Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

GRAFT ILIAC LIMB 14x14x120

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270677362
Hospital Revenue Code	278
Min. Negotiated Rate	$566.23
Max. Negotiated Rate	$11,747.50
Rate for Payer: Aetna Commercial	$8,928.10
Rate for Payer: Aetna Medicare Advantage	$7,048.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,991.23
Rate for Payer: Cigna Commercial	$11,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25
Rate for Payer: UnitedHealthcare Community & State	$566.23
Rate for Payer: Wellpoint Medicaid Managed Care	$622.62

GRAFT ILIAC LIMB 14x14x120

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270677362
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.25
Max. Negotiated Rate	$5,685.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25

GRAFT ILIAC LIMB 14x14x140MM

Facility

$24,995.00

Service Code	HCPCS C1768
Hospital Charge Code	270678255
Hospital Revenue Code	278
Min. Negotiated Rate	$602.38
Max. Negotiated Rate	$12,497.50
Rate for Payer: Aetna Commercial	$9,498.10
Rate for Payer: Aetna Medicare Advantage	$7,498.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,373.73
Rate for Payer: Cigna Commercial	$12,497.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25
Rate for Payer: UnitedHealthcare Community & State	$602.38
Rate for Payer: Wellpoint Medicaid Managed Care	$662.37

GRAFT ILIAC LIMB 14x14x140MM

Facility

$24,995.00

Service Code	HCPCS C1768
Hospital Charge Code	270678255
Hospital Revenue Code	278
Min. Negotiated Rate	$3,749.25
Max. Negotiated Rate	$6,048.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25

GRAFT ILIAC LIMB 14x14x160MM

Facility

$24,995.00

Hospital Charge Code	270678253
Hospital Revenue Code	278
Min. Negotiated Rate	$3,749.25
Max. Negotiated Rate	$6,048.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25

GRAFT ILIAC LIMB 14x14x160MM

Facility

$24,995.00

Hospital Charge Code	270678253
Hospital Revenue Code	278
Min. Negotiated Rate	$602.38
Max. Negotiated Rate	$12,497.50
Rate for Payer: Aetna Commercial	$9,498.10
Rate for Payer: Aetna Medicare Advantage	$7,498.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,373.73
Rate for Payer: Cigna Commercial	$12,497.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25
Rate for Payer: UnitedHealthcare Community & State	$602.38
Rate for Payer: Wellpoint Medicaid Managed Care	$662.37

GRAFT ILIAC LIMB 14x14x80

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270677224
Hospital Revenue Code	278
Min. Negotiated Rate	$566.23
Max. Negotiated Rate	$11,747.50
Rate for Payer: Aetna Commercial	$8,928.10
Rate for Payer: Aetna Medicare Advantage	$7,048.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,991.23
Rate for Payer: Cigna Commercial	$11,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25
Rate for Payer: UnitedHealthcare Community & State	$566.23
Rate for Payer: Wellpoint Medicaid Managed Care	$622.62

GRAFT ILIAC LIMB 14x14x80

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270677224
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.25
Max. Negotiated Rate	$5,685.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25

GRAFT ILIAC LIMB 14x16x120

Facility

$30,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270677355
Hospital Revenue Code	278
Min. Negotiated Rate	$729.02
Max. Negotiated Rate	$15,125.00
Rate for Payer: Aetna Commercial	$11,495.00
Rate for Payer: Aetna Medicare Advantage	$9,075.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,713.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,713.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,713.75
Rate for Payer: Cigna Commercial	$15,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,320.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,655.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,537.50
Rate for Payer: UnitedHealthcare Community & State	$729.02
Rate for Payer: Wellpoint Medicaid Managed Care	$801.62

GRAFT ILIAC LIMB 14x16x120

Facility

$30,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270677355
Hospital Revenue Code	278
Min. Negotiated Rate	$4,537.50
Max. Negotiated Rate	$7,320.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,320.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,655.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,537.50

GRAFT ILIAC LIMB 14x16x160MM

Facility

$24,995.00

Hospital Charge Code	270678254
Hospital Revenue Code	278
Min. Negotiated Rate	$3,749.25
Max. Negotiated Rate	$6,048.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25

GRAFT ILIAC LIMB 14x16x160MM

Facility

$24,995.00

Hospital Charge Code	270678254
Hospital Revenue Code	278
Min. Negotiated Rate	$602.38
Max. Negotiated Rate	$12,497.50
Rate for Payer: Aetna Commercial	$9,498.10
Rate for Payer: Aetna Medicare Advantage	$7,498.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,373.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,999.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,373.73
Rate for Payer: Cigna Commercial	$12,497.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,048.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,498.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,749.25
Rate for Payer: UnitedHealthcare Community & State	$602.38
Rate for Payer: Wellpoint Medicaid Managed Care	$662.37

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270686649O
Hospital Revenue Code	278
Min. Negotiated Rate	$566.23
Max. Negotiated Rate	$11,747.50
Rate for Payer: Aetna Commercial	$8,928.10
Rate for Payer: Aetna Medicare Advantage	$7,048.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,991.23
Rate for Payer: Cigna Commercial	$11,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25
Rate for Payer: UnitedHealthcare Community & State	$566.23
Rate for Payer: Wellpoint Medicaid Managed Care	$622.62

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270686649
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.25
Max. Negotiated Rate	$5,685.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270646689
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.25
Max. Negotiated Rate	$5,685.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270646689
Hospital Revenue Code	278
Min. Negotiated Rate	$566.23
Max. Negotiated Rate	$11,747.50
Rate for Payer: Aetna Commercial	$8,928.10
Rate for Payer: Aetna Medicare Advantage	$7,048.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,991.23
Rate for Payer: Cigna Commercial	$11,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25
Rate for Payer: UnitedHealthcare Community & State	$566.23
Rate for Payer: Wellpoint Medicaid Managed Care	$622.62

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270686649
Hospital Revenue Code	278
Min. Negotiated Rate	$566.23
Max. Negotiated Rate	$11,747.50
Rate for Payer: Aetna Commercial	$8,928.10
Rate for Payer: Aetna Medicare Advantage	$7,048.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,991.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,991.23
Rate for Payer: Cigna Commercial	$11,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25
Rate for Payer: UnitedHealthcare Community & State	$566.23
Rate for Payer: Wellpoint Medicaid Managed Care	$622.62

GRAFT ILIAC LIMB 14X18X140mm

Facility

$23,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270686649O
Hospital Revenue Code	278
Min. Negotiated Rate	$3,524.25
Max. Negotiated Rate	$5,685.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,699.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,685.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,168.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,524.25

GRAFT ILIAC LIMB 22X160MM

Facility

$27,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270687404
Hospital Revenue Code	278
Min. Negotiated Rate	$662.63
Max. Negotiated Rate	$13,747.50
Rate for Payer: Aetna Commercial	$10,448.10
Rate for Payer: Aetna Medicare Advantage	$8,248.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,011.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,011.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,499.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,011.23
Rate for Payer: Cigna Commercial	$13,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,653.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,048.90
Rate for Payer: Qualcare PPO/HMO/WC	$4,124.25
Rate for Payer: UnitedHealthcare Community & State	$662.63
Rate for Payer: Wellpoint Medicaid Managed Care	$728.62

GRAFT ILIAC LIMB 22X160MM

Facility

$27,495.00

Service Code	HCPCS C1768
Hospital Charge Code	270687404
Hospital Revenue Code	278
Min. Negotiated Rate	$4,124.25
Max. Negotiated Rate	$6,653.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,499.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,653.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,048.90
Rate for Payer: Qualcare PPO/HMO/WC	$4,124.25

GRAFT ILLIAC EXTENSION

Facility

$14,225.00

Hospital Charge Code	270646001
Hospital Revenue Code	278
Min. Negotiated Rate	$342.82
Max. Negotiated Rate	$7,112.50
Rate for Payer: Aetna Commercial	$5,405.50
Rate for Payer: Aetna Medicare Advantage	$4,267.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,627.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,627.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,845.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,627.38
Rate for Payer: Cigna Commercial	$7,112.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,442.45
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,129.50
Rate for Payer: Qualcare PPO/HMO/WC	$2,133.75
Rate for Payer: UnitedHealthcare Community & State	$342.82
Rate for Payer: Wellpoint Medicaid Managed Care	$376.96

GRAFT ILLIAC EXTENSION

Facility

$14,225.00

Hospital Charge Code	270646001
Hospital Revenue Code	278
Min. Negotiated Rate	$2,133.75
Max. Negotiated Rate	$3,442.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,845.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,442.45
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,129.50
Rate for Payer: Qualcare PPO/HMO/WC	$2,133.75

GRAFT IPSILATERL LIMB TFLE1254

Facility

$13,392.00

Hospital Charge Code	270633905
Hospital Revenue Code	278
Min. Negotiated Rate	$2,008.80
Max. Negotiated Rate	$3,240.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,678.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,240.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,946.24
Rate for Payer: Qualcare PPO/HMO/WC	$2,008.80

GRAFT IPSILATERL LIMB TFLE1254

Facility

$13,392.00

Hospital Charge Code	270633905
Hospital Revenue Code	278
Min. Negotiated Rate	$322.75
Max. Negotiated Rate	$6,696.00
Rate for Payer: Aetna Commercial	$5,088.96
Rate for Payer: Aetna Medicare Advantage	$4,017.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,414.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,414.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,678.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,414.96
Rate for Payer: Cigna Commercial	$6,696.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,240.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,946.24
Rate for Payer: Qualcare PPO/HMO/WC	$2,008.80
Rate for Payer: UnitedHealthcare Community & State	$322.75
Rate for Payer: Wellpoint Medicaid Managed Care	$354.89

GRAFT JACKET 4x4 86TM4X4

Facility

$6,423.25

Hospital Charge Code	270634533
Hospital Revenue Code	272
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$3,211.62
Rate for Payer: Aetna Commercial	$2,440.84
Rate for Payer: Aetna Medicare Advantage	$1,926.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,637.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,637.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,637.93
Rate for Payer: Cigna Commercial	$3,211.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,926.97
Rate for Payer: Oxford Commercial	$1,284.65
Rate for Payer: Qualcare PPO/HMO/WC	$963.49
Rate for Payer: UnitedHealthcare Commercial	$1,284.65
Rate for Payer: UnitedHealthcare Community & State	$154.80
Rate for Payer: Wellpoint Medicaid Managed Care	$170.22

Know your out-of-pocket cost for care.

All Charges