Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SEL CATH PLACEMENT PUL ART

Facility

$359.00

Service Code	HCPCS 36015RT
Hospital Charge Code	366836015R
Hospital Revenue Code	361
Min. Negotiated Rate	$53.85
Max. Negotiated Rate	$53.85
Rate for Payer: Qualcare PPO/HMO/WC	$53.85

SEL CATH PLACEMENT PUL ART

Facility

$359.00

Service Code	HCPCS 36015RT
Hospital Charge Code	411036015
Hospital Revenue Code	361
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$1,626.00
Rate for Payer: Aetna Commercial	$136.42
Rate for Payer: Aetna Medicare Advantage	$107.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$91.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$91.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$91.55
Rate for Payer: Cigna Commercial	$179.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$107.70
Rate for Payer: Qualcare PPO/HMO/WC	$53.85
Rate for Payer: UnitedHealthcare Community & State	$8.65
Rate for Payer: Wellpoint Medicaid Managed Care	$9.51

SEL CATH PLACEMENT PUL ART

Facility

$359.00

Service Code	HCPCS 36015RT
Hospital Charge Code	366836015R
Hospital Revenue Code	361
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$1,626.00
Rate for Payer: Aetna Commercial	$136.42
Rate for Payer: Aetna Medicare Advantage	$107.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$91.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$91.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$91.55
Rate for Payer: Cigna Commercial	$179.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$107.70
Rate for Payer: Qualcare PPO/HMO/WC	$53.85
Rate for Payer: UnitedHealthcare Community & State	$8.65
Rate for Payer: Wellpoint Medicaid Managed Care	$9.51

SELDANE/60MG/TAB

Facility

$6.00

Hospital Charge Code	60633858
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.80
Rate for Payer: Oxford Commercial	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$1.20
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

SELDANE/60MG/TAB

Facility

$6.00

Hospital Charge Code	60633858
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

SELEGILINE 5 MG TAB

Facility

$15.41

Service Code	NDC 60505005501
Hospital Charge Code	6027064
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$7.71
Rate for Payer: Aetna Commercial	$5.86
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	$7.71
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

SELEGILINE 5 MG TAB

Facility

$15.41

Service Code	NDC 60505005501
Hospital Charge Code	6027064
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$2.31
Rate for Payer: Qualcare PPO/HMO/WC	$2.31

SELEGILINE 6 MG/24 HR PATCH

Facility

$110.05

Hospital Charge Code	60629953
Hospital Revenue Code	250
Min. Negotiated Rate	$16.51
Max. Negotiated Rate	$16.51
Rate for Payer: Qualcare PPO/HMO/WC	$16.51

SELEGILINE 6 MG/24 HR PATCH

Facility

$110.05

Hospital Charge Code	60629953
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$55.02
Rate for Payer: Aetna Commercial	$41.82
Rate for Payer: Aetna Medicare Advantage	$33.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.06
Rate for Payer: Cigna Commercial	$55.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.02
Rate for Payer: Oxford Commercial	$22.01
Rate for Payer: Qualcare PPO/HMO/WC	$16.51
Rate for Payer: UnitedHealthcare Commercial	$22.01
Rate for Payer: UnitedHealthcare Community & State	$2.65
Rate for Payer: Wellpoint Medicaid Managed Care	$2.92

SELENIUM

Facility

$175.50

Service Code	HCPCS 84255
Hospital Charge Code	39900130
Hospital Revenue Code	301
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$26.32
Rate for Payer: Qualcare PPO/HMO/WC	$26.32

SELENIUM

Facility

$449.00

Service Code	HCPCS 84255
Hospital Charge Code	38472609
Hospital Revenue Code	301
Min. Negotiated Rate	$67.35
Max. Negotiated Rate	$67.35
Rate for Payer: Qualcare PPO/HMO/WC	$67.35

SELENIUM

Facility

$449.00

Service Code	HCPCS 84255
Hospital Charge Code	38472609
Hospital Revenue Code	301
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$224.50
Rate for Payer: Aetna Commercial	$69.44
Rate for Payer: Aetna Medicare Advantage	$82.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$25.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$57.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$92.16
Rate for Payer: Cigna Commercial	$224.50
Rate for Payer: Cigna Medicare Advantage	$25.53
Rate for Payer: Clover Medicare Advantage	$24.25
Rate for Payer: EmblemHealth Commercial	$76.59
Rate for Payer: Humana Medicare Advantage	$26.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$25.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$134.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$67.35
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.53
Rate for Payer: Wellcare Medicare Advantage	$25.53
Rate for Payer: Wellpoint Medicaid Managed Care	$11.90

SELENIUM

Facility

$175.50

Service Code	HCPCS 84255
Hospital Charge Code	39900130
Hospital Revenue Code	301
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$69.44
Rate for Payer: Aetna Medicare Advantage	$82.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$25.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$57.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$92.16
Rate for Payer: Cigna Commercial	$87.75
Rate for Payer: Cigna Medicare Advantage	$25.53
Rate for Payer: Clover Medicare Advantage	$24.25
Rate for Payer: EmblemHealth Commercial	$76.59
Rate for Payer: Humana Medicare Advantage	$26.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$25.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.65
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$26.32
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.53
Rate for Payer: Wellcare Medicare Advantage	$25.53
Rate for Payer: Wellpoint Medicaid Managed Care	$4.65

SELENIUM 2.5% SHAMPOO

Facility

$72.00

Hospital Charge Code	60628362
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$27.36
Rate for Payer: Aetna Medicare Advantage	$21.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.36
Rate for Payer: Cigna Commercial	$36.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.60
Rate for Payer: Oxford Commercial	$14.40
Rate for Payer: Qualcare PPO/HMO/WC	$10.80
Rate for Payer: UnitedHealthcare Commercial	$14.40
Rate for Payer: UnitedHealthcare Community & State	$1.74
Rate for Payer: Wellpoint Medicaid Managed Care	$1.91

SELENIUM 2.5% SHAMPOO

Facility

$72.00

Hospital Charge Code	60628362
Hospital Revenue Code	250
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$10.80
Rate for Payer: Qualcare PPO/HMO/WC	$10.80

SELENIUM 400 MCG/10ML INJ

Facility

$22.45

Hospital Charge Code	60628928
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$3.37
Rate for Payer: Qualcare PPO/HMO/WC	$3.37

SELENIUM 400 MCG/10ML INJ

Facility

$22.45

Hospital Charge Code	60628928
Hospital Revenue Code	250
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$11.22
Rate for Payer: Aetna Commercial	$8.53
Rate for Payer: Aetna Medicare Advantage	$6.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.72
Rate for Payer: Cigna Commercial	$11.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.74
Rate for Payer: Oxford Commercial	$4.49
Rate for Payer: Qualcare PPO/HMO/WC	$3.37
Rate for Payer: UnitedHealthcare Commercial	$4.49
Rate for Payer: UnitedHealthcare Community & State	$0.54
Rate for Payer: Wellpoint Medicaid Managed Care	$0.59

SELENIUM 40MCG SDV

Facility

$2.00

Hospital Charge Code	60635520
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna Commercial	$0.76
Rate for Payer: Aetna Medicare Advantage	$0.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.51
Rate for Payer: Cigna Commercial	$1.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.60
Rate for Payer: Oxford Commercial	$0.40
Rate for Payer: Qualcare PPO/HMO/WC	$0.30
Rate for Payer: UnitedHealthcare Commercial	$0.40
Rate for Payer: UnitedHealthcare Community & State	$0.05
Rate for Payer: Wellpoint Medicaid Managed Care	$0.05

SELENIUM 40MCG SDV

Facility

$2.00

Hospital Charge Code	60635520
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Qualcare PPO/HMO/WC	$0.30

SELENIUM 50 MCG TAB

Facility

$2.45

Hospital Charge Code	60628927
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna Commercial	$0.93
Rate for Payer: Aetna Medicare Advantage	$0.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.62
Rate for Payer: Cigna Commercial	$1.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.74
Rate for Payer: Oxford Commercial	$0.49
Rate for Payer: Qualcare PPO/HMO/WC	$0.37
Rate for Payer: UnitedHealthcare Commercial	$0.49
Rate for Payer: UnitedHealthcare Community & State	$0.06
Rate for Payer: Wellpoint Medicaid Managed Care	$0.06

SELENIUM 50 MCG TAB

Facility

$2.45

Hospital Charge Code	60628927
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Qualcare PPO/HMO/WC	$0.37

SELENIUM, SERUM/PLASMA

Facility

$175.50

Service Code	HCPCS 84255
Hospital Charge Code	3038138
Hospital Revenue Code	301
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$26.32
Rate for Payer: Qualcare PPO/HMO/WC	$26.32

SELENIUM, SERUM/PLASMA

Facility

$175.50

Service Code	HCPCS 84255
Hospital Charge Code	3038138
Hospital Revenue Code	301
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$69.44
Rate for Payer: Aetna Medicare Advantage	$82.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$92.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$25.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$57.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$92.16
Rate for Payer: Cigna Commercial	$87.75
Rate for Payer: Cigna Medicare Advantage	$25.53
Rate for Payer: Clover Medicare Advantage	$24.25
Rate for Payer: EmblemHealth Commercial	$76.59
Rate for Payer: Humana Medicare Advantage	$26.30
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$25.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.65
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$26.32
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.53
Rate for Payer: Wellcare Medicare Advantage	$25.53
Rate for Payer: Wellpoint Medicaid Managed Care	$4.65

SELENIUM SULF 2.5% 120ML

Facility

$19.85

Hospital Charge Code	6004865
Hospital Revenue Code	251
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$2.98
Rate for Payer: Qualcare PPO/HMO/WC	$2.98

SELENIUM SULF 2.5% 120ML

Facility

$19.85

Hospital Charge Code	6004865
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$9.93
Rate for Payer: Aetna Commercial	$7.54
Rate for Payer: Aetna Medicare Advantage	$5.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.06
Rate for Payer: Cigna Commercial	$9.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.96
Rate for Payer: Oxford Commercial	$3.97
Rate for Payer: Qualcare PPO/HMO/WC	$2.98
Rate for Payer: UnitedHealthcare Commercial	$3.97
Rate for Payer: UnitedHealthcare Community & State	$0.48
Rate for Payer: Wellpoint Medicaid Managed Care	$0.53

Know your out-of-pocket cost for care.

All Charges