Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	7412012
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	366875774L
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	366875774L
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	2691915
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	7412012
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	2691915
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-LT

Facility

$5,100.00

Service Code	HCPCS 75774LT
Hospital Charge Code	321075774L
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	7412013
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	7412013
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	2691920
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	2691920
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	366875774R
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	321075774R
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	321075774R
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

DX-VISCERAL SEL EA ADD-RT

Facility

$5,100.00

Service Code	HCPCS 75774RT
Hospital Charge Code	366875774R
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

D-XYLOSE ABSORPTION,B, 1 HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	3990247
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

D-XYLOSE ABSORPTION,B, 1 HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	3990247
Hospital Revenue Code	301
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.12
Rate for Payer: Aetna Medicare Advantage	$41.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.60
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.91
Rate for Payer: Clover Medicare Advantage	$12.26
Rate for Payer: EmblemHealth Commercial	$38.73
Rate for Payer: Humana Medicare Advantage	$13.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.91
Rate for Payer: Wellcare Medicare Advantage	$12.91
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

D-XYLOSE ABSORPTION,B,1HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	4010846201
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

D-XYLOSE ABSORPTION,B,1HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	4010846201
Hospital Revenue Code	301
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.12
Rate for Payer: Aetna Medicare Advantage	$41.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.60
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.91
Rate for Payer: Clover Medicare Advantage	$12.26
Rate for Payer: EmblemHealth Commercial	$38.73
Rate for Payer: Humana Medicare Advantage	$13.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.91
Rate for Payer: Wellcare Medicare Advantage	$12.91
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

D-XYLOSE ABSORPTION,B, 2 HR

Facility

$397.50

Service Code	HCPCS 84620
Hospital Charge Code	3990248
Hospital Revenue Code	301
Min. Negotiated Rate	$59.62
Max. Negotiated Rate	$59.62
Rate for Payer: Qualcare PPO/HMO/WC	$59.62

D-XYLOSE ABSORPTION,B, 2 HR

Facility

$397.50

Service Code	HCPCS 84620
Hospital Charge Code	3990248
Hospital Revenue Code	301
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$198.75
Rate for Payer: Aetna Commercial	$35.12
Rate for Payer: Aetna Medicare Advantage	$41.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.60
Rate for Payer: Cigna Commercial	$198.75
Rate for Payer: Cigna Medicare Advantage	$12.91
Rate for Payer: Clover Medicare Advantage	$12.26
Rate for Payer: EmblemHealth Commercial	$38.73
Rate for Payer: Humana Medicare Advantage	$13.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$119.25
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$59.62
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.91
Rate for Payer: Wellcare Medicare Advantage	$12.91
Rate for Payer: Wellpoint Medicaid Managed Care	$10.53

D-XYLOSE ABSORPTION,B,2HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	4010846202
Hospital Revenue Code	301
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.12
Rate for Payer: Aetna Medicare Advantage	$41.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.60
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.91
Rate for Payer: Clover Medicare Advantage	$12.26
Rate for Payer: EmblemHealth Commercial	$38.73
Rate for Payer: Humana Medicare Advantage	$13.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.91
Rate for Payer: Wellcare Medicare Advantage	$12.91
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

D-XYLOSE ABSORPTION,B,2HR

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	4010846202
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

D-XYLOSEABSORPTION,B,FAST

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	401084620F
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

D-XYLOSEABSORPTION,B,FAST

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	401084620F
Hospital Revenue Code	301
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$35.12
Rate for Payer: Aetna Medicare Advantage	$41.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.60
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.91
Rate for Payer: Clover Medicare Advantage	$12.26
Rate for Payer: EmblemHealth Commercial	$38.73
Rate for Payer: Humana Medicare Advantage	$13.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.91
Rate for Payer: Wellcare Medicare Advantage	$12.91
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

Know your out-of-pocket cost for care.

All Charges