Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

XR SACRUM

Facility

$5,100.00

Service Code	HCPCS 72220
Hospital Charge Code	2001477
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SACRUM

Facility

$5,100.00

Service Code	HCPCS 72220
Hospital Charge Code	2001477
Hospital Revenue Code	320
Min. Negotiated Rate	$31.94
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$31.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
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: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$247.19
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

XR SACRUM & COCCYX MIN 2 VWS

Facility

$5,100.00

Service Code	HCPCS 72220
Hospital Charge Code	2000693
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SACRUM & COCCYX MIN 2 VWS

Facility

$5,100.00

Service Code	HCPCS 72220
Hospital Charge Code	2000693
Hospital Revenue Code	320
Min. Negotiated Rate	$31.94
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$31.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
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: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$247.19
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

XR SALIVARY GLAND FOR CALCULUS

Facility

$302.45

Service Code	HCPCS 70380
Hospital Charge Code	2004638
Hospital Revenue Code	320
Min. Negotiated Rate	$45.37
Max. Negotiated Rate	$45.37
Rate for Payer: Qualcare PPO/HMO/WC	$45.37

XR SALIVARY GLAND FOR CALCULUS

Facility

$302.45

Service Code	HCPCS 70380
Hospital Charge Code	2004638
Hospital Revenue Code	320
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
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	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.73
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$45.37
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$7.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellpoint Medicaid Managed Care	$8.01

XR SALIVARY GLND CALCULUS RGHT

Facility

$258.70

Service Code	HCPCS 70380
Hospital Charge Code	2011380
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR SALIVARY GLND CALCULUS RGHT

Facility

$258.70

Service Code	HCPCS 70380
Hospital Charge Code	2011380
Hospital Revenue Code	320
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
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	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.61
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$38.80
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$6.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR SALIVRY GLND CALCULUS BLTRL

Facility

$258.70

Service Code	HCPCS 70380
Hospital Charge Code	2011379
Hospital Revenue Code	320
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$38.80
Rate for Payer: Qualcare PPO/HMO/WC	$38.80

XR SALIVRY GLND CALCULUS BLTRL

Facility

$258.70

Service Code	HCPCS 70380
Hospital Charge Code	2011379
Hospital Revenue Code	320
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$281.22
Rate for Payer: Aetna Medicare Advantage	$334.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$373.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$103.39
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	$373.21
Rate for Payer: Cigna Commercial	$207.24
Rate for Payer: Cigna Medicare Advantage	$72.37
Rate for Payer: Clover Medicare Advantage	$98.22
Rate for Payer: EmblemHealth Commercial	$310.17
Rate for Payer: Humana Medicare Advantage	$106.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$103.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.61
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$38.80
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$6.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$103.39
Rate for Payer: Wellcare Medicare Advantage	$103.39
Rate for Payer: Wellpoint Medicaid Managed Care	$6.86

XR SCANOGRAM BONE LENGTH STUDY

Facility

$607.50

Service Code	HCPCS 77073
Hospital Charge Code	2002079
Hospital Revenue Code	320
Min. Negotiated Rate	$14.64
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	$25.09
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	$182.25
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$91.12
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$14.64
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	$216.59
Rate for Payer: Wellpoint Medicaid Managed Care	$16.10

XR SCANOGRAM BONE LENGTH STUDY

Facility

$607.50

Service Code	HCPCS 77073
Hospital Charge Code	2002079
Hospital Revenue Code	320
Min. Negotiated Rate	$91.12
Max. Negotiated Rate	$91.12
Rate for Payer: Qualcare PPO/HMO/WC	$91.12

XR SCAPULA BILATERAL

Facility

$5,100.00

Service Code	HCPCS 7301050
Hospital Charge Code	2011381
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 SCAPULA BILATERAL

Facility

$5,100.00

Service Code	HCPCS 7301050
Hospital Charge Code	2011381
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SCAPULA LT

Facility

$5,100.00

Service Code	HCPCS 73010LT
Hospital Charge Code	2002244
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 SCAPULA LT

Facility

$5,100.00

Service Code	HCPCS 73010LT
Hospital Charge Code	2002244
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SCAPULA RT COMPL

Facility

$5,100.00

Service Code	HCPCS 73010RT
Hospital Charge Code	2002245
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

XR SCAPULA RT COMPL

Facility

$5,100.00

Service Code	HCPCS 73010RT
Hospital Charge Code	2002245
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 SCOLIOSIS SERIES ERECT ONLY

Facility

$442.45

Hospital Charge Code	2001022
Hospital Revenue Code	320
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$168.13
Rate for Payer: Aetna Medicare Advantage	$132.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.82
Rate for Payer: Cigna Commercial	$221.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.74
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$66.37
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$10.66
Rate for Payer: Wellpoint Medicaid Managed Care	$11.72

XR SCOLIOSIS SERIES ERECT ONLY

Facility

$442.45

Hospital Charge Code	2001022
Hospital Revenue Code	320
Min. Negotiated Rate	$66.37
Max. Negotiated Rate	$66.37
Rate for Payer: Qualcare PPO/HMO/WC	$66.37

XR SEC ART M-THROMBECT ADD ON

Facility

$18,307.80

Service Code	HCPCS 37186
Hospital Charge Code	7411494
Hospital Revenue Code	361
Min. Negotiated Rate	$2,746.17
Max. Negotiated Rate	$2,746.17
Rate for Payer: Qualcare PPO/HMO/WC	$2,746.17

XR SEC ART M-THROMBECT ADD ON

Facility

$18,307.80

Service Code	HCPCS 37186
Hospital Charge Code	411037186
Hospital Revenue Code	361
Min. Negotiated Rate	$2,746.17
Max. Negotiated Rate	$2,746.17
Rate for Payer: Qualcare PPO/HMO/WC	$2,746.17

XR SEC ART M-THROMBECT ADD ON

Facility

$18,307.80

Service Code	HCPCS 37186
Hospital Charge Code	366837186
Hospital Revenue Code	361
Min. Negotiated Rate	$441.22
Max. Negotiated Rate	$9,153.90
Rate for Payer: Aetna Commercial	$6,956.96
Rate for Payer: Aetna Medicare Advantage	$5,492.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,668.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,668.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,668.49
Rate for Payer: Cigna Commercial	$9,153.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,492.34
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,746.17
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$441.22
Rate for Payer: Wellpoint Medicaid Managed Care	$485.16

XR SEC ART M-THROMBECT ADD ON

Facility

$18,307.80

Service Code	HCPCS 37186
Hospital Charge Code	7411494
Hospital Revenue Code	361
Min. Negotiated Rate	$441.22
Max. Negotiated Rate	$9,153.90
Rate for Payer: Aetna Commercial	$6,956.96
Rate for Payer: Aetna Medicare Advantage	$5,492.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,668.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,668.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,668.49
Rate for Payer: Cigna Commercial	$9,153.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,492.34
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,746.17
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$441.22
Rate for Payer: Wellpoint Medicaid Managed Care	$485.16

XR SEC ART M-THROMBECT ADD ON

Facility

$12,129.00

Service Code	HCPCS 37186
Hospital Charge Code	321037186
Hospital Revenue Code	361
Min. Negotiated Rate	$1,819.35
Max. Negotiated Rate	$1,819.35
Rate for Payer: Qualcare PPO/HMO/WC	$1,819.35

Know your out-of-pocket cost for care.

All Charges