Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

DOLUTEGRAVIR 50MG (TIVICAY)

Facility

$353.22

Service Code	NDC 49702022813
Hospital Charge Code	606380001
Hospital Revenue Code	250
Min. Negotiated Rate	$52.98
Max. Negotiated Rate	$52.98
Rate for Payer: Qualcare PPO/HMO/WC	$52.98

DOMEBORO OTIC/60ML

Facility

$6.70

Service Code	NDC 16500002324
Hospital Charge Code	60632885
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$3.35
Rate for Payer: Aetna Commercial	$2.55
Rate for Payer: Aetna Medicare Advantage	$2.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.71
Rate for Payer: Cigna Commercial	$3.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.74
Rate for Payer: Oxford Commercial	$1.34
Rate for Payer: Qualcare PPO/HMO/WC	$1.00
Rate for Payer: UnitedHealthcare Commercial	$1.34
Rate for Payer: UnitedHealthcare Community & State	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

DOMEBORO OTIC/60ML

Facility

$6.70

Service Code	NDC 16500002324
Hospital Charge Code	60632885
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.00

DOME COMPONENT ALTA

Facility

$539.00

Hospital Charge Code	270335172
Hospital Revenue Code	278
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$130.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$107.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$130.44
Rate for Payer: Qualcare PPO/HMO/WC	$80.85

DOME COMPONENT ALTA

Facility

$539.00

Hospital Charge Code	270335172
Hospital Revenue Code	278
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$269.50
Rate for Payer: Aetna Commercial	$204.82
Rate for Payer: Aetna Medicare Advantage	$161.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$137.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$137.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$107.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$137.44
Rate for Payer: Cigna Commercial	$269.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$130.44
Rate for Payer: Qualcare PPO/HMO/WC	$80.85
Rate for Payer: UnitedHealthcare Community & State	$17.03
Rate for Payer: Wellpoint Medicaid Managed Care	$15.31

DOMED PATELLA SZ 1

Facility

$1,500.00

Hospital Charge Code	270672653
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

DOMED PATELLA SZ 1

Facility

$1,500.00

Hospital Charge Code	270672653
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

DOMED PATELLA SZ 2

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672654
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

DOMED PATELLA SZ 2

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672654
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

DOMED PATELLA SZ 3

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672655
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

DOMED PATELLA SZ 3

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672655
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

DOMED PATELLA SZ 4

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672656
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

DOMED PATELLA SZ 4

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270672656
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

DOME EXTENSION

Facility

$500.00

Hospital Charge Code	270672661
Hospital Revenue Code	278
Min. Negotiated Rate	$14.20
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare Advantage	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.50
Rate for Payer: Cigna Commercial	$250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$121.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.00
Rate for Payer: UnitedHealthcare Community & State	$15.80
Rate for Payer: Wellpoint Medicaid Managed Care	$14.20

DOME EXTENSION

Facility

$500.00

Hospital Charge Code	270672661
Hospital Revenue Code	278
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$121.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$121.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.00

DOME INFINITY TALAR FLT CUTSZ2

Facility

$63,270.00

Service Code	HCPCS C1776
Hospital Charge Code	270698113
Hospital Revenue Code	278
Min. Negotiated Rate	$9,490.50
Max. Negotiated Rate	$15,311.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,654.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,311.34
Rate for Payer: Qualcare PPO/HMO/WC	$9,490.50

DOME INFINITY TALAR FLT CUTSZ2

Facility

$63,270.00

Service Code	HCPCS C1776
Hospital Charge Code	270698113
Hospital Revenue Code	278
Min. Negotiated Rate	$1,796.87
Max. Negotiated Rate	$31,635.00
Rate for Payer: Aetna Commercial	$24,042.60
Rate for Payer: Aetna Medicare Advantage	$18,981.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,133.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,133.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,654.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,133.85
Rate for Payer: Cigna Commercial	$31,635.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,311.34
Rate for Payer: Qualcare PPO/HMO/WC	$9,490.50
Rate for Payer: UnitedHealthcare Community & State	$1,999.33
Rate for Payer: Wellpoint Medicaid Managed Care	$1,796.87

DOME SULCUS TALAR SZ 2

Facility

$18,895.00

Service Code	HCPCS C1776
Hospital Charge Code	270676975
Hospital Revenue Code	278
Min. Negotiated Rate	$2,834.25
Max. Negotiated Rate	$4,572.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,779.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,572.59
Rate for Payer: Qualcare PPO/HMO/WC	$2,834.25

DOME SULCUS TALAR SZ 2

Facility

$18,895.00

Service Code	HCPCS C1776
Hospital Charge Code	270676975
Hospital Revenue Code	278
Min. Negotiated Rate	$536.62
Max. Negotiated Rate	$9,447.50
Rate for Payer: Aetna Commercial	$7,180.10
Rate for Payer: Aetna Medicare Advantage	$5,668.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,818.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,818.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,779.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,818.23
Rate for Payer: Cigna Commercial	$9,447.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,572.59
Rate for Payer: Qualcare PPO/HMO/WC	$2,834.25
Rate for Payer: UnitedHealthcare Community & State	$597.08
Rate for Payer: Wellpoint Medicaid Managed Care	$536.62

DOME TALAR INFINITY SZ4

Facility

$24,145.00

Service Code	HCPCS C1776
Hospital Charge Code	270678154
Hospital Revenue Code	278
Min. Negotiated Rate	$685.72
Max. Negotiated Rate	$12,072.50
Rate for Payer: Aetna Commercial	$9,175.10
Rate for Payer: Aetna Medicare Advantage	$7,243.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,156.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,156.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,829.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,156.98
Rate for Payer: Cigna Commercial	$12,072.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,843.09
Rate for Payer: Qualcare PPO/HMO/WC	$3,621.75
Rate for Payer: UnitedHealthcare Community & State	$762.98
Rate for Payer: Wellpoint Medicaid Managed Care	$685.72

DOME TALAR INFINITY SZ4

Facility

$24,145.00

Service Code	HCPCS C1776
Hospital Charge Code	270678154
Hospital Revenue Code	278
Min. Negotiated Rate	$3,621.75
Max. Negotiated Rate	$5,843.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,829.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,843.09
Rate for Payer: Qualcare PPO/HMO/WC	$3,621.75

DONEPEZIL 10 MG TAB

Facility

$57.96

Service Code	NDC 59746033090
Hospital Charge Code	60628609
Hospital Revenue Code	250
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$8.69
Rate for Payer: Qualcare PPO/HMO/WC	$8.69

DONEPEZIL 10 MG TAB

Facility

$57.96

Service Code	NDC 59746033090
Hospital Charge Code	60628609
Hospital Revenue Code	250
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$28.98
Rate for Payer: Aetna Commercial	$22.02
Rate for Payer: Aetna Medicare Advantage	$17.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.78
Rate for Payer: Cigna Commercial	$28.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.07
Rate for Payer: Oxford Commercial	$11.59
Rate for Payer: Qualcare PPO/HMO/WC	$8.69
Rate for Payer: UnitedHealthcare Commercial	$11.59
Rate for Payer: UnitedHealthcare Community & State	$1.83
Rate for Payer: Wellpoint Medicaid Managed Care	$1.65

DONEPEZIL 5 MG TAB

Facility

$52.19

Service Code	NDC 13668010290
Hospital Charge Code	60628610
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$26.09
Rate for Payer: Aetna Commercial	$19.83
Rate for Payer: Aetna Medicare Advantage	$15.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.31
Rate for Payer: Cigna Commercial	$26.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.57
Rate for Payer: Oxford Commercial	$10.44
Rate for Payer: Qualcare PPO/HMO/WC	$7.83
Rate for Payer: UnitedHealthcare Commercial	$10.44
Rate for Payer: UnitedHealthcare Community & State	$1.65
Rate for Payer: Wellpoint Medicaid Managed Care	$1.48

DONEPEZIL 5 MG TAB

Facility

$52.19

Service Code	NDC 13668010290
Hospital Charge Code	60628610
Hospital Revenue Code	250
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$7.83
Rate for Payer: Qualcare PPO/HMO/WC	$7.83

Know your out-of-pocket cost for care.

All Charges