Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PSN REV TM TIB CENTRAL CONE SZ

Facility

$38,280.00

Service Code	HCPCS C1776
Hospital Charge Code	270700106
Hospital Revenue Code	278
Min. Negotiated Rate	$5,742.00
Max. Negotiated Rate	$9,263.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,656.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,263.76
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,421.60
Rate for Payer: Qualcare PPO/HMO/WC	$5,742.00

PSN REV TM TIB CENTRAL CONE SZ

Facility

$38,280.00

Service Code	HCPCS C1776
Hospital Charge Code	270700106
Hospital Revenue Code	278
Min. Negotiated Rate	$922.55
Max. Negotiated Rate	$19,140.00
Rate for Payer: Aetna Commercial	$14,546.40
Rate for Payer: Aetna Medicare Advantage	$11,484.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9,761.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9,761.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,656.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9,761.40
Rate for Payer: Cigna Commercial	$19,140.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,263.76
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,421.60
Rate for Payer: Qualcare PPO/HMO/WC	$5,742.00
Rate for Payer: UnitedHealthcare Community & State	$922.55
Rate for Payer: Wellpoint Medicaid Managed Care	$1,014.42

PSN SM CR VE ASF 12MM 8-11

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270699476
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

PSN SM CR VE ASF 12MM 8-11

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270699476
Hospital Revenue Code	278
Min. Negotiated Rate	$144.60
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$144.60
Rate for Payer: Wellpoint Medicaid Managed Care	$159.00

PSNSTEMREV3MMOFFSETEXT11X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695263
Hospital Revenue Code	278
Min. Negotiated Rate	$2,827.50
Max. Negotiated Rate	$4,561.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50

PSNSTEMREV3MMOFFSETEXT11X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695263
Hospital Revenue Code	278
Min. Negotiated Rate	$454.29
Max. Negotiated Rate	$9,425.00
Rate for Payer: Aetna Commercial	$7,163.00
Rate for Payer: Aetna Medicare Advantage	$5,655.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,806.75
Rate for Payer: Cigna Commercial	$9,425.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50
Rate for Payer: UnitedHealthcare Community & State	$454.29
Rate for Payer: Wellpoint Medicaid Managed Care	$499.52

PSNSTEMREV3MMOFFSETEXT12X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695261
Hospital Revenue Code	278
Min. Negotiated Rate	$2,827.50
Max. Negotiated Rate	$4,561.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50

PSNSTEMREV3MMOFFSETEXT12X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695261
Hospital Revenue Code	278
Min. Negotiated Rate	$454.29
Max. Negotiated Rate	$9,425.00
Rate for Payer: Aetna Commercial	$7,163.00
Rate for Payer: Aetna Medicare Advantage	$5,655.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,806.75
Rate for Payer: Cigna Commercial	$9,425.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50
Rate for Payer: UnitedHealthcare Community & State	$454.29
Rate for Payer: Wellpoint Medicaid Managed Care	$499.52

PSNSTEMREV3MMOFFSETEXT17X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695146
Hospital Revenue Code	278
Min. Negotiated Rate	$2,827.50
Max. Negotiated Rate	$4,561.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50

PSNSTEMREV3MMOFFSETEXT17X135MM

Facility

$18,850.00

Service Code	HCPCS C1776
Hospital Charge Code	270695146
Hospital Revenue Code	278
Min. Negotiated Rate	$454.29
Max. Negotiated Rate	$9,425.00
Rate for Payer: Aetna Commercial	$7,163.00
Rate for Payer: Aetna Medicare Advantage	$5,655.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,806.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,770.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,806.75
Rate for Payer: Cigna Commercial	$9,425.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,561.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,147.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,827.50
Rate for Payer: UnitedHealthcare Community & State	$454.29
Rate for Payer: Wellpoint Medicaid Managed Care	$499.52

PSN TBI ASF CPS 16MM VER3

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694092
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

PSN TBI ASF CPS 16MM VER3

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694092
Hospital Revenue Code	278
Min. Negotiated Rate	$144.60
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$144.60
Rate for Payer: Wellpoint Medicaid Managed Care	$159.00

PSN TBI MC VE ASF R 12MM

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270699204
Hospital Revenue Code	278
Min. Negotiated Rate	$148.94
Max. Negotiated Rate	$3,090.00
Rate for Payer: Aetna Commercial	$2,348.40
Rate for Payer: Aetna Medicare Advantage	$1,854.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,575.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,575.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,236.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,575.90
Rate for Payer: Cigna Commercial	$3,090.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,495.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,359.60
Rate for Payer: Qualcare PPO/HMO/WC	$927.00
Rate for Payer: UnitedHealthcare Community & State	$148.94
Rate for Payer: Wellpoint Medicaid Managed Care	$163.77

PSN TBI MC VE ASF R 12MM

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270699204
Hospital Revenue Code	278
Min. Negotiated Rate	$927.00
Max. Negotiated Rate	$1,495.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,236.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,495.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,359.60
Rate for Payer: Qualcare PPO/HMO/WC	$927.00

PSN THIB STM 5 DEG SZ GL

Facility

$4,120.00

Service Code	HCPCS C1776
Hospital Charge Code	270693461
Hospital Revenue Code	278
Min. Negotiated Rate	$618.00
Max. Negotiated Rate	$997.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$824.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$997.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$906.40
Rate for Payer: Qualcare PPO/HMO/WC	$618.00

PSN THIB STM 5 DEG SZ GL

Facility

$4,120.00

Service Code	HCPCS C1776
Hospital Charge Code	270693461
Hospital Revenue Code	278
Min. Negotiated Rate	$99.29
Max. Negotiated Rate	$2,060.00
Rate for Payer: Aetna Commercial	$1,565.60
Rate for Payer: Aetna Medicare Advantage	$1,236.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,050.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,050.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$824.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,050.60
Rate for Payer: Cigna Commercial	$2,060.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$997.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$906.40
Rate for Payer: Qualcare PPO/HMO/WC	$618.00
Rate for Payer: UnitedHealthcare Community & State	$99.29
Rate for Payer: Wellpoint Medicaid Managed Care	$109.18

PSN TIBIA PRO 2 PEG SZ F R

Facility

$11,830.00

Service Code	HCPCS C1776
Hospital Charge Code	270695190
Hospital Revenue Code	278
Min. Negotiated Rate	$285.10
Max. Negotiated Rate	$5,915.00
Rate for Payer: Aetna Commercial	$4,495.40
Rate for Payer: Aetna Medicare Advantage	$3,549.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,016.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,016.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,366.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,016.65
Rate for Payer: Cigna Commercial	$5,915.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,862.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,602.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,774.50
Rate for Payer: UnitedHealthcare Community & State	$285.10
Rate for Payer: Wellpoint Medicaid Managed Care	$313.50

PSN TIBIA PRO 2 PEG SZ F R

Facility

$11,830.00

Service Code	HCPCS C1776
Hospital Charge Code	270695190
Hospital Revenue Code	278
Min. Negotiated Rate	$1,774.50
Max. Negotiated Rate	$2,862.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,366.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,862.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,602.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,774.50

PSN TIB INS 11MM

Facility

$3,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270696786
Hospital Revenue Code	278
Min. Negotiated Rate	$90.38
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$1,425.00
Rate for Payer: Aetna Medicare Advantage	$1,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$956.25
Rate for Payer: Cigna Commercial	$1,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$907.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$825.00
Rate for Payer: Qualcare PPO/HMO/WC	$562.50
Rate for Payer: UnitedHealthcare Community & State	$90.38
Rate for Payer: Wellpoint Medicaid Managed Care	$99.38

PSN TIB INS 11MM

Facility

$3,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270696786
Hospital Revenue Code	278
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$907.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$907.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$825.00
Rate for Payer: Qualcare PPO/HMO/WC	$562.50

PSN TIB INS ASF PS 10MM PLY L

Facility

$3,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270695658
Hospital Revenue Code	278
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$907.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$907.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$825.00
Rate for Payer: Qualcare PPO/HMO/WC	$562.50

PSN TIB INS ASF PS 10MM PLY L

Facility

$3,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270695658
Hospital Revenue Code	278
Min. Negotiated Rate	$90.38
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$1,425.00
Rate for Payer: Aetna Medicare Advantage	$1,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$956.25
Rate for Payer: Cigna Commercial	$1,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$907.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$825.00
Rate for Payer: Qualcare PPO/HMO/WC	$562.50
Rate for Payer: UnitedHealthcare Community & State	$90.38
Rate for Payer: Wellpoint Medicaid Managed Care	$99.38

PSN TIB INS ASF VEL CVD 20MM

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270693852
Hospital Revenue Code	278
Min. Negotiated Rate	$144.60
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$144.60
Rate for Payer: Wellpoint Medicaid Managed Care	$159.00

PSN TIB INS ASF VEL CVD 20MM

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270693852
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

PSN TIB POR 0 DEG SPK KEL C RT

Facility

$26,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270703871
Hospital Revenue Code	278
Min. Negotiated Rate	$632.62
Max. Negotiated Rate	$13,125.00
Rate for Payer: Aetna Commercial	$9,975.00
Rate for Payer: Aetna Medicare Advantage	$7,875.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,693.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,693.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,693.75
Rate for Payer: Cigna Commercial	$13,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,352.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,775.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,937.50
Rate for Payer: UnitedHealthcare Community & State	$632.62
Rate for Payer: Wellpoint Medicaid Managed Care	$695.62

Know your out-of-pocket cost for care.

All Charges