Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PETROLATUM OINT OPH 3.5GM

Facility

$15.40

Hospital Charge Code	6009997
Hospital Revenue Code	251
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$2.31
Rate for Payer: Qualcare PPO/HMO/WC	$2.31

PETROLATUM OINT OPH 3.5GM

Facility

$15.40

Hospital Charge Code	6009997
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$7.70
Rate for Payer: Aetna Commercial	$5.85
Rate for Payer: Aetna Medicare Advantage	$4.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.93
Rate for Payer: Cigna Commercial	$7.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.62
Rate for Payer: Oxford Commercial	$3.08
Rate for Payer: Qualcare PPO/HMO/WC	$2.31
Rate for Payer: UnitedHealthcare Commercial	$3.08
Rate for Payer: UnitedHealthcare Community & State	$0.37
Rate for Payer: Wellpoint Medicaid Managed Care	$0.41

PETROLATUM TOPICAL 100% OINT

Facility

$4.00

Service Code	NDC 168005345
Hospital Charge Code	6004170
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PETROLATUM TOPICAL 100% OINT

Facility

$4.00

Service Code	NDC 168005345
Hospital Charge Code	6004170
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

PET W CT ATTENU CORR WHL BODY

Facility

$13,724.25

Service Code	HCPCS 78816
Hospital Charge Code	4501027
Hospital Revenue Code	404
Min. Negotiated Rate	$330.75
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	$4,117.27
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,058.64
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$330.75
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	$363.69

PET W CT ATTENU CORR WHL BODY

Facility

$13,724.25

Service Code	HCPCS 78816
Hospital Charge Code	4501027
Hospital Revenue Code	404
Min. Negotiated Rate	$2,058.64
Max. Negotiated Rate	$2,058.64
Rate for Payer: Qualcare PPO/HMO/WC	$2,058.64

PET W CT ATTENU LOC IM LIM ARE

Facility

$13,649.25

Service Code	HCPCS 78814
Hospital Charge Code	4501025
Hospital Revenue Code	404
Min. Negotiated Rate	$328.95
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	$4,094.78
Rate for Payer: Oxford Commercial	$10,230.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,047.39
Rate for Payer: UnitedHealthcare Commercial	$16,027.00
Rate for Payer: UnitedHealthcare Community & State	$328.95
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	$361.71

PET W CT ATTENU LOC IM LIM ARE

Facility

$13,649.25

Service Code	HCPCS 78814
Hospital Charge Code	4501025
Hospital Revenue Code	404
Min. Negotiated Rate	$2,047.39
Max. Negotiated Rate	$2,047.39
Rate for Payer: Qualcare PPO/HMO/WC	$2,047.39

PET W CT ATTENU SK BS TO THIGH

Facility

$21,817.37

Service Code	HCPCS 78815
Hospital Charge Code	4501026
Hospital Revenue Code	404
Min. Negotiated Rate	$525.80
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	$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: UnitedHealthcare Medicare Advantage	$1,698.82
Rate for Payer: Wellcare Medicare Advantage	$1,698.82
Rate for Payer: Wellpoint Medicaid Managed Care	$578.16

PET W CT ATTENU SK BS TO THIGH

Facility

$21,817.37

Service Code	HCPCS 78815
Hospital Charge Code	4501026
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 WHOLE BODY CA INIT

Facility

$21,817.37

Service Code	HCPCS 78816PI
Hospital Charge Code	4501027PI
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 WHOLE BODY CA INIT

Facility

$21,817.37

Service Code	HCPCS 78816PI
Hospital Charge Code	4501027PI
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 WHOLE BODY CA SUBS

Facility

$21,817.37

Service Code	HCPCS 78816PS
Hospital Charge Code	4501027PS
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 WHOLE BODY CA SUBS

Facility

$21,817.37

Service Code	HCPCS 78816PS
Hospital Charge Code	4501027PS
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

PFI BIONTCOVID19VAC30MCG/0.3ML

Facility

$0.01

Service Code	HCPCS 91300
Hospital Charge Code	606390386
Hospital Revenue Code	636
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.00
Rate for Payer: Aetna Medicare Advantage	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.00
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.00
Rate for Payer: UnitedHealthcare Community & State	$0.00
Rate for Payer: Wellpoint Medicaid Managed Care	$0.00

PFI BIONTCOVID19VAC30MCG/0.3ML

Facility

$0.01

Service Code	HCPCS 91300
Hospital Charge Code	606390386
Hospital Revenue Code	636
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

PFIZBIONTCOVID19VACC ADM DOSE1

Facility

$50.00

Service Code	HCPCS 0001A
Hospital Charge Code	39500001A
Hospital Revenue Code	771
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare Advantage	$15.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.75
Rate for Payer: Cigna Commercial	$25.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.00
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$7.50
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$1.21
Rate for Payer: Wellpoint Medicaid Managed Care	$1.32

PFIZBIONTCOVID19VACC ADM DOSE1

Facility

$50.00

Service Code	HCPCS 0001A
Hospital Charge Code	39500001A
Hospital Revenue Code	771
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.50

PFIZBIONTCOVID19VACC ADM DOSE2

Facility

$50.00

Service Code	HCPCS 0002A
Hospital Charge Code	39500002A
Hospital Revenue Code	771
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.50

PFIZBIONTCOVID19VACC ADM DOSE2

Facility

$50.00

Service Code	HCPCS 0002A
Hospital Charge Code	39500002A
Hospital Revenue Code	771
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare Advantage	$15.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.75
Rate for Payer: Cigna Commercial	$25.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.00
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$7.50
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$1.21
Rate for Payer: Wellpoint Medicaid Managed Care	$1.32

PFIZBIONTCOVID19VACC ADM DOSE3

Facility

$50.00

Service Code	HCPCS 0003A
Hospital Charge Code	39500003A
Hospital Revenue Code	771
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare Advantage	$15.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.75
Rate for Payer: Cigna Commercial	$25.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.00
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$7.50
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$1.21
Rate for Payer: Wellpoint Medicaid Managed Care	$1.32

PFIZBIONTCOVID19VACC ADM DOSE3

Facility

$50.00

Service Code	HCPCS 0003A
Hospital Charge Code	39500003A
Hospital Revenue Code	771
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.50

PFIZBIONTCOVID19VAXADM BOOSTER

Facility

$50.00

Service Code	HCPCS 0004A
Hospital Charge Code	39500004A
Hospital Revenue Code	771
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.50

PFIZBIONTCOVID19VAXADM BOOSTER

Facility

$50.00

Service Code	HCPCS 0004A
Hospital Charge Code	39500004A
Hospital Revenue Code	771
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare Advantage	$15.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.75
Rate for Payer: Cigna Commercial	$25.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.00
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$7.50
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$1.21
Rate for Payer: Wellpoint Medicaid Managed Care	$1.32

PFIZBIONT PEDI COVID19 10MCG

Facility

$0.01

Service Code	HCPCS 91307
Hospital Charge Code	606390468
Hospital Revenue Code	636
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

Know your out-of-pocket cost for care.

All Charges