Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

IODIXANOL(VISIP) 320/ML 200ML

Facility

$5.96

Service Code	HCPCS Q9967
Hospital Charge Code	60630206
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna Commercial	$2.26
Rate for Payer: Aetna Medicare Advantage	$1.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.52
Rate for Payer: Cigna Commercial	$2.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.44
Rate for Payer: Qualcare PPO/HMO/WC	$0.89
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

IODIXANOL(VISIP) 320/ML 200ML

Facility

$5.96

Service Code	HCPCS Q9967
Hospital Charge Code	60630206
Hospital Revenue Code	636
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.44
Rate for Payer: Qualcare PPO/HMO/WC	$0.89

IODOFORM PACKING STRIP 1"

Facility

$30.15

Service Code	NDC 8080783300
Hospital Charge Code	6063943114
Hospital Revenue Code	270
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$4.52
Rate for Payer: Qualcare PPO/HMO/WC	$4.52

IODOFORM PACKING STRIP 1"

Facility

$30.15

Service Code	NDC 8080783300
Hospital Charge Code	6063943114
Hospital Revenue Code	270
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$15.07
Rate for Payer: Aetna Commercial	$11.46
Rate for Payer: Aetna Medicare Advantage	$9.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.69
Rate for Payer: Cigna Commercial	$15.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.04
Rate for Payer: Oxford Commercial	$6.03
Rate for Payer: Qualcare PPO/HMO/WC	$4.52
Rate for Payer: UnitedHealthcare Commercial	$6.03
Rate for Payer: UnitedHealthcare Community & State	$0.73
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

IODOFORM PACKING STRIP 1/2"

Facility

$25.66

Service Code	NDC 8080783200
Hospital Charge Code	6063943115
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$3.85
Rate for Payer: Qualcare PPO/HMO/WC	$3.85

IODOFORM PACKING STRIP 1/2"

Facility

$25.66

Service Code	NDC 8080783200
Hospital Charge Code	6063943115
Hospital Revenue Code	270
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$12.83
Rate for Payer: Aetna Commercial	$9.75
Rate for Payer: Aetna Medicare Advantage	$7.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.54
Rate for Payer: Cigna Commercial	$12.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.70
Rate for Payer: Oxford Commercial	$5.13
Rate for Payer: Qualcare PPO/HMO/WC	$3.85
Rate for Payer: UnitedHealthcare Commercial	$5.13
Rate for Payer: UnitedHealthcare Community & State	$0.62
Rate for Payer: Wellpoint Medicaid Managed Care	$0.68

IODOFORM PACKING STRIP 1/4"

Facility

$25.80

Service Code	NDC 8080783100
Hospital Charge Code	6063943116
Hospital Revenue Code	270
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$3.87
Rate for Payer: Qualcare PPO/HMO/WC	$3.87

IODOFORM PACKING STRIP 1/4"

Facility

$25.80

Service Code	NDC 8080783100
Hospital Charge Code	6063943116
Hospital Revenue Code	270
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$12.90
Rate for Payer: Aetna Commercial	$9.80
Rate for Payer: Aetna Medicare Advantage	$7.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.58
Rate for Payer: Cigna Commercial	$12.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.74
Rate for Payer: Oxford Commercial	$5.16
Rate for Payer: Qualcare PPO/HMO/WC	$3.87
Rate for Payer: UnitedHealthcare Commercial	$5.16
Rate for Payer: UnitedHealthcare Community & State	$0.62
Rate for Payer: Wellpoint Medicaid Managed Care	$0.68

IO EXPAND INTERB SYS 10X22MM L

Facility

$62,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698134
Hospital Revenue Code	278
Min. Negotiated Rate	$9,375.00
Max. Negotiated Rate	$15,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,125.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$13,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,375.00

IO EXPAND INTERB SYS 10X22MM L

Facility

$62,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698134
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.25
Max. Negotiated Rate	$31,250.00
Rate for Payer: Aetna Commercial	$23,750.00
Rate for Payer: Aetna Medicare Advantage	$18,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,937.50
Rate for Payer: Cigna Commercial	$31,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,125.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$13,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,375.00
Rate for Payer: UnitedHealthcare Community & State	$1,506.25
Rate for Payer: Wellpoint Medicaid Managed Care	$1,656.25

IO EXPAND INTERB SYS 10X26MM L

Facility

$62,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698135
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.25
Max. Negotiated Rate	$31,250.00
Rate for Payer: Aetna Commercial	$23,750.00
Rate for Payer: Aetna Medicare Advantage	$18,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,937.50
Rate for Payer: Cigna Commercial	$31,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,125.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$13,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,375.00
Rate for Payer: UnitedHealthcare Community & State	$1,506.25
Rate for Payer: Wellpoint Medicaid Managed Care	$1,656.25

IO EXPAND INTERB SYS 10X26MM L

Facility

$62,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270698135
Hospital Revenue Code	278
Min. Negotiated Rate	$9,375.00
Max. Negotiated Rate	$15,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,125.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$13,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,375.00

IOHEXOL

Facility

$357.15

Hospital Charge Code	6012678
Hospital Revenue Code	250
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$178.57
Rate for Payer: Aetna Commercial	$135.72
Rate for Payer: Aetna Medicare Advantage	$107.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$91.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$91.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$91.07
Rate for Payer: Cigna Commercial	$178.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$107.14
Rate for Payer: Oxford Commercial	$71.43
Rate for Payer: Qualcare PPO/HMO/WC	$53.57
Rate for Payer: UnitedHealthcare Commercial	$71.43
Rate for Payer: UnitedHealthcare Community & State	$8.61
Rate for Payer: Wellpoint Medicaid Managed Care	$9.46

IOHEXOL

Facility

$357.15

Hospital Charge Code	6012678
Hospital Revenue Code	250
Min. Negotiated Rate	$53.57
Max. Negotiated Rate	$53.57
Rate for Payer: Qualcare PPO/HMO/WC	$53.57

IOHEXOL 240 MG SOL

Facility

$350.08

Service Code	NDC 407141230
Hospital Charge Code	60627878
Hospital Revenue Code	255
Min. Negotiated Rate	$52.51
Max. Negotiated Rate	$52.51
Rate for Payer: Qualcare PPO/HMO/WC	$52.51

IOHEXOL 240 MG SOL

Facility

$350.08

Service Code	NDC 407141230
Hospital Charge Code	60627878
Hospital Revenue Code	255
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$175.04
Rate for Payer: Aetna Commercial	$133.03
Rate for Payer: Aetna Medicare Advantage	$105.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$89.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$89.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$89.27
Rate for Payer: Cigna Commercial	$175.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$105.02
Rate for Payer: Oxford Commercial	$70.02
Rate for Payer: Qualcare PPO/HMO/WC	$52.51
Rate for Payer: UnitedHealthcare Commercial	$70.02
Rate for Payer: UnitedHealthcare Community & State	$8.44
Rate for Payer: Wellpoint Medicaid Managed Care	$9.28

IOHEXOL 300 100 ML

Facility

$751.00

Service Code	NDC 407141363
Hospital Charge Code	6063943209
Hospital Revenue Code	255
Min. Negotiated Rate	$112.65
Max. Negotiated Rate	$112.65
Rate for Payer: Qualcare PPO/HMO/WC	$112.65

IOHEXOL 300 100 ML

Facility

$751.00

Service Code	NDC 407141363
Hospital Charge Code	6063943209
Hospital Revenue Code	255
Min. Negotiated Rate	$18.10
Max. Negotiated Rate	$375.50
Rate for Payer: Aetna Commercial	$285.38
Rate for Payer: Aetna Medicare Advantage	$225.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.50
Rate for Payer: Cigna Commercial	$375.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$225.30
Rate for Payer: Oxford Commercial	$150.20
Rate for Payer: Qualcare PPO/HMO/WC	$112.65
Rate for Payer: UnitedHealthcare Commercial	$150.20
Rate for Payer: UnitedHealthcare Community & State	$18.10
Rate for Payer: Wellpoint Medicaid Managed Care	$19.90

IOHEXOL 300 50 ML

Facility

$383.31

Service Code	NDC 407141361
Hospital Charge Code	6063943211
Hospital Revenue Code	255
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$191.66
Rate for Payer: Aetna Commercial	$145.66
Rate for Payer: Aetna Medicare Advantage	$114.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$97.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$97.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$97.74
Rate for Payer: Cigna Commercial	$191.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$114.99
Rate for Payer: Oxford Commercial	$76.66
Rate for Payer: Qualcare PPO/HMO/WC	$57.50
Rate for Payer: UnitedHealthcare Commercial	$76.66
Rate for Payer: UnitedHealthcare Community & State	$9.24
Rate for Payer: Wellpoint Medicaid Managed Care	$10.16

IOHEXOL 300 50 ML

Facility

$383.31

Service Code	NDC 407141361
Hospital Charge Code	6063943211
Hospital Revenue Code	255
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$57.50
Rate for Payer: Qualcare PPO/HMO/WC	$57.50

IOHEXOL 300ML/30ML

Facility

$229.94

Service Code	NDC 407141361
Hospital Charge Code	606390584
Hospital Revenue Code	250
Min. Negotiated Rate	$34.49
Max. Negotiated Rate	$34.49
Rate for Payer: Qualcare PPO/HMO/WC	$34.49

IOHEXOL 300ML/30ML

Facility

$229.94

Service Code	NDC 407141361
Hospital Charge Code	606390584
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$114.97
Rate for Payer: Aetna Commercial	$87.38
Rate for Payer: Aetna Medicare Advantage	$68.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.63
Rate for Payer: Cigna Commercial	$114.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$68.98
Rate for Payer: Oxford Commercial	$45.99
Rate for Payer: Qualcare PPO/HMO/WC	$34.49
Rate for Payer: UnitedHealthcare Commercial	$45.99
Rate for Payer: UnitedHealthcare Community & State	$5.54
Rate for Payer: Wellpoint Medicaid Managed Care	$6.09

IOHEXOL(OMNI)350/ML100ML PERML

Facility

$3.75

Service Code	HCPCS Q9967
Hospital Charge Code	60630201
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.91
Rate for Payer: Qualcare PPO/HMO/WC	$0.56

IOHEXOL(OMNI)350/ML100ML PERML

Facility

$3.75

Service Code	HCPCS Q9967
Hospital Charge Code	60630201
Hospital Revenue Code	636
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	$0.91
Rate for Payer: Qualcare PPO/HMO/WC	$0.56
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.10

IOHEXOL(OMNI)350/ML150ML PERML

Facility

$3.75

Service Code	HCPCS Q9967
Hospital Charge Code	60630202
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.91
Rate for Payer: Qualcare PPO/HMO/WC	$0.56

Know your out-of-pocket cost for care.

All Charges