Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CLOMID/50MG/TAB

Facility

$38.00

Hospital Charge Code	60632716
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$14.44
Rate for Payer: Aetna Medicare Advantage	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.69
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.40
Rate for Payer: Oxford Commercial	$7.60
Rate for Payer: Qualcare PPO/HMO/WC	$5.70
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Community & State	$0.92
Rate for Payer: Wellpoint Medicaid Managed Care	$1.01

CLOMIPHENE TAB 50MG

Facility

$34.60

Hospital Charge Code	6001259
Hospital Revenue Code	252
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$17.30
Rate for Payer: Aetna Commercial	$13.15
Rate for Payer: Aetna Medicare Advantage	$10.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.82
Rate for Payer: Cigna Commercial	$17.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.38
Rate for Payer: Oxford Commercial	$6.92
Rate for Payer: Qualcare PPO/HMO/WC	$5.19
Rate for Payer: UnitedHealthcare Commercial	$6.92
Rate for Payer: UnitedHealthcare Community & State	$0.83
Rate for Payer: Wellpoint Medicaid Managed Care	$0.92

CLOMIPHENE TAB 50MG

Facility

$34.60

Hospital Charge Code	6001259
Hospital Revenue Code	252
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$5.19
Rate for Payer: Qualcare PPO/HMO/WC	$5.19

CLOMIPRAMINE 25 MG CAP

Facility

$75.31

Service Code	NDC 51672401106
Hospital Charge Code	60628595
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$37.66
Rate for Payer: Aetna Commercial	$28.62
Rate for Payer: Aetna Medicare Advantage	$22.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.20
Rate for Payer: Cigna Commercial	$37.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$22.59
Rate for Payer: Oxford Commercial	$15.06
Rate for Payer: Qualcare PPO/HMO/WC	$11.30
Rate for Payer: UnitedHealthcare Commercial	$15.06
Rate for Payer: UnitedHealthcare Community & State	$1.81
Rate for Payer: Wellpoint Medicaid Managed Care	$2.00

CLOMIPRAMINE 25 MG CAP

Facility

$75.31

Service Code	NDC 51672401106
Hospital Charge Code	60628595
Hospital Revenue Code	250
Min. Negotiated Rate	$11.30
Max. Negotiated Rate	$11.30
Rate for Payer: Qualcare PPO/HMO/WC	$11.30

CLOMIPRAMINE 50MG CAPSULE

Facility

$75.31

Service Code	NDC 51672401206
Hospital Charge Code	606390170
Hospital Revenue Code	250
Min. Negotiated Rate	$11.30
Max. Negotiated Rate	$11.30
Rate for Payer: Qualcare PPO/HMO/WC	$11.30

CLOMIPRAMINE 50MG CAPSULE

Facility

$75.31

Service Code	NDC 51672401206
Hospital Charge Code	606390170
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$37.66
Rate for Payer: Aetna Commercial	$28.62
Rate for Payer: Aetna Medicare Advantage	$22.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.20
Rate for Payer: Cigna Commercial	$37.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$22.59
Rate for Payer: Oxford Commercial	$15.06
Rate for Payer: Qualcare PPO/HMO/WC	$11.30
Rate for Payer: UnitedHealthcare Commercial	$15.06
Rate for Payer: UnitedHealthcare Community & State	$1.81
Rate for Payer: Wellpoint Medicaid Managed Care	$2.00

CLOMIPRAMINE & NORCLOM

Facility

$245.00

Service Code	HCPCS 83789
Hospital Charge Code	38472934
Hospital Revenue Code	301
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$36.75
Rate for Payer: Qualcare PPO/HMO/WC	$36.75

CLOMIPRAMINE & NORCLOM

Facility

$245.00

Service Code	HCPCS 83789
Hospital Charge Code	38472934
Hospital Revenue Code	301
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$65.58
Rate for Payer: Aetna Medicare Advantage	$78.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$87.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$87.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$24.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$87.03
Rate for Payer: Cigna Commercial	$122.50
Rate for Payer: Cigna Medicare Advantage	$24.11
Rate for Payer: Clover Medicare Advantage	$22.90
Rate for Payer: EmblemHealth Commercial	$72.33
Rate for Payer: Humana Medicare Advantage	$24.83
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$24.11
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$73.50
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$36.75
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$19.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.11
Rate for Payer: Wellcare Medicare Advantage	$24.11
Rate for Payer: Wellpoint Medicaid Managed Care	$6.49

CLONAZEPAM

Facility

$572.15

Service Code	HCPCS 80346
Hospital Charge Code	3038541
Hospital Revenue Code	301
Min. Negotiated Rate	$15.16
Max. Negotiated Rate	$286.07
Rate for Payer: Aetna Commercial	$217.42
Rate for Payer: Aetna Medicare Advantage	$171.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$145.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$145.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$145.90
Rate for Payer: Cigna Commercial	$286.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$171.65
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$85.82
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: Wellpoint Medicaid Managed Care	$15.16

CLONAZEPAM

Facility

$572.15

Service Code	HCPCS 80346
Hospital Charge Code	3038541
Hospital Revenue Code	301
Min. Negotiated Rate	$85.82
Max. Negotiated Rate	$85.82
Rate for Payer: Qualcare PPO/HMO/WC	$85.82

CLONAZEPAM 0.25MG ODT TAB

Facility

$2.98

Hospital Charge Code	60630167
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

CLONAZEPAM 0.25MG ODT TAB

Facility

$2.98

Hospital Charge Code	60630167
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna Commercial	$1.13
Rate for Payer: Aetna Medicare Advantage	$0.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.76
Rate for Payer: Cigna Commercial	$1.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.89
Rate for Payer: Oxford Commercial	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$0.60
Rate for Payer: UnitedHealthcare Community & State	$0.07
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

CLONAZEPAM 0.25MG TABRAPIDDSLV

Facility

$8.71

Service Code	NDC 49884030702
Hospital Charge Code	606390376
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.31
Rate for Payer: Qualcare PPO/HMO/WC	$1.31

CLONAZEPAM 0.25MG TABRAPIDDSLV

Facility

$8.71

Service Code	NDC 49884030702
Hospital Charge Code	606390376
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$4.36
Rate for Payer: Aetna Commercial	$3.31
Rate for Payer: Aetna Medicare Advantage	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.22
Rate for Payer: Cigna Commercial	$4.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.61
Rate for Payer: Oxford Commercial	$1.74
Rate for Payer: Qualcare PPO/HMO/WC	$1.31
Rate for Payer: UnitedHealthcare Commercial	$1.74
Rate for Payer: UnitedHealthcare Community & State	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.23

CLONAZEPAM 0.5 MG TAB

Facility

$5.36

Service Code	NDC 51079088120
Hospital Charge Code	6011126
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$2.68
Rate for Payer: Aetna Commercial	$2.04
Rate for Payer: Aetna Medicare Advantage	$1.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.37
Rate for Payer: Cigna Commercial	$2.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.61
Rate for Payer: Oxford Commercial	$1.07
Rate for Payer: Qualcare PPO/HMO/WC	$0.80
Rate for Payer: UnitedHealthcare Commercial	$1.07
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.14

CLONAZEPAM 0.5 MG TAB

Facility

$5.36

Service Code	NDC 51079088120
Hospital Charge Code	6011126
Hospital Revenue Code	251
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.80

CLONAZEPAM 1 MG TAB

Facility

$6.10

Service Code	NDC 51079088221
Hospital Charge Code	60627740
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna Commercial	$2.32
Rate for Payer: Aetna Medicare Advantage	$1.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.56
Rate for Payer: Cigna Commercial	$3.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.83
Rate for Payer: Oxford Commercial	$1.22
Rate for Payer: Qualcare PPO/HMO/WC	$0.92
Rate for Payer: UnitedHealthcare Commercial	$1.22
Rate for Payer: UnitedHealthcare Community & State	$0.15
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

CLONAZEPAM 1 MG TAB

Facility

$6.10

Service Code	NDC 51079088221
Hospital Charge Code	60627740
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$0.92
Rate for Payer: Qualcare PPO/HMO/WC	$0.92

CLONAZEPAM 1MG TAB RAPDIS

Facility

$9.92

Service Code	NDC 49884030902
Hospital Charge Code	606390299
Hospital Revenue Code	250
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$1.49
Rate for Payer: Qualcare PPO/HMO/WC	$1.49

CLONAZEPAM 1MG TAB RAPDIS

Facility

$9.92

Service Code	NDC 49884030902
Hospital Charge Code	606390299
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$4.96
Rate for Payer: Aetna Commercial	$3.77
Rate for Payer: Aetna Medicare Advantage	$2.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.53
Rate for Payer: Cigna Commercial	$4.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.98
Rate for Payer: Oxford Commercial	$1.98
Rate for Payer: Qualcare PPO/HMO/WC	$1.49
Rate for Payer: UnitedHealthcare Commercial	$1.98
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

CLONAZEPAM (KLONOPIN)

Facility

$180.00

Service Code	HCPCS 80346
Hospital Charge Code	38473121
Hospital Revenue Code	301
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare Advantage	$54.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$45.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$45.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$45.90
Rate for Payer: Cigna Commercial	$90.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$54.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.00
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: Wellpoint Medicaid Managed Care	$4.77

CLONAZEPAM (KLONOPIN)

Facility

$180.00

Service Code	HCPCS 80346
Hospital Charge Code	38473121
Hospital Revenue Code	301
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.00

CLONAZEPAM, (KLONOPIN) SERUM

Facility

$181.65

Service Code	HCPCS 80346
Hospital Charge Code	3007309
Hospital Revenue Code	301
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$69.03
Rate for Payer: Aetna Medicare Advantage	$54.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.32
Rate for Payer: Cigna Commercial	$90.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$54.49
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.25
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: Wellpoint Medicaid Managed Care	$4.81

CLONAZEPAM, (KLONOPIN) SERUM

Facility

$181.65

Service Code	HCPCS 80346
Hospital Charge Code	3007309
Hospital Revenue Code	301
Min. Negotiated Rate	$27.25
Max. Negotiated Rate	$27.25
Rate for Payer: Qualcare PPO/HMO/WC	$27.25

Know your out-of-pocket cost for care.

All Charges