Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

BREAST EXPANDER W/TABS 700cc

Facility

$6,750.00

Service Code	HCPCS C1789
Hospital Charge Code	270665567
Hospital Revenue Code	278
Min. Negotiated Rate	$191.70
Max. Negotiated Rate	$3,375.00
Rate for Payer: Aetna Commercial	$2,565.00
Rate for Payer: Aetna Medicare Advantage	$2,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,721.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,721.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,721.25
Rate for Payer: Cigna Commercial	$3,375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,633.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,012.50
Rate for Payer: UnitedHealthcare Community & State	$213.30
Rate for Payer: Wellpoint Medicaid Managed Care	$191.70

BREAST EXPANDER W/TABS 850cc

Facility

$6,750.00

Service Code	HCPCS C1789
Hospital Charge Code	270664495
Hospital Revenue Code	278
Min. Negotiated Rate	$191.70
Max. Negotiated Rate	$3,375.00
Rate for Payer: Aetna Commercial	$2,565.00
Rate for Payer: Aetna Medicare Advantage	$2,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,721.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,721.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,721.25
Rate for Payer: Cigna Commercial	$3,375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,633.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,012.50
Rate for Payer: UnitedHealthcare Community & State	$213.30
Rate for Payer: Wellpoint Medicaid Managed Care	$191.70

BREAST EXPANDER W/TABS 850cc

Facility

$6,750.00

Service Code	HCPCS C1789
Hospital Charge Code	270664495
Hospital Revenue Code	278
Min. Negotiated Rate	$1,012.50
Max. Negotiated Rate	$1,633.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,350.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,633.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,012.50

BREAST IMP 250CC SMOOTH RND PL

Facility

$5,375.00

Service Code	HCPCS C1789
Hospital Charge Code	270700558
Hospital Revenue Code	278
Min. Negotiated Rate	$152.65
Max. Negotiated Rate	$2,687.50
Rate for Payer: Aetna Commercial	$2,042.50
Rate for Payer: Aetna Medicare Advantage	$1,612.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,370.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,370.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,075.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,370.62
Rate for Payer: Cigna Commercial	$2,687.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,300.75
Rate for Payer: Qualcare PPO/HMO/WC	$806.25
Rate for Payer: UnitedHealthcare Community & State	$169.85
Rate for Payer: Wellpoint Medicaid Managed Care	$152.65

BREAST IMP 250CC SMOOTH RND PL

Facility

$5,375.00

Service Code	HCPCS C1789
Hospital Charge Code	270700558
Hospital Revenue Code	278
Min. Negotiated Rate	$806.25
Max. Negotiated Rate	$1,300.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,075.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,300.75
Rate for Payer: Qualcare PPO/HMO/WC	$806.25

BREAST IMPLANT 500CC MODERA

Facility

$1,500.00

Hospital Charge Code	270667911
Hospital Revenue Code	278
Min. Negotiated Rate	$42.60
Max. Negotiated Rate	$750.00
Rate for Payer: Aetna Commercial	$570.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$363.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: UnitedHealthcare Community & State	$47.40
Rate for Payer: Wellpoint Medicaid Managed Care	$42.60

BREAST IMPLANT 500CC MODERA

Facility

$1,500.00

Hospital Charge Code	270667911
Hospital Revenue Code	278
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$363.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$363.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

BREAST IMPLANT GEL OVAL 400CC

Facility

$4,975.00

Hospital Charge Code	270667903
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL OVAL 400CC

Facility

$4,975.00

Hospital Charge Code	270667903
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT GEL OVAL 450CC

Facility

$4,975.00

Hospital Charge Code	270667904
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT GEL OVAL 450CC

Facility

$4,975.00

Hospital Charge Code	270667904
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL OVAL 480CC

Facility

$4,975.00

Hospital Charge Code	270667905
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL OVAL 480CC

Facility

$4,975.00

Hospital Charge Code	270667905
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT GEL ROUND 370CC

Facility

$4,975.00

Hospital Charge Code	270667908
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL ROUND 370CC

Facility

$4,975.00

Hospital Charge Code	270667908
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT GEL ROUND 425CC

Facility

$4,975.00

Hospital Charge Code	270667906
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT GEL ROUND 425CC

Facility

$4,975.00

Hospital Charge Code	270667906
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL ROUND 485CC

Facility

$4,975.00

Hospital Charge Code	270667907
Hospital Revenue Code	278
Min. Negotiated Rate	$141.29
Max. Negotiated Rate	$2,487.50
Rate for Payer: Aetna Commercial	$1,890.50
Rate for Payer: Aetna Medicare Advantage	$1,492.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,268.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,268.62
Rate for Payer: Cigna Commercial	$2,487.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25
Rate for Payer: UnitedHealthcare Community & State	$157.21
Rate for Payer: Wellpoint Medicaid Managed Care	$141.29

BREAST IMPLANT GEL ROUND 485CC

Facility

$4,975.00

Hospital Charge Code	270667907
Hospital Revenue Code	278
Min. Negotiated Rate	$746.25
Max. Negotiated Rate	$1,203.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,203.95
Rate for Payer: Qualcare PPO/HMO/WC	$746.25

BREAST IMPLANT HIGH PRO 400CC

Facility

$4,900.00

Hospital Charge Code	270672828
Hospital Revenue Code	278
Min. Negotiated Rate	$139.16
Max. Negotiated Rate	$2,450.00
Rate for Payer: Aetna Commercial	$1,862.00
Rate for Payer: Aetna Medicare Advantage	$1,470.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,249.50
Rate for Payer: Cigna Commercial	$2,450.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00
Rate for Payer: UnitedHealthcare Community & State	$154.84
Rate for Payer: Wellpoint Medicaid Managed Care	$139.16

BREAST IMPLANT HIGH PRO 400CC

Facility

$4,900.00

Hospital Charge Code	270672828
Hospital Revenue Code	278
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$1,185.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00

BREAST IMPLANT HIGH PRO 450CC

Facility

$4,900.00

Hospital Charge Code	270672829
Hospital Revenue Code	278
Min. Negotiated Rate	$139.16
Max. Negotiated Rate	$2,450.00
Rate for Payer: Aetna Commercial	$1,862.00
Rate for Payer: Aetna Medicare Advantage	$1,470.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,249.50
Rate for Payer: Cigna Commercial	$2,450.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00
Rate for Payer: UnitedHealthcare Community & State	$154.84
Rate for Payer: Wellpoint Medicaid Managed Care	$139.16

BREAST IMPLANT HIGH PRO 450CC

Facility

$4,900.00

Hospital Charge Code	270672829
Hospital Revenue Code	278
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$1,185.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00

BREAST IMPLANT HIGH PRO 500CC

Facility

$4,900.00

Hospital Charge Code	270672830
Hospital Revenue Code	278
Min. Negotiated Rate	$139.16
Max. Negotiated Rate	$2,450.00
Rate for Payer: Aetna Commercial	$1,862.00
Rate for Payer: Aetna Medicare Advantage	$1,470.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,249.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,249.50
Rate for Payer: Cigna Commercial	$2,450.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00
Rate for Payer: UnitedHealthcare Community & State	$154.84
Rate for Payer: Wellpoint Medicaid Managed Care	$139.16

BREAST IMPLANT HIGH PRO 500CC

Facility

$4,900.00

Hospital Charge Code	270672830
Hospital Revenue Code	278
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$1,185.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$980.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,185.80
Rate for Payer: Qualcare PPO/HMO/WC	$735.00

Know your out-of-pocket cost for care.

All Charges