Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

OMNIPEN INJ/1GM

Facility

$32.00

Hospital Charge Code	60634246
Hospital Revenue Code	250
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$12.16
Rate for Payer: Aetna Medicare Advantage	$9.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.16
Rate for Payer: Cigna Commercial	$16.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.60
Rate for Payer: Oxford Commercial	$6.40
Rate for Payer: Qualcare PPO/HMO/WC	$4.80
Rate for Payer: UnitedHealthcare Commercial	$6.40
Rate for Payer: UnitedHealthcare Community & State	$0.77
Rate for Payer: Wellpoint Medicaid Managed Care	$0.85

OMNIPEN INJ/1GM

Facility

$32.00

Hospital Charge Code	60634246
Hospital Revenue Code	250
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$4.80
Rate for Payer: Qualcare PPO/HMO/WC	$4.80

OMNIPEN INJ/2GM

Facility

$51.00

Hospital Charge Code	60634247
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$19.38
Rate for Payer: Aetna Medicare Advantage	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.01
Rate for Payer: Cigna Commercial	$25.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.30
Rate for Payer: Oxford Commercial	$10.20
Rate for Payer: Qualcare PPO/HMO/WC	$7.65
Rate for Payer: UnitedHealthcare Commercial	$10.20
Rate for Payer: UnitedHealthcare Community & State	$1.23
Rate for Payer: Wellpoint Medicaid Managed Care	$1.35

OMNIPEN INJ/2GM

Facility

$51.00

Hospital Charge Code	60634247
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: Qualcare PPO/HMO/WC	$7.65

OMNIPEN-N/1GM

Facility

$24.00

Hospital Charge Code	60633570
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$9.12
Rate for Payer: Aetna Medicare Advantage	$7.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.12
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.20
Rate for Payer: Oxford Commercial	$4.80
Rate for Payer: Qualcare PPO/HMO/WC	$3.60
Rate for Payer: UnitedHealthcare Commercial	$4.80
Rate for Payer: UnitedHealthcare Community & State	$0.58
Rate for Payer: Wellpoint Medicaid Managed Care	$0.64

OMNIPEN-N/1GM

Facility

$24.00

Hospital Charge Code	60633570
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.60

OMNIPEN-N/2GM

Facility

$48.00

Hospital Charge Code	60633571
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$18.24
Rate for Payer: Aetna Medicare Advantage	$14.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.24
Rate for Payer: Cigna Commercial	$24.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.40
Rate for Payer: Oxford Commercial	$9.60
Rate for Payer: Qualcare PPO/HMO/WC	$7.20
Rate for Payer: UnitedHealthcare Commercial	$9.60
Rate for Payer: UnitedHealthcare Community & State	$1.16
Rate for Payer: Wellpoint Medicaid Managed Care	$1.27

OMNIPEN-N/2GM

Facility

$48.00

Hospital Charge Code	60633571
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Qualcare PPO/HMO/WC	$7.20

OMNIPEN-N/500MG

Facility

$21.00

Hospital Charge Code	60633569
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: Aetna Medicare Advantage	$6.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.36
Rate for Payer: Cigna Commercial	$10.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.30
Rate for Payer: Oxford Commercial	$4.20
Rate for Payer: Qualcare PPO/HMO/WC	$3.15
Rate for Payer: UnitedHealthcare Commercial	$4.20
Rate for Payer: UnitedHealthcare Community & State	$0.51
Rate for Payer: Wellpoint Medicaid Managed Care	$0.56

OMNIPEN-N/500MG

Facility

$21.00

Hospital Charge Code	60633569
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.15
Rate for Payer: Qualcare PPO/HMO/WC	$3.15

OMNISCAN 10ml

Facility

$123.00

Service Code	HCPCS A9579
Hospital Charge Code	601529
Hospital Revenue Code	255
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$18.45
Rate for Payer: Qualcare PPO/HMO/WC	$18.45

OMNISCAN 10ml

Facility

$123.00

Service Code	HCPCS A9579
Hospital Charge Code	601529
Hospital Revenue Code	255
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$61.50
Rate for Payer: Aetna Commercial	$46.74
Rate for Payer: Aetna Medicare Advantage	$36.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.36
Rate for Payer: Cigna Commercial	$61.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.90
Rate for Payer: Oxford Commercial	$24.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.45
Rate for Payer: UnitedHealthcare Commercial	$24.60
Rate for Payer: UnitedHealthcare Community & State	$2.96
Rate for Payer: Wellpoint Medicaid Managed Care	$3.26

OMNISCAN 15ML

Facility

$496.60

Service Code	HCPCS A9579
Hospital Charge Code	2680405
Hospital Revenue Code	255
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$188.71
Rate for Payer: Aetna Medicare Advantage	$148.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$126.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$126.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.63
Rate for Payer: Cigna Commercial	$248.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$148.98
Rate for Payer: Oxford Commercial	$99.32
Rate for Payer: Qualcare PPO/HMO/WC	$74.49
Rate for Payer: UnitedHealthcare Commercial	$99.32
Rate for Payer: UnitedHealthcare Community & State	$11.97
Rate for Payer: Wellpoint Medicaid Managed Care	$13.16

OMNISCAN 15ML

Facility

$496.60

Hospital Charge Code	7412028
Hospital Revenue Code	636
Min. Negotiated Rate	$74.49
Max. Negotiated Rate	$120.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$120.18
Rate for Payer: Qualcare PPO/HMO/WC	$74.49

OMNISCAN 15ML

Facility

$496.60

Hospital Charge Code	7412028
Hospital Revenue Code	636
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$188.71
Rate for Payer: Aetna Medicare Advantage	$148.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$126.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$126.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$126.63
Rate for Payer: Cigna Commercial	$248.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$120.18
Rate for Payer: Qualcare PPO/HMO/WC	$74.49
Rate for Payer: UnitedHealthcare Community & State	$11.97
Rate for Payer: Wellpoint Medicaid Managed Care	$13.16

OMNISCAN 15ML

Facility

$496.60

Service Code	HCPCS A9579
Hospital Charge Code	2680405
Hospital Revenue Code	255
Min. Negotiated Rate	$74.49
Max. Negotiated Rate	$74.49
Rate for Payer: Qualcare PPO/HMO/WC	$74.49

OMNISCAN 15 ML

Facility

$131.25

Service Code	HCPCS A9579
Hospital Charge Code	2011540
Hospital Revenue Code	255
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$65.62
Rate for Payer: Aetna Commercial	$49.88
Rate for Payer: Aetna Medicare Advantage	$39.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.47
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$26.25
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$26.25
Rate for Payer: UnitedHealthcare Community & State	$3.16
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

OMNISCAN 15 ML

Facility

$131.25

Service Code	HCPCS A9579
Hospital Charge Code	2011540
Hospital Revenue Code	255
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

OMNISCAN 15ml NO SAFEPAK

Facility

$184.50

Service Code	HCPCS A9579
Hospital Charge Code	602913
Hospital Revenue Code	255
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$92.25
Rate for Payer: Aetna Commercial	$70.11
Rate for Payer: Aetna Medicare Advantage	$55.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.05
Rate for Payer: Cigna Commercial	$92.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$55.35
Rate for Payer: Oxford Commercial	$36.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.68
Rate for Payer: UnitedHealthcare Commercial	$36.90
Rate for Payer: UnitedHealthcare Community & State	$4.45
Rate for Payer: Wellpoint Medicaid Managed Care	$4.89

OMNISCAN 15ml NO SAFEPAK

Facility

$184.50

Service Code	HCPCS A9579
Hospital Charge Code	602913
Hospital Revenue Code	255
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$27.68
Rate for Payer: Qualcare PPO/HMO/WC	$27.68

OMNISCAN 20ml

Facility

$246.00

Service Code	HCPCS A9579
Hospital Charge Code	635147
Hospital Revenue Code	255
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$36.90
Rate for Payer: Qualcare PPO/HMO/WC	$36.90

OMNISCAN 20ml

Facility

$246.00

Service Code	HCPCS A9579
Hospital Charge Code	635147
Hospital Revenue Code	255
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$93.48
Rate for Payer: Aetna Medicare Advantage	$73.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$62.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$62.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$62.73
Rate for Payer: Cigna Commercial	$123.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$73.80
Rate for Payer: Oxford Commercial	$49.20
Rate for Payer: Qualcare PPO/HMO/WC	$36.90
Rate for Payer: UnitedHealthcare Commercial	$49.20
Rate for Payer: UnitedHealthcare Community & State	$5.93
Rate for Payer: Wellpoint Medicaid Managed Care	$6.52

OMNISCAN 20 ML

Facility

$150.00

Service Code	HCPCS A9579
Hospital Charge Code	2011545
Hospital Revenue Code	255
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Qualcare PPO/HMO/WC	$22.50

OMNISCAN 20 ML

Facility

$150.00

Service Code	HCPCS A9579
Hospital Charge Code	2011545
Hospital Revenue Code	255
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare Advantage	$45.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.25
Rate for Payer: Cigna Commercial	$75.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.00
Rate for Payer: Oxford Commercial	$30.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.50
Rate for Payer: UnitedHealthcare Commercial	$30.00
Rate for Payer: UnitedHealthcare Community & State	$3.62
Rate for Payer: Wellpoint Medicaid Managed Care	$3.98

OMNISCAN 287MG INJ 20ML VIAL

Facility

$703.50

Service Code	NDC 407069020
Hospital Charge Code	60630198
Hospital Revenue Code	255
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$351.75
Rate for Payer: Aetna Commercial	$267.33
Rate for Payer: Aetna Medicare Advantage	$211.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$179.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$179.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$179.39
Rate for Payer: Cigna Commercial	$351.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$211.05
Rate for Payer: Oxford Commercial	$140.70
Rate for Payer: Qualcare PPO/HMO/WC	$105.53
Rate for Payer: UnitedHealthcare Commercial	$140.70
Rate for Payer: UnitedHealthcare Community & State	$16.95
Rate for Payer: Wellpoint Medicaid Managed Care	$18.64

Know your out-of-pocket cost for care.

All Charges