Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

INDIV PT IP/PH 45-50M W/ E/M**

Facility

$838.00

Service Code	HCPCS 90819
Hospital Charge Code	50020
Hospital Revenue Code	914
Min. Negotiated Rate	$20.20
Max. Negotiated Rate	$419.00
Rate for Payer: Aetna Commercial	$318.44
Rate for Payer: Aetna Medicare Advantage	$251.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$213.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$213.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$213.69
Rate for Payer: Cigna Commercial	$419.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$251.40
Rate for Payer: Qualcare PPO/HMO/WC	$125.70
Rate for Payer: UnitedHealthcare Community & State	$20.20
Rate for Payer: Wellpoint Medicaid Managed Care	$22.21

INDIV PT IP/PH 45-50M W/ E/M**

Facility

$838.00

Service Code	HCPCS 90819
Hospital Charge Code	50020
Hospital Revenue Code	914
Min. Negotiated Rate	$125.70
Max. Negotiated Rate	$125.70
Rate for Payer: Qualcare PPO/HMO/WC	$125.70

INDIV PT IP/PH 45-50M W/O E/M

Facility

$165.80

Service Code	HCPCS 90818
Hospital Charge Code	50004
Hospital Revenue Code	914
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$82.90
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: Aetna Medicare Advantage	$49.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$42.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$42.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$42.28
Rate for Payer: Cigna Commercial	$82.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$49.74
Rate for Payer: Qualcare PPO/HMO/WC	$24.87
Rate for Payer: UnitedHealthcare Community & State	$4.00
Rate for Payer: Wellpoint Medicaid Managed Care	$4.39

INDIV PT IP/PH 45-50M W/O E/M

Facility

$165.80

Service Code	HCPCS 90818
Hospital Charge Code	50004
Hospital Revenue Code	914
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$24.87
Rate for Payer: Qualcare PPO/HMO/WC	$24.87

INDIV PT THER OP 30-45M W/O EM

Facility

$245.80

Service Code	HCPCS 90804
Hospital Charge Code	9310086
Hospital Revenue Code	914
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$122.90
Rate for Payer: Aetna Commercial	$93.40
Rate for Payer: Aetna Medicare Advantage	$73.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$62.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$62.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$62.68
Rate for Payer: Cigna Commercial	$122.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$73.74
Rate for Payer: Qualcare PPO/HMO/WC	$36.87
Rate for Payer: UnitedHealthcare Community & State	$5.92
Rate for Payer: Wellpoint Medicaid Managed Care	$6.51

INDIV PT THER OP 30-45M W/O EM

Facility

$245.80

Service Code	HCPCS 90804
Hospital Charge Code	9310086
Hospital Revenue Code	914
Min. Negotiated Rate	$36.87
Max. Negotiated Rate	$36.87
Rate for Payer: Qualcare PPO/HMO/WC	$36.87

INDIV PT THER OP 45-50M W/ E/M

Facility

$409.00

Service Code	HCPCS 90807
Hospital Charge Code	9310083
Hospital Revenue Code	914
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$204.50
Rate for Payer: Aetna Commercial	$155.42
Rate for Payer: Aetna Medicare Advantage	$122.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$104.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$104.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$104.30
Rate for Payer: Cigna Commercial	$204.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$122.70
Rate for Payer: Qualcare PPO/HMO/WC	$61.35
Rate for Payer: UnitedHealthcare Community & State	$9.86
Rate for Payer: Wellpoint Medicaid Managed Care	$10.84

INDIV PT THER OP 45-50M W/ E/M

Facility

$409.00

Service Code	HCPCS 90807
Hospital Charge Code	9310083
Hospital Revenue Code	914
Min. Negotiated Rate	$61.35
Max. Negotiated Rate	$61.35
Rate for Payer: Qualcare PPO/HMO/WC	$61.35

INDIV PT THER OP 45-50M W/O EM

Facility

$449.95

Service Code	HCPCS 90806
Hospital Charge Code	9310080
Hospital Revenue Code	914
Min. Negotiated Rate	$67.49
Max. Negotiated Rate	$67.49
Rate for Payer: Qualcare PPO/HMO/WC	$67.49

INDIV PT THER OP 45-50M W/O EM

Facility

$449.95

Service Code	HCPCS 90806
Hospital Charge Code	9310080
Hospital Revenue Code	914
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$224.97
Rate for Payer: Aetna Commercial	$170.98
Rate for Payer: Aetna Medicare Advantage	$134.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$114.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$114.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$114.74
Rate for Payer: Cigna Commercial	$224.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$134.99
Rate for Payer: Qualcare PPO/HMO/WC	$67.49
Rate for Payer: UnitedHealthcare Community & State	$10.84
Rate for Payer: Wellpoint Medicaid Managed Care	$11.92

INDIV.THERAPY 20-30 MTS

Facility

$1,296.00

Service Code	HCPCS 90804
Hospital Charge Code	84504020
Hospital Revenue Code	914
Min. Negotiated Rate	$31.23
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna Commercial	$492.48
Rate for Payer: Aetna Medicare Advantage	$388.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$330.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$330.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$330.48
Rate for Payer: Cigna Commercial	$648.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$388.80
Rate for Payer: Qualcare PPO/HMO/WC	$194.40
Rate for Payer: UnitedHealthcare Community & State	$31.23
Rate for Payer: Wellpoint Medicaid Managed Care	$34.34

INDIV.THERAPY 20-30 MTS

Facility

$1,296.00

Service Code	HCPCS 90804
Hospital Charge Code	84504020
Hospital Revenue Code	914
Min. Negotiated Rate	$194.40
Max. Negotiated Rate	$194.40
Rate for Payer: Qualcare PPO/HMO/WC	$194.40

INDOCIN/50MG/EACH

Facility

$8.00

Hospital Charge Code	60633179
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.04
Rate for Payer: Aetna Medicare Advantage	$2.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.04
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.40
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$1.20
Rate for Payer: UnitedHealthcare Commercial	$1.60
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.21

INDOCIN/50MG/EACH

Facility

$8.00

Hospital Charge Code	60633179
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

INDOCIN 50MG SUPP

Facility

$1,136.52

Service Code	NDC 69344010233
Hospital Charge Code	60630246
Hospital Revenue Code	250
Min. Negotiated Rate	$170.48
Max. Negotiated Rate	$170.48
Rate for Payer: Qualcare PPO/HMO/WC	$170.48

INDOCIN 50MG SUPP

Facility

$1,136.52

Service Code	NDC 69344010233
Hospital Charge Code	60630246
Hospital Revenue Code	250
Min. Negotiated Rate	$27.39
Max. Negotiated Rate	$568.26
Rate for Payer: Aetna Commercial	$431.88
Rate for Payer: Aetna Medicare Advantage	$340.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$289.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$289.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$289.81
Rate for Payer: Cigna Commercial	$568.26
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$340.96
Rate for Payer: Oxford Commercial	$227.30
Rate for Payer: Qualcare PPO/HMO/WC	$170.48
Rate for Payer: UnitedHealthcare Commercial	$227.30
Rate for Payer: UnitedHealthcare Community & State	$27.39
Rate for Payer: Wellpoint Medicaid Managed Care	$30.12

INDOCIN SR/75MG/CAP

Facility

$8.00

Hospital Charge Code	60633180
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

INDOCIN SR/75MG/CAP

Facility

$8.00

Hospital Charge Code	60633180
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.04
Rate for Payer: Aetna Medicare Advantage	$2.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.04
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.40
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$1.20
Rate for Payer: UnitedHealthcare Commercial	$1.60
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.21

INDOCYANINE GREEN

Facility

$916.02

Service Code	NDC 17478070102
Hospital Charge Code	60635705
Hospital Revenue Code	250
Min. Negotiated Rate	$22.08
Max. Negotiated Rate	$458.01
Rate for Payer: Aetna Commercial	$348.09
Rate for Payer: Aetna Medicare Advantage	$274.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$233.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$233.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$233.59
Rate for Payer: Cigna Commercial	$458.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$274.81
Rate for Payer: Oxford Commercial	$183.20
Rate for Payer: Qualcare PPO/HMO/WC	$137.40
Rate for Payer: UnitedHealthcare Commercial	$183.20
Rate for Payer: UnitedHealthcare Community & State	$22.08
Rate for Payer: Wellpoint Medicaid Managed Care	$24.27

INDOCYANINE GREEN

Facility

$916.02

Service Code	NDC 17478070102
Hospital Charge Code	60635705
Hospital Revenue Code	250
Min. Negotiated Rate	$137.40
Max. Negotiated Rate	$137.40
Rate for Payer: Qualcare PPO/HMO/WC	$137.40

INDOMETHACIN 25 MG CAP

Facility

$4.00

Service Code	NDC 93402901
Hospital Charge Code	60627684
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

INDOMETHACIN 25 MG CAP

Facility

$4.00

Service Code	NDC 93402901
Hospital Charge Code	60627684
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633182
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633182
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

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633181
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

Know your out-of-pocket cost for care.

All Charges