Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CH THYROXINE FREE

Facility

$453.00

Service Code	HCPCS 84439
Hospital Charge Code	397073610
Hospital Revenue Code	301
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$226.50
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Aetna Medicare Advantage	$29.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$32.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$32.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$32.56
Rate for Payer: Cigna Commercial	$226.50
Rate for Payer: Cigna Medicare Advantage	$9.02
Rate for Payer: Clover Medicare Advantage	$8.57
Rate for Payer: EmblemHealth Commercial	$27.06
Rate for Payer: Humana Medicare Advantage	$9.29
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$135.90
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$67.95
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$7.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.02
Rate for Payer: Wellcare Medicare Advantage	$9.02
Rate for Payer: Wellpoint Medicaid Managed Care	$12.00

CH THYROXINE FREE

Facility

$453.00

Service Code	HCPCS 84439
Hospital Charge Code	397073610
Hospital Revenue Code	301
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$67.95
Rate for Payer: Qualcare PPO/HMO/WC	$67.95

CH TIBC

Facility

$390.00

Service Code	HCPCS 83550
Hospital Charge Code	397071312
Hospital Revenue Code	301
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$23.77
Rate for Payer: Aetna Medicare Advantage	$28.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.55
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$8.74
Rate for Payer: Clover Medicare Advantage	$8.30
Rate for Payer: EmblemHealth Commercial	$26.22
Rate for Payer: Humana Medicare Advantage	$9.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.74
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.74
Rate for Payer: Wellcare Medicare Advantage	$8.74
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CH TIBC

Facility

$390.00

Service Code	HCPCS 83550
Hospital Charge Code	397071312
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CH TISSUE CULTURE

Facility

$1,149.00

Service Code	HCPCS 88230
Hospital Charge Code	397073334
Hospital Revenue Code	311
Min. Negotiated Rate	$172.35
Max. Negotiated Rate	$172.35
Rate for Payer: Qualcare PPO/HMO/WC	$172.35

CH TISSUE CULTURE

Facility

$1,347.00

Service Code	HCPCS 88230
Hospital Charge Code	397073329
Hospital Revenue Code	311
Min. Negotiated Rate	$202.05
Max. Negotiated Rate	$202.05
Rate for Payer: Qualcare PPO/HMO/WC	$202.05

CH TISSUE CULTURE

Facility

$1,331.00

Service Code	HCPCS 88231
Hospital Charge Code	397073326
Hospital Revenue Code	311
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$665.50
Rate for Payer: Aetna Commercial	$505.78
Rate for Payer: Aetna Medicare Advantage	$399.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$339.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$339.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$339.40
Rate for Payer: Cigna Commercial	$665.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$399.30
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$199.65
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$32.08
Rate for Payer: Wellpoint Medicaid Managed Care	$35.27

CH TISSUE CULTURE

Facility

$1,149.00

Service Code	HCPCS 88230
Hospital Charge Code	397073334
Hospital Revenue Code	311
Min. Negotiated Rate	$30.45
Max. Negotiated Rate	$574.50
Rate for Payer: Aetna Commercial	$316.85
Rate for Payer: Aetna Medicare Advantage	$377.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$420.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$420.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$116.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$420.49
Rate for Payer: Cigna Commercial	$574.50
Rate for Payer: Cigna Medicare Advantage	$116.49
Rate for Payer: Clover Medicare Advantage	$110.67
Rate for Payer: EmblemHealth Commercial	$349.47
Rate for Payer: Humana Medicare Advantage	$119.98
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$116.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$344.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$172.35
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$93.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.49
Rate for Payer: Wellcare Medicare Advantage	$116.49
Rate for Payer: Wellpoint Medicaid Managed Care	$30.45

CH TISSUE CULTURE

Facility

$1,347.00

Service Code	HCPCS 88230
Hospital Charge Code	397073329
Hospital Revenue Code	311
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$673.50
Rate for Payer: Aetna Commercial	$316.85
Rate for Payer: Aetna Medicare Advantage	$377.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$420.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$420.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$116.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$420.49
Rate for Payer: Cigna Commercial	$673.50
Rate for Payer: Cigna Medicare Advantage	$116.49
Rate for Payer: Clover Medicare Advantage	$110.67
Rate for Payer: EmblemHealth Commercial	$349.47
Rate for Payer: Humana Medicare Advantage	$119.98
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$116.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$404.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$202.05
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$93.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.49
Rate for Payer: Wellcare Medicare Advantage	$116.49
Rate for Payer: Wellpoint Medicaid Managed Care	$35.70

CH TISSUE CULTURE

Facility

$93.65

Service Code	HCPCS 87070
Hospital Charge Code	397041247
Hospital Revenue Code	306
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$14.05
Rate for Payer: Qualcare PPO/HMO/WC	$14.05

CH TISSUE CULTURE

Facility

$1,331.00

Service Code	HCPCS 88231
Hospital Charge Code	397073326
Hospital Revenue Code	311
Min. Negotiated Rate	$199.65
Max. Negotiated Rate	$199.65
Rate for Payer: Qualcare PPO/HMO/WC	$199.65

CH TISSUE CULTURE

Facility

$93.65

Service Code	HCPCS 87070
Hospital Charge Code	397041247
Hospital Revenue Code	306
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$23.45
Rate for Payer: Aetna Medicare Advantage	$27.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$8.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.12
Rate for Payer: Cigna Commercial	$46.83
Rate for Payer: Cigna Medicare Advantage	$8.62
Rate for Payer: Clover Medicare Advantage	$8.19
Rate for Payer: EmblemHealth Commercial	$25.86
Rate for Payer: Humana Medicare Advantage	$8.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$8.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.09
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$6.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.62
Rate for Payer: Wellcare Medicare Advantage	$8.62
Rate for Payer: Wellpoint Medicaid Managed Care	$2.48

CH TISSUE TRANSGLUTAM AB IGG

Facility

$74.00

Service Code	HCPCS 83516
Hospital Charge Code	397071368
Hospital Revenue Code	301
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Aetna Medicare Advantage	$37.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.62
Rate for Payer: Cigna Commercial	$37.00
Rate for Payer: Cigna Medicare Advantage	$11.53
Rate for Payer: Clover Medicare Advantage	$10.95
Rate for Payer: EmblemHealth Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$11.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$22.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.10
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.53
Rate for Payer: Wellcare Medicare Advantage	$11.53
Rate for Payer: Wellpoint Medicaid Managed Care	$1.96

CH TISSUE TRANSGLUTAM AB IGG

Facility

$74.00

Service Code	HCPCS 83516
Hospital Charge Code	397071368
Hospital Revenue Code	301
Min. Negotiated Rate	$11.10
Max. Negotiated Rate	$11.10
Rate for Payer: Qualcare PPO/HMO/WC	$11.10

CH TOBRAMYCIN - PEAK

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397073146
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CH TOBRAMYCIN - PEAK

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397073146
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$43.87
Rate for Payer: Aetna Medicare Advantage	$52.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.22
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$16.13
Rate for Payer: Clover Medicare Advantage	$15.32
Rate for Payer: EmblemHealth Commercial	$48.39
Rate for Payer: Humana Medicare Advantage	$16.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.13
Rate for Payer: Wellcare Medicare Advantage	$16.13
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CH TOBRAMYCIN RANDOM

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397073180
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CH TOBRAMYCIN RANDOM

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397073180
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$43.87
Rate for Payer: Aetna Medicare Advantage	$52.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.22
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$16.13
Rate for Payer: Clover Medicare Advantage	$15.32
Rate for Payer: EmblemHealth Commercial	$48.39
Rate for Payer: Humana Medicare Advantage	$16.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.13
Rate for Payer: Wellcare Medicare Advantage	$16.13
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CH TOBRAMYCIN TROUGH

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397071319
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$43.87
Rate for Payer: Aetna Medicare Advantage	$52.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$24.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.22
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$16.13
Rate for Payer: Clover Medicare Advantage	$15.32
Rate for Payer: EmblemHealth Commercial	$48.39
Rate for Payer: Humana Medicare Advantage	$16.61
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.13
Rate for Payer: Wellcare Medicare Advantage	$16.13
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CH TOBRAMYCIN TROUGH

Facility

$390.00

Service Code	HCPCS 80200
Hospital Charge Code	397071319
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CH TOCAINIDE

Facility

$85.00

Service Code	HCPCS 80299
Hospital Charge Code	397073118
Hospital Revenue Code	301
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$12.75
Rate for Payer: Qualcare PPO/HMO/WC	$12.75

CH TOCAINIDE

Facility

$85.00

Service Code	HCPCS 80299
Hospital Charge Code	397073118
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$50.70
Rate for Payer: Aetna Medicare Advantage	$60.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$67.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$67.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$67.28
Rate for Payer: Cigna Commercial	$42.50
Rate for Payer: Cigna Medicare Advantage	$18.64
Rate for Payer: Clover Medicare Advantage	$17.71
Rate for Payer: EmblemHealth Commercial	$55.92
Rate for Payer: Humana Medicare Advantage	$19.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$18.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$14.91
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.64
Rate for Payer: Wellcare Medicare Advantage	$18.64
Rate for Payer: Wellpoint Medicaid Managed Care	$2.25

CH TOLUENE BLOOD

Facility

$309.00

Service Code	HCPCS 84600
Hospital Charge Code	397073661
Hospital Revenue Code	301
Min. Negotiated Rate	$8.19
Max. Negotiated Rate	$154.50
Rate for Payer: Aetna Commercial	$46.54
Rate for Payer: Aetna Medicare Advantage	$55.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$61.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$61.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$17.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$61.76
Rate for Payer: Cigna Commercial	$154.50
Rate for Payer: Cigna Medicare Advantage	$17.11
Rate for Payer: Clover Medicare Advantage	$16.25
Rate for Payer: EmblemHealth Commercial	$51.33
Rate for Payer: Humana Medicare Advantage	$17.62
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$17.11
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$92.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$46.35
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$13.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.11
Rate for Payer: Wellcare Medicare Advantage	$17.11
Rate for Payer: Wellpoint Medicaid Managed Care	$8.19

CH TOLUENE BLOOD

Facility

$309.00

Service Code	HCPCS 84600
Hospital Charge Code	397073661
Hospital Revenue Code	301
Min. Negotiated Rate	$46.35
Max. Negotiated Rate	$46.35
Rate for Payer: Qualcare PPO/HMO/WC	$46.35

CH TOPIRAMATE (TOPAMAX)

Facility

$119.00

Service Code	HCPCS 80201
Hospital Charge Code	397073555
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$32.42
Rate for Payer: Aetna Medicare Advantage	$38.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.03
Rate for Payer: Cigna Commercial	$59.50
Rate for Payer: Cigna Medicare Advantage	$11.92
Rate for Payer: Clover Medicare Advantage	$11.32
Rate for Payer: EmblemHealth Commercial	$35.76
Rate for Payer: Humana Medicare Advantage	$12.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$35.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$17.85
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.92
Rate for Payer: Wellcare Medicare Advantage	$11.92
Rate for Payer: Wellpoint Medicaid Managed Care	$3.15

Know your out-of-pocket cost for care.

All Charges