Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

AMPICILLIN SODIUM 250 MG VIAL

Facility

$18.09

Service Code	HCPCS J0290
Hospital Charge Code	60627292
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$9.04
Rate for Payer: Aetna Commercial	$6.87
Rate for Payer: Aetna Medicare Advantage	$5.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.61
Rate for Payer: Cigna Commercial	$9.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.38
Rate for Payer: Qualcare PPO/HMO/WC	$2.71
Rate for Payer: UnitedHealthcare Community & State	$0.44
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

AMPICILLIN SODIUM 250 MG VIAL

Facility

$15.65

Hospital Charge Code	60627292A
Hospital Revenue Code	250
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$2.35
Rate for Payer: Qualcare PPO/HMO/WC	$2.35

AMPICILLIN SODIUM 250 MG VIAL

Facility

$15.65

Hospital Charge Code	60627292A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$7.83
Rate for Payer: Aetna Commercial	$5.95
Rate for Payer: Aetna Medicare Advantage	$4.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.99
Rate for Payer: Cigna Commercial	$7.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.70
Rate for Payer: Oxford Commercial	$3.13
Rate for Payer: Qualcare PPO/HMO/WC	$2.35
Rate for Payer: UnitedHealthcare Commercial	$3.13
Rate for Payer: UnitedHealthcare Community & State	$0.38
Rate for Payer: Wellpoint Medicaid Managed Care	$0.41

AMPICILLIN SODIUM 2 GM VIAL

Facility

$63.85

Service Code	HCPCS J0290
Hospital Charge Code	60627293
Hospital Revenue Code	636
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$15.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.45
Rate for Payer: Qualcare PPO/HMO/WC	$9.58

AMPICILLIN SODIUM 2 GM VIAL

Facility

$63.85

Service Code	HCPCS J0290
Hospital Charge Code	60627293
Hospital Revenue Code	636
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$31.93
Rate for Payer: Aetna Commercial	$24.26
Rate for Payer: Aetna Medicare Advantage	$19.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16.28
Rate for Payer: Cigna Commercial	$31.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.45
Rate for Payer: Qualcare PPO/HMO/WC	$9.58
Rate for Payer: UnitedHealthcare Community & State	$1.54
Rate for Payer: Wellpoint Medicaid Managed Care	$1.69

AMPICILLIN SODIUM 500 MG VIAL

Facility

$19.77

Service Code	HCPCS J0290
Hospital Charge Code	60627295
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$4.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.78
Rate for Payer: Qualcare PPO/HMO/WC	$2.97

AMPICILLIN SODIUM 500 MG VIAL

Facility

$19.77

Service Code	HCPCS J0290
Hospital Charge Code	60627295
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna Commercial	$7.51
Rate for Payer: Aetna Medicare Advantage	$5.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.04
Rate for Payer: Cigna Commercial	$9.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.78
Rate for Payer: Qualcare PPO/HMO/WC	$2.97
Rate for Payer: UnitedHealthcare Community & State	$0.48
Rate for Payer: Wellpoint Medicaid Managed Care	$0.52

AMPICILLIN SSP 250MG/5ML

Facility

$4.36

Service Code	NDC 67253018310
Hospital Charge Code	60627299
Hospital Revenue Code	251
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.65
Rate for Payer: Qualcare PPO/HMO/WC	$0.65

AMPICILLIN SSP 250MG/5ML

Facility

$4.36

Service Code	NDC 67253018310
Hospital Charge Code	60627299
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$1.66
Rate for Payer: Aetna Medicare Advantage	$1.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.11
Rate for Payer: Cigna Commercial	$2.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.31
Rate for Payer: Oxford Commercial	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.65
Rate for Payer: UnitedHealthcare Commercial	$0.87
Rate for Payer: UnitedHealthcare Community & State	$0.11
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

AMPICILLIN SULBAC 1.5GM IM INJ

Facility

$41.60

Hospital Charge Code	60627301
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$6.24
Rate for Payer: Qualcare PPO/HMO/WC	$6.24

AMPICILLIN SULBAC 1.5GM IM INJ

Facility

$41.60

Hospital Charge Code	60627301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna Commercial	$15.81
Rate for Payer: Aetna Medicare Advantage	$12.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.61
Rate for Payer: Cigna Commercial	$20.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.48
Rate for Payer: Oxford Commercial	$8.32
Rate for Payer: Qualcare PPO/HMO/WC	$6.24
Rate for Payer: UnitedHealthcare Commercial	$8.32
Rate for Payer: UnitedHealthcare Community & State	$1.00
Rate for Payer: Wellpoint Medicaid Managed Care	$1.10

AMPICILLIN/SULBACTAM

Facility

$70.82

Service Code	HCPCS J0295
Hospital Charge Code	6006571
Hospital Revenue Code	636
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$17.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.14
Rate for Payer: Qualcare PPO/HMO/WC	$10.62

AMPICILLIN/SULBACTAM

Facility

$115.37

Service Code	HCPCS J0295
Hospital Charge Code	6007504
Hospital Revenue Code	636
Min. Negotiated Rate	$17.31
Max. Negotiated Rate	$27.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.92
Rate for Payer: Qualcare PPO/HMO/WC	$17.31

AMPICILLIN/SULBACTAM

Facility

$70.82

Service Code	HCPCS J0295
Hospital Charge Code	6006571
Hospital Revenue Code	636
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$35.41
Rate for Payer: Aetna Commercial	$26.91
Rate for Payer: Aetna Medicare Advantage	$21.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.06
Rate for Payer: Cigna Commercial	$35.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.14
Rate for Payer: Qualcare PPO/HMO/WC	$10.62
Rate for Payer: UnitedHealthcare Community & State	$1.71
Rate for Payer: Wellpoint Medicaid Managed Care	$1.88

AMPICILLIN/SULBACTAM

Facility

$115.37

Service Code	HCPCS J0295
Hospital Charge Code	6007504
Hospital Revenue Code	636
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$57.69
Rate for Payer: Aetna Commercial	$43.84
Rate for Payer: Aetna Medicare Advantage	$34.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.42
Rate for Payer: Cigna Commercial	$57.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.92
Rate for Payer: Qualcare PPO/HMO/WC	$17.31
Rate for Payer: UnitedHealthcare Community & State	$2.78
Rate for Payer: Wellpoint Medicaid Managed Care	$3.06

AMPLATZER VASCULAR PLUG II 8MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679200O
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

AMPLATZER VASCULAR PLUG II 8MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679200
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

AMPLATZER VASCULAR PLUG II 8MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679200
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

AMPLATZER VASCULAR PLUG II 8MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679200O
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

AMPLATZER VASCUL PLUG II 10MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679201
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

AMPLATZER VASCUL PLUG II 10MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679201O
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

AMPLATZER VASCUL PLUG II 10MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679201
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

AMPLATZER VASCUL PLUG II 10MM

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679201O
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

AMPLATZER VASCUL PLUG II 12mm

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679202
Hospital Revenue Code	278
Min. Negotiated Rate	$787.50
Max. Negotiated Rate	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50

AMPLATZER VASCUL PLUG II 12mm

Facility

$5,250.00

Service Code	HCPCS C1768
Hospital Charge Code	270679202
Hospital Revenue Code	278
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$1,995.00
Rate for Payer: Aetna Medicare Advantage	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,338.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,338.75
Rate for Payer: Cigna Commercial	$2,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,270.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,155.00
Rate for Payer: Qualcare PPO/HMO/WC	$787.50
Rate for Payer: UnitedHealthcare Community & State	$126.53
Rate for Payer: Wellpoint Medicaid Managed Care	$139.12

Know your out-of-pocket cost for care.

All Charges