Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

STOXIL 0.5%/4GM

Facility

$89.00

Hospital Charge Code	60633921
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$44.50
Rate for Payer: Aetna Commercial	$33.82
Rate for Payer: Aetna Medicare Advantage	$26.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.70
Rate for Payer: Cigna Commercial	$44.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.70
Rate for Payer: Oxford Commercial	$17.80
Rate for Payer: Qualcare PPO/HMO/WC	$13.35
Rate for Payer: UnitedHealthcare Commercial	$17.80
Rate for Payer: UnitedHealthcare Community & State	$2.14
Rate for Payer: Wellpoint Medicaid Managed Care	$2.36

STOXIL 0.5%/4GM

Facility

$89.00

Hospital Charge Code	60633921
Hospital Revenue Code	250
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$13.35
Rate for Payer: Qualcare PPO/HMO/WC	$13.35

STOXIL/15ML

Facility

$95.00

Hospital Charge Code	60634552
Hospital Revenue Code	250
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare Advantage	$28.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.50
Rate for Payer: Oxford Commercial	$19.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.25
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Community & State	$2.29
Rate for Payer: Wellpoint Medicaid Managed Care	$2.52

STOXIL/15ML

Facility

$95.00

Hospital Charge Code	60634552
Hospital Revenue Code	250
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$14.25
Rate for Payer: Qualcare PPO/HMO/WC	$14.25

STOXIL OINTMENT/4G

Facility

$84.00

Hospital Charge Code	60634551
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Qualcare PPO/HMO/WC	$12.60

STOXIL OINTMENT/4G

Facility

$84.00

Hospital Charge Code	60634551
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

STOXIL OPHTH SOLN 1%

Facility

$66.00

Hospital Charge Code	60634531
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

STOXIL OPHTH SOLN 1%

Facility

$66.00

Hospital Charge Code	60634531
Hospital Revenue Code	250
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: Qualcare PPO/HMO/WC	$9.90

ST POLY LINER

Facility

$6,362.25

Service Code	HCPCS C1776
Hospital Charge Code	270688879
Hospital Revenue Code	278
Min. Negotiated Rate	$153.33
Max. Negotiated Rate	$3,181.12
Rate for Payer: Aetna Commercial	$2,417.66
Rate for Payer: Aetna Medicare Advantage	$1,908.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,622.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,622.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,272.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,622.37
Rate for Payer: Cigna Commercial	$3,181.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,539.66
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,399.69
Rate for Payer: Qualcare PPO/HMO/WC	$954.34
Rate for Payer: UnitedHealthcare Community & State	$153.33
Rate for Payer: Wellpoint Medicaid Managed Care	$168.60

ST POLY LINER

Facility

$6,362.25

Service Code	HCPCS C1776
Hospital Charge Code	270688879
Hospital Revenue Code	278
Min. Negotiated Rate	$954.34
Max. Negotiated Rate	$1,539.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,272.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,539.66
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,399.69
Rate for Payer: Qualcare PPO/HMO/WC	$954.34

ST PR GPS6FR6x40m6506X40X120

Facility

$1,395.00

Service Code	HCPCS C2617
Hospital Charge Code	270636673S
Hospital Revenue Code	278
Min. Negotiated Rate	$209.25
Max. Negotiated Rate	$337.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$279.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$337.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$306.90
Rate for Payer: Qualcare PPO/HMO/WC	$209.25

ST PR GPS6FR6x40m6506X40X120

Facility

$6,624.80

Service Code	HCPCS C2617
Hospital Charge Code	270636673
Hospital Revenue Code	278
Min. Negotiated Rate	$993.72
Max. Negotiated Rate	$1,603.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,324.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,603.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,457.46
Rate for Payer: Qualcare PPO/HMO/WC	$993.72

ST PR GPS6FR6x40m6506X40X120

Facility

$6,624.80

Service Code	HCPCS C2617
Hospital Charge Code	270636673
Hospital Revenue Code	278
Min. Negotiated Rate	$159.66
Max. Negotiated Rate	$3,312.40
Rate for Payer: Aetna Commercial	$2,517.42
Rate for Payer: Aetna Medicare Advantage	$1,987.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,689.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,689.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,324.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,689.32
Rate for Payer: Cigna Commercial	$3,312.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,603.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,457.46
Rate for Payer: Qualcare PPO/HMO/WC	$993.72
Rate for Payer: UnitedHealthcare Community & State	$159.66
Rate for Payer: Wellpoint Medicaid Managed Care	$175.56

ST PR GPS6FR6x40m6506X40X120

Facility

$1,395.00

Service Code	HCPCS C2617
Hospital Charge Code	270636673N
Hospital Revenue Code	278
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$697.50
Rate for Payer: Aetna Commercial	$530.10
Rate for Payer: Aetna Medicare Advantage	$418.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$355.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$355.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$279.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$355.73
Rate for Payer: Cigna Commercial	$697.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$337.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$306.90
Rate for Payer: Qualcare PPO/HMO/WC	$209.25
Rate for Payer: UnitedHealthcare Community & State	$33.62
Rate for Payer: Wellpoint Medicaid Managed Care	$36.97

ST PR GPS6FR6x40m6506X40X120

Facility

$1,395.00

Service Code	HCPCS C2617
Hospital Charge Code	270636673S
Hospital Revenue Code	278
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$697.50
Rate for Payer: Aetna Commercial	$530.10
Rate for Payer: Aetna Medicare Advantage	$418.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$355.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$355.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$279.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$355.73
Rate for Payer: Cigna Commercial	$697.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$337.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$306.90
Rate for Payer: Qualcare PPO/HMO/WC	$209.25
Rate for Payer: UnitedHealthcare Community & State	$33.62
Rate for Payer: Wellpoint Medicaid Managed Care	$36.97

ST PR GPS6FR6x40m6506X40X120

Facility

$1,395.00

Service Code	HCPCS C2617
Hospital Charge Code	270636673N
Hospital Revenue Code	278
Min. Negotiated Rate	$209.25
Max. Negotiated Rate	$337.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$279.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$337.59
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$306.90
Rate for Payer: Qualcare PPO/HMO/WC	$209.25

ST PR GPS6FR6x40mSERB650640120

Facility

$7,192.00

Hospital Charge Code	270636673V
Hospital Revenue Code	278
Min. Negotiated Rate	$1,078.80
Max. Negotiated Rate	$1,740.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,438.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,740.46
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,582.24
Rate for Payer: Qualcare PPO/HMO/WC	$1,078.80

ST PR GPS6FR6x40mSERB650640120

Facility

$7,192.00

Hospital Charge Code	270636673V
Hospital Revenue Code	278
Min. Negotiated Rate	$173.33
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna Commercial	$2,732.96
Rate for Payer: Aetna Medicare Advantage	$2,157.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,833.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,833.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,438.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,833.96
Rate for Payer: Cigna Commercial	$3,596.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,740.46
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,582.24
Rate for Payer: Qualcare PPO/HMO/WC	$1,078.80
Rate for Payer: UnitedHealthcare Community & State	$173.33
Rate for Payer: Wellpoint Medicaid Managed Care	$190.59

ST PRO10/7x30 135cSECX10730135

Facility

$11,250.00

Hospital Charge Code	270638656V
Hospital Revenue Code	278
Min. Negotiated Rate	$1,687.50
Max. Negotiated Rate	$2,722.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,722.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,475.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,687.50

ST PRO10/7x30 135cSECX10730135

Facility

$8,400.00

Service Code	HCPCS C1876
Hospital Charge Code	270638656C
Hospital Revenue Code	761
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$1,260.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,260.00

ST PRO10/7x30 135cSECX10730135

Facility

$11,250.00

Hospital Charge Code	270638656V
Hospital Revenue Code	278
Min. Negotiated Rate	$271.12
Max. Negotiated Rate	$5,625.00
Rate for Payer: Aetna Commercial	$4,275.00
Rate for Payer: Aetna Medicare Advantage	$3,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,868.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,868.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,868.75
Rate for Payer: Cigna Commercial	$5,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,722.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,475.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,687.50
Rate for Payer: UnitedHealthcare Community & State	$271.12
Rate for Payer: Wellpoint Medicaid Managed Care	$298.12

ST PRO10/7x30 135cSECX10730135

Facility

$8,400.00

Service Code	HCPCS C1876
Hospital Charge Code	270638656C
Hospital Revenue Code	761
Min. Negotiated Rate	$202.44
Max. Negotiated Rate	$4,200.00
Rate for Payer: Aetna Commercial	$3,192.00
Rate for Payer: Aetna Medicare Advantage	$2,520.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,142.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,142.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,142.00
Rate for Payer: Cigna Commercial	$4,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,520.00
Rate for Payer: Oxford Commercial	$1,680.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,260.00
Rate for Payer: UnitedHealthcare Commercial	$1,680.00
Rate for Payer: UnitedHealthcare Community & State	$202.44
Rate for Payer: Wellpoint Medicaid Managed Care	$222.60

ST PROMU RX 3.0X15M 100954115B

Facility

$10,250.00

Hospital Charge Code	270642316C
Hospital Revenue Code	278
Min. Negotiated Rate	$1,537.50
Max. Negotiated Rate	$2,480.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,480.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,255.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,537.50

ST PROMU RX 3.0X15M 100954115B

Facility

$10,250.00

Hospital Charge Code	270642316C
Hospital Revenue Code	278
Min. Negotiated Rate	$247.03
Max. Negotiated Rate	$5,125.00
Rate for Payer: Aetna Commercial	$3,895.00
Rate for Payer: Aetna Medicare Advantage	$3,075.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,613.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,613.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,613.75
Rate for Payer: Cigna Commercial	$5,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,480.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,255.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,537.50
Rate for Payer: UnitedHealthcare Community & State	$247.03
Rate for Payer: Wellpoint Medicaid Managed Care	$271.62

ST PROMU RX 3.0X18M 100954118B

Facility

$10,250.00

Hospital Charge Code	270642256C
Hospital Revenue Code	278
Min. Negotiated Rate	$1,537.50
Max. Negotiated Rate	$2,480.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,480.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,255.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,537.50

Know your out-of-pocket cost for care.

All Charges