Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MRI DORSAL SP W/GAD INJ

Facility

$13,500.00

Service Code	HCPCS 72147
Hospital Charge Code	94061077
Hospital Revenue Code	612
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$638.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$616.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI DRAINAGE OF PERITONEAL ABC

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400552
Hospital Revenue Code	610
Min. Negotiated Rate	$271.24
Max. Negotiated Rate	$271.24
Rate for Payer: Qualcare PPO/HMO/WC	$271.24

MRI DRAINAGE OF PERITONEAL ABC

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400552
Hospital Revenue Code	610
Min. Negotiated Rate	$43.58
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$687.13
Rate for Payer: Aetna Medicare Advantage	$542.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$216.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$461.10
Rate for Payer: Cigna Commercial	$904.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$542.48
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$271.24
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$43.58
Rate for Payer: Wellpoint Medicaid Managed Care	$47.92

MRI DRAINAGE RETRPERITNEAL ABS

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400553
Hospital Revenue Code	610
Min. Negotiated Rate	$271.24
Max. Negotiated Rate	$271.24
Rate for Payer: Qualcare PPO/HMO/WC	$271.24

MRI DRAINAGE RETRPERITNEAL ABS

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400553
Hospital Revenue Code	610
Min. Negotiated Rate	$43.58
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$687.13
Rate for Payer: Aetna Medicare Advantage	$542.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$216.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$461.10
Rate for Payer: Cigna Commercial	$904.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$542.48
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$271.24
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$43.58
Rate for Payer: Wellpoint Medicaid Managed Care	$47.92

MRI DRAIN SBDIAPHRGM/SBPHRENIC

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400551
Hospital Revenue Code	610
Min. Negotiated Rate	$43.58
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$687.13
Rate for Payer: Aetna Medicare Advantage	$542.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$461.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$216.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$461.10
Rate for Payer: Cigna Commercial	$904.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$542.48
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$271.24
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$43.58
Rate for Payer: Wellpoint Medicaid Managed Care	$47.92

MRI DRAIN SBDIAPHRGM/SBPHRENIC

Facility

$1,808.25

Service Code	HCPCS 77021
Hospital Charge Code	2400551
Hospital Revenue Code	610
Min. Negotiated Rate	$271.24
Max. Negotiated Rate	$271.24
Rate for Payer: Qualcare PPO/HMO/WC	$271.24

MRI ELBOW W/CONTRAST BILATERAL

Facility

$11,820.00

Service Code	HCPCS 7322250
Hospital Charge Code	2400436
Hospital Revenue Code	614
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$4,491.60
Rate for Payer: Aetna Medicare Advantage	$3,546.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,014.10
Rate for Payer: Cigna Commercial	$5,910.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,546.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$284.86
Rate for Payer: Wellpoint Medicaid Managed Care	$313.23

MRI ELBOW W/CONTRAST BILATERAL

Facility

$11,820.00

Service Code	HCPCS 7322250
Hospital Charge Code	2400436
Hospital Revenue Code	614
Min. Negotiated Rate	$1,773.00
Max. Negotiated Rate	$1,773.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00

MRI ELBOW W/CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73222LT
Hospital Charge Code	2400437
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI ELBOW W/CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73222LT
Hospital Charge Code	2400437
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI ELBOW W/CONTRAST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73222RT
Hospital Charge Code	2400438
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI ELBOW W/CONTRAST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73222RT
Hospital Charge Code	2400438
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI ELBOW W/O CONTRAST BILTERL

Facility

$8,575.90

Service Code	HCPCS 7322150
Hospital Charge Code	2400439
Hospital Revenue Code	614
Min. Negotiated Rate	$1,286.38
Max. Negotiated Rate	$1,286.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,286.38

MRI ELBOW W/O CONTRAST BILTERL

Facility

$8,575.90

Service Code	HCPCS 7322150
Hospital Charge Code	2400439
Hospital Revenue Code	614
Min. Negotiated Rate	$206.68
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$3,258.84
Rate for Payer: Aetna Medicare Advantage	$2,572.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,186.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,186.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,186.85
Rate for Payer: Cigna Commercial	$4,287.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,572.77
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,286.38
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$206.68
Rate for Payer: Wellpoint Medicaid Managed Care	$227.26

MRI ELBOW W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400440
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI ELBOW W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400440
Hospital Revenue Code	614
Min. Negotiated Rate	$103.34
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,629.42
Rate for Payer: Aetna Medicare Advantage	$1,286.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,093.43
Rate for Payer: Cigna Commercial	$2,143.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.38
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$643.19
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$103.34
Rate for Payer: Wellpoint Medicaid Managed Care	$113.63

MRI ELBOW W/O CONTRAST RIGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400441
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI ELBOW W/O CONTRAST RIGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400441
Hospital Revenue Code	614
Min. Negotiated Rate	$103.34
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,629.42
Rate for Payer: Aetna Medicare Advantage	$1,286.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,093.43
Rate for Payer: Cigna Commercial	$2,143.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.38
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$643.19
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$103.34
Rate for Payer: Wellpoint Medicaid Managed Care	$113.63

MRI ELBOW W/&W/O CONTRST BLTRL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400433
Hospital Revenue Code	614
Min. Negotiated Rate	$1,773.00
Max. Negotiated Rate	$1,773.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00

MRI ELBOW W/&W/O CONTRST BLTRL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400433
Hospital Revenue Code	614
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$4,491.60
Rate for Payer: Aetna Medicare Advantage	$3,546.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,014.10
Rate for Payer: Cigna Commercial	$5,910.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,546.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$284.86
Rate for Payer: Wellpoint Medicaid Managed Care	$313.23

MRI ELBOW W/&W/O CONTRST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400434
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI ELBOW W/&W/O CONTRST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400434
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI ELBOW W/&W/O CONTRST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400435
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI ELBOW W/&W/O CONTRST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400435
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

Know your out-of-pocket cost for care.

All Charges