Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

IMWD 4X5 DOMESTIC

Facility

$12,155.00

Service Code	HCPCS Q4108
Hospital Charge Code	270660226
Hospital Revenue Code	278
Min. Negotiated Rate	$1,823.25
Max. Negotiated Rate	$2,941.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,431.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,941.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,674.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,823.25

IMWD 4X5 DOMESTIC

Facility

$12,155.00

Service Code	HCPCS Q4108
Hospital Charge Code	270660226
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,941.51
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,431.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,941.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,674.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,823.25
Rate for Payer: UnitedHealthcare Community & State	$292.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$322.11

In-111 Chloride

Facility

$2,677.25

Hospital Charge Code	4509078
Hospital Revenue Code	343
Min. Negotiated Rate	$64.52
Max. Negotiated Rate	$1,338.62
Rate for Payer: Aetna Commercial	$1,017.36
Rate for Payer: Aetna Medicare Advantage	$803.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$682.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$682.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$682.70
Rate for Payer: Cigna Commercial	$1,338.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$803.17
Rate for Payer: Qualcare PPO/HMO/WC	$401.59
Rate for Payer: UnitedHealthcare Community & State	$64.52
Rate for Payer: Wellpoint Medicaid Managed Care	$70.95

In-111 Chloride

Facility

$2,677.25

Hospital Charge Code	4509078
Hospital Revenue Code	343
Min. Negotiated Rate	$401.59
Max. Negotiated Rate	$401.59
Rate for Payer: Qualcare PPO/HMO/WC	$401.59

IN 111 LABELED WBC 20.0 MCI

Facility

$258.67

Hospital Charge Code	4509094
Hospital Revenue Code	343
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$129.34
Rate for Payer: Aetna Commercial	$98.29
Rate for Payer: Aetna Medicare Advantage	$77.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$65.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$65.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$65.96
Rate for Payer: Cigna Commercial	$129.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.60
Rate for Payer: Qualcare PPO/HMO/WC	$38.80
Rate for Payer: UnitedHealthcare Community & State	$6.23
Rate for Payer: Wellpoint Medicaid Managed Care	$6.85

IN 111 LABELED WBC 20.0 MCI

Facility

$258.67

Hospital Charge Code	4509094
Hospital Revenue Code	343
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

IN 111 LABELED WBC PER DOSE

Facility

$7,612.71

Service Code	HCPCS A9570
Hospital Charge Code	4509081
Hospital Revenue Code	343
Min. Negotiated Rate	$1,141.91
Max. Negotiated Rate	$1,141.91
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.91

IN 111 LABELED WBC PER DOSE

Facility

$7,612.71

Service Code	HCPCS A9570
Hospital Charge Code	4509081
Hospital Revenue Code	343
Min. Negotiated Rate	$183.47
Max. Negotiated Rate	$3,982.18
Rate for Payer: Aetna Commercial	$3,000.68
Rate for Payer: Aetna Medicare Advantage	$3,574.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,982.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,982.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,103.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$798.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,982.18
Rate for Payer: Cigna Medicare Advantage	$772.23
Rate for Payer: Clover Medicare Advantage	$1,048.03
Rate for Payer: EmblemHealth Commercial	$3,309.57
Rate for Payer: Humana Medicare Advantage	$1,136.29
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,103.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,283.81
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.91
Rate for Payer: UnitedHealthcare Community & State	$183.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,103.19
Rate for Payer: Wellcare Medicare Advantage	$1,103.19
Rate for Payer: Wellpoint Medicaid Managed Care	$201.74

IN 111 PENTETATE PER 0.5 MCI

Facility

$6,984.14

Hospital Charge Code	4509079
Hospital Revenue Code	343
Min. Negotiated Rate	$1,047.62
Max. Negotiated Rate	$1,047.62
Rate for Payer: Qualcare PPO/HMO/WC	$1,047.62

IN 111 PENTETATE PER 0.5 MCI

Facility

$6,984.14

Hospital Charge Code	4509079
Hospital Revenue Code	343
Min. Negotiated Rate	$168.32
Max. Negotiated Rate	$3,492.07
Rate for Payer: Aetna Commercial	$2,653.97
Rate for Payer: Aetna Medicare Advantage	$2,095.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,780.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,780.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,780.96
Rate for Payer: Cigna Commercial	$3,492.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,095.24
Rate for Payer: Qualcare PPO/HMO/WC	$1,047.62
Rate for Payer: UnitedHealthcare Community & State	$168.32
Rate for Payer: Wellpoint Medicaid Managed Care	$185.08

IN-111 PENTETREOTIDE PER DOSE

Facility

$12,338.65

Service Code	HCPCS A9572
Hospital Charge Code	4509080
Hospital Revenue Code	343
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$7,222.79
Rate for Payer: Aetna Commercial	$5,442.56
Rate for Payer: Aetna Medicare Advantage	$6,483.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,222.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,222.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,000.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,482.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,222.79
Rate for Payer: Cigna Medicare Advantage	$1,400.66
Rate for Payer: Clover Medicare Advantage	$1,900.89
Rate for Payer: EmblemHealth Commercial	$6,002.82
Rate for Payer: Humana Medicare Advantage	$2,060.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,000.94
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,701.59
Rate for Payer: Qualcare PPO/HMO/WC	$1,850.80
Rate for Payer: UnitedHealthcare Community & State	$297.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,000.94
Rate for Payer: Wellcare Medicare Advantage	$2,000.94
Rate for Payer: Wellpoint Medicaid Managed Care	$326.97

IN-111 PENTETREOTIDE PER DOSE

Facility

$12,338.65

Service Code	HCPCS A9572
Hospital Charge Code	4509080
Hospital Revenue Code	343
Min. Negotiated Rate	$1,850.80
Max. Negotiated Rate	$1,850.80
Rate for Payer: Qualcare PPO/HMO/WC	$1,850.80

INBONE SCREW REMOVAL

Facility

$680.00

Hospital Charge Code	270687135
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$102.00
Rate for Payer: Qualcare PPO/HMO/WC	$102.00

INBONE SCREW REMOVAL

Facility

$680.00

Hospital Charge Code	270687135
Hospital Revenue Code	272
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$340.00
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Aetna Medicare Advantage	$204.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$173.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$173.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$173.40
Rate for Payer: Cigna Commercial	$340.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$204.00
Rate for Payer: Oxford Commercial	$136.00
Rate for Payer: Qualcare PPO/HMO/WC	$102.00
Rate for Payer: UnitedHealthcare Commercial	$136.00
Rate for Payer: UnitedHealthcare Community & State	$16.39
Rate for Payer: Wellpoint Medicaid Managed Care	$18.02

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$48,098.67

Service Code	MSDRG 642
Min. Negotiated Rate	$14,645.43
Max. Negotiated Rate	$48,098.67
Rate for Payer: Aetna Commercial	$33,306.59
Rate for Payer: Aetna Medicare Advantage	$48,098.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30,239.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30,239.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15,416.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30,239.30
Rate for Payer: Cigna Commercial	$26,613.18
Rate for Payer: Cigna Medicare Advantage	$15,416.24
Rate for Payer: Clover Medicare Advantage	$14,645.43
Rate for Payer: EmblemHealth Commercial	$46,248.72
Rate for Payer: Humana Medicare Advantage	$15,878.73
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15,416.24
Rate for Payer: Oxford Commercial	$19,127.24
Rate for Payer: UnitedHealthcare Commercial	$33,540.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$15,416.24
Rate for Payer: Wellcare Medicare Advantage	$15,416.24

INBORN ERRORS OF METABOLISM

Facility

$13,429.74

Service Code	APR-DRG 4233
Min. Negotiated Rate	$13,166.41
Max. Negotiated Rate	$13,429.74
Rate for Payer: UnitedHealthcare Community & State	$13,166.41
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$13,429.74
Rate for Payer: Wellpoint Medicaid Managed Care	$13,166.41

INBORN ERRORS OF METABOLISM

Facility

$31,317.69

Service Code	APR-DRG 4234
Min. Negotiated Rate	$30,703.62
Max. Negotiated Rate	$31,317.69
Rate for Payer: UnitedHealthcare Community & State	$30,703.62
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$31,317.69
Rate for Payer: Wellpoint Medicaid Managed Care	$30,703.62

INBORN ERRORS OF METABOLISM

Facility

$8,387.95

Service Code	APR-DRG 4232
Min. Negotiated Rate	$8,223.48
Max. Negotiated Rate	$8,387.95
Rate for Payer: UnitedHealthcare Community & State	$8,223.48
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$8,387.95
Rate for Payer: Wellpoint Medicaid Managed Care	$8,223.48

INBORN ERRORS OF METABOLISM

Facility

$6,598.03

Service Code	APR-DRG 4231
Min. Negotiated Rate	$6,468.66
Max. Negotiated Rate	$6,598.03
Rate for Payer: UnitedHealthcare Community & State	$6,468.66
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$6,598.03
Rate for Payer: Wellpoint Medicaid Managed Care	$6,468.66

INC ACHILLES TENDON W GN ANSTH

Facility

$19,467.90

Service Code	HCPCS 27606
Hospital Charge Code	16000479
Hospital Revenue Code	360
Min. Negotiated Rate	$469.18
Max. Negotiated Rate	$14,031.70
Rate for Payer: Aetna Commercial	$10,573.24
Rate for Payer: Aetna Medicare Advantage	$12,594.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,031.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,887.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14,031.70
Rate for Payer: Cigna Commercial	$7,791.93
Rate for Payer: Cigna Medicare Advantage	$3,887.22
Rate for Payer: Clover Medicare Advantage	$3,692.86
Rate for Payer: EmblemHealth Commercial	$11,661.66
Rate for Payer: Humana Medicare Advantage	$4,003.84
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,887.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,840.37
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,920.18
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$469.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,887.22
Rate for Payer: Wellcare Medicare Advantage	$3,887.22
Rate for Payer: Wellpoint Medicaid Managed Care	$515.90

INC ACHILLES TENDON W GN ANSTH

Facility

$19,467.90

Service Code	HCPCS 27606
Hospital Charge Code	16000479
Hospital Revenue Code	360
Min. Negotiated Rate	$2,920.18
Max. Negotiated Rate	$2,920.18
Rate for Payer: Qualcare PPO/HMO/WC	$2,920.18

INCENTIVE PROCEDURE SUPPLY****

Facility

$21.00

Hospital Charge Code	9500133
Hospital Revenue Code	279
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: Aetna Medicare Advantage	$6.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.36
Rate for Payer: Cigna Commercial	$10.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.30
Rate for Payer: Oxford Commercial	$4.20
Rate for Payer: Qualcare PPO/HMO/WC	$3.15
Rate for Payer: UnitedHealthcare Commercial	$4.20
Rate for Payer: UnitedHealthcare Community & State	$0.51
Rate for Payer: Wellpoint Medicaid Managed Care	$0.56

INCENTIVE PROCEDURE SUPPLY****

Facility

$21.00

Hospital Charge Code	9500133
Hospital Revenue Code	279
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.15
Rate for Payer: Qualcare PPO/HMO/WC	$3.15

INCENTIVE SPIROMETER 4000 ML

Facility

$9.95

Hospital Charge Code	270651469
Hospital Revenue Code	270
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$4.97
Rate for Payer: Aetna Commercial	$3.78
Rate for Payer: Aetna Medicare Advantage	$2.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.54
Rate for Payer: Cigna Commercial	$4.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.98
Rate for Payer: Oxford Commercial	$1.99
Rate for Payer: Qualcare PPO/HMO/WC	$1.49
Rate for Payer: UnitedHealthcare Commercial	$1.99
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

INCENTIVE SPIROMETER 4000 ML

Facility

$9.95

Hospital Charge Code	270651469
Hospital Revenue Code	270
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$1.49
Rate for Payer: Qualcare PPO/HMO/WC	$1.49

Know your out-of-pocket cost for care.

All Charges