Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

TIBIAL TRAY CEMENTED SZ4F/3T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270680393
Hospital Revenue Code	278
Min. Negotiated Rate	$142.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$158.00
Rate for Payer: Wellpoint Medicaid Managed Care	$142.00

TIBIAL TRAY CEMENTED SZ 4F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270679004
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

TIBIAL TRAY CEMENTED SZ 4F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270679004
Hospital Revenue Code	278
Min. Negotiated Rate	$142.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$158.00
Rate for Payer: Wellpoint Medicaid Managed Care	$142.00

TIBIAL TRAY CEMENTED SZ 5F/5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677577
Hospital Revenue Code	278
Min. Negotiated Rate	$142.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$158.00
Rate for Payer: Wellpoint Medicaid Managed Care	$142.00

TIBIAL TRAY CEMENTED SZ 5F/5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677577
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

TIBIAL TRAY COCR FINNED 63MM

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270639117
Hospital Revenue Code	278
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$1,089.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$900.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,089.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00

TIBIAL TRAY COCR FINNED 63MM

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270639117
Hospital Revenue Code	278
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$1,710.00
Rate for Payer: Aetna Medicare Advantage	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$900.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,147.50
Rate for Payer: Cigna Commercial	$2,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,089.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00
Rate for Payer: UnitedHealthcare Community & State	$142.20
Rate for Payer: Wellpoint Medicaid Managed Care	$127.80

TIBIAL TRAY COMP OFFSET 63MM

Facility

$14,010.00

Service Code	HCPCS C1776
Hospital Charge Code	270675927
Hospital Revenue Code	278
Min. Negotiated Rate	$397.88
Max. Negotiated Rate	$7,005.00
Rate for Payer: Aetna Commercial	$5,323.80
Rate for Payer: Aetna Medicare Advantage	$4,203.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,572.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,572.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,802.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,572.55
Rate for Payer: Cigna Commercial	$7,005.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,390.42
Rate for Payer: Qualcare PPO/HMO/WC	$2,101.50
Rate for Payer: UnitedHealthcare Community & State	$442.72
Rate for Payer: Wellpoint Medicaid Managed Care	$397.88

TIBIAL TRAY COMP OFFSET 63MM

Facility

$14,010.00

Service Code	HCPCS C1776
Hospital Charge Code	270675927
Hospital Revenue Code	278
Min. Negotiated Rate	$2,101.50
Max. Negotiated Rate	$3,390.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,802.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,390.42
Rate for Payer: Qualcare PPO/HMO/WC	$2,101.50

TIBIAL TRAY FIXED CEMENTED SZ4

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270671825
Hospital Revenue Code	278
Min. Negotiated Rate	$156.20
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$173.80
Rate for Payer: Wellpoint Medicaid Managed Care	$156.20

TIBIAL TRAY FIXED CEMENTED SZ4

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270671825
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY FIXED SIZE 1

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270686216
Hospital Revenue Code	278
Min. Negotiated Rate	$156.20
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$173.80
Rate for Payer: Wellpoint Medicaid Managed Care	$156.20

TIBIAL TRAY FIXED SIZE 1

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270686216
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY FIXED SZ2 LEFT

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270676449
Hospital Revenue Code	278
Min. Negotiated Rate	$156.20
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$173.80
Rate for Payer: Wellpoint Medicaid Managed Care	$156.20

TIBIAL TRAY FIXED SZ2 LEFT

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270676449
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY FIXED SZ3 RT

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270675655
Hospital Revenue Code	278
Min. Negotiated Rate	$156.20
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$173.80
Rate for Payer: Wellpoint Medicaid Managed Care	$156.20

TIBIAL TRAY FIXED SZ3 RT

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270675655
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY INFINITY SZ 3 LNG

Facility

$17,240.00

Service Code	HCPCS C1776
Hospital Charge Code	270676973
Hospital Revenue Code	278
Min. Negotiated Rate	$489.62
Max. Negotiated Rate	$8,620.00
Rate for Payer: Aetna Commercial	$6,551.20
Rate for Payer: Aetna Medicare Advantage	$5,172.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,396.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,396.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,448.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,396.20
Rate for Payer: Cigna Commercial	$8,620.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,172.08
Rate for Payer: Qualcare PPO/HMO/WC	$2,586.00
Rate for Payer: UnitedHealthcare Community & State	$544.78
Rate for Payer: Wellpoint Medicaid Managed Care	$489.62

TIBIAL TRAY INFINITY SZ 3 LNG

Facility

$17,240.00

Service Code	HCPCS C1776
Hospital Charge Code	270676973
Hospital Revenue Code	278
Min. Negotiated Rate	$2,586.00
Max. Negotiated Rate	$4,172.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,448.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,172.08
Rate for Payer: Qualcare PPO/HMO/WC	$2,586.00

TIBIAL TRAY OFFSET 3F/3T

Facility

$11,513.25

Service Code	HCPCS C1776
Hospital Charge Code	270674855
Hospital Revenue Code	278
Min. Negotiated Rate	$1,726.99
Max. Negotiated Rate	$2,786.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,302.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,786.21
Rate for Payer: Qualcare PPO/HMO/WC	$1,726.99

TIBIAL TRAY OFFSET 3F/3T

Facility

$11,513.25

Service Code	HCPCS C1776
Hospital Charge Code	270674855
Hospital Revenue Code	278
Min. Negotiated Rate	$326.98
Max. Negotiated Rate	$5,756.62
Rate for Payer: Aetna Commercial	$4,375.03
Rate for Payer: Aetna Medicare Advantage	$3,453.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,935.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,935.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,302.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,935.88
Rate for Payer: Cigna Commercial	$5,756.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,786.21
Rate for Payer: Qualcare PPO/HMO/WC	$1,726.99
Rate for Payer: UnitedHealthcare Community & State	$363.82
Rate for Payer: Wellpoint Medicaid Managed Care	$326.98

TIBIAL TRAY PRIM 71mm W/LCK BR

Facility

$11,060.00

Service Code	HCPCS C1713
Hospital Charge Code	270646613
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.00
Max. Negotiated Rate	$2,676.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,212.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,676.52
Rate for Payer: Qualcare PPO/HMO/WC	$1,659.00

TIBIAL TRAY PRIM 71mm W/LCK BR

Facility

$11,060.00

Service Code	HCPCS C1713
Hospital Charge Code	270646613
Hospital Revenue Code	278
Min. Negotiated Rate	$314.10
Max. Negotiated Rate	$5,530.00
Rate for Payer: Aetna Commercial	$4,202.80
Rate for Payer: Aetna Medicare Advantage	$3,318.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,820.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,820.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,212.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,820.30
Rate for Payer: Cigna Commercial	$5,530.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,676.52
Rate for Payer: Qualcare PPO/HMO/WC	$1,659.00
Rate for Payer: UnitedHealthcare Community & State	$349.50
Rate for Payer: Wellpoint Medicaid Managed Care	$314.10

TIBIAL TRAY SZ 1 STD INFINITY

Facility

$22,400.00

Service Code	HCPCS C1776
Hospital Charge Code	270670885
Hospital Revenue Code	278
Min. Negotiated Rate	$636.16
Max. Negotiated Rate	$11,200.00
Rate for Payer: Aetna Commercial	$8,512.00
Rate for Payer: Aetna Medicare Advantage	$6,720.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,712.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,712.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,480.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,712.00
Rate for Payer: Cigna Commercial	$11,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,420.80
Rate for Payer: Qualcare PPO/HMO/WC	$3,360.00
Rate for Payer: UnitedHealthcare Community & State	$707.84
Rate for Payer: Wellpoint Medicaid Managed Care	$636.16

TIBIAL TRAY SZ 1 STD INFINITY

Facility

$22,400.00

Service Code	HCPCS C1776
Hospital Charge Code	270670885
Hospital Revenue Code	278
Min. Negotiated Rate	$3,360.00
Max. Negotiated Rate	$5,420.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,480.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,420.80
Rate for Payer: Qualcare PPO/HMO/WC	$3,360.00

Know your out-of-pocket cost for care.

All Charges