Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

IMM ADM BY NASL/ORAL @ ADDTL

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	87502415
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM ADM BY NASL/ORAL @ ADDTL

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	87502415
Hospital Revenue Code	771
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$59.28
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$78.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$46.80
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$3.76
Rate for Payer: Wellpoint Medicaid Managed Care	$4.13

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	83652299
Hospital Revenue Code	771
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$308.77
Rate for Payer: Aetna Commercial	$232.67
Rate for Payer: Aetna Medicare Advantage	$277.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$308.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$308.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$85.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$308.77
Rate for Payer: Cigna Commercial	$171.47
Rate for Payer: Cigna Medicare Advantage	$85.54
Rate for Payer: Clover Medicare Advantage	$81.26
Rate for Payer: EmblemHealth Commercial	$256.62
Rate for Payer: Humana Medicare Advantage	$88.11
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$85.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$46.80
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$3.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$85.54
Rate for Payer: Wellcare Medicare Advantage	$85.54
Rate for Payer: Wellpoint Medicaid Managed Care	$4.13

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	83652299
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	87502395
Hospital Revenue Code	771
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$308.77
Rate for Payer: Aetna Commercial	$232.67
Rate for Payer: Aetna Medicare Advantage	$277.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$308.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$308.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$85.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$308.77
Rate for Payer: Cigna Commercial	$171.47
Rate for Payer: Cigna Medicare Advantage	$85.54
Rate for Payer: Clover Medicare Advantage	$81.26
Rate for Payer: EmblemHealth Commercial	$256.62
Rate for Payer: Humana Medicare Advantage	$88.11
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$85.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$46.80
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$3.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$85.54
Rate for Payer: Wellcare Medicare Advantage	$85.54
Rate for Payer: Wellpoint Medicaid Managed Care	$4.13

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	87502395
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	73050810
Hospital Revenue Code	771
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$11.78
Rate for Payer: Aetna Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.91
Rate for Payer: Cigna Commercial	$15.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.30
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.65
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$0.75
Rate for Payer: Wellpoint Medicaid Managed Care	$0.82

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	73050810
Hospital Revenue Code	771
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$4.65
Rate for Payer: Qualcare PPO/HMO/WC	$4.65

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	83652293
Hospital Revenue Code	771
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$4.65
Rate for Payer: Qualcare PPO/HMO/WC	$4.65

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	83652293
Hospital Revenue Code	771
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$11.78
Rate for Payer: Aetna Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.91
Rate for Payer: Cigna Commercial	$15.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.30
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.65
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$0.75
Rate for Payer: Wellpoint Medicaid Managed Care	$0.82

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	73050805
Hospital Revenue Code	771
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$15.58
Rate for Payer: Aetna Medicare Advantage	$12.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.46
Rate for Payer: Cigna Commercial	$20.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.30
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.15
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$0.99
Rate for Payer: Wellpoint Medicaid Managed Care	$1.09

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	83652291
Hospital Revenue Code	771
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$15.58
Rate for Payer: Aetna Medicare Advantage	$12.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.46
Rate for Payer: Cigna Commercial	$20.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.30
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.15
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$0.99
Rate for Payer: Wellpoint Medicaid Managed Care	$1.09

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	73050805
Hospital Revenue Code	771
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: Qualcare PPO/HMO/WC	$6.15

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	83652291
Hospital Revenue Code	771
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: Qualcare PPO/HMO/WC	$6.15

IMM GLOB 50MG/ML 10GM/200ML

Facility

$9,460.40

Service Code	HCPCS J1568
Hospital Charge Code	60635794
Hospital Revenue Code	636
Min. Negotiated Rate	$1,419.06
Max. Negotiated Rate	$2,289.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,289.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,419.06

IMM GLOB 50MG/ML 10GM/200ML

Facility

$9,460.40

Service Code	HCPCS J1568
Hospital Charge Code	60635794
Hospital Revenue Code	636
Min. Negotiated Rate	$44.69
Max. Negotiated Rate	$2,289.42
Rate for Payer: Aetna Commercial	$127.95
Rate for Payer: Aetna Medicare Advantage	$152.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$169.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$169.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$47.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$49.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$169.80
Rate for Payer: Cigna Medicare Advantage	$47.04
Rate for Payer: Clover Medicare Advantage	$44.69
Rate for Payer: EmblemHealth Commercial	$141.12
Rate for Payer: Humana Medicare Advantage	$48.45
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$47.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,289.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,419.06
Rate for Payer: UnitedHealthcare Community & State	$228.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$47.04
Rate for Payer: Wellcare Medicare Advantage	$47.04
Rate for Payer: Wellpoint Medicaid Managed Care	$250.70

IMM GLOB GAMM 5% 10GM 200ML VL

Facility

$3,241.70

Hospital Charge Code	606350916
Hospital Revenue Code	636
Min. Negotiated Rate	$486.25
Max. Negotiated Rate	$784.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$784.49
Rate for Payer: Qualcare PPO/HMO/WC	$486.25

IMM GLOB GAMM 5% 10GM 200ML VL

Facility

$3,241.70

Hospital Charge Code	606350916
Hospital Revenue Code	636
Min. Negotiated Rate	$78.12
Max. Negotiated Rate	$1,620.85
Rate for Payer: Aetna Commercial	$1,231.85
Rate for Payer: Aetna Medicare Advantage	$972.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$826.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$826.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$826.63
Rate for Payer: Cigna Commercial	$1,620.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$784.49
Rate for Payer: Qualcare PPO/HMO/WC	$486.25
Rate for Payer: UnitedHealthcare Community & State	$78.12
Rate for Payer: Wellpoint Medicaid Managed Care	$85.91

IMM KNEE XX-LRG 22 1876-507-22

Facility

$135.00

Hospital Charge Code	270635397
Hospital Revenue Code	272
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare Advantage	$40.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.42
Rate for Payer: Cigna Commercial	$67.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.50
Rate for Payer: Oxford Commercial	$27.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.25
Rate for Payer: UnitedHealthcare Commercial	$27.00
Rate for Payer: UnitedHealthcare Community & State	$3.25
Rate for Payer: Wellpoint Medicaid Managed Care	$3.58

IMM KNEE XX-LRG 22 1876-507-22

Facility

$135.00

Hospital Charge Code	270635397
Hospital Revenue Code	272
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$20.25
Rate for Payer: Qualcare PPO/HMO/WC	$20.25

IMMOBILIZER HAND XL DISP

Facility

$151.33

Hospital Charge Code	270642434
Hospital Revenue Code	272
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$75.67
Rate for Payer: Aetna Commercial	$57.51
Rate for Payer: Aetna Medicare Advantage	$45.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.59
Rate for Payer: Cigna Commercial	$75.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.40
Rate for Payer: Oxford Commercial	$30.27
Rate for Payer: Qualcare PPO/HMO/WC	$22.70
Rate for Payer: UnitedHealthcare Commercial	$30.27
Rate for Payer: UnitedHealthcare Community & State	$3.65
Rate for Payer: Wellpoint Medicaid Managed Care	$4.01

IMMOBILIZER HAND XL DISP

Facility

$151.33

Hospital Charge Code	270642434
Hospital Revenue Code	272
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$22.70
Rate for Payer: Qualcare PPO/HMO/WC	$22.70

IMMOBILIZER KNEE *******

Facility

$102.00

Hospital Charge Code	8001935
Hospital Revenue Code	279
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$15.30
Rate for Payer: Qualcare PPO/HMO/WC	$15.30

IMMOBILIZER KNEE *******

Facility

$102.00

Hospital Charge Code	8001935
Hospital Revenue Code	279
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$38.76
Rate for Payer: Aetna Medicare Advantage	$30.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.01
Rate for Payer: Cigna Commercial	$51.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$30.60
Rate for Payer: Oxford Commercial	$20.40
Rate for Payer: Qualcare PPO/HMO/WC	$15.30
Rate for Payer: UnitedHealthcare Commercial	$20.40
Rate for Payer: UnitedHealthcare Community & State	$2.46
Rate for Payer: Wellpoint Medicaid Managed Care	$2.70

IMMOBILIZER KNEE 16 UNIVERSAL

Facility

$51.90

Service Code	HCPCS L1830
Hospital Charge Code	270650067
Hospital Revenue Code	274
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$12.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$10.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$11.42
Rate for Payer: Qualcare PPO/HMO/WC	$7.79

Know your out-of-pocket cost for care.

All Charges