Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MODIFIED DAKINS SOLN 1/2 STREN

Facility

$10.90

Hospital Charge Code	60628545
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.64

MODIFIED DAKINS SOLN 1/2 STREN

Facility

$10.90

Hospital Charge Code	60628545
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$4.14
Rate for Payer: Aetna Medicare Advantage	$3.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.78
Rate for Payer: Cigna Commercial	$5.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.27
Rate for Payer: Oxford Commercial	$2.18
Rate for Payer: Qualcare PPO/HMO/WC	$1.64
Rate for Payer: UnitedHealthcare Commercial	$2.18
Rate for Payer: UnitedHealthcare Community & State	$0.26
Rate for Payer: Wellpoint Medicaid Managed Care	$0.29

MODIFIED DAKINS SOLN 1/4 STREN

Facility

$9.00

Hospital Charge Code	60628546
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna Commercial	$3.42
Rate for Payer: Aetna Medicare Advantage	$2.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.29
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.70
Rate for Payer: Oxford Commercial	$1.80
Rate for Payer: Qualcare PPO/HMO/WC	$1.35
Rate for Payer: UnitedHealthcare Commercial	$1.80
Rate for Payer: UnitedHealthcare Community & State	$0.22
Rate for Payer: Wellpoint Medicaid Managed Care	$0.24

MODIFIED DAKINS SOLN 1/4 STREN

Facility

$9.00

Hospital Charge Code	60628546
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: Qualcare PPO/HMO/WC	$1.35

MODIFIED DAKINS SOLN FULLSTREN

Facility

$9.00

Hospital Charge Code	60628547
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: Qualcare PPO/HMO/WC	$1.35

MODIFIED DAKINS SOLN FULLSTREN

Facility

$9.00

Hospital Charge Code	60628547
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna Commercial	$3.42
Rate for Payer: Aetna Medicare Advantage	$2.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.29
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.70
Rate for Payer: Oxford Commercial	$1.80
Rate for Payer: Qualcare PPO/HMO/WC	$1.35
Rate for Payer: UnitedHealthcare Commercial	$1.80
Rate for Payer: UnitedHealthcare Community & State	$0.22
Rate for Payer: Wellpoint Medicaid Managed Care	$0.24

MODIFIER ROAD RUNNER THE FIRM

Facility

$306.00

Service Code	HCPCS C1769
Hospital Charge Code	270660261
Hospital Revenue Code	278
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna Commercial	$116.28
Rate for Payer: Aetna Medicare Advantage	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$78.03
Rate for Payer: Cigna Commercial	$153.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$67.32
Rate for Payer: Qualcare PPO/HMO/WC	$45.90
Rate for Payer: UnitedHealthcare Community & State	$7.37
Rate for Payer: Wellpoint Medicaid Managed Care	$8.11

MODIFIER ROAD RUNNER THE FIRM

Facility

$306.00

Service Code	HCPCS C1769
Hospital Charge Code	270660261
Hospital Revenue Code	278
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$74.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.05
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$67.32
Rate for Payer: Qualcare PPO/HMO/WC	$45.90

MOD POLYAXIAL HEAD

Facility

$3,125.00

Hospital Charge Code	270702840
Hospital Revenue Code	278
Min. Negotiated Rate	$468.75
Max. Negotiated Rate	$756.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$756.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$687.50
Rate for Payer: Qualcare PPO/HMO/WC	$468.75

MOD POLYAXIAL HEAD

Facility

$3,125.00

Hospital Charge Code	270702840
Hospital Revenue Code	278
Min. Negotiated Rate	$75.31
Max. Negotiated Rate	$1,562.50
Rate for Payer: Aetna Commercial	$1,187.50
Rate for Payer: Aetna Medicare Advantage	$937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$796.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$796.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$625.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$796.88
Rate for Payer: Cigna Commercial	$1,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$756.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$687.50
Rate for Payer: Qualcare PPO/HMO/WC	$468.75
Rate for Payer: UnitedHealthcare Community & State	$75.31
Rate for Payer: Wellpoint Medicaid Managed Care	$82.81

MOD REFORM MIS EXTENDED TABS

Facility

$6,740.00

Service Code	HCPCS C1713
Hospital Charge Code	270696621
Hospital Revenue Code	278
Min. Negotiated Rate	$162.43
Max. Negotiated Rate	$3,370.00
Rate for Payer: Aetna Commercial	$2,561.20
Rate for Payer: Aetna Medicare Advantage	$2,022.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,718.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,718.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,348.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,718.70
Rate for Payer: Cigna Commercial	$3,370.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,631.08
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,482.80
Rate for Payer: Qualcare PPO/HMO/WC	$1,011.00
Rate for Payer: UnitedHealthcare Community & State	$162.43
Rate for Payer: Wellpoint Medicaid Managed Care	$178.61

MOD REFORM MIS EXTENDED TABS

Facility

$6,740.00

Service Code	HCPCS C1713
Hospital Charge Code	270696621
Hospital Revenue Code	278
Min. Negotiated Rate	$1,011.00
Max. Negotiated Rate	$1,631.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,348.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,631.08
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,482.80
Rate for Payer: Qualcare PPO/HMO/WC	$1,011.00

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	366899155
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2500267
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	366899155
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	7412072
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	7412072
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2500267
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5100851
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5100851
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2692143
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2692143
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	321099155
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5792288
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	321099155
Hospital Revenue Code	370
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$191.73
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$252.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$151.37
Rate for Payer: Oxford Commercial	$100.91
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$100.91
Rate for Payer: UnitedHealthcare Community & State	$12.16
Rate for Payer: Wellpoint Medicaid Managed Care	$13.37

Know your out-of-pocket cost for care.

All Charges