Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

POLYCILLIN-N/250MG

Facility

$18.00

Hospital Charge Code	60633687
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$6.84
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.40
Rate for Payer: Oxford Commercial	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Commercial	$3.60
Rate for Payer: UnitedHealthcare Community & State	$0.43
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

POLYCILLIN-N/250MG

Facility

$24.00

Hospital Charge Code	60633684
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

POLYCILLIN-N/250MG

Facility

$24.00

Hospital Charge Code	60633684
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.60

POLYCILLIN-N/250MG

Facility

$18.00

Hospital Charge Code	60633687
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$2.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

POLYCILLIN-N/2GM

Facility

$66.00

Hospital Charge Code	60633686
Hospital Revenue Code	250
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$25.08
Rate for Payer: Aetna Medicare Advantage	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16.83
Rate for Payer: Cigna Commercial	$33.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.80
Rate for Payer: Oxford Commercial	$13.20
Rate for Payer: Qualcare PPO/HMO/WC	$9.90
Rate for Payer: UnitedHealthcare Commercial	$13.20
Rate for Payer: UnitedHealthcare Community & State	$1.59
Rate for Payer: Wellpoint Medicaid Managed Care	$1.75

POLYCILLIN-N/2GM

Facility

$66.00

Hospital Charge Code	60633686
Hospital Revenue Code	250
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: Qualcare PPO/HMO/WC	$9.90

POLYCILLIN-N/500MG

Facility

$42.00

Hospital Charge Code	60633685
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$15.96
Rate for Payer: Aetna Medicare Advantage	$12.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.71
Rate for Payer: Cigna Commercial	$21.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.60
Rate for Payer: Oxford Commercial	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$6.30
Rate for Payer: UnitedHealthcare Commercial	$8.40
Rate for Payer: UnitedHealthcare Community & State	$1.01
Rate for Payer: Wellpoint Medicaid Managed Care	$1.11

POLYCILLIN-N/500MG

Facility

$42.00

Hospital Charge Code	60633685
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$6.30
Rate for Payer: Qualcare PPO/HMO/WC	$6.30

POLYCITRA

Facility

$42.00

Hospital Charge Code	60634433
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$15.96
Rate for Payer: Aetna Medicare Advantage	$12.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.71
Rate for Payer: Cigna Commercial	$21.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.60
Rate for Payer: Oxford Commercial	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$6.30
Rate for Payer: UnitedHealthcare Commercial	$8.40
Rate for Payer: UnitedHealthcare Community & State	$1.01
Rate for Payer: Wellpoint Medicaid Managed Care	$1.11

POLYCITRA

Facility

$42.00

Hospital Charge Code	60634433
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$6.30
Rate for Payer: Qualcare PPO/HMO/WC	$6.30

POLYCITRA/473ML

Facility

$38.00

Hospital Charge Code	60633688
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$14.44
Rate for Payer: Aetna Medicare Advantage	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.69
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.40
Rate for Payer: Oxford Commercial	$7.60
Rate for Payer: Qualcare PPO/HMO/WC	$5.70
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Community & State	$0.92
Rate for Payer: Wellpoint Medicaid Managed Care	$1.01

POLYCITRA/473ML

Facility

$38.00

Hospital Charge Code	60633688
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$5.70
Rate for Payer: Qualcare PPO/HMO/WC	$5.70

POLYCITRA-K

Facility

$30.00

Hospital Charge Code	60634434
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare Advantage	$9.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.65
Rate for Payer: Cigna Commercial	$15.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.00
Rate for Payer: Oxford Commercial	$6.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.50
Rate for Payer: UnitedHealthcare Commercial	$6.00
Rate for Payer: UnitedHealthcare Community & State	$0.72
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

POLYCITRA-K

Facility

$30.00

Hospital Charge Code	60634434
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$4.50

POLYCOSE

Facility

$15.00

Hospital Charge Code	60634858
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

POLYCOSE

Facility

$15.00

Hospital Charge Code	60634858
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$3.00
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.40

POLYETHYLENE GLYCOL 3350 UD

Facility

$20.17

Service Code	NDC 574041207
Hospital Charge Code	60629844
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.03
Rate for Payer: Qualcare PPO/HMO/WC	$3.03

POLYETHYLENE GLYCOL 3350 UD

Facility

$20.17

Service Code	NDC 574041207
Hospital Charge Code	60629844
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$10.09
Rate for Payer: Aetna Commercial	$7.66
Rate for Payer: Aetna Medicare Advantage	$6.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.14
Rate for Payer: Cigna Commercial	$10.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.05
Rate for Payer: Oxford Commercial	$4.03
Rate for Payer: Qualcare PPO/HMO/WC	$3.03
Rate for Payer: UnitedHealthcare Commercial	$4.03
Rate for Payer: UnitedHealthcare Community & State	$0.49
Rate for Payer: Wellpoint Medicaid Managed Care	$0.53

POLYETHYLENE INSERT 36MM

Facility

$6,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270671318
Hospital Revenue Code	278
Min. Negotiated Rate	$1,031.25
Max. Negotiated Rate	$1,663.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,375.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,663.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,512.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,031.25

POLYETHYLENE INSERT 36MM

Facility

$6,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270671318
Hospital Revenue Code	278
Min. Negotiated Rate	$165.69
Max. Negotiated Rate	$3,437.50
Rate for Payer: Aetna Commercial	$2,612.50
Rate for Payer: Aetna Medicare Advantage	$2,062.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,753.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,753.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,753.12
Rate for Payer: Cigna Commercial	$3,437.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,663.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,512.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,031.25
Rate for Payer: UnitedHealthcare Community & State	$165.69
Rate for Payer: Wellpoint Medicaid Managed Care	$182.19

POLYGIA 75

Facility

$665.00

Hospital Charge Code	270335194
Hospital Revenue Code	272
Min. Negotiated Rate	$16.03
Max. Negotiated Rate	$332.50
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare Advantage	$199.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$169.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$169.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$169.57
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$199.50
Rate for Payer: Oxford Commercial	$133.00
Rate for Payer: Qualcare PPO/HMO/WC	$99.75
Rate for Payer: UnitedHealthcare Commercial	$133.00
Rate for Payer: UnitedHealthcare Community & State	$16.03
Rate for Payer: Wellpoint Medicaid Managed Care	$17.62

POLYGIA 75

Facility

$665.00

Hospital Charge Code	270335194
Hospital Revenue Code	272
Min. Negotiated Rate	$99.75
Max. Negotiated Rate	$99.75
Rate for Payer: Qualcare PPO/HMO/WC	$99.75

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.25
Max. Negotiated Rate	$1,905.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,732.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$189.79
Max. Negotiated Rate	$3,937.50
Rate for Payer: Aetna Commercial	$2,992.50
Rate for Payer: Aetna Medicare Advantage	$2,362.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,008.12
Rate for Payer: Cigna Commercial	$3,937.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,732.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25
Rate for Payer: UnitedHealthcare Community & State	$189.79
Rate for Payer: Wellpoint Medicaid Managed Care	$208.69

POLY INFINITY SZ 4+ 7MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270678156
Hospital Revenue Code	278
Min. Negotiated Rate	$234.97
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$3,705.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,145.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50
Rate for Payer: UnitedHealthcare Community & State	$234.97
Rate for Payer: Wellpoint Medicaid Managed Care	$258.38

Know your out-of-pocket cost for care.

All Charges