Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MRI WRIST W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400547
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI WRIST W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400547
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 WRIST W/O CONTRAST RIGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400548
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI WRIST W/O CONTRAST RIGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400548
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 WRIST W/&W/0 CONTRAST RGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400542
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI WRIST W/&W/0 CONTRAST RGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400542
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 WRIST W/&W/O CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223LT
Hospital Charge Code	2400541
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 WRIST W/&W/O CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73223LT
Hospital Charge Code	2400541
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI WRIST W/&W/O CONTRST BLTRL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400540
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 WRIST W/&W/O CONTRST BLTRL

Facility

$11,820.00

Service Code	HCPCS 7322350
Hospital Charge Code	2400540
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

MR LWR EX ANY JT LOW LT W/ C

Facility

$13,500.00

Service Code	HCPCS 73722LT
Hospital Charge Code	2400271
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EX ANY JT LOW LT W/ C

Facility

$13,500.00

Service Code	HCPCS 73722LT
Hospital Charge Code	2400271
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX ANY JT LOW LT W/WO C

Facility

$13,500.00

Service Code	HCPCS 73723LT
Hospital Charge Code	2400280
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EX ANY JT LOW LT W/WO C

Facility

$13,500.00

Service Code	HCPCS 73723LT
Hospital Charge Code	2400280
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX ANY JT LOW RT W/ C

Facility

$13,500.00

Service Code	HCPCS 73722RT
Hospital Charge Code	2400283
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX ANY JT LOW RT W/ C

Facility

$13,500.00

Service Code	HCPCS 73722RT
Hospital Charge Code	2400283
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EX ANY JT LOW RT W/WO C

Facility

$13,500.00

Service Code	HCPCS 73723RT
Hospital Charge Code	2400284
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX ANY JT LOW RT W/WO C

Facility

$13,500.00

Service Code	HCPCS 73723RT
Hospital Charge Code	2400284
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EX OTH THN JT LT W/O C

Facility

$13,500.00

Service Code	HCPCS 73718LT
Hospital Charge Code	2400270
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX OTH THN JT LT W/O C

Facility

$13,500.00

Service Code	HCPCS 73718LT
Hospital Charge Code	2400270
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EX OTH THN JT RT W/O C

Facility

$13,500.00

Service Code	HCPCS 73718RT
Hospital Charge Code	2400275
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EX OTH THN JT RT W/O C

Facility

$13,500.00

Service Code	HCPCS 73718RT
Hospital Charge Code	2400275
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EXT OTH THN JT LT W/ C

Facility

$13,500.00

Service Code	HCPCS 73719LT
Hospital Charge Code	2400272
Hospital Revenue Code	614
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
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: Wellpoint Medicaid Managed Care	$357.75

MR LWR EXT OTH THN JT LT W/ C

Facility

$13,500.00

Service Code	HCPCS 73719LT
Hospital Charge Code	2400272
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MR LWR EXT OTH THN LT RT W/ C

Facility

$13,500.00

Service Code	HCPCS 73719RT
Hospital Charge Code	2400276
Hospital Revenue Code	614
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

Know your out-of-pocket cost for care.

All Charges