Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

FHC DTAP/HEPB/IPV

Facility

$208.00

Service Code	HCPCS 90723
Hospital Charge Code	9400094
Hospital Revenue Code	636
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$50.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.34
Rate for Payer: Qualcare PPO/HMO/WC	$31.20

FHC DTAP/HEPB/IPV

Facility

$208.00

Service Code	HCPCS 90723
Hospital Charge Code	9400094
Hospital Revenue Code	636
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$194.72
Rate for Payer: Aetna Commercial	$79.04
Rate for Payer: Aetna Medicare Advantage	$62.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$194.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.04
Rate for Payer: Cigna Commercial	$104.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.34
Rate for Payer: Qualcare PPO/HMO/WC	$31.20
Rate for Payer: UnitedHealthcare Community & State	$5.01
Rate for Payer: Wellpoint Medicaid Managed Care	$5.51

FHC EST PT PREV MED VS 0-1 YR

Professional

Both

$440.00

Service Code	HCPCS 99391
Hospital Charge Code	9400020
Hospital Revenue Code	960
Min. Negotiated Rate	$46.59
Max. Negotiated Rate	$68.21
Rate for Payer: Aetna Commercial	$68.21
Rate for Payer: Aetna Medicare Advantage	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$50.00
Rate for Payer: UnitedHealthcare Commercial	$51.31
Rate for Payer: UnitedHealthcare Community & State	$51.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.31
Rate for Payer: Wellpoint Medicaid Managed Care	$46.59

FHC EST PT PREV MED VS 12-17YR

Professional

Both

$281.65

Service Code	HCPCS 99394
Hospital Charge Code	9400022
Hospital Revenue Code	960
Min. Negotiated Rate	$59.43
Max. Negotiated Rate	$84.78
Rate for Payer: Aetna Commercial	$84.78
Rate for Payer: Aetna Medicare Advantage	$65.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$59.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$59.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$59.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$59.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$59.43
Rate for Payer: Fidelis All Plans	$65.44
Rate for Payer: Wellpoint Medicaid Managed Care	$66.39

FHC EST PT PREV MED VS 1-4 YR

Professional

Both

$281.65

Service Code	HCPCS 99392
Hospital Charge Code	9400024
Hospital Revenue Code	960
Min. Negotiated Rate	$57.26
Max. Negotiated Rate	$76.44
Rate for Payer: Aetna Commercial	$71.42
Rate for Payer: Aetna Medicare Advantage	$76.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$57.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$57.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$57.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$57.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$57.26
Rate for Payer: Fidelis All Plans	$76.44
Rate for Payer: UnitedHealthcare Commercial	$71.41
Rate for Payer: UnitedHealthcare Community & State	$71.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$71.41
Rate for Payer: Wellpoint Medicaid Managed Care	$59.67

FHC EST PT PREV MED VS 1-4YR

Professional

Both

$440.00

Service Code	HCPCS 99382
Hospital Charge Code	9400264
Hospital Revenue Code	960
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Medicare Advantage	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$50.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$50.00

FHC EST PT PREV MED VS 18-39YR

Professional

Both

$281.65

Service Code	HCPCS 99395
Hospital Charge Code	9400026
Hospital Revenue Code	960
Min. Negotiated Rate	$65.57
Max. Negotiated Rate	$194.38
Rate for Payer: Aetna Commercial	$115.58
Rate for Payer: Aetna Medicare Advantage	$194.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$72.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$72.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$72.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$72.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$72.38
Rate for Payer: Cigna Commercial	$194.38
Rate for Payer: Cigna Medicare Advantage	$194.38
Rate for Payer: Fidelis All Plans	$74.50
Rate for Payer: Marpai Administrators LLC Commercial	$103.34
Rate for Payer: UnitedHealthcare Commercial	$65.57
Rate for Payer: UnitedHealthcare Community & State	$65.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$65.57
Rate for Payer: Wellpoint Medicaid Managed Care	$79.16

FHC EST PT PREV MED VS 40-64YR

Facility

$281.65

Service Code	HCPCS 99396
Hospital Charge Code	9400028
Hospital Revenue Code	510
Min. Negotiated Rate	$42.25
Max. Negotiated Rate	$42.25
Rate for Payer: Qualcare PPO/HMO/WC	$42.25

FHC EST PT PREV MED VS 40-64YR

Facility

$281.65

Service Code	HCPCS 99396
Hospital Charge Code	9400028
Hospital Revenue Code	510
Min. Negotiated Rate	$6.79
Max. Negotiated Rate	$140.82
Rate for Payer: Aetna Commercial	$107.03
Rate for Payer: Aetna Medicare Advantage	$84.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$71.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$71.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$71.82
Rate for Payer: Cigna Commercial	$140.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$84.50
Rate for Payer: Qualcare PPO/HMO/WC	$42.25
Rate for Payer: UnitedHealthcare Community & State	$6.79
Rate for Payer: Wellpoint Medicaid Managed Care	$7.46

FHC EST PT PREV MED VS 5-11YR

Professional

Both

$281.65

Service Code	HCPCS 99393
Hospital Charge Code	9400030
Hospital Revenue Code	960
Min. Negotiated Rate	$47.56
Max. Negotiated Rate	$70.23
Rate for Payer: Aetna Commercial	$70.23
Rate for Payer: Aetna Medicare Advantage	$67.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$67.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$67.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$67.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$67.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$67.51
Rate for Payer: Wellpoint Medicaid Managed Care	$47.56

FHC EST PT PREV MED VS 65+ YR

Professional

Both

$440.00

Service Code	HCPCS 99397
Hospital Charge Code	9400032
Hospital Revenue Code	960
Min. Negotiated Rate	$41.99
Max. Negotiated Rate	$221.55
Rate for Payer: Aetna Commercial	$101.06
Rate for Payer: Aetna Medicare Advantage	$85.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$41.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$41.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.99
Rate for Payer: Cigna Commercial	$221.55
Rate for Payer: Cigna Medicare Advantage	$221.55
Rate for Payer: Marpai Administrators LLC Commercial	$155.71
Rate for Payer: UnitedHealthcare Commercial	$97.41
Rate for Payer: UnitedHealthcare Community & State	$97.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$97.41
Rate for Payer: Wellpoint Medicaid Managed Care	$90.11

FHC EST PT VS LEVEL 1

Facility

$90.00

Service Code	HCPCS 99211
Hospital Charge Code	9400034
Hospital Revenue Code	510
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare Advantage	$27.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.95
Rate for Payer: Cigna Commercial	$45.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.50
Rate for Payer: UnitedHealthcare Community & State	$2.17
Rate for Payer: Wellpoint Medicaid Managed Care	$2.38

FHC EST PT VS LEVEL 1

Facility

$90.00

Service Code	HCPCS 99211
Hospital Charge Code	9400034
Hospital Revenue Code	510
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Qualcare PPO/HMO/WC	$13.50

FHC EST PT VS LEVEL 2

Facility

$200.00

Service Code	HCPCS 99212
Hospital Charge Code	9400062
Hospital Revenue Code	510
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00

FHC EST PT VS LEVEL 2

Facility

$200.00

Service Code	HCPCS 99212
Hospital Charge Code	9400062
Hospital Revenue Code	510
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare Advantage	$60.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.00
Rate for Payer: Cigna Commercial	$100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$60.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00
Rate for Payer: UnitedHealthcare Community & State	$4.82
Rate for Payer: Wellpoint Medicaid Managed Care	$5.30

FHC EST PT VS LEVEL 3

Facility

$292.50

Service Code	HCPCS 99213
Hospital Charge Code	9400036
Hospital Revenue Code	510
Min. Negotiated Rate	$43.88
Max. Negotiated Rate	$43.88
Rate for Payer: Qualcare PPO/HMO/WC	$43.88

FHC EST PT VS LEVEL 3

Facility

$292.50

Service Code	HCPCS 99213
Hospital Charge Code	9400036
Hospital Revenue Code	510
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$146.25
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare Advantage	$87.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$74.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$74.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$74.59
Rate for Payer: Cigna Commercial	$146.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$87.75
Rate for Payer: Qualcare PPO/HMO/WC	$43.88
Rate for Payer: UnitedHealthcare Community & State	$7.05
Rate for Payer: Wellpoint Medicaid Managed Care	$7.75

FHC EST PT VS LEVEL 4

Facility

$554.00

Service Code	HCPCS 99214
Hospital Charge Code	9400064
Hospital Revenue Code	510
Min. Negotiated Rate	$83.10
Max. Negotiated Rate	$83.10
Rate for Payer: Qualcare PPO/HMO/WC	$83.10

FHC EST PT VS LEVEL 4

Facility

$554.00

Service Code	HCPCS 99214
Hospital Charge Code	9400064
Hospital Revenue Code	510
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$210.52
Rate for Payer: Aetna Medicare Advantage	$166.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$141.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$141.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$141.27
Rate for Payer: Cigna Commercial	$277.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$166.20
Rate for Payer: Qualcare PPO/HMO/WC	$83.10
Rate for Payer: UnitedHealthcare Community & State	$13.35
Rate for Payer: Wellpoint Medicaid Managed Care	$14.68

FHC EST PT VS LEVEL 5

Facility

$501.25

Service Code	HCPCS 99215
Hospital Charge Code	9400066
Hospital Revenue Code	510
Min. Negotiated Rate	$75.19
Max. Negotiated Rate	$75.19
Rate for Payer: Qualcare PPO/HMO/WC	$75.19

FHC EST PT VS LEVEL 5

Facility

$501.25

Service Code	HCPCS 99215
Hospital Charge Code	9400066
Hospital Revenue Code	510
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$250.62
Rate for Payer: Aetna Commercial	$190.47
Rate for Payer: Aetna Medicare Advantage	$150.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.82
Rate for Payer: Cigna Commercial	$250.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$150.38
Rate for Payer: Qualcare PPO/HMO/WC	$75.19
Rate for Payer: UnitedHealthcare Community & State	$12.08
Rate for Payer: Wellpoint Medicaid Managed Care	$13.28

FHC HEALTHSTART ENROLLMENT

Facility

$309.65

Service Code	HCPCS 99241
Hospital Charge Code	9400052
Hospital Revenue Code	510
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$154.82
Rate for Payer: Aetna Commercial	$117.67
Rate for Payer: Aetna Medicare Advantage	$92.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$78.96
Rate for Payer: Cigna Commercial	$154.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$92.89
Rate for Payer: Qualcare PPO/HMO/WC	$46.45
Rate for Payer: UnitedHealthcare Community & State	$7.46
Rate for Payer: Wellpoint Medicaid Managed Care	$8.21

FHC HEALTHSTART ENROLLMENT

Facility

$309.65

Service Code	HCPCS 99241
Hospital Charge Code	9400052
Hospital Revenue Code	510
Min. Negotiated Rate	$46.45
Max. Negotiated Rate	$46.45
Rate for Payer: Qualcare PPO/HMO/WC	$46.45

FHC HEARING REFERRAL

Facility

$128.85

Service Code	HCPCS 92700EP
Hospital Charge Code	9400099
Hospital Revenue Code	444
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$19.33
Rate for Payer: Qualcare PPO/HMO/WC	$19.33

FHC HEARING REFERRAL

Facility

$128.85

Service Code	HCPCS 92700EP
Hospital Charge Code	9400099
Hospital Revenue Code	444
Min. Negotiated Rate	$3.11
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$48.96
Rate for Payer: Aetna Medicare Advantage	$38.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$32.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$32.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$32.86
Rate for Payer: Cigna Commercial	$64.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$38.66
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.33
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$3.11
Rate for Payer: Wellpoint Medicaid Managed Care	$3.41

Know your out-of-pocket cost for care.

All Charges