Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	411075726L
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-LT

Facility

$8,514.00

Service Code	HCPCS 75726LT
Hospital Charge Code	7412004
Hospital Revenue Code	323
Min. Negotiated Rate	$1,277.10
Max. Negotiated Rate	$1,277.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	321075726L
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$8,514.00

Service Code	HCPCS 75726RT
Hospital Charge Code	7412005
Hospital Revenue Code	323
Min. Negotiated Rate	$1,277.10
Max. Negotiated Rate	$1,277.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	321075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$617.65
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$9,738.81
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,688.53
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$617.65
Rate for Payer: Wellpoint Medicaid Managed Care	$679.15

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	321075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$8,514.00

Service Code	HCPCS 75726RT
Hospital Charge Code	7412005
Hospital Revenue Code	323
Min. Negotiated Rate	$205.19
Max. Negotiated Rate	$4,257.00
Rate for Payer: Aetna Commercial	$3,235.32
Rate for Payer: Aetna Medicare Advantage	$2,554.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,171.07
Rate for Payer: Cigna Commercial	$4,257.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,554.20
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$205.19
Rate for Payer: Wellpoint Medicaid Managed Care	$225.62

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	2691880
Hospital Revenue Code	323
Min. Negotiated Rate	$617.65
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$9,738.81
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,688.53
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$617.65
Rate for Payer: Wellpoint Medicaid Managed Care	$679.15

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	411075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	411075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$617.65
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$9,738.81
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,688.53
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$617.65
Rate for Payer: Wellpoint Medicaid Managed Care	$679.15

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	2691880
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	366875726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	366875726R
Hospital Revenue Code	323
Min. Negotiated Rate	$617.65
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$9,738.81
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,688.53
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$617.65
Rate for Payer: Wellpoint Medicaid Managed Care	$679.15

VISCERA RETAINER MED *******

Facility

$34.00

Hospital Charge Code	1601079
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Qualcare PPO/HMO/WC	$5.10

VISCERA RETAINER MED *******

Facility

$34.00

Hospital Charge Code	1601079
Hospital Revenue Code	272
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$12.92
Rate for Payer: Aetna Medicare Advantage	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.67
Rate for Payer: Cigna Commercial	$17.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.20
Rate for Payer: Oxford Commercial	$6.80
Rate for Payer: Qualcare PPO/HMO/WC	$5.10
Rate for Payer: UnitedHealthcare Commercial	$6.80
Rate for Payer: UnitedHealthcare Community & State	$0.82
Rate for Payer: Wellpoint Medicaid Managed Care	$0.90

VISCOAT .05ML SYRINGE (STF)

Facility

$455.00

Hospital Charge Code	270330681
Hospital Revenue Code	250
Min. Negotiated Rate	$68.25
Max. Negotiated Rate	$68.25
Rate for Payer: Qualcare PPO/HMO/WC	$68.25

VISCOAT .05ML SYRINGE (STF)

Facility

$455.00

Hospital Charge Code	270330681
Hospital Revenue Code	250
Min. Negotiated Rate	$10.97
Max. Negotiated Rate	$227.50
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare Advantage	$136.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$116.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$116.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$116.03
Rate for Payer: Cigna Commercial	$227.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$136.50
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$68.25
Rate for Payer: UnitedHealthcare Commercial	$91.00
Rate for Payer: UnitedHealthcare Community & State	$10.97
Rate for Payer: Wellpoint Medicaid Managed Care	$12.06

VISCOAT 05ML SYRINGE(STM)

Facility

$382.00

Hospital Charge Code	270332494
Hospital Revenue Code	250
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$145.16
Rate for Payer: Aetna Medicare Advantage	$114.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$97.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$97.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$97.41
Rate for Payer: Cigna Commercial	$191.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$114.60
Rate for Payer: Oxford Commercial	$76.40
Rate for Payer: Qualcare PPO/HMO/WC	$57.30
Rate for Payer: UnitedHealthcare Commercial	$76.40
Rate for Payer: UnitedHealthcare Community & State	$9.21
Rate for Payer: Wellpoint Medicaid Managed Care	$10.12

VISCOAT 05ML SYRINGE(STM)

Facility

$382.00

Hospital Charge Code	270332494
Hospital Revenue Code	250
Min. Negotiated Rate	$57.30
Max. Negotiated Rate	$57.30
Rate for Payer: Qualcare PPO/HMO/WC	$57.30

VISCOAT INJ 0.5ML

Facility

$1,228.80

Hospital Charge Code	6006811
Hospital Revenue Code	250
Min. Negotiated Rate	$184.32
Max. Negotiated Rate	$184.32
Rate for Payer: Qualcare PPO/HMO/WC	$184.32

VISCOAT INJ 0.5ML

Facility

$1,228.80

Hospital Charge Code	6006811
Hospital Revenue Code	250
Min. Negotiated Rate	$29.61
Max. Negotiated Rate	$614.40
Rate for Payer: Aetna Commercial	$466.94
Rate for Payer: Aetna Medicare Advantage	$368.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$313.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$313.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$313.34
Rate for Payer: Cigna Commercial	$614.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$368.64
Rate for Payer: Oxford Commercial	$245.76
Rate for Payer: Qualcare PPO/HMO/WC	$184.32
Rate for Payer: UnitedHealthcare Commercial	$245.76
Rate for Payer: UnitedHealthcare Community & State	$29.61
Rate for Payer: Wellpoint Medicaid Managed Care	$32.56

VISCOAT PROVISC OPH

Facility

$1,328.00

Hospital Charge Code	60628086
Hospital Revenue Code	250
Min. Negotiated Rate	$199.20
Max. Negotiated Rate	$199.20
Rate for Payer: Qualcare PPO/HMO/WC	$199.20

VISCOAT PROVISC OPH

Facility

$1,328.00

Hospital Charge Code	60628086
Hospital Revenue Code	250
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$504.64
Rate for Payer: Aetna Medicare Advantage	$398.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$338.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$338.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$338.64
Rate for Payer: Cigna Commercial	$664.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$398.40
Rate for Payer: Oxford Commercial	$265.60
Rate for Payer: Qualcare PPO/HMO/WC	$199.20
Rate for Payer: UnitedHealthcare Commercial	$265.60
Rate for Payer: UnitedHealthcare Community & State	$32.00
Rate for Payer: Wellpoint Medicaid Managed Care	$35.19

VISCOSITY

Facility

$57.65

Service Code	HCPCS 85810
Hospital Charge Code	3007739
Hospital Revenue Code	305
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$8.65
Rate for Payer: Qualcare PPO/HMO/WC	$8.65

VISCOSITY

Facility

$57.65

Service Code	HCPCS 85810
Hospital Charge Code	3007739
Hospital Revenue Code	305
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.74
Rate for Payer: Aetna Medicare Advantage	$37.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$42.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$42.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$42.13
Rate for Payer: Cigna Commercial	$28.82
Rate for Payer: Cigna Medicare Advantage	$11.67
Rate for Payer: Clover Medicare Advantage	$11.09
Rate for Payer: EmblemHealth Commercial	$35.01
Rate for Payer: Humana Medicare Advantage	$12.02
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.30
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$8.65
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.67
Rate for Payer: Wellcare Medicare Advantage	$11.67
Rate for Payer: Wellpoint Medicaid Managed Care	$1.53

Know your out-of-pocket cost for care.

All Charges