Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

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	$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 3.5F/2

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270685335
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/2

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270685335
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 3F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270675761
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 3F/2T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270675761
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 3F/3T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270676964
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 3F/3T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270676964
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 3F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677403
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 3F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677403
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 SZ4 5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270684044
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 SZ4 5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270684044
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 SZ4F/3T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270680393
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 SZ4F/3T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270680393
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 4F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270679004
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 4F/4T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270679004
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 5F/5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677577
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 5F/5T

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677577
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 COCR FINNED 63MM

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270639117
Hospital Revenue Code	278
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$1,710.00
Rate for Payer: Aetna Medicare Advantage	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$900.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,147.50
Rate for Payer: Cigna Commercial	$2,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,089.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$990.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00
Rate for Payer: UnitedHealthcare Community & State	$108.45
Rate for Payer: Wellpoint Medicaid Managed Care	$119.25

TIBIAL TRAY COCR FINNED 63MM

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270639117
Hospital Revenue Code	278
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$1,089.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$900.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,089.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$990.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00

TIBIAL TRAY COMP OFFSET 63MM

Facility

$14,010.00

Service Code	HCPCS C1776
Hospital Charge Code	270675927
Hospital Revenue Code	278
Min. Negotiated Rate	$337.64
Max. Negotiated Rate	$7,005.00
Rate for Payer: Aetna Commercial	$5,323.80
Rate for Payer: Aetna Medicare Advantage	$4,203.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,572.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,572.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,802.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,572.55
Rate for Payer: Cigna Commercial	$7,005.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,390.42
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,082.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,101.50
Rate for Payer: UnitedHealthcare Community & State	$337.64
Rate for Payer: Wellpoint Medicaid Managed Care	$371.26

TIBIAL TRAY COMP OFFSET 63MM

Facility

$14,010.00

Service Code	HCPCS C1776
Hospital Charge Code	270675927
Hospital Revenue Code	278
Min. Negotiated Rate	$2,101.50
Max. Negotiated Rate	$3,390.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,802.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,390.42
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,082.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,101.50

TIBIAL TRAY FIXED CEMENTED SZ4

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270671825
Hospital Revenue Code	278
Min. Negotiated Rate	$132.55
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$132.55
Rate for Payer: Wellpoint Medicaid Managed Care	$145.75

TIBIAL TRAY FIXED CEMENTED SZ4

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270671825
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY FIXED SIZE 1

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270686216
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

TIBIAL TRAY FIXED SIZE 1

Facility

$5,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270686216
Hospital Revenue Code	278
Min. Negotiated Rate	$132.55
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$132.55
Rate for Payer: Wellpoint Medicaid Managed Care	$145.75

Know your out-of-pocket cost for care.

All Charges