Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MODULE OXYGEN DELIVERY PURPLE

Facility

$60.00

Hospital Charge Code	270613275
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00

MODULE OXYGEN DELIVERY WHITE

Facility

$120.00

Hospital Charge Code	270613277
Hospital Revenue Code	271
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare Advantage	$36.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.60
Rate for Payer: Cigna Commercial	$60.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.00
Rate for Payer: Oxford Commercial	$24.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.00
Rate for Payer: UnitedHealthcare Commercial	$24.00
Rate for Payer: UnitedHealthcare Community & State	$2.89
Rate for Payer: Wellpoint Medicaid Managed Care	$3.18

MODULE OXYGEN DELIVERY WHITE

Facility

$120.00

Hospital Charge Code	270613277
Hospital Revenue Code	271
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.00

MODULE OXYGEN DELIVERY YELLOW

Facility

$60.00

Hospital Charge Code	270613276
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00

MODULE OXYGEN DELIVERY YELLOW

Facility

$60.00

Hospital Charge Code	270613276
Hospital Revenue Code	270
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare Advantage	$18.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.30
Rate for Payer: Cigna Commercial	$30.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.00
Rate for Payer: Oxford Commercial	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00
Rate for Payer: UnitedHealthcare Commercial	$12.00
Rate for Payer: UnitedHealthcare Community & State	$1.45
Rate for Payer: Wellpoint Medicaid Managed Care	$1.59

MODULE PEDS EMERG COMPLETE

Facility

$166.92

Hospital Charge Code	270611450
Hospital Revenue Code	271
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$83.46
Rate for Payer: Aetna Commercial	$63.43
Rate for Payer: Aetna Medicare Advantage	$50.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$42.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$42.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$42.56
Rate for Payer: Cigna Commercial	$83.46
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.08
Rate for Payer: Oxford Commercial	$33.38
Rate for Payer: Qualcare PPO/HMO/WC	$25.04
Rate for Payer: UnitedHealthcare Commercial	$33.38
Rate for Payer: UnitedHealthcare Community & State	$4.02
Rate for Payer: Wellpoint Medicaid Managed Care	$4.42

MODULE PEDS EMERG COMPLETE

Facility

$166.92

Hospital Charge Code	270611450
Hospital Revenue Code	271
Min. Negotiated Rate	$25.04
Max. Negotiated Rate	$25.04
Rate for Payer: Qualcare PPO/HMO/WC	$25.04

MODULE YELLOW COMBO PACK

Facility

$197.50

Hospital Charge Code	270645753
Hospital Revenue Code	271
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$98.75
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare Advantage	$59.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$50.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$50.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$50.36
Rate for Payer: Cigna Commercial	$98.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$59.25
Rate for Payer: Oxford Commercial	$39.50
Rate for Payer: Qualcare PPO/HMO/WC	$29.62
Rate for Payer: UnitedHealthcare Commercial	$39.50
Rate for Payer: UnitedHealthcare Community & State	$4.76
Rate for Payer: Wellpoint Medicaid Managed Care	$5.23

MODULE YELLOW COMBO PACK

Facility

$197.50

Hospital Charge Code	270645753
Hospital Revenue Code	271
Min. Negotiated Rate	$29.62
Max. Negotiated Rate	$29.62
Rate for Payer: Qualcare PPO/HMO/WC	$29.62

MODULUS TLIF-O 10X10X25MM 4D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698827
Hospital Revenue Code	278
Min. Negotiated Rate	$783.25
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$12,350.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00
Rate for Payer: UnitedHealthcare Community & State	$783.25
Rate for Payer: Wellpoint Medicaid Managed Care	$861.25

MODULUS TLIF-O 10X10X25MM 4D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698827
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

MODULUS TLIF-O 10X10X25MM 8D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270697648
Hospital Revenue Code	278
Min. Negotiated Rate	$783.25
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$12,350.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00
Rate for Payer: UnitedHealthcare Community & State	$783.25
Rate for Payer: Wellpoint Medicaid Managed Care	$861.25

MODULUS TLIF-O 10X10X25MM 8D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270697648
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

MODULUS TLIF-O 12X10X30MM 8D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270697646
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

MODULUS TLIF-O 12X10X30MM 8D

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270697646
Hospital Revenue Code	278
Min. Negotiated Rate	$783.25
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$12,350.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00
Rate for Payer: UnitedHealthcare Community & State	$783.25
Rate for Payer: Wellpoint Medicaid Managed Care	$861.25

MODULUS TLIF-O 7X10X25MM

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270693363
Hospital Revenue Code	278
Min. Negotiated Rate	$783.25
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$12,350.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00
Rate for Payer: UnitedHealthcare Community & State	$783.25
Rate for Payer: Wellpoint Medicaid Managed Care	$861.25

MODULUS TLIF-O 7X10X25MM

Facility

$32,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270693363
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,150.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

MODURETIC/TAB

Facility

$3.00

Hospital Charge Code	60633442
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
Rate for Payer: Oxford Commercial	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$0.60
Rate for Payer: UnitedHealthcare Community & State	$0.07
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

MODURETIC/TAB

Facility

$3.00

Hospital Charge Code	60633442
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

MOLDABLE BONE MATRIX/2.5CC ALL

Facility

$4,400.00

Service Code	HCPCS C1763
Hospital Charge Code	270704126
Hospital Revenue Code	278
Min. Negotiated Rate	$660.00
Max. Negotiated Rate	$1,064.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$880.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,064.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$968.00
Rate for Payer: Qualcare PPO/HMO/WC	$660.00

MOLDABLE BONE MATRIX/2.5CC ALL

Facility

$4,400.00

Service Code	HCPCS C1763
Hospital Charge Code	270704126
Hospital Revenue Code	278
Min. Negotiated Rate	$106.04
Max. Negotiated Rate	$2,200.00
Rate for Payer: Aetna Commercial	$1,672.00
Rate for Payer: Aetna Medicare Advantage	$1,320.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,122.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,122.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$880.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,122.00
Rate for Payer: Cigna Commercial	$2,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,064.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$968.00
Rate for Payer: Qualcare PPO/HMO/WC	$660.00
Rate for Payer: UnitedHealthcare Community & State	$106.04
Rate for Payer: Wellpoint Medicaid Managed Care	$116.60

MOLD FEM CEMENT SPACER 60MM

Facility

$13,670.00

Hospital Charge Code	270677428
Hospital Revenue Code	272
Min. Negotiated Rate	$2,050.50
Max. Negotiated Rate	$2,050.50
Rate for Payer: Qualcare PPO/HMO/WC	$2,050.50

MOLD FEM CEMENT SPACER 60MM

Facility

$13,670.00

Hospital Charge Code	270677428
Hospital Revenue Code	272
Min. Negotiated Rate	$329.45
Max. Negotiated Rate	$6,835.00
Rate for Payer: Aetna Commercial	$5,194.60
Rate for Payer: Aetna Medicare Advantage	$4,101.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,485.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,485.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,485.85
Rate for Payer: Cigna Commercial	$6,835.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,101.00
Rate for Payer: Oxford Commercial	$2,734.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,050.50
Rate for Payer: UnitedHealthcare Commercial	$2,734.00
Rate for Payer: UnitedHealthcare Community & State	$329.45
Rate for Payer: Wellpoint Medicaid Managed Care	$362.25

MOLD ID

Facility

$70.95

Service Code	HCPCS 87107
Hospital Charge Code	39900267
Hospital Revenue Code	309
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$28.07
Rate for Payer: Aetna Medicare Advantage	$33.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$37.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$37.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$37.25
Rate for Payer: Cigna Commercial	$35.48
Rate for Payer: Cigna Medicare Advantage	$10.32
Rate for Payer: Clover Medicare Advantage	$9.80
Rate for Payer: EmblemHealth Commercial	$30.96
Rate for Payer: Humana Medicare Advantage	$10.63
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.29
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$10.64
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$8.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.32
Rate for Payer: Wellcare Medicare Advantage	$10.32
Rate for Payer: Wellpoint Medicaid Managed Care	$1.88

MOLD ID

Facility

$70.95

Service Code	HCPCS 87107
Hospital Charge Code	39900267
Hospital Revenue Code	309
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$10.64
Rate for Payer: Qualcare PPO/HMO/WC	$10.64

Know your out-of-pocket cost for care.

All Charges