Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

D-XYLOSEABSORPTION,B, FASTING

Facility

$397.50

Service Code	HCPCS 84620
Hospital Charge Code	3990246
Hospital Revenue Code	301
Min. Negotiated Rate	$59.62
Max. Negotiated Rate	$59.62
Rate for Payer: Qualcare PPO/HMO/WC	$59.62

D-XYLOSEABSORPTION,B, FASTING

Facility

$397.50

Service Code	HCPCS 84620
Hospital Charge Code	3990246
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, URINE

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	3990249
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, URINE

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	3990249
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, U

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	401084620
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, U

Facility

$390.00

Service Code	HCPCS 84620
Hospital Charge Code	401084620
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

DYAZIDE/CAP

Facility

$4.00

Hospital Charge Code	60632913
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DYAZIDE/CAP

Facility

$4.00

Hospital Charge Code	60632914
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DYAZIDE/CAP

Facility

$4.00

Hospital Charge Code	60632914
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DYAZIDE/CAP

Facility

$4.00

Hospital Charge Code	60632913
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DYCLONE-DECADRON/60ML

Facility

$43.00

Hospital Charge Code	60634872
Hospital Revenue Code	250
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$6.45
Rate for Payer: Qualcare PPO/HMO/WC	$6.45

DYCLONE-DECADRON/60ML

Facility

$43.00

Hospital Charge Code	60634872
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$21.50
Rate for Payer: Aetna Commercial	$16.34
Rate for Payer: Aetna Medicare Advantage	$12.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.96
Rate for Payer: Cigna Commercial	$21.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.90
Rate for Payer: Oxford Commercial	$8.60
Rate for Payer: Qualcare PPO/HMO/WC	$6.45
Rate for Payer: UnitedHealthcare Commercial	$8.60
Rate for Payer: UnitedHealthcare Community & State	$1.04
Rate for Payer: Wellpoint Medicaid Managed Care	$1.14

DYCLONE RX

Facility

$61.00

Hospital Charge Code	60634780
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$30.50
Rate for Payer: Aetna Commercial	$23.18
Rate for Payer: Aetna Medicare Advantage	$18.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.55
Rate for Payer: Cigna Commercial	$30.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.30
Rate for Payer: Oxford Commercial	$12.20
Rate for Payer: Qualcare PPO/HMO/WC	$9.15
Rate for Payer: UnitedHealthcare Commercial	$12.20
Rate for Payer: UnitedHealthcare Community & State	$1.47
Rate for Payer: Wellpoint Medicaid Managed Care	$1.62

DYCLONE RX

Facility

$61.00

Hospital Charge Code	60634780
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$9.15
Rate for Payer: Qualcare PPO/HMO/WC	$9.15

DYCLONE RX 0.5%/60ML

Facility

$61.00

Hospital Charge Code	60634753
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$30.50
Rate for Payer: Aetna Commercial	$23.18
Rate for Payer: Aetna Medicare Advantage	$18.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.55
Rate for Payer: Cigna Commercial	$30.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.30
Rate for Payer: Oxford Commercial	$12.20
Rate for Payer: Qualcare PPO/HMO/WC	$9.15
Rate for Payer: UnitedHealthcare Commercial	$12.20
Rate for Payer: UnitedHealthcare Community & State	$1.47
Rate for Payer: Wellpoint Medicaid Managed Care	$1.62

DYCLONE RX 0.5%/60ML

Facility

$61.00

Hospital Charge Code	60634753
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$9.15
Rate for Payer: Qualcare PPO/HMO/WC	$9.15

DYCLONE TOPICAL 0.5%/30ML

Facility

$134.00

Hospital Charge Code	60632915
Hospital Revenue Code	250
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$50.92
Rate for Payer: Aetna Medicare Advantage	$40.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.17
Rate for Payer: Cigna Commercial	$67.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.20
Rate for Payer: Oxford Commercial	$26.80
Rate for Payer: Qualcare PPO/HMO/WC	$20.10
Rate for Payer: UnitedHealthcare Commercial	$26.80
Rate for Payer: UnitedHealthcare Community & State	$3.23
Rate for Payer: Wellpoint Medicaid Managed Care	$3.55

DYCLONE TOPICAL 0.5%/30ML

Facility

$134.00

Hospital Charge Code	60632915
Hospital Revenue Code	250
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$20.10
Rate for Payer: Qualcare PPO/HMO/WC	$20.10

DYCLONE TOPICAL 1%/30ML

Facility

$161.00

Hospital Charge Code	60632916
Hospital Revenue Code	250
Min. Negotiated Rate	$24.15
Max. Negotiated Rate	$24.15
Rate for Payer: Qualcare PPO/HMO/WC	$24.15

DYCLONE TOPICAL 1%/30ML

Facility

$161.00

Hospital Charge Code	60632916
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$80.50
Rate for Payer: Aetna Commercial	$61.18
Rate for Payer: Aetna Medicare Advantage	$48.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.05
Rate for Payer: Cigna Commercial	$80.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.30
Rate for Payer: Oxford Commercial	$32.20
Rate for Payer: Qualcare PPO/HMO/WC	$24.15
Rate for Payer: UnitedHealthcare Commercial	$32.20
Rate for Payer: UnitedHealthcare Community & State	$3.88
Rate for Payer: Wellpoint Medicaid Managed Care	$4.27

DYCLONINE HCL TOP 0.5%

Facility

$203.55

Hospital Charge Code	6002109
Hospital Revenue Code	252
Min. Negotiated Rate	$30.53
Max. Negotiated Rate	$30.53
Rate for Payer: Qualcare PPO/HMO/WC	$30.53

DYCLONINE HCL TOP 0.5%

Facility

$203.55

Hospital Charge Code	6002109
Hospital Revenue Code	252
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$101.78
Rate for Payer: Aetna Commercial	$77.35
Rate for Payer: Aetna Medicare Advantage	$61.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.91
Rate for Payer: Cigna Commercial	$101.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$61.06
Rate for Payer: Oxford Commercial	$40.71
Rate for Payer: Qualcare PPO/HMO/WC	$30.53
Rate for Payer: UnitedHealthcare Commercial	$40.71
Rate for Payer: UnitedHealthcare Community & State	$4.91
Rate for Payer: Wellpoint Medicaid Managed Care	$5.39

DYE BLUE 1% LYMPHAZURIN LYM100

Facility

$611.25

Hospital Charge Code	270615173
Hospital Revenue Code	272
Min. Negotiated Rate	$91.69
Max. Negotiated Rate	$91.69
Rate for Payer: Qualcare PPO/HMO/WC	$91.69

DYE BLUE 1% LYMPHAZURIN LYM100

Facility

$611.25

Hospital Charge Code	270615173
Hospital Revenue Code	272
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$305.62
Rate for Payer: Aetna Commercial	$232.28
Rate for Payer: Aetna Medicare Advantage	$183.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$155.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$155.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$155.87
Rate for Payer: Cigna Commercial	$305.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$183.38
Rate for Payer: Oxford Commercial	$122.25
Rate for Payer: Qualcare PPO/HMO/WC	$91.69
Rate for Payer: UnitedHealthcare Commercial	$122.25
Rate for Payer: UnitedHealthcare Community & State	$14.73
Rate for Payer: Wellpoint Medicaid Managed Care	$16.20

DYE ELEVIEW AMP BLUE

Facility

$405.00

Hospital Charge Code	270682877
Hospital Revenue Code	272
Min. Negotiated Rate	$9.76
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna Commercial	$153.90
Rate for Payer: Aetna Medicare Advantage	$121.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$103.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$103.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$103.28
Rate for Payer: Cigna Commercial	$202.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$121.50
Rate for Payer: Oxford Commercial	$81.00
Rate for Payer: Qualcare PPO/HMO/WC	$60.75
Rate for Payer: UnitedHealthcare Commercial	$81.00
Rate for Payer: UnitedHealthcare Community & State	$9.76
Rate for Payer: Wellpoint Medicaid Managed Care	$10.73

Know your out-of-pocket cost for care.

All Charges