Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SPHERE INSERT FLEX LEFT 17MM S

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270687763
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

SPHERE INSERT FLEX RIGHT 12 MM

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270688449
Hospital Revenue Code	278
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$120.50
Rate for Payer: Wellpoint Medicaid Managed Care	$132.50

SPHERE INSERT FLEX RIGHT 12 MM

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270688449
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

SPHERE INSERT FLEX RT 11 MM S3

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270687939
Hospital Revenue Code	278
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$120.50
Rate for Payer: Wellpoint Medicaid Managed Care	$132.50

SPHERE INSERT FLEX RT 11 MM S3

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270687939
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

SPHERE INSERT FLEX RT 20 MM S1

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683772
Hospital Revenue Code	278
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$120.50
Rate for Payer: Wellpoint Medicaid Managed Care	$132.50

SPHERE INSERT FLEX RT 20 MM S1

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683772
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

SPHERE INSERT RIGHT 17 MM S4

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683897
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

SPHERE INSERT RIGHT 17 MM S4

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683897
Hospital Revenue Code	278
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$120.50
Rate for Payer: Wellpoint Medicaid Managed Care	$132.50

SPHERE INSERT SET

Facility

$500.00

Service Code	HCPCS C1776
Hospital Charge Code	270688398
Hospital Revenue Code	278
Min. Negotiated Rate	$12.05
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: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$110.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.00
Rate for Payer: UnitedHealthcare Community & State	$12.05
Rate for Payer: Wellpoint Medicaid Managed Care	$13.25

SPHERE INSERT SET

Facility

$500.00

Service Code	HCPCS C1776
Hospital Charge Code	270688398
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: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$110.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.00

SPHERES OPTISPHERE OSL26B

Facility

$5,925.00

Hospital Charge Code	270685240
Hospital Revenue Code	278
Min. Negotiated Rate	$888.75
Max. Negotiated Rate	$1,433.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,185.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,433.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,303.50
Rate for Payer: Qualcare PPO/HMO/WC	$888.75

SPHERES OPTISPHERE OSL26B

Facility

$5,925.00

Hospital Charge Code	270685240
Hospital Revenue Code	278
Min. Negotiated Rate	$142.79
Max. Negotiated Rate	$2,962.50
Rate for Payer: Aetna Commercial	$2,251.50
Rate for Payer: Aetna Medicare Advantage	$1,777.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,510.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,510.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,185.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,510.88
Rate for Payer: Cigna Commercial	$2,962.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,433.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,303.50
Rate for Payer: Qualcare PPO/HMO/WC	$888.75
Rate for Payer: UnitedHealthcare Community & State	$142.79
Rate for Payer: Wellpoint Medicaid Managed Care	$157.01

SPHERES OPTISPHERE OSL26B

Facility

$5,925.00

Hospital Charge Code	270685240N
Hospital Revenue Code	278
Min. Negotiated Rate	$888.75
Max. Negotiated Rate	$1,433.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,185.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,433.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,303.50
Rate for Payer: Qualcare PPO/HMO/WC	$888.75

SPHERES OPTISPHERE OSL26B

Facility

$5,925.00

Hospital Charge Code	270685240N
Hospital Revenue Code	278
Min. Negotiated Rate	$142.79
Max. Negotiated Rate	$2,962.50
Rate for Payer: Aetna Commercial	$2,251.50
Rate for Payer: Aetna Medicare Advantage	$1,777.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,510.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,510.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,185.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,510.88
Rate for Payer: Cigna Commercial	$2,962.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,433.85
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,303.50
Rate for Payer: Qualcare PPO/HMO/WC	$888.75
Rate for Payer: UnitedHealthcare Community & State	$142.79
Rate for Payer: Wellpoint Medicaid Managed Care	$157.01

SPHERES STERILE 4 PACK

Facility

$50.75

Hospital Charge Code	270681213
Hospital Revenue Code	272
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$25.38
Rate for Payer: Aetna Commercial	$19.29
Rate for Payer: Aetna Medicare Advantage	$15.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.94
Rate for Payer: Cigna Commercial	$25.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.22
Rate for Payer: Oxford Commercial	$10.15
Rate for Payer: Qualcare PPO/HMO/WC	$7.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Community & State	$1.22
Rate for Payer: Wellpoint Medicaid Managed Care	$1.34

SPHERES STERILE 4 PACK

Facility

$50.75

Hospital Charge Code	270681213
Hospital Revenue Code	272
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$7.61
Rate for Payer: Qualcare PPO/HMO/WC	$7.61

SPHINCTEROTOME***

Facility

$1,117.00

Hospital Charge Code	2300648
Hospital Revenue Code	279
Min. Negotiated Rate	$167.55
Max. Negotiated Rate	$167.55
Rate for Payer: Qualcare PPO/HMO/WC	$167.55

SPHINCTEROTOME***

Facility

$1,117.00

Hospital Charge Code	2300648
Hospital Revenue Code	279
Min. Negotiated Rate	$26.92
Max. Negotiated Rate	$558.50
Rate for Payer: Aetna Commercial	$424.46
Rate for Payer: Aetna Medicare Advantage	$335.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$284.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$284.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$284.83
Rate for Payer: Cigna Commercial	$558.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$335.10
Rate for Payer: Oxford Commercial	$223.40
Rate for Payer: Qualcare PPO/HMO/WC	$167.55
Rate for Payer: UnitedHealthcare Commercial	$223.40
Rate for Payer: UnitedHealthcare Community & State	$26.92
Rate for Payer: Wellpoint Medicaid Managed Care	$29.60

SPHINCTEROTOME 3 LUM 7F TRI25M

Facility

$697.70

Hospital Charge Code	270632003
Hospital Revenue Code	272
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$348.85
Rate for Payer: Aetna Commercial	$265.13
Rate for Payer: Aetna Medicare Advantage	$209.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$177.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$177.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$177.91
Rate for Payer: Cigna Commercial	$348.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$209.31
Rate for Payer: Oxford Commercial	$139.54
Rate for Payer: Qualcare PPO/HMO/WC	$104.66
Rate for Payer: UnitedHealthcare Commercial	$139.54
Rate for Payer: UnitedHealthcare Community & State	$16.81
Rate for Payer: Wellpoint Medicaid Managed Care	$18.49

SPHINCTEROTOME 3 LUM 7F TRI25M

Facility

$697.70

Hospital Charge Code	270632003
Hospital Revenue Code	272
Min. Negotiated Rate	$104.66
Max. Negotiated Rate	$104.66
Rate for Payer: Qualcare PPO/HMO/WC	$104.66

SPHINCTEROTOME 5MM 20MM

Facility

$980.00

Hospital Charge Code	270701540
Hospital Revenue Code	278
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare Advantage	$294.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$249.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$249.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$196.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$249.90
Rate for Payer: Cigna Commercial	$490.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$237.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$215.60
Rate for Payer: Qualcare PPO/HMO/WC	$147.00
Rate for Payer: UnitedHealthcare Community & State	$23.62
Rate for Payer: Wellpoint Medicaid Managed Care	$25.97

SPHINCTEROTOME 5MM 20MM

Facility

$980.00

Hospital Charge Code	270701541
Hospital Revenue Code	278
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare Advantage	$294.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$249.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$249.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$196.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$249.90
Rate for Payer: Cigna Commercial	$490.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$237.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$215.60
Rate for Payer: Qualcare PPO/HMO/WC	$147.00
Rate for Payer: UnitedHealthcare Community & State	$23.62
Rate for Payer: Wellpoint Medicaid Managed Care	$25.97

SPHINCTEROTOME 5MM 20MM

Facility

$980.00

Hospital Charge Code	270701541
Hospital Revenue Code	278
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$237.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$196.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$237.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$215.60
Rate for Payer: Qualcare PPO/HMO/WC	$147.00

SPHINCTEROTOME 5MM 20MM

Facility

$980.00

Hospital Charge Code	270701540
Hospital Revenue Code	278
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$237.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$196.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$237.16
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$215.60
Rate for Payer: Qualcare PPO/HMO/WC	$147.00

Know your out-of-pocket cost for care.

All Charges