Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TIBIAL STEM EXTENSION 100MM

Facility

$6,300.00

Hospital Charge Code	270672659
Hospital Revenue Code	278
Min. Negotiated Rate	$151.83
Max. Negotiated Rate	$3,150.00
Rate for Payer: Aetna Commercial	$2,394.00
Rate for Payer: Aetna Medicare Advantage	$1,890.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,606.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,606.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,260.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,606.50
Rate for Payer: Cigna Commercial	$3,150.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,524.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,386.00
Rate for Payer: Qualcare PPO/HMO/WC	$945.00
Rate for Payer: UnitedHealthcare Community & State	$151.83
Rate for Payer: Wellpoint Medicaid Managed Care	$166.95

TIBIAL STEM EXTENSION 100MM

Facility

$6,300.00

Hospital Charge Code	270672659
Hospital Revenue Code	278
Min. Negotiated Rate	$945.00
Max. Negotiated Rate	$1,524.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,260.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,524.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,386.00
Rate for Payer: Qualcare PPO/HMO/WC	$945.00

TIBIAL STEM EXTENSION 150MM

Facility

$8,400.00

Hospital Charge Code	270672660
Hospital Revenue Code	278
Min. Negotiated Rate	$202.44
Max. Negotiated Rate	$4,200.00
Rate for Payer: Aetna Commercial	$3,192.00
Rate for Payer: Aetna Medicare Advantage	$2,520.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,142.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,142.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,680.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,142.00
Rate for Payer: Cigna Commercial	$4,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,032.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,848.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,260.00
Rate for Payer: UnitedHealthcare Community & State	$202.44
Rate for Payer: Wellpoint Medicaid Managed Care	$222.60

TIBIAL STEM EXTENSION 150MM

Facility

$8,400.00

Hospital Charge Code	270672660
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,032.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,680.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,032.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,848.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,260.00

TIBIAL STEM EXTENSION 25MM

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270672657
Hospital Revenue Code	278
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$484.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$484.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$440.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

TIBIAL STEM EXTENSION 25MM

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270672657
Hospital Revenue Code	278
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$1,000.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare Advantage	$600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$510.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$510.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$510.00
Rate for Payer: Cigna Commercial	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$484.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$440.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$48.20
Rate for Payer: Wellpoint Medicaid Managed Care	$53.00

TIBIAL STEM EXTENSION 50MM

Facility

$3,000.00

Hospital Charge Code	270672658
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$726.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$726.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$660.00
Rate for Payer: Qualcare PPO/HMO/WC	$450.00

TIBIAL STEM EXTENSION 50MM

Facility

$3,000.00

Hospital Charge Code	270672658
Hospital Revenue Code	278
Min. Negotiated Rate	$72.30
Max. Negotiated Rate	$1,500.00
Rate for Payer: Aetna Commercial	$1,140.00
Rate for Payer: Aetna Medicare Advantage	$900.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$765.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$765.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$765.00
Rate for Payer: Cigna Commercial	$1,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$726.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$660.00
Rate for Payer: Qualcare PPO/HMO/WC	$450.00
Rate for Payer: UnitedHealthcare Community & State	$72.30
Rate for Payer: Wellpoint Medicaid Managed Care	$79.50

TIBIAL TRAY 67MM W/LCKG BAR

Facility

$6,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270646501
Hospital Revenue Code	278
Min. Negotiated Rate	$156.65
Max. Negotiated Rate	$3,250.00
Rate for Payer: Aetna Commercial	$2,470.00
Rate for Payer: Aetna Medicare Advantage	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,657.50
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,573.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,430.00
Rate for Payer: Qualcare PPO/HMO/WC	$975.00
Rate for Payer: UnitedHealthcare Community & State	$156.65
Rate for Payer: Wellpoint Medicaid Managed Care	$172.25

TIBIAL TRAY 67MM W/LCKG BAR

Facility

$6,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270646501
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$1,573.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,573.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,430.00
Rate for Payer: Qualcare PPO/HMO/WC	$975.00

TIBIAL TRAY CEMENTED 2.5F/2.5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677171
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

TIBIAL TRAY CEMENTED 2.5F/2.5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677171
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

TIBIAL TRAY CEMENTED 2.5F/2.5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270678219
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

TIBIAL TRAY CEMENTED 2.5F/2.5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270678219
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

TIBIAL TRAY CEMENTED SZ 1.5F/1

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270674364
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

TIBIAL TRAY CEMENTED SZ 1.5F/1

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270674364
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

TIBIAL TRAY CEMENTED SZ 1F/1T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683445
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

TIBIAL TRAY CEMENTED SZ 1F/1T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270683445
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

TIBIAL TRAY CEMENTED SZ 1F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270684883
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

TIBIAL TRAY CEMENTED SZ 1F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270684883
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

TIBIAL TRAY CEMENTED SZ 2F/1T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270685203
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

TIBIAL TRAY CEMENTED SZ 2F/1T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270685203
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

TIBIAL TRAY CEMENTED SZ 2F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270675279
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

TIBIAL TRAY CEMENTED SZ 2F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270675279
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

TIBIAL TRAY CEMENTED SZ 3.5F /

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270682565
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

Know your out-of-pocket cost for care.

All Charges