Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CUP BIPOL 28/57MM 50005728***

Facility

$3,250.00

Hospital Charge Code	1604263
Hospital Revenue Code	274
Min. Negotiated Rate	$487.50
Max. Negotiated Rate	$786.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$650.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$786.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$715.00
Rate for Payer: Qualcare PPO/HMO/WC	$487.50

CUP BIPOL 28/57MM 50005728***

Facility

$3,250.00

Hospital Charge Code	1604263
Hospital Revenue Code	274
Min. Negotiated Rate	$78.33
Max. Negotiated Rate	$1,625.00
Rate for Payer: Aetna Commercial	$1,235.00
Rate for Payer: Aetna Medicare Advantage	$975.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$828.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$828.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$828.75
Rate for Payer: Cigna Commercial	$1,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$786.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$715.00
Rate for Payer: Qualcare PPO/HMO/WC	$487.50
Rate for Payer: UnitedHealthcare Community & State	$78.33
Rate for Payer: Wellpoint Medicaid Managed Care	$86.12

CUP BI-POLAR 28x43mm

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270605406
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

CUP BI-POLAR 28x43mm

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270605406
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

CUP BI-POLAR 28x44mm

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270610621
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$847.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$847.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$770.00
Rate for Payer: Qualcare PPO/HMO/WC	$525.00

CUP BI-POLAR 28x44mm

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270610621
Hospital Revenue Code	278
Min. Negotiated Rate	$84.35
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$1,330.00
Rate for Payer: Aetna Medicare Advantage	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$892.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$892.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$892.50
Rate for Payer: Cigna Commercial	$1,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$847.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$770.00
Rate for Payer: Qualcare PPO/HMO/WC	$525.00
Rate for Payer: UnitedHealthcare Community & State	$84.35
Rate for Payer: Wellpoint Medicaid Managed Care	$92.75

CUP BI-POLAR 28x47mm

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270608159
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

CUP BI-POLAR 28x47mm

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270608159
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

CUP BIPOLAR 28X50 11-165224

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270606324
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

CUP BIPOLAR 28X50 11-165224

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270606324
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

CUP BIPOLAR 28x52 LOC 11165228

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270616770
Hospital Revenue Code	278
Min. Negotiated Rate	$797.25
Max. Negotiated Rate	$1,286.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25

CUP BIPOLAR 28x52 LOC 11165228

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270616770
Hospital Revenue Code	278
Min. Negotiated Rate	$128.09
Max. Negotiated Rate	$2,657.50
Rate for Payer: Aetna Commercial	$2,019.70
Rate for Payer: Aetna Medicare Advantage	$1,594.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,355.33
Rate for Payer: Cigna Commercial	$2,657.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25
Rate for Payer: UnitedHealthcare Community & State	$128.09
Rate for Payer: Wellpoint Medicaid Managed Care	$140.85

CUP BI-POLAR RINGLOC 28x54MM

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270611025
Hospital Revenue Code	278
Min. Negotiated Rate	$797.25
Max. Negotiated Rate	$1,286.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25

CUP BI-POLAR RINGLOC 28x54MM

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270611025
Hospital Revenue Code	278
Min. Negotiated Rate	$128.09
Max. Negotiated Rate	$2,657.50
Rate for Payer: Aetna Commercial	$2,019.70
Rate for Payer: Aetna Medicare Advantage	$1,594.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,355.33
Rate for Payer: Cigna Commercial	$2,657.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25
Rate for Payer: UnitedHealthcare Community & State	$128.09
Rate for Payer: Wellpoint Medicaid Managed Care	$140.85

CUP BMT BIPOL 11-165214

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270608730
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

CUP BMT BIPOL 11-165214

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270608730
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

CUP BMT BIPOL 11-165234

Facility

$4,952.85

Hospital Charge Code	270605338
Hospital Revenue Code	278
Min. Negotiated Rate	$742.93
Max. Negotiated Rate	$1,198.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$990.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,198.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,089.63
Rate for Payer: Qualcare PPO/HMO/WC	$742.93

CUP BMT BIPOL 11-165234

Facility

$4,952.85

Hospital Charge Code	270605338
Hospital Revenue Code	278
Min. Negotiated Rate	$119.36
Max. Negotiated Rate	$2,476.43
Rate for Payer: Aetna Commercial	$1,882.08
Rate for Payer: Aetna Medicare Advantage	$1,485.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,262.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,262.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$990.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,262.98
Rate for Payer: Cigna Commercial	$2,476.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,198.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,089.63
Rate for Payer: Qualcare PPO/HMO/WC	$742.93
Rate for Payer: UnitedHealthcare Community & State	$119.36
Rate for Payer: Wellpoint Medicaid Managed Care	$131.25

CUP BMT BIPOL 41MM 11-165206

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270608494
Hospital Revenue Code	278
Min. Negotiated Rate	$797.25
Max. Negotiated Rate	$1,286.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25

CUP BMT BIPOL 41MM 11-165206

Facility

$5,315.00

Service Code	HCPCS C1776
Hospital Charge Code	270608494
Hospital Revenue Code	278
Min. Negotiated Rate	$128.09
Max. Negotiated Rate	$2,657.50
Rate for Payer: Aetna Commercial	$2,019.70
Rate for Payer: Aetna Medicare Advantage	$1,594.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,355.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,063.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,355.33
Rate for Payer: Cigna Commercial	$2,657.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.23
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,169.30
Rate for Payer: Qualcare PPO/HMO/WC	$797.25
Rate for Payer: UnitedHealthcare Community & State	$128.09
Rate for Payer: Wellpoint Medicaid Managed Care	$140.85

CUP BMT BIPOL 42MM 11-165208

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270608162
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$847.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$847.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$770.00
Rate for Payer: Qualcare PPO/HMO/WC	$525.00

CUP BMT BIPOL 42MM 11-165208

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270608162
Hospital Revenue Code	278
Min. Negotiated Rate	$84.35
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$1,330.00
Rate for Payer: Aetna Medicare Advantage	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$892.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$892.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$892.50
Rate for Payer: Cigna Commercial	$1,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$847.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$770.00
Rate for Payer: Qualcare PPO/HMO/WC	$525.00
Rate for Payer: UnitedHealthcare Community & State	$84.35
Rate for Payer: Wellpoint Medicaid Managed Care	$92.75

CUP BMT BIPOL 46MM 11-165216

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270607277
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

CUP BMT BIPOL 46MM 11-165216

Facility

$5,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270607277
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

CUP BMT BIPOL 48MM 11-165220

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270617430
Hospital Revenue Code	278
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$847.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$847.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$770.00
Rate for Payer: Qualcare PPO/HMO/WC	$525.00

Know your out-of-pocket cost for care.

All Charges