Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SELSUN BLUE 1%/120ML

Facility

$23.00

Hospital Charge Code	60633859
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna Commercial	$8.74
Rate for Payer: Aetna Medicare Advantage	$6.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.87
Rate for Payer: Cigna Commercial	$11.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.90
Rate for Payer: Oxford Commercial	$4.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.45
Rate for Payer: UnitedHealthcare Commercial	$4.60
Rate for Payer: UnitedHealthcare Community & State	$0.55
Rate for Payer: Wellpoint Medicaid Managed Care	$0.61

SELSUN BLUE 1%/120ML

Facility

$23.00

Hospital Charge Code	60633859
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$3.45
Rate for Payer: Qualcare PPO/HMO/WC	$3.45

SELZENTRY 150MG TAB

Facility

$80.00

Hospital Charge Code	60635697
Hospital Revenue Code	250
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare Advantage	$24.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.40
Rate for Payer: Cigna Commercial	$40.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.00
Rate for Payer: Oxford Commercial	$16.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00
Rate for Payer: UnitedHealthcare Commercial	$16.00
Rate for Payer: UnitedHealthcare Community & State	$1.93
Rate for Payer: Wellpoint Medicaid Managed Care	$2.12

SELZENTRY 150MG TAB

Facility

$80.00

Hospital Charge Code	60635697
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00

SEMEN ANALYSIS

Facility

$390.00

Service Code	HCPCS 89320
Hospital Charge Code	3004058
Hospital Revenue Code	300
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

SEMEN ANALYSIS

Facility

$390.00

Service Code	HCPCS 89320
Hospital Charge Code	3004058
Hospital Revenue Code	300
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$33.48
Rate for Payer: Aetna Medicare Advantage	$39.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.44
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.31
Rate for Payer: Clover Medicare Advantage	$11.69
Rate for Payer: EmblemHealth Commercial	$36.93
Rate for Payer: Humana Medicare Advantage	$12.68
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.31
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	$9.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.31
Rate for Payer: Wellcare Medicare Advantage	$12.31
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

SEMEN ANALYSIS, COMPLETE

Facility

$790.00

Service Code	HCPCS 89320
Hospital Charge Code	38473033
Hospital Revenue Code	309
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$118.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.50

SEMEN ANALYSIS, COMPLETE

Facility

$790.00

Service Code	HCPCS 89320
Hospital Charge Code	38473033
Hospital Revenue Code	309
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$395.00
Rate for Payer: Aetna Commercial	$33.48
Rate for Payer: Aetna Medicare Advantage	$39.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.44
Rate for Payer: Cigna Commercial	$395.00
Rate for Payer: Cigna Medicare Advantage	$12.31
Rate for Payer: Clover Medicare Advantage	$11.69
Rate for Payer: EmblemHealth Commercial	$36.93
Rate for Payer: Humana Medicare Advantage	$12.68
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.31
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$237.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$118.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.31
Rate for Payer: Wellcare Medicare Advantage	$12.31
Rate for Payer: Wellpoint Medicaid Managed Care	$20.93

SEMEN ANALYSIS, PRESENCE

Facility

$85.00

Service Code	HCPCS 89321
Hospital Charge Code	38473034
Hospital Revenue Code	309
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Qualcare PPO/HMO/WC	$12.75

SEMEN ANALYSIS, PRESENCE

Facility

$85.00

Service Code	HCPCS 89321
Hospital Charge Code	38473034
Hospital Revenue Code	309
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$32.78
Rate for Payer: Aetna Medicare Advantage	$39.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.50
Rate for Payer: Cigna Commercial	$42.50
Rate for Payer: Cigna Medicare Advantage	$12.05
Rate for Payer: Clover Medicare Advantage	$11.45
Rate for Payer: EmblemHealth Commercial	$36.15
Rate for Payer: Humana Medicare Advantage	$12.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.05
Rate for Payer: Wellcare Medicare Advantage	$12.05
Rate for Payer: Wellpoint Medicaid Managed Care	$2.25

SEMEN ANALYSIS PRESENCE MOTILT

Facility

$24.00

Service Code	HCPCS 89300
Hospital Charge Code	38477021
Hospital Revenue Code	300
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.60

SEMEN ANALYSIS PRESENCE MOTILT

Facility

$24.00

Service Code	HCPCS 89300
Hospital Charge Code	38477021
Hospital Revenue Code	300
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$26.76
Rate for Payer: Aetna Medicare Advantage	$31.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$35.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$35.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$35.52
Rate for Payer: Cigna Commercial	$12.00
Rate for Payer: Cigna Medicare Advantage	$9.84
Rate for Payer: Clover Medicare Advantage	$9.35
Rate for Payer: EmblemHealth Commercial	$29.52
Rate for Payer: Humana Medicare Advantage	$10.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$3.60
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$0.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.84
Rate for Payer: Wellcare Medicare Advantage	$9.84
Rate for Payer: Wellpoint Medicaid Managed Care	$0.64

SEMEN ANALYSIS-VOLUM/CNT/MOT

Facility

$109.79

Service Code	HCPCS 89322
Hospital Charge Code	38477131
Hospital Revenue Code	300
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$42.16
Rate for Payer: Aetna Medicare Advantage	$50.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.95
Rate for Payer: Cigna Commercial	$54.90
Rate for Payer: Cigna Medicare Advantage	$15.50
Rate for Payer: Clover Medicare Advantage	$14.72
Rate for Payer: EmblemHealth Commercial	$46.50
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.94
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.47
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.50
Rate for Payer: Wellcare Medicare Advantage	$15.50
Rate for Payer: Wellpoint Medicaid Managed Care	$2.91

SEMEN ANALYSIS-VOLUM/CNT/MOT

Facility

$109.79

Service Code	HCPCS 89322
Hospital Charge Code	38477131
Hospital Revenue Code	300
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$16.47
Rate for Payer: Qualcare PPO/HMO/WC	$16.47

SEMITENDINOSIS GRAFT FROZEN

Facility

$9,750.00

Hospital Charge Code	270678186
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
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

SEMITENDINOSIS GRAFT FROZEN

Facility

$9,750.00

Hospital Charge Code	270678186
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

SEMITENDINOSUS GRAFT W/GRACIL

Facility

$8,615.00

Hospital Charge Code	270656958
Hospital Revenue Code	278
Min. Negotiated Rate	$1,292.25
Max. Negotiated Rate	$2,084.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,723.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,084.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,895.30
Rate for Payer: Qualcare PPO/HMO/WC	$1,292.25

SEMITENDINOSUS GRAFT W/GRACIL

Facility

$8,615.00

Hospital Charge Code	270656958
Hospital Revenue Code	278
Min. Negotiated Rate	$207.62
Max. Negotiated Rate	$4,307.50
Rate for Payer: Aetna Commercial	$3,273.70
Rate for Payer: Aetna Medicare Advantage	$2,584.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,196.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,196.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,723.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,196.82
Rate for Payer: Cigna Commercial	$4,307.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,084.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,895.30
Rate for Payer: Qualcare PPO/HMO/WC	$1,292.25
Rate for Payer: UnitedHealthcare Community & State	$207.62
Rate for Payer: Wellpoint Medicaid Managed Care	$228.30

SEMITENDINOSUS W/GRACELIS

Facility

$8,565.00

Service Code	HCPCS C1762
Hospital Charge Code	270671214
Hospital Revenue Code	278
Min. Negotiated Rate	$1,284.75
Max. Negotiated Rate	$2,072.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,713.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,072.73
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,884.30
Rate for Payer: Qualcare PPO/HMO/WC	$1,284.75

SEMITENDINOSUS W/GRACELIS

Facility

$8,565.00

Service Code	HCPCS C1762
Hospital Charge Code	270671214
Hospital Revenue Code	278
Min. Negotiated Rate	$206.42
Max. Negotiated Rate	$4,282.50
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare Advantage	$2,569.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,184.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,184.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,713.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,184.07
Rate for Payer: Cigna Commercial	$4,282.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,072.73
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,884.30
Rate for Payer: Qualcare PPO/HMO/WC	$1,284.75
Rate for Payer: UnitedHealthcare Community & State	$206.42
Rate for Payer: Wellpoint Medicaid Managed Care	$226.97

SEM PRESS FIR STEM SZ 12

Facility

$7,803.00

Hospital Charge Code	270689493
Hospital Revenue Code	272
Min. Negotiated Rate	$1,170.45
Max. Negotiated Rate	$1,170.45
Rate for Payer: Qualcare PPO/HMO/WC	$1,170.45

SEM PRESS FIR STEM SZ 12

Facility

$7,803.00

Hospital Charge Code	270689493
Hospital Revenue Code	272
Min. Negotiated Rate	$188.05
Max. Negotiated Rate	$3,901.50
Rate for Payer: Aetna Commercial	$2,965.14
Rate for Payer: Aetna Medicare Advantage	$2,340.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,989.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,989.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,989.77
Rate for Payer: Cigna Commercial	$3,901.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,340.90
Rate for Payer: Oxford Commercial	$1,560.60
Rate for Payer: Qualcare PPO/HMO/WC	$1,170.45
Rate for Payer: UnitedHealthcare Commercial	$1,560.60
Rate for Payer: UnitedHealthcare Community & State	$188.05
Rate for Payer: Wellpoint Medicaid Managed Care	$206.78

SENNA 8.6 MG TAB

Facility

$4.00

Service Code	NDC 67618030050
Hospital Charge Code	60628702
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

SENNA 8.6 MG TAB

Facility

$4.00

Service Code	NDC 67618030050
Hospital Charge Code	60628702
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

SENNA 8.8 MG/5 ML SYRUP

Facility

$4.00

Service Code	NDC 59390012541
Hospital Charge Code	60629038
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

Know your out-of-pocket cost for care.

All Charges