Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SILVER SULFADIAZINE 50 GM CRE

Facility

$311.22

Service Code	NDC 49999014350
Hospital Charge Code	60628365
Hospital Revenue Code	250
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$155.61
Rate for Payer: Aetna Commercial	$118.26
Rate for Payer: Aetna Medicare Advantage	$93.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.36
Rate for Payer: Cigna Commercial	$155.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$93.37
Rate for Payer: Oxford Commercial	$62.24
Rate for Payer: Qualcare PPO/HMO/WC	$46.68
Rate for Payer: UnitedHealthcare Commercial	$62.24
Rate for Payer: UnitedHealthcare Community & State	$7.50
Rate for Payer: Wellpoint Medicaid Managed Care	$8.25

S&I LV GRAM

Facility

$2,167.25

Hospital Charge Code	5100169
Hospital Revenue Code	481
Min. Negotiated Rate	$325.09
Max. Negotiated Rate	$325.09
Rate for Payer: Qualcare PPO/HMO/WC	$325.09

S&I LV GRAM

Facility

$2,167.25

Hospital Charge Code	5100169
Hospital Revenue Code	481
Min. Negotiated Rate	$52.23
Max. Negotiated Rate	$6,600.00
Rate for Payer: Aetna Commercial	$823.55
Rate for Payer: Aetna Medicare Advantage	$650.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$552.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$552.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,194.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$552.65
Rate for Payer: Cigna Commercial	$1,083.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$650.17
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$325.09
Rate for Payer: UnitedHealthcare Community & State	$52.23
Rate for Payer: Wellpoint Medicaid Managed Care	$57.43

S&I LV GRAM

Facility

$2,167.25

Hospital Charge Code	74110018
Hospital Revenue Code	481
Min. Negotiated Rate	$325.09
Max. Negotiated Rate	$325.09
Rate for Payer: Qualcare PPO/HMO/WC	$325.09

S&I LV GRAM

Facility

$2,167.25

Hospital Charge Code	74110018
Hospital Revenue Code	481
Min. Negotiated Rate	$52.23
Max. Negotiated Rate	$6,600.00
Rate for Payer: Aetna Commercial	$823.55
Rate for Payer: Aetna Medicare Advantage	$650.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$552.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$552.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,194.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$552.65
Rate for Payer: Cigna Commercial	$1,083.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$650.17
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$325.09
Rate for Payer: UnitedHealthcare Community & State	$52.23
Rate for Payer: Wellpoint Medicaid Managed Care	$57.43

SILVR SULFADIAZIN 1% CRM 25 GM

Facility

$90.79

Service Code	NDC 67877012425
Hospital Charge Code	606390116
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$45.40
Rate for Payer: Aetna Commercial	$34.50
Rate for Payer: Aetna Medicare Advantage	$27.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.15
Rate for Payer: Cigna Commercial	$45.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.24
Rate for Payer: Oxford Commercial	$18.16
Rate for Payer: Qualcare PPO/HMO/WC	$13.62
Rate for Payer: UnitedHealthcare Commercial	$18.16
Rate for Payer: UnitedHealthcare Community & State	$2.19
Rate for Payer: Wellpoint Medicaid Managed Care	$2.41

SILVR SULFADIAZIN 1% CRM 25 GM

Facility

$90.79

Service Code	NDC 67877012425
Hospital Charge Code	606390116
Hospital Revenue Code	250
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$13.62
Rate for Payer: Qualcare PPO/HMO/WC	$13.62

SIMETHICONE 125 MG CHE

Facility

$4.00

Service Code	NDC 536453408
Hospital Charge Code	60628122
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

SIMETHICONE 125 MG CHE

Facility

$4.00

Service Code	NDC 536453408
Hospital Charge Code	60628122
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

SIMETHICONE 80 MG CHE

Facility

$4.00

Service Code	NDC 63739022510
Hospital Charge Code	60628121
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

SIMETHICONE 80 MG CHE

Facility

$4.00

Service Code	NDC 63739022510
Hospital Charge Code	60628121
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

SIMETHICONE LQ 40MG/.6ML 30ML

Facility

$4.00

Service Code	NDC 536222075
Hospital Charge Code	6004915
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

SIMETHICONE LQ 40MG/.6ML 30ML

Facility

$4.00

Service Code	NDC 536222075
Hospital Charge Code	6004915
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

SIMILAC INFANT FORMULA 6O ML

Facility

$104.00

Hospital Charge Code	60628741
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Qualcare PPO/HMO/WC	$15.60

SIMILAC INFANT FORMULA 6O ML

Facility

$104.00

Hospital Charge Code	60628741
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$39.52
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.20
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$20.80
Rate for Payer: UnitedHealthcare Community & State	$2.51
Rate for Payer: Wellpoint Medicaid Managed Care	$2.76

SIMILAC PROBIOTIC TRI-BLEND

Facility

$37.92

Service Code	NDC 99999999999
Hospital Charge Code	606390389
Hospital Revenue Code	250
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$5.69
Rate for Payer: Qualcare PPO/HMO/WC	$5.69

SIMILAC PROBIOTIC TRI-BLEND

Facility

$37.92

Service Code	NDC 99999999999
Hospital Charge Code	606390389
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$18.96
Rate for Payer: Aetna Commercial	$14.41
Rate for Payer: Aetna Medicare Advantage	$11.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.67
Rate for Payer: Cigna Commercial	$18.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.38
Rate for Payer: Oxford Commercial	$7.58
Rate for Payer: Qualcare PPO/HMO/WC	$5.69
Rate for Payer: UnitedHealthcare Commercial	$7.58
Rate for Payer: UnitedHealthcare Community & State	$0.91
Rate for Payer: Wellpoint Medicaid Managed Care	$1.00

SI MOCHIX-5CC /GRANULE 1-2MM

Facility

$10,105.00

Service Code	HCPCS C1765
Hospital Charge Code	270704783
Hospital Revenue Code	278
Min. Negotiated Rate	$1,515.75
Max. Negotiated Rate	$2,445.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,021.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,445.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,223.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,515.75

SI MOCHIX-5CC /GRANULE 1-2MM

Facility

$10,105.00

Service Code	HCPCS C1765
Hospital Charge Code	270704783
Hospital Revenue Code	278
Min. Negotiated Rate	$243.53
Max. Negotiated Rate	$5,052.50
Rate for Payer: Aetna Commercial	$3,839.90
Rate for Payer: Aetna Medicare Advantage	$3,031.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,576.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,576.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,021.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,576.78
Rate for Payer: Cigna Commercial	$5,052.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,445.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,223.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,515.75
Rate for Payer: UnitedHealthcare Community & State	$243.53
Rate for Payer: Wellpoint Medicaid Managed Care	$267.78

SIMPLE BLADDER IRRIGATE LAVAGE

Facility

$26,701.00

Service Code	HCPCS 25545
Hospital Charge Code	16000618
Hospital Revenue Code	360
Min. Negotiated Rate	$4,005.15
Max. Negotiated Rate	$4,005.15
Rate for Payer: Qualcare PPO/HMO/WC	$4,005.15

SIMPLE BLADDER IRRIGATE LAVAGE

Facility

$26,701.00

Service Code	HCPCS 25545
Hospital Charge Code	16000618
Hospital Revenue Code	360
Min. Negotiated Rate	$643.49
Max. Negotiated Rate	$31,117.67
Rate for Payer: Aetna Commercial	$23,447.95
Rate for Payer: Aetna Medicare Advantage	$27,930.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31,117.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8,620.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,355.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31,117.67
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: Cigna Medicare Advantage	$8,620.57
Rate for Payer: Clover Medicare Advantage	$8,189.54
Rate for Payer: EmblemHealth Commercial	$25,861.71
Rate for Payer: Humana Medicare Advantage	$8,879.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8,620.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,010.30
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,005.15
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$643.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$8,620.57
Rate for Payer: Wellcare Medicare Advantage	$8,620.57
Rate for Payer: Wellpoint Medicaid Managed Care	$707.58

SIMPLE CYSTOMETROGRAM

Facility

$4,978.50

Service Code	HCPCS 51725
Hospital Charge Code	1600000534
Hospital Revenue Code	360
Min. Negotiated Rate	$746.77
Max. Negotiated Rate	$746.77
Rate for Payer: Qualcare PPO/HMO/WC	$746.77

SIMPLE CYSTOMETROGRAM

Facility

$4,978.50

Service Code	HCPCS 51725
Hospital Charge Code	1600000534
Hospital Revenue Code	360
Min. Negotiated Rate	$119.98
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$807.38
Rate for Payer: Aetna Medicare Advantage	$961.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,071.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,071.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$296.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,071.47
Rate for Payer: Cigna Commercial	$594.98
Rate for Payer: Cigna Medicare Advantage	$296.83
Rate for Payer: Clover Medicare Advantage	$281.99
Rate for Payer: EmblemHealth Commercial	$890.49
Rate for Payer: Humana Medicare Advantage	$305.73
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$296.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,493.55
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$746.77
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$119.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$296.83
Rate for Payer: Wellcare Medicare Advantage	$296.83
Rate for Payer: Wellpoint Medicaid Managed Care	$131.93

SIMPLE OTHR LOC LAC REP TO 2.5

Facility

$1,473.00

Service Code	HCPCS 12001
Hospital Charge Code	1600000706
Hospital Revenue Code	360
Min. Negotiated Rate	$220.95
Max. Negotiated Rate	$220.95
Rate for Payer: Qualcare PPO/HMO/WC	$220.95

SIMPLE OTHR LOC LAC REP TO 2.5

Facility

$1,473.00

Service Code	HCPCS 12001
Hospital Charge Code	1600000706
Hospital Revenue Code	360
Min. Negotiated Rate	$35.50
Max. Negotiated Rate	$2,220.00
Rate for Payer: Aetna Commercial	$648.34
Rate for Payer: Aetna Medicare Advantage	$772.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$860.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$860.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$238.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$860.41
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: Cigna Medicare Advantage	$238.36
Rate for Payer: Clover Medicare Advantage	$226.44
Rate for Payer: EmblemHealth Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$245.51
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$238.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$441.90
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$220.95
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$35.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$238.36
Rate for Payer: Wellcare Medicare Advantage	$238.36
Rate for Payer: Wellpoint Medicaid Managed Care	$39.03

Know your out-of-pocket cost for care.

All Charges