
Rate for Payer: Qualcare PPO/HMO/WC	$429.90

GRAFT GTX 20 10 B201040*****

Facility

$2,866.00

Hospital Charge Code	1604172
Hospital Revenue Code	278
Min. Negotiated Rate	$429.90
Max. Negotiated Rate	$1,433.00
Rate for Payer: Aetna Commercial	$859.80
Rate for Payer: Aetna Medicare Advantage	$859.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$730.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$730.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$573.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$730.83
Rate for Payer: Cigna Commercial	$1,433.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$693.57
Rate for Payer: Qualcare PPO/HMO/WC	$429.90

GRAFT GTX 2 20 1320030020

Facility

$9,679.25

Hospital Charge Code	270601138
Hospital Revenue Code	278
Min. Negotiated Rate	$1,451.89
Max. Negotiated Rate	$2,342.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,935.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,342.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,451.89

GRAFT GTX 2 20 1320030020

Facility

$9,679.25

Hospital Charge Code	270601138
Hospital Revenue Code	278
Min. Negotiated Rate	$1,451.89
Max. Negotiated Rate	$4,839.62
Rate for Payer: Aetna Commercial	$2,903.78
Rate for Payer: Aetna Medicare Advantage	$2,903.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,468.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,468.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,935.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,468.21
Rate for Payer: Cigna Commercial	$4,839.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,342.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,451.89

GRAFT GTX 4.5 6.5 40CM******

Facility

$1,839.00

Hospital Charge Code	1603976
Hospital Revenue Code	278
Min. Negotiated Rate	$275.85
Max. Negotiated Rate	$919.50
Rate for Payer: Aetna Commercial	$551.70
Rate for Payer: Aetna Medicare Advantage	$551.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$468.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$468.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$367.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$468.94
Rate for Payer: Cigna Commercial	$919.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$445.04
Rate for Payer: Qualcare PPO/HMO/WC	$275.85

GRAFT GTX 4.5 6.5 40CM******

Facility

$1,839.00

Hospital Charge Code	1603976
Hospital Revenue Code	278
Min. Negotiated Rate	$275.85
Max. Negotiated Rate	$445.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$367.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$445.04
Rate for Payer: Qualcare PPO/HMO/WC	$275.85

GRAFT GTX 4.5-6.5 40 V45040L

Facility

$3,672.85

Hospital Charge Code	270601140
Hospital Revenue Code	278
Min. Negotiated Rate	$550.93
Max. Negotiated Rate	$1,836.42
Rate for Payer: Aetna Commercial	$1,101.86
Rate for Payer: Aetna Medicare Advantage	$1,101.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$936.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$936.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$734.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$936.58
Rate for Payer: Cigna Commercial	$1,836.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$888.83
Rate for Payer: Qualcare PPO/HMO/WC	$550.93

GRAFT GTX 4.5-6.5 40 V45040L

Facility

$3,672.85

Hospital Charge Code	270601140
Hospital Revenue Code	278
Min. Negotiated Rate	$550.93
Max. Negotiated Rate	$888.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$734.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$888.83
Rate for Payer: Qualcare PPO/HMO/WC	$550.93

GRAFT GTX 4.5-6.5 VT45040L****

Facility

$2,178.00

Hospital Charge Code	1603943
Hospital Revenue Code	278
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$527.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$435.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$527.08
Rate for Payer: Qualcare PPO/HMO/WC	$326.70

GRAFT GTX 4.5-6.5 VT45040L****

Facility

$2,178.00

Hospital Charge Code	1603943
Hospital Revenue Code	278
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$1,089.00
Rate for Payer: Aetna Commercial	$653.40
Rate for Payer: Aetna Medicare Advantage	$653.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$555.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$555.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$435.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$555.39
Rate for Payer: Cigna Commercial	$1,089.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$527.08
Rate for Payer: Qualcare PPO/HMO/WC	$326.70

GRAFT GTX 4.5-6.5 VT45040L

Facility

$3,520.85

Hospital Charge Code	270601135
Hospital Revenue Code	278
Min. Negotiated Rate	$528.13
Max. Negotiated Rate	$1,760.42
Rate for Payer: Aetna Commercial	$1,056.26
Rate for Payer: Aetna Medicare Advantage	$1,056.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$897.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$897.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$704.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$897.82
Rate for Payer: Cigna Commercial	$1,760.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$852.05
Rate for Payer: Qualcare PPO/HMO/WC	$528.13

GRAFT GTX 4.5-6.5 VT45040L

Facility

$3,520.85

Hospital Charge Code	270601135
Hospital Revenue Code	278
Min. Negotiated Rate	$528.13
Max. Negotiated Rate	$852.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$704.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$852.05
Rate for Payer: Qualcare PPO/HMO/WC	$528.13

GRAFT GTX 6 50 V06050L

Facility

$3,712.00

Hospital Charge Code	270601139
Hospital Revenue Code	278
Min. Negotiated Rate	$556.80
Max. Negotiated Rate	$1,856.00
Rate for Payer: Aetna Commercial	$1,113.60
Rate for Payer: Aetna Medicare Advantage	$1,113.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$946.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$946.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$742.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$946.56
Rate for Payer: Cigna Commercial	$1,856.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$898.30
Rate for Payer: Qualcare PPO/HMO/WC	$556.80

GRAFT GTX 6 50 V06050L

Facility

$3,712.00

Hospital Charge Code	270601139
Hospital Revenue Code	278
Min. Negotiated Rate	$556.80
Max. Negotiated Rate	$898.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$742.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$898.30
Rate for Payer: Qualcare PPO/HMO/WC	$556.80

GRAFT GTX 6MM 50CM V06050L****

Facility

$2,298.00

Hospital Charge Code	1603968
Hospital Revenue Code	278
Min. Negotiated Rate	$344.70
Max. Negotiated Rate	$1,149.00
Rate for Payer: Aetna Commercial	$689.40
Rate for Payer: Aetna Medicare Advantage	$689.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$585.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$585.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$459.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$585.99
Rate for Payer: Cigna Commercial	$1,149.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$556.12
Rate for Payer: Qualcare PPO/HMO/WC	$344.70

GRAFT GTX 6MM 50CM V06050L****

Facility

$2,298.00

Hospital Charge Code	1603968
Hospital Revenue Code	278
Min. Negotiated Rate	$344.70
Max. Negotiated Rate	$556.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$459.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$556.12
Rate for Payer: Qualcare PPO/HMO/WC	$344.70

GRAFT GTX 8MM 90CM V08090L****

Facility

$3,813.00

Hospital Charge Code	1603992
Hospital Revenue Code	278
Min. Negotiated Rate	$571.95
Max. Negotiated Rate	$922.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$762.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$922.75
Rate for Payer: Qualcare PPO/HMO/WC	$571.95

Know your out-of-pocket cost for care.

All Charges