Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

INFANT FORMULA 24CAL/02 NATURA

Facility

$104.00

Hospital Charge Code	60628855
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$39.52
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.20
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$20.80
Rate for Payer: UnitedHealthcare Community & State	$2.51
Rate for Payer: Wellpoint Medicaid Managed Care	$2.76

INFANT FORMULA 24CAL/02 SPEC

Facility

$104.00

Hospital Charge Code	60628856
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Qualcare PPO/HMO/WC	$15.60

INFANT FORMULA 24CAL/02 SPEC

Facility

$104.00

Hospital Charge Code	60628856
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$39.52
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.20
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$20.80
Rate for Payer: UnitedHealthcare Community & State	$2.51
Rate for Payer: Wellpoint Medicaid Managed Care	$2.76

INFANT FORMULA 60 ML BTL

Facility

$30.00

Hospital Charge Code	60628938
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$4.50

INFANT FORMULA 60 ML BTL

Facility

$30.00

Hospital Charge Code	60628938
Hospital Revenue Code	270
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare Advantage	$9.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.65
Rate for Payer: Cigna Commercial	$15.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.00
Rate for Payer: Oxford Commercial	$6.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.50
Rate for Payer: UnitedHealthcare Commercial	$6.00
Rate for Payer: UnitedHealthcare Community & State	$0.72
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

INFANT FORMULA HYPOALLER 960ML

Facility

$104.00

Hospital Charge Code	60628770
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$39.52
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.20
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$20.80
Rate for Payer: UnitedHealthcare Community & State	$2.51
Rate for Payer: Wellpoint Medicaid Managed Care	$2.76

INFANT FORMULA HYPOALLER 960ML

Facility

$104.00

Hospital Charge Code	60628770
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Qualcare PPO/HMO/WC	$15.60

INFANT FORMULA SOY DIARRHEA

Facility

$17.00

Hospital Charge Code	60628824
Hospital Revenue Code	270
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Qualcare PPO/HMO/WC	$2.55

INFANT FORMULA SOY DIARRHEA

Facility

$17.00

Hospital Charge Code	60628824
Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna Commercial	$6.46
Rate for Payer: Aetna Medicare Advantage	$5.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.33
Rate for Payer: Cigna Commercial	$8.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.10
Rate for Payer: Oxford Commercial	$3.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.55
Rate for Payer: UnitedHealthcare Commercial	$3.40
Rate for Payer: UnitedHealthcare Community & State	$0.41
Rate for Payer: Wellpoint Medicaid Managed Care	$0.45

INFANT FORMULA W/ IRON

Facility

$3.75

Hospital Charge Code	60629106
Hospital Revenue Code	272
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.56
Rate for Payer: Qualcare PPO/HMO/WC	$0.56

INFANT FORMULA W/ IRON

Facility

$3.75

Hospital Charge Code	60629106
Hospital Revenue Code	272
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna Commercial	$1.43
Rate for Payer: Aetna Medicare Advantage	$1.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.96
Rate for Payer: Cigna Commercial	$1.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.12
Rate for Payer: Oxford Commercial	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.56
Rate for Payer: UnitedHealthcare Commercial	$0.75
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.10

INFANT FORMULA W/ IRON 960ML

Facility

$16.20

Service Code	HCPCS B9998
Hospital Charge Code	600628744
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$2.43
Rate for Payer: Qualcare PPO/HMO/WC	$2.43

INFANT FORMULA W/ IRON 960ML

Facility

$16.20

Service Code	HCPCS B9998
Hospital Charge Code	600628744
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Aetna Medicare Advantage	$4.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.13
Rate for Payer: Cigna Commercial	$8.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.86
Rate for Payer: Oxford Commercial	$3.24
Rate for Payer: Qualcare PPO/HMO/WC	$2.43
Rate for Payer: UnitedHealthcare Commercial	$3.24
Rate for Payer: UnitedHealthcare Community & State	$0.39
Rate for Payer: Wellpoint Medicaid Managed Care	$0.43

INFANT FORMULA W/ IRON 960ML

Facility

$104.00

Hospital Charge Code	60628744
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Qualcare PPO/HMO/WC	$15.60

INFANT FORMULA W/ IRON 960ML

Facility

$104.00

Hospital Charge Code	60628744
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$39.52
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.20
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$20.80
Rate for Payer: UnitedHealthcare Community & State	$2.51
Rate for Payer: Wellpoint Medicaid Managed Care	$2.76

INFANT PROFILE***

Facility

$38.00

Service Code	HCPCS 80054
Hospital Charge Code	3003597
Hospital Revenue Code	301
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$14.44
Rate for Payer: Aetna Medicare Advantage	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.69
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.70
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$0.92
Rate for Payer: Wellpoint Medicaid Managed Care	$1.01

INFANT PROFILE***

Facility

$38.00

Service Code	HCPCS 80054
Hospital Charge Code	3003597
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$5.70
Rate for Payer: Qualcare PPO/HMO/WC	$5.70

INF CONCONURRENT THERAPEUTIC

Facility

$2,800.00

Service Code	HCPCS 96368
Hospital Charge Code	395096368
Hospital Revenue Code	260
Min. Negotiated Rate	$21.68
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,064.00
Rate for Payer: Aetna Medicare Advantage	$840.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$714.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$714.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$714.00
Rate for Payer: Cigna Commercial	$1,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$840.00
Rate for Payer: Oxford Commercial	$707.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00
Rate for Payer: UnitedHealthcare Commercial	$919.00
Rate for Payer: UnitedHealthcare Community & State	$67.48
Rate for Payer: Wellpoint Medicaid Managed Care	$74.20

INF CONCONURRENT THERAPEUTIC

Facility

$2,800.00

Service Code	HCPCS 96368
Hospital Charge Code	395096368
Hospital Revenue Code	260
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$420.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00

INF CONCURRENT THERAPEUTIC

Facility

$145.60

Service Code	HCPCS 96368
Hospital Charge Code	8200518
Hospital Revenue Code	260
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$21.84
Rate for Payer: Qualcare PPO/HMO/WC	$21.84

INF CONCURRENT THERAPEUTIC

Facility

$2,800.00

Service Code	HCPCS 96368
Hospital Charge Code	93500047
Hospital Revenue Code	260
Min. Negotiated Rate	$21.68
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,064.00
Rate for Payer: Aetna Medicare Advantage	$840.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$714.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$714.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$714.00
Rate for Payer: Cigna Commercial	$1,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$840.00
Rate for Payer: Oxford Commercial	$707.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00
Rate for Payer: UnitedHealthcare Commercial	$919.00
Rate for Payer: UnitedHealthcare Community & State	$67.48
Rate for Payer: Wellpoint Medicaid Managed Care	$74.20

INF CONCURRENT THERAPEUTIC

Facility

$145.60

Service Code	HCPCS 96368
Hospital Charge Code	5700405
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$55.33
Rate for Payer: Aetna Medicare Advantage	$43.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$37.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$37.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$37.13
Rate for Payer: Cigna Commercial	$72.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.68
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.84
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: Wellpoint Medicaid Managed Care	$3.86

INF CONCURRENT THERAPEUTIC

Facility

$111.00

Service Code	HCPCS 96368
Hospital Charge Code	73050930
Hospital Revenue Code	260
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$919.00
Rate for Payer: Aetna Commercial	$42.18
Rate for Payer: Aetna Medicare Advantage	$33.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.30
Rate for Payer: Cigna Commercial	$55.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.30
Rate for Payer: Oxford Commercial	$707.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.65
Rate for Payer: UnitedHealthcare Commercial	$919.00
Rate for Payer: UnitedHealthcare Community & State	$2.68
Rate for Payer: Wellpoint Medicaid Managed Care	$2.94

INF CONCURRENT THERAPEUTIC

Facility

$2,800.00

Service Code	HCPCS 96368
Hospital Charge Code	73190101
Hospital Revenue Code	260
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$420.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00

INF CONCURRENT THERAPEUTIC

Facility

$2,800.00

Service Code	HCPCS 96368
Hospital Charge Code	93500047
Hospital Revenue Code	260
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$420.00
Rate for Payer: Qualcare PPO/HMO/WC	$420.00

Know your out-of-pocket cost for care.

All Charges