Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PET BRAIN IMAG METAB EVAL- PS

Facility

$40,000.00

Service Code	HCPCS 78608PS
Hospital Charge Code	80000050PS
Hospital Revenue Code	404
Min. Negotiated Rate	$6,000.00
Max. Negotiated Rate	$6,000.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00

PET BRAIN IMAG METAB EVAL- PS

Facility

$40,000.00

Service Code	HCPCS 78608PS
Hospital Charge Code	80000050PS
Hospital Revenue Code	404
Min. Negotiated Rate	$964.00
Max. Negotiated Rate	$20,000.00
Rate for Payer: Aetna Commercial	$15,200.00
Rate for Payer: Aetna Medicare Advantage	$12,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10,200.00
Rate for Payer: Cigna Commercial	$20,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12,000.00
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$964.00
Rate for Payer: Wellpoint Medicaid Managed Care	$1,060.00

PET BS TO THIGH CA INIT

Facility

$21,817.37

Service Code	HCPCS 78815PI
Hospital Charge Code	4501026PI
Hospital Revenue Code	404
Min. Negotiated Rate	$3,272.61
Max. Negotiated Rate	$3,272.61
Rate for Payer: Qualcare PPO/HMO/WC	$3,272.61

PET BS TO THIGH CA INIT

Facility

$21,817.37

Service Code	HCPCS 78815PI
Hospital Charge Code	4501026PI
Hospital Revenue Code	404
Min. Negotiated Rate	$525.80
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$8,290.60
Rate for Payer: Aetna Medicare Advantage	$6,545.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,563.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,563.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,563.43
Rate for Payer: Cigna Commercial	$10,908.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,545.21
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,272.61
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$525.80
Rate for Payer: Wellpoint Medicaid Managed Care	$578.16

PET BS TO THIGH CA SUBS

Facility

$21,817.37

Service Code	HCPCS 78815PS
Hospital Charge Code	4501026PS
Hospital Revenue Code	404
Min. Negotiated Rate	$3,272.61
Max. Negotiated Rate	$3,272.61
Rate for Payer: Qualcare PPO/HMO/WC	$3,272.61

PET BS TO THIGH CA SUBS

Facility

$21,817.37

Service Code	HCPCS 78815PS
Hospital Charge Code	4501026PS
Hospital Revenue Code	404
Min. Negotiated Rate	$525.80
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$8,290.60
Rate for Payer: Aetna Medicare Advantage	$6,545.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,563.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,563.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,563.43
Rate for Payer: Cigna Commercial	$10,908.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,545.21
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,272.61
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$525.80
Rate for Payer: Wellpoint Medicaid Managed Care	$578.16

PET IMAGE W/CT LMTD

Facility

$1,556.65

Service Code	HCPCS 78814
Hospital Charge Code	85000885
Hospital Revenue Code	404
Min. Negotiated Rate	$233.50
Max. Negotiated Rate	$233.50
Rate for Payer: Qualcare PPO/HMO/WC	$233.50

PET IMAGE W/CT LMTD

Facility

$1,556.65

Service Code	HCPCS 78814
Hospital Charge Code	85000885
Hospital Revenue Code	404
Min. Negotiated Rate	$37.52
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$4,620.79
Rate for Payer: Aetna Medicare Advantage	$5,504.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,698.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,090.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,132.23
Rate for Payer: Cigna Commercial	$3,405.27
Rate for Payer: Cigna Medicare Advantage	$1,698.82
Rate for Payer: Clover Medicare Advantage	$1,613.88
Rate for Payer: EmblemHealth Commercial	$5,096.46
Rate for Payer: Humana Medicare Advantage	$1,749.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,698.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$467.00
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$233.50
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$37.52
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$41.25

PET IMAGE W/CT LMTD - GLOBAL

Facility

$6,849.47

Service Code	HCPCS 78814
Hospital Charge Code	80000001
Hospital Revenue Code	404
Min. Negotiated Rate	$165.07
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$4,620.79
Rate for Payer: Aetna Medicare Advantage	$5,504.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,698.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,090.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,132.23
Rate for Payer: Cigna Commercial	$3,405.27
Rate for Payer: Cigna Medicare Advantage	$1,698.82
Rate for Payer: Clover Medicare Advantage	$1,613.88
Rate for Payer: EmblemHealth Commercial	$5,096.46
Rate for Payer: Humana Medicare Advantage	$1,749.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,698.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,054.84
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.42
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$165.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$181.51

PET IMAGE W/CT LMTD - GLOBAL

Facility

$6,849.47

Service Code	HCPCS 78814
Hospital Charge Code	80000001
Hospital Revenue Code	404
Min. Negotiated Rate	$1,027.42
Max. Negotiated Rate	$1,027.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.42

PET IMAGE W/CT LMTD- GLOBAL

Facility

$6,849.47

Service Code	HCPCS 78816
Hospital Charge Code	80000030
Hospital Revenue Code	404
Min. Negotiated Rate	$165.07
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$4,620.79
Rate for Payer: Aetna Medicare Advantage	$5,504.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,698.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,090.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,132.23
Rate for Payer: Cigna Commercial	$3,405.27
Rate for Payer: Cigna Medicare Advantage	$1,698.82
Rate for Payer: Clover Medicare Advantage	$1,613.88
Rate for Payer: EmblemHealth Commercial	$5,096.46
Rate for Payer: Humana Medicare Advantage	$1,749.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,698.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,054.84
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.42
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$165.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$181.51

PET IMAGE W/CT LMTD- GLOBAL

Facility

$6,849.47

Service Code	HCPCS 78816
Hospital Charge Code	80000030
Hospital Revenue Code	404
Min. Negotiated Rate	$1,027.42
Max. Negotiated Rate	$1,027.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,027.42

PET IMAGE W/CT LMTD - PC

Facility

$585.90

Service Code	HCPCS 7881426
Hospital Charge Code	80000010
Hospital Revenue Code	404
Min. Negotiated Rate	$87.89
Max. Negotiated Rate	$87.89
Rate for Payer: Qualcare PPO/HMO/WC	$87.89

PET IMAGE W/CT LMTD - PC

Facility

$585.90

Service Code	HCPCS 7881426
Hospital Charge Code	80000010
Hospital Revenue Code	404
Min. Negotiated Rate	$14.12
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$222.64
Rate for Payer: Aetna Medicare Advantage	$175.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$149.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$149.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$149.40
Rate for Payer: Cigna Commercial	$292.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$175.77
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$87.89
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$14.12
Rate for Payer: Wellpoint Medicaid Managed Care	$15.53

PET IMAGE W/CT LMTD- PC

Facility

$652.85

Service Code	HCPCS 7881626
Hospital Charge Code	80000040
Hospital Revenue Code	404
Min. Negotiated Rate	$97.93
Max. Negotiated Rate	$97.93
Rate for Payer: Qualcare PPO/HMO/WC	$97.93

PET IMAGE W/CT LMTD- PC

Facility

$652.85

Service Code	HCPCS 7881626
Hospital Charge Code	80000040
Hospital Revenue Code	404
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$248.08
Rate for Payer: Aetna Medicare Advantage	$195.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$166.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$166.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$166.48
Rate for Payer: Cigna Commercial	$326.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.85
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$97.93
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$15.73
Rate for Payer: Wellpoint Medicaid Managed Care	$17.30

PET IMAGE W/CT LMTD -TC

Facility

$6,147.90

Service Code	HCPCS 78814
Hospital Charge Code	80000005
Hospital Revenue Code	404
Min. Negotiated Rate	$148.16
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$4,620.79
Rate for Payer: Aetna Medicare Advantage	$5,504.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,698.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,090.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,132.23
Rate for Payer: Cigna Commercial	$3,405.27
Rate for Payer: Cigna Medicare Advantage	$1,698.82
Rate for Payer: Clover Medicare Advantage	$1,613.88
Rate for Payer: EmblemHealth Commercial	$5,096.46
Rate for Payer: Humana Medicare Advantage	$1,749.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,698.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,844.37
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$922.18
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$148.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$162.92

PET IMAGE W/CT LMTD -TC

Facility

$6,147.90

Service Code	HCPCS 78814
Hospital Charge Code	80000005
Hospital Revenue Code	404
Min. Negotiated Rate	$922.18
Max. Negotiated Rate	$922.18
Rate for Payer: Qualcare PPO/HMO/WC	$922.18

PET IMAGE W/CT LMTD- TC

Facility

$6,147.90

Service Code	HCPCS 78816
Hospital Charge Code	80000035
Hospital Revenue Code	404
Min. Negotiated Rate	$148.16
Max. Negotiated Rate	$16,027.00
Rate for Payer: Aetna Commercial	$4,620.79
Rate for Payer: Aetna Medicare Advantage	$5,504.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,132.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,698.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,090.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,132.23
Rate for Payer: Cigna Commercial	$3,405.27
Rate for Payer: Cigna Medicare Advantage	$1,698.82
Rate for Payer: Clover Medicare Advantage	$1,613.88
Rate for Payer: EmblemHealth Commercial	$5,096.46
Rate for Payer: Humana Medicare Advantage	$1,749.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,698.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,844.37
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$922.18
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$148.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$162.92

PET IMAGE W/CT LMTD- TC

Facility

$6,147.90

Service Code	HCPCS 78816
Hospital Charge Code	80000035
Hospital Revenue Code	404
Min. Negotiated Rate	$922.18
Max. Negotiated Rate	$922.18
Rate for Payer: Qualcare PPO/HMO/WC	$922.18

PET IMAGE W/CT LTD - PI

Facility

$40,000.00

Service Code	HCPCS 78816PI
Hospital Charge Code	80000030PI
Hospital Revenue Code	404
Min. Negotiated Rate	$964.00
Max. Negotiated Rate	$20,000.00
Rate for Payer: Aetna Commercial	$15,200.00
Rate for Payer: Aetna Medicare Advantage	$12,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10,200.00
Rate for Payer: Cigna Commercial	$20,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12,000.00
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$964.00
Rate for Payer: Wellpoint Medicaid Managed Care	$1,060.00

PET IMAGE W/CT LTD - PI

Facility

$40,000.00

Service Code	HCPCS 78816PI
Hospital Charge Code	80000030PI
Hospital Revenue Code	404
Min. Negotiated Rate	$6,000.00
Max. Negotiated Rate	$6,000.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00

PET IMAGE W/CT LTD- PS

Facility

$40,000.00

Service Code	HCPCS 78816PS
Hospital Charge Code	80000030PS
Hospital Revenue Code	404
Min. Negotiated Rate	$6,000.00
Max. Negotiated Rate	$6,000.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00

PET IMAGE W/CT LTD- PS

Facility

$40,000.00

Service Code	HCPCS 78816PS
Hospital Charge Code	80000030PS
Hospital Revenue Code	404
Min. Negotiated Rate	$964.00
Max. Negotiated Rate	$20,000.00
Rate for Payer: Aetna Commercial	$15,200.00
Rate for Payer: Aetna Medicare Advantage	$12,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10,200.00
Rate for Payer: Cigna Commercial	$20,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12,000.00
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$6,000.00
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$964.00
Rate for Payer: Wellpoint Medicaid Managed Care	$1,060.00

PET IMAGE W/CT SKULL-THIGH-PC

Facility

$648.25

Service Code	HCPCS 7881526
Hospital Charge Code	80000025
Hospital Revenue Code	404
Min. Negotiated Rate	$97.24
Max. Negotiated Rate	$97.24
Rate for Payer: Qualcare PPO/HMO/WC	$97.24

Know your out-of-pocket cost for care.

All Charges