Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

POLYETHYLENE INSERT 36MM

Facility

$6,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270671318
Hospital Revenue Code	278
Min. Negotiated Rate	$1,031.25
Max. Negotiated Rate	$1,663.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,663.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,031.25

POLYETHYLENE INSERT 36MM

Facility

$6,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270671318
Hospital Revenue Code	278
Min. Negotiated Rate	$195.25
Max. Negotiated Rate	$3,437.50
Rate for Payer: Aetna Commercial	$2,612.50
Rate for Payer: Aetna Medicare Advantage	$2,062.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,753.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,753.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,753.12
Rate for Payer: Cigna Commercial	$3,437.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,663.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,031.25
Rate for Payer: UnitedHealthcare Community & State	$217.25
Rate for Payer: Wellpoint Medicaid Managed Care	$195.25

POLYGIA 75

Facility

$665.00

Hospital Charge Code	270335194
Hospital Revenue Code	272
Min. Negotiated Rate	$99.75
Max. Negotiated Rate	$99.75
Rate for Payer: Qualcare PPO/HMO/WC	$99.75

POLYGIA 75

Facility

$665.00

Hospital Charge Code	270335194
Hospital Revenue Code	272
Min. Negotiated Rate	$18.89
Max. Negotiated Rate	$332.50
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare Advantage	$199.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$169.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$169.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$169.57
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$172.90
Rate for Payer: Oxford Commercial	$133.00
Rate for Payer: Qualcare PPO/HMO/WC	$99.75
Rate for Payer: UnitedHealthcare Commercial	$133.00
Rate for Payer: UnitedHealthcare Community & State	$21.01
Rate for Payer: Wellpoint Medicaid Managed Care	$18.89

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.25
Max. Negotiated Rate	$1,905.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$223.65
Max. Negotiated Rate	$3,937.50
Rate for Payer: Aetna Commercial	$2,992.50
Rate for Payer: Aetna Medicare Advantage	$2,362.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,008.12
Rate for Payer: Cigna Commercial	$3,937.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25
Rate for Payer: UnitedHealthcare Community & State	$248.85
Rate for Payer: Wellpoint Medicaid Managed Care	$223.65

POLY INFINITY SZ 4+ 7MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270678156
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INFINITY SZ 4+ 7MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270678156
Hospital Revenue Code	278
Min. Negotiated Rate	$276.90
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$3,705.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50
Rate for Payer: UnitedHealthcare Community & State	$308.10
Rate for Payer: Wellpoint Medicaid Managed Care	$276.90

POLY INSERT SZ1/1+ 6MM

Facility

$10,145.00

Hospital Charge Code	270670886
Hospital Revenue Code	278
Min. Negotiated Rate	$288.12
Max. Negotiated Rate	$5,072.50
Rate for Payer: Aetna Commercial	$3,855.10
Rate for Payer: Aetna Medicare Advantage	$3,043.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,586.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,586.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,029.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,586.97
Rate for Payer: Cigna Commercial	$5,072.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,455.09
Rate for Payer: Qualcare PPO/HMO/WC	$1,521.75
Rate for Payer: UnitedHealthcare Community & State	$320.58
Rate for Payer: Wellpoint Medicaid Managed Care	$288.12

POLY INSERT SZ1/1+ 6MM

Facility

$10,145.00

Hospital Charge Code	270670886
Hospital Revenue Code	278
Min. Negotiated Rate	$1,521.75
Max. Negotiated Rate	$2,455.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,029.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,455.09
Rate for Payer: Qualcare PPO/HMO/WC	$1,521.75

POLY INSERT SZ 1/1+ 8MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270675066
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ 1/1+ 8MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270675066
Hospital Revenue Code	278
Min. Negotiated Rate	$276.90
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$3,705.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50
Rate for Payer: UnitedHealthcare Community & State	$308.10
Rate for Payer: Wellpoint Medicaid Managed Care	$276.90

POLY INSERT SZ 2+ 6MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270676974
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ 2+ 6MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270676974
Hospital Revenue Code	278
Min. Negotiated Rate	$276.90
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$3,705.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50
Rate for Payer: UnitedHealthcare Community & State	$308.10
Rate for Payer: Wellpoint Medicaid Managed Care	$276.90

POLY LINER HIGH WALL/SZ F 36MM

Facility

$6,000.00

Service Code	HCPCS C1765
Hospital Charge Code	270705045
Hospital Revenue Code	278
Min. Negotiated Rate	$170.40
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$189.60
Rate for Payer: Wellpoint Medicaid Managed Care	$170.40

POLY LINER HIGH WALL/SZ F 36MM

Facility

$6,000.00

Service Code	HCPCS C1765
Hospital Charge Code	270705045
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

POLY LINER HIGH WALL SZ G

Facility

$32,500.00

Hospital Charge Code	270702513
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

POLY LINER HIGH WALL SZ G

Facility

$32,500.00

Hospital Charge Code	270702513
Hospital Revenue Code	278
Min. Negotiated Rate	$923.00
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$12,350.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00
Rate for Payer: UnitedHealthcare Community & State	$1,027.00
Rate for Payer: Wellpoint Medicaid Managed Care	$923.00

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535W
Hospital Revenue Code	272
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.82

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535W
Hospital Revenue Code	272
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna Commercial	$2.07
Rate for Payer: Aetna Medicare Advantage	$1.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.39
Rate for Payer: Cigna Commercial	$2.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.42
Rate for Payer: Oxford Commercial	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$0.82
Rate for Payer: UnitedHealthcare Commercial	$1.09
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535
Hospital Revenue Code	272
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.82

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535
Hospital Revenue Code	272
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna Commercial	$2.07
Rate for Payer: Aetna Medicare Advantage	$1.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.39
Rate for Payer: Cigna Commercial	$2.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.42
Rate for Payer: Oxford Commercial	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$0.82
Rate for Payer: UnitedHealthcare Commercial	$1.09
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

POLYMYXIN B 500000 U INJ

Facility

$90.45

Service Code	NDC 39822016605
Hospital Charge Code	60630050
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$45.23
Rate for Payer: Aetna Commercial	$34.37
Rate for Payer: Aetna Medicare Advantage	$27.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.06
Rate for Payer: Cigna Commercial	$45.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.52
Rate for Payer: Oxford Commercial	$18.09
Rate for Payer: Qualcare PPO/HMO/WC	$13.57
Rate for Payer: UnitedHealthcare Commercial	$18.09
Rate for Payer: UnitedHealthcare Community & State	$2.86
Rate for Payer: Wellpoint Medicaid Managed Care	$2.57

POLYMYXIN B 500000 U INJ

Facility

$90.45

Service Code	NDC 39822016605
Hospital Charge Code	60630050
Hospital Revenue Code	250
Min. Negotiated Rate	$13.57
Max. Negotiated Rate	$13.57
Rate for Payer: Qualcare PPO/HMO/WC	$13.57

POLYMYXIN B/TRIMETHOPRIM OPTH

Facility

$442.07

Service Code	NDC 23782410
Hospital Charge Code	60632326
Hospital Revenue Code	250
Min. Negotiated Rate	$12.55
Max. Negotiated Rate	$221.03
Rate for Payer: Aetna Commercial	$167.99
Rate for Payer: Aetna Medicare Advantage	$132.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.73
Rate for Payer: Cigna Commercial	$221.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$114.94
Rate for Payer: Oxford Commercial	$88.41
Rate for Payer: Qualcare PPO/HMO/WC	$66.31
Rate for Payer: UnitedHealthcare Commercial	$88.41
Rate for Payer: UnitedHealthcare Community & State	$13.97
Rate for Payer: Wellpoint Medicaid Managed Care	$12.55

Know your out-of-pocket cost for care.

All Charges