Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

BALN SPRT RX2.25x12 SP22512X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651190C
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

BALN SPRT RX2.25x12 SP22512X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651190C
Hospital Revenue Code	278
Min. Negotiated Rate	$18.07
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: UnitedHealthcare Community & State	$18.07
Rate for Payer: Wellpoint Medicaid Managed Care	$19.88

BALN SPRT RX2.25x21 NCSP22521X

Facility

$750.00

Hospital Charge Code	270651191C
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

BALN SPRT RX2.25x21 NCSP22521X

Facility

$750.00

Hospital Charge Code	270651191C
Hospital Revenue Code	278
Min. Negotiated Rate	$18.07
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: UnitedHealthcare Community & State	$18.07
Rate for Payer: Wellpoint Medicaid Managed Care	$19.88

BALN SPRT RX2.5x06 NCSP2506X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651192C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.5x06 NCSP2506X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651192C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.5x09 NCSP2509X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651193C
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

BALN SPRT RX2.5x09 NCSP2509X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651193C
Hospital Revenue Code	278
Min. Negotiated Rate	$18.07
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: UnitedHealthcare Community & State	$18.07
Rate for Payer: Wellpoint Medicaid Managed Care	$19.88

BALN SPRT RX2.5x12 NCSP2512X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651194C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.5x12 NCSP2512X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651194C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.5x15 NCSP2515X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651195C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.5x15 NCSP2515X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651195C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.5x21 NCSP2521X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651196C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.5x21 NCSP2521X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651196C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.5x27 NCSP2527X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651197C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.5x27 NCSP2527X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651197C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.75x06 NCSP27506X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651198C
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

BALN SPRT RX2.75x06 NCSP27506X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651198C
Hospital Revenue Code	278
Min. Negotiated Rate	$18.07
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: UnitedHealthcare Community & State	$18.07
Rate for Payer: Wellpoint Medicaid Managed Care	$19.88

BALN SPRT RX2.75x09 NCSP27509X

Facility

$625.00

Service Code	HCPCS C1725
Hospital Charge Code	270651199C
Hospital Revenue Code	278
Min. Negotiated Rate	$93.75
Max. Negotiated Rate	$151.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$137.50
Rate for Payer: Qualcare PPO/HMO/WC	$93.75

BALN SPRT RX2.75x09 NCSP27509X

Facility

$625.00

Service Code	HCPCS C1725
Hospital Charge Code	270651199C
Hospital Revenue Code	278
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$312.50
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare Advantage	$187.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$159.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$159.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$159.38
Rate for Payer: Cigna Commercial	$312.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$137.50
Rate for Payer: Qualcare PPO/HMO/WC	$93.75
Rate for Payer: UnitedHealthcare Community & State	$15.06
Rate for Payer: Wellpoint Medicaid Managed Care	$16.56

BALN SPRT RX2.75x12 NCSP27512X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651201C
Hospital Revenue Code	278
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare Advantage	$157.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.88
Rate for Payer: Cigna Commercial	$262.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75
Rate for Payer: UnitedHealthcare Community & State	$12.65
Rate for Payer: Wellpoint Medicaid Managed Care	$13.91

BALN SPRT RX2.75x12 NCSP27512X

Facility

$525.00

Service Code	HCPCS C1725
Hospital Charge Code	270651201C
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$127.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$115.50
Rate for Payer: Qualcare PPO/HMO/WC	$78.75

BALN SPRT RX2.75x15 NCSP27515X

Facility

$625.00

Service Code	HCPCS C1725
Hospital Charge Code	270651202C
Hospital Revenue Code	278
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$312.50
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare Advantage	$187.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$159.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$159.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$159.38
Rate for Payer: Cigna Commercial	$312.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$137.50
Rate for Payer: Qualcare PPO/HMO/WC	$93.75
Rate for Payer: UnitedHealthcare Community & State	$15.06
Rate for Payer: Wellpoint Medicaid Managed Care	$16.56

BALN SPRT RX2.75x15 NCSP27515X

Facility

$625.00

Service Code	HCPCS C1725
Hospital Charge Code	270651202C
Hospital Revenue Code	278
Min. Negotiated Rate	$93.75
Max. Negotiated Rate	$151.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$137.50
Rate for Payer: Qualcare PPO/HMO/WC	$93.75

BALN SPRT RX2.75x21 NCSP27521X

Facility

$750.00

Service Code	HCPCS C1725
Hospital Charge Code	270651203C
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$181.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$181.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$165.00
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

Know your out-of-pocket cost for care.

All Charges