Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR LE LT INFANT MIN 2VW

Facility

$5,100.00

Service Code	HCPCS 73592LT
Hospital Charge Code	2002160
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

XR LE LT INFANT MIN 2VW

Facility

$5,100.00

Service Code	HCPCS 73592LT
Hospital Charge Code	2002160
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR LE RT INFANT MIN 2VW

Facility

$5,100.00

Service Code	HCPCS 73592RT
Hospital Charge Code	2002161
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR LE RT INFANT MIN 2VW

Facility

$5,100.00

Service Code	HCPCS 73592RT
Hospital Charge Code	2002161
Hospital Revenue Code	320
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

XR LOOPOGRAM ANTE URO

Facility

$906.25

Service Code	HCPCS 74425
Hospital Charge Code	2002053
Hospital Revenue Code	320
Min. Negotiated Rate	$135.94
Max. Negotiated Rate	$135.94
Rate for Payer: Qualcare PPO/HMO/WC	$135.94

XR LOOPOGRAM ANTE URO

Facility

$906.25

Service Code	HCPCS 74425
Hospital Charge Code	2002053
Hospital Revenue Code	320
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$54.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$290.13
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$271.88
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$135.94
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$21.84
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$24.02

XR LUMBOSACRAL SPINE W/ OBLIQ

Facility

$5,151.86

Service Code	HCPCS 72110
Hospital Charge Code	2002038
Hospital Revenue Code	320
Min. Negotiated Rate	$53.24
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna Medicare Advantage	$402.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$448.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$448.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$124.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$53.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$448.32
Rate for Payer: Cigna Commercial	$248.96
Rate for Payer: Cigna Medicare Advantage	$86.94
Rate for Payer: Clover Medicare Advantage	$117.99
Rate for Payer: EmblemHealth Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$127.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$124.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,545.56
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$772.78
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$124.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.20
Rate for Payer: Wellcare Medicare Advantage	$124.20
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$407.88
Rate for Payer: Wellpoint Medicaid Managed Care	$136.52

XR LUMBOSACRAL SPINE W/ OBLIQ

Facility

$5,151.86

Service Code	HCPCS 72110
Hospital Charge Code	2002038
Hospital Revenue Code	320
Min. Negotiated Rate	$772.78
Max. Negotiated Rate	$772.78
Rate for Payer: Qualcare PPO/HMO/WC	$772.78

XR MAM DIG FILM RADIOGR IMAGES

Facility

$1,201.95

Service Code	HCPCS 77052
Hospital Charge Code	2002585
Hospital Revenue Code	403
Min. Negotiated Rate	$28.97
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$456.74
Rate for Payer: Aetna Medicare Advantage	$360.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$306.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$306.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$306.50
Rate for Payer: Cigna Commercial	$600.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$360.58
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$180.29
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$28.97
Rate for Payer: Wellpoint Medicaid Managed Care	$31.85

XR MAM DIG FILM RADIOGR IMAGES

Facility

$1,201.95

Service Code	HCPCS 77052
Hospital Charge Code	2002585
Hospital Revenue Code	403
Min. Negotiated Rate	$180.29
Max. Negotiated Rate	$180.29
Rate for Payer: Qualcare PPO/HMO/WC	$180.29

XR MAMMO DUOTOGRAM/GALA MULT

Facility

$822.50

Service Code	HCPCS 77054
Hospital Charge Code	2002583
Hospital Revenue Code	320
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$119.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$198.43
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$246.75
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$123.38
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$19.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$21.80

XR MAMMO DUOTOGRAM/GALA MULT

Facility

$822.50

Service Code	HCPCS 77054
Hospital Charge Code	2002583
Hospital Revenue Code	320
Min. Negotiated Rate	$123.38
Max. Negotiated Rate	$123.38
Rate for Payer: Qualcare PPO/HMO/WC	$123.38

XR MAMMO DUOTOGRAM/GALA SNGL

Facility

$822.50

Service Code	HCPCS 77053
Hospital Charge Code	2002584
Hospital Revenue Code	320
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$21.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$198.43
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$246.75
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$123.38
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$19.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$21.80

XR MAMMO DUOTOGRAM/GALA SNGL

Facility

$822.50

Service Code	HCPCS 77053
Hospital Charge Code	2002584
Hospital Revenue Code	320
Min. Negotiated Rate	$123.38
Max. Negotiated Rate	$123.38
Rate for Payer: Qualcare PPO/HMO/WC	$123.38

XR MAMMOGRAPHY SCREEN BI

Facility

$434.40

Service Code	HCPCS 77057
Hospital Charge Code	2000917
Hospital Revenue Code	403
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$165.07
Rate for Payer: Aetna Medicare Advantage	$130.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$110.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$110.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$110.77
Rate for Payer: Cigna Commercial	$217.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$130.32
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.16
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$10.47
Rate for Payer: Wellpoint Medicaid Managed Care	$11.51

XR MAMMOGRAPHY SCREEN BI

Facility

$434.40

Service Code	HCPCS 77057
Hospital Charge Code	2000917
Hospital Revenue Code	403
Min. Negotiated Rate	$65.16
Max. Negotiated Rate	$65.16
Rate for Payer: Qualcare PPO/HMO/WC	$65.16

XR MAMMOGRAPHY SCREEN UNI

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	2000628
Hospital Revenue Code	401
Min. Negotiated Rate	$116.62
Max. Negotiated Rate	$116.62
Rate for Payer: Qualcare PPO/HMO/WC	$116.62

XR MAMMOGRAPHY SCREEN UNI

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	2000628
Hospital Revenue Code	401
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare Advantage	$233.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$198.26
Rate for Payer: Cigna Commercial	$388.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$233.25
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$116.62
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$18.74
Rate for Payer: Wellpoint Medicaid Managed Care	$20.60

XR MAMMOGRAPHY UNILATERAL

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	94064047
Hospital Revenue Code	401
Min. Negotiated Rate	$116.62
Max. Negotiated Rate	$116.62
Rate for Payer: Qualcare PPO/HMO/WC	$116.62

XR MAMMOGRAPHY UNILATERAL

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	94064047
Hospital Revenue Code	401
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare Advantage	$233.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$198.26
Rate for Payer: Cigna Commercial	$388.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$233.25
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$116.62
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$18.74
Rate for Payer: Wellpoint Medicaid Managed Care	$20.60

XR MAMMOGRAPHY UNILATERAL

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	2000924
Hospital Revenue Code	401
Min. Negotiated Rate	$116.62
Max. Negotiated Rate	$116.62
Rate for Payer: Qualcare PPO/HMO/WC	$116.62

XR MAMMOGRAPHY UNILATERAL

Facility

$777.50

Service Code	HCPCS 77055
Hospital Charge Code	2000924
Hospital Revenue Code	401
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare Advantage	$233.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$198.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$198.26
Rate for Payer: Cigna Commercial	$388.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$233.25
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$116.62
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$18.74
Rate for Payer: Wellpoint Medicaid Managed Care	$20.60

XR MAMO SCREEN TO DIAGNOSTIC

Facility

$434.40

Service Code	HCPCS 77057
Hospital Charge Code	2000918
Hospital Revenue Code	403
Min. Negotiated Rate	$65.16
Max. Negotiated Rate	$65.16
Rate for Payer: Qualcare PPO/HMO/WC	$65.16

XR MAMO SCREEN TO DIAGNOSTIC

Facility

$434.40

Service Code	HCPCS 77057
Hospital Charge Code	2000918
Hospital Revenue Code	403
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$165.07
Rate for Payer: Aetna Medicare Advantage	$130.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$110.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$110.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$110.77
Rate for Payer: Cigna Commercial	$217.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$130.32
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.16
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$10.47
Rate for Payer: Wellpoint Medicaid Managed Care	$11.51

XR MANDIBLE

Facility

$5,100.00

Service Code	HCPCS 70110
Hospital Charge Code	2000354
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

Know your out-of-pocket cost for care.

All Charges