Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

POLY-VI-FLOR W/IRON/0.5MG

Facility

$71.00

Hospital Charge Code	60633677
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$10.65
Rate for Payer: Qualcare PPO/HMO/WC	$10.65

POLY-VI-FLOR W/IRON/0.5MG

Facility

$56.00

Hospital Charge Code	60633676
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$21.28
Rate for Payer: Aetna Medicare Advantage	$16.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.28
Rate for Payer: Cigna Commercial	$28.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.80
Rate for Payer: Oxford Commercial	$11.20
Rate for Payer: Qualcare PPO/HMO/WC	$8.40
Rate for Payer: UnitedHealthcare Commercial	$11.20
Rate for Payer: UnitedHealthcare Community & State	$1.35
Rate for Payer: Wellpoint Medicaid Managed Care	$1.48

POLY-VI-FLOR W/IRON/1MG/1

Facility

$71.00

Hospital Charge Code	60633678
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$10.65
Rate for Payer: Qualcare PPO/HMO/WC	$10.65

POLY-VI-FLOR W/IRON/1MG/1

Facility

$71.00

Hospital Charge Code	60633678
Hospital Revenue Code	250
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$35.50
Rate for Payer: Aetna Commercial	$26.98
Rate for Payer: Aetna Medicare Advantage	$21.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.11
Rate for Payer: Cigna Commercial	$35.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.30
Rate for Payer: Oxford Commercial	$14.20
Rate for Payer: Qualcare PPO/HMO/WC	$10.65
Rate for Payer: UnitedHealthcare Commercial	$14.20
Rate for Payer: UnitedHealthcare Community & State	$1.71
Rate for Payer: Wellpoint Medicaid Managed Care	$1.88

POLYVINYL ALCOHOL POVIDONE OPH

Facility

$29.35

Service Code	NDC 536197072
Hospital Charge Code	60628094
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$14.68
Rate for Payer: Aetna Commercial	$11.15
Rate for Payer: Aetna Medicare Advantage	$8.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.48
Rate for Payer: Cigna Commercial	$14.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.80
Rate for Payer: Oxford Commercial	$5.87
Rate for Payer: Qualcare PPO/HMO/WC	$4.40
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: UnitedHealthcare Community & State	$0.71
Rate for Payer: Wellpoint Medicaid Managed Care	$0.78

POLYVINYL ALCOHOL POVIDONE OPH

Facility

$29.35

Service Code	NDC 536197072
Hospital Charge Code	60628094
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$4.40
Rate for Payer: Qualcare PPO/HMO/WC	$4.40

POLYVINYL ALCOHOL SOL OPH 30ML

Facility

$34.60

Hospital Charge Code	6004501
Hospital Revenue Code	251
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$5.19
Rate for Payer: Qualcare PPO/HMO/WC	$5.19

POLYVINYL ALCOHOL SOL OPH 30ML

Facility

$34.60

Hospital Charge Code	6004501
Hospital Revenue Code	251
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$17.30
Rate for Payer: Aetna Commercial	$13.15
Rate for Payer: Aetna Medicare Advantage	$10.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.82
Rate for Payer: Cigna Commercial	$17.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.38
Rate for Payer: Oxford Commercial	$6.92
Rate for Payer: Qualcare PPO/HMO/WC	$5.19
Rate for Payer: UnitedHealthcare Commercial	$6.92
Rate for Payer: UnitedHealthcare Community & State	$0.83
Rate for Payer: Wellpoint Medicaid Managed Care	$0.92

POLY VI SOL DROP

Facility

$0.66

Hospital Charge Code	6063943268
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Qualcare PPO/HMO/WC	$0.10

POLY VI SOL DROP

Facility

$0.66

Hospital Charge Code	6063943268
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna Commercial	$0.25
Rate for Payer: Aetna Medicare Advantage	$0.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.17
Rate for Payer: Cigna Commercial	$0.33
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.20
Rate for Payer: Oxford Commercial	$0.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.10
Rate for Payer: UnitedHealthcare Commercial	$0.13
Rate for Payer: UnitedHealthcare Community & State	$0.02
Rate for Payer: Wellpoint Medicaid Managed Care	$0.02

POLY VI SOL DROP

Facility

$4.00

Service Code	NDC 536845080
Hospital Charge Code	6063943231
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

POLY VI SOL DROP

Facility

$4.00

Service Code	NDC 536845080
Hospital Charge Code	6063943231
Hospital Revenue Code	250
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

PONOCAINE 2% SOL 30ML

Facility

$84.00

Hospital Charge Code	60635631
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$31.92
Rate for Payer: Aetna Medicare Advantage	$25.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.42
Rate for Payer: Cigna Commercial	$42.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.20
Rate for Payer: Oxford Commercial	$16.80
Rate for Payer: Qualcare PPO/HMO/WC	$12.60
Rate for Payer: UnitedHealthcare Commercial	$16.80
Rate for Payer: UnitedHealthcare Community & State	$2.02
Rate for Payer: Wellpoint Medicaid Managed Care	$2.23

PONOCAINE 2% SOL 30ML

Facility

$84.00

Hospital Charge Code	60635631
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Qualcare PPO/HMO/WC	$12.60

PONSTEL/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633692
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PONSTEL/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633692
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
Rate for Payer: Oxford Commercial	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$0.60
Rate for Payer: UnitedHealthcare Community & State	$0.07
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

PONTOCAINE 2%/30ML

Facility

$97.00

Hospital Charge Code	60633693
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$48.50
Rate for Payer: Aetna Commercial	$36.86
Rate for Payer: Aetna Medicare Advantage	$29.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.73
Rate for Payer: Cigna Commercial	$48.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.10
Rate for Payer: Oxford Commercial	$19.40
Rate for Payer: Qualcare PPO/HMO/WC	$14.55
Rate for Payer: UnitedHealthcare Commercial	$19.40
Rate for Payer: UnitedHealthcare Community & State	$2.34
Rate for Payer: Wellpoint Medicaid Managed Care	$2.57

PONTOCAINE 2%/30ML

Facility

$97.00

Hospital Charge Code	60633693
Hospital Revenue Code	250
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$14.55
Rate for Payer: Qualcare PPO/HMO/WC	$14.55

POOLING CHARGE

Facility

$390.00

Service Code	HCPCS 86965
Hospital Charge Code	3100519
Hospital Revenue Code	300
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$730.60
Rate for Payer: Aetna Commercial	$550.53
Rate for Payer: Aetna Medicare Advantage	$655.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$730.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$730.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$202.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$58.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$730.60
Rate for Payer: Cigna Commercial	$405.73
Rate for Payer: Cigna Medicare Advantage	$202.40
Rate for Payer: Clover Medicare Advantage	$192.28
Rate for Payer: EmblemHealth Commercial	$607.20
Rate for Payer: Humana Medicare Advantage	$208.47
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$202.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$25.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$202.40
Rate for Payer: Wellcare Medicare Advantage	$202.40
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

POOLING CHARGE

Facility

$390.00

Service Code	HCPCS 86965
Hospital Charge Code	3100519
Hospital Revenue Code	300
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

POOLING OF PLATELETS OR BLOOD

Facility

$149.00

Service Code	HCPCS 86965
Hospital Charge Code	38471081
Hospital Revenue Code	309
Min. Negotiated Rate	$22.35
Max. Negotiated Rate	$22.35
Rate for Payer: Qualcare PPO/HMO/WC	$22.35

POOLING OF PLATELETS OR BLOOD

Facility

$149.00

Service Code	HCPCS 86965
Hospital Charge Code	38471081
Hospital Revenue Code	309
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$730.60
Rate for Payer: Aetna Commercial	$550.53
Rate for Payer: Aetna Medicare Advantage	$655.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$730.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$730.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$202.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$58.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$730.60
Rate for Payer: Cigna Commercial	$405.73
Rate for Payer: Cigna Medicare Advantage	$202.40
Rate for Payer: Clover Medicare Advantage	$192.28
Rate for Payer: EmblemHealth Commercial	$607.20
Rate for Payer: Humana Medicare Advantage	$208.47
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$202.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$44.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.35
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$25.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$202.40
Rate for Payer: Wellcare Medicare Advantage	$202.40
Rate for Payer: Wellpoint Medicaid Managed Care	$3.95

PORACTANT ALFA 80 MG/ML(1.5ML)

Facility

$2,457.96

Hospital Charge Code	6063943232
Hospital Revenue Code	250
Min. Negotiated Rate	$59.24
Max. Negotiated Rate	$1,228.98
Rate for Payer: Aetna Commercial	$934.02
Rate for Payer: Aetna Medicare Advantage	$737.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$626.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$626.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$626.78
Rate for Payer: Cigna Commercial	$1,228.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$737.39
Rate for Payer: Oxford Commercial	$491.59
Rate for Payer: Qualcare PPO/HMO/WC	$368.69
Rate for Payer: UnitedHealthcare Commercial	$491.59
Rate for Payer: UnitedHealthcare Community & State	$59.24
Rate for Payer: Wellpoint Medicaid Managed Care	$65.14

PORACTANT ALFA 80 MG/ML(1.5ML)

Facility

$2,457.96

Hospital Charge Code	6063943232
Hospital Revenue Code	250
Min. Negotiated Rate	$368.69
Max. Negotiated Rate	$368.69
Rate for Payer: Qualcare PPO/HMO/WC	$368.69

PORACTANT ALFA 80 MG/ML(3ML)

Facility

$9,495.91

Service Code	NDC 10122051003
Hospital Charge Code	6063943233
Hospital Revenue Code	250
Min. Negotiated Rate	$228.85
Max. Negotiated Rate	$4,747.95
Rate for Payer: Aetna Commercial	$3,608.45
Rate for Payer: Aetna Medicare Advantage	$2,848.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,421.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,421.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,421.46
Rate for Payer: Cigna Commercial	$4,747.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,848.77
Rate for Payer: Oxford Commercial	$1,899.18
Rate for Payer: Qualcare PPO/HMO/WC	$1,424.39
Rate for Payer: UnitedHealthcare Commercial	$1,899.18
Rate for Payer: UnitedHealthcare Community & State	$228.85
Rate for Payer: Wellpoint Medicaid Managed Care	$251.64

Know your out-of-pocket cost for care.

All Charges