Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CLOT INHIBIT PROT C ANTIGEN

Facility

$390.00

Service Code	HCPCS 85302
Hospital Charge Code	401485302
Hospital Revenue Code	305
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$32.67
Rate for Payer: Aetna Medicare Advantage	$38.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.01
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	$43.35
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.01
Rate for Payer: Clover Medicare Advantage	$11.41
Rate for Payer: EmblemHealth Commercial	$36.03
Rate for Payer: Humana Medicare Advantage	$12.37
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.01
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	$9.61
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.01
Rate for Payer: Wellcare Medicare Advantage	$12.01
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CLOT INHIBIT PROT C ANTIGEN

Facility

$390.00

Service Code	HCPCS 85302
Hospital Charge Code	401485302
Hospital Revenue Code	305
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CLOT INHIBIT PROT S FREE

Facility

$390.00

Service Code	HCPCS 85306
Hospital Charge Code	401485306
Hospital Revenue Code	305
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CLOT INHIBIT PROT S FREE

Facility

$390.00

Service Code	HCPCS 85306
Hospital Charge Code	401485306
Hospital Revenue Code	305
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$41.67
Rate for Payer: Aetna Medicare Advantage	$49.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$38.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.30
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$15.32
Rate for Payer: Clover Medicare Advantage	$14.55
Rate for Payer: EmblemHealth Commercial	$45.96
Rate for Payer: Humana Medicare Advantage	$15.78
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.32
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	$12.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.32
Rate for Payer: Wellcare Medicare Advantage	$15.32
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CLOT INHIBIT PROT S TOTAL

Facility

$390.00

Service Code	HCPCS 85305
Hospital Charge Code	401485305
Hospital Revenue Code	305
Min. Negotiated Rate	$9.29
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$31.58
Rate for Payer: Aetna Medicare Advantage	$37.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$30.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.91
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$11.61
Rate for Payer: Clover Medicare Advantage	$11.03
Rate for Payer: EmblemHealth Commercial	$34.83
Rate for Payer: Humana Medicare Advantage	$11.96
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.61
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	$9.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.61
Rate for Payer: Wellcare Medicare Advantage	$11.61
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

CLOT INHIBIT PROT S TOTAL

Facility

$390.00

Service Code	HCPCS 85305
Hospital Charge Code	401485305
Hospital Revenue Code	305
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

CLOT RETRACTION***

Facility

$18.00

Hospital Charge Code	3010824
Hospital Revenue Code	309
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$6.84
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$0.43
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

CLOT RETRACTION***

Facility

$18.00

Hospital Charge Code	3010824
Hospital Revenue Code	309
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$2.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

CLOT RETRACTION TIME

Facility

$63.25

Service Code	HCPCS 85170
Hospital Charge Code	3000825
Hospital Revenue Code	305
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$9.49
Rate for Payer: Qualcare PPO/HMO/WC	$9.49

CLOT RETRACTION TIME

Facility

$63.25

Service Code	HCPCS 85170
Hospital Charge Code	3000825
Hospital Revenue Code	305
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$44.34
Rate for Payer: Aetna Medicare Advantage	$52.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.84
Rate for Payer: Cigna Commercial	$31.62
Rate for Payer: Cigna Medicare Advantage	$16.30
Rate for Payer: Clover Medicare Advantage	$15.48
Rate for Payer: EmblemHealth Commercial	$48.90
Rate for Payer: Humana Medicare Advantage	$16.79
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.98
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.49
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$13.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.30
Rate for Payer: Wellcare Medicare Advantage	$16.30
Rate for Payer: Wellpoint Medicaid Managed Care	$1.68

CLOTRIMAZOLE 10 MG TROCHE

Facility

$9.78

Service Code	NDC 574010714
Hospital Charge Code	60628336
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.47
Rate for Payer: Qualcare PPO/HMO/WC	$1.47

CLOTRIMAZOLE 10 MG TROCHE

Facility

$9.78

Service Code	NDC 574010714
Hospital Charge Code	60628336
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna Medicare Advantage	$2.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.49
Rate for Payer: Cigna Commercial	$4.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.93
Rate for Payer: Oxford Commercial	$1.96
Rate for Payer: Qualcare PPO/HMO/WC	$1.47
Rate for Payer: UnitedHealthcare Commercial	$1.96
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

CLOTRIMAZOLE 1 % CRE

Facility

$57.55

Service Code	NDC 45802043411
Hospital Charge Code	60628334
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$28.77
Rate for Payer: Aetna Commercial	$21.87
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.68
Rate for Payer: Cigna Commercial	$28.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.27
Rate for Payer: Oxford Commercial	$11.51
Rate for Payer: Qualcare PPO/HMO/WC	$8.63
Rate for Payer: UnitedHealthcare Commercial	$11.51
Rate for Payer: UnitedHealthcare Community & State	$1.39
Rate for Payer: Wellpoint Medicaid Managed Care	$1.53

CLOTRIMAZOLE 1 % CRE

Facility

$57.55

Service Code	NDC 45802043411
Hospital Charge Code	60628334
Hospital Revenue Code	250
Min. Negotiated Rate	$8.63
Max. Negotiated Rate	$8.63
Rate for Payer: Qualcare PPO/HMO/WC	$8.63

CLOTRIMAZOLE 1% TOP SOLN

Facility

$302.37

Service Code	NDC 93024843
Hospital Charge Code	60628335
Hospital Revenue Code	250
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$151.19
Rate for Payer: Aetna Commercial	$114.90
Rate for Payer: Aetna Medicare Advantage	$90.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$77.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$77.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$77.10
Rate for Payer: Cigna Commercial	$151.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.71
Rate for Payer: Oxford Commercial	$60.47
Rate for Payer: Qualcare PPO/HMO/WC	$45.36
Rate for Payer: UnitedHealthcare Commercial	$60.47
Rate for Payer: UnitedHealthcare Community & State	$7.29
Rate for Payer: Wellpoint Medicaid Managed Care	$8.01

CLOTRIMAZOLE 1% TOP SOLN

Facility

$302.37

Service Code	NDC 93024843
Hospital Charge Code	60628335
Hospital Revenue Code	250
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$45.36
Rate for Payer: Qualcare PPO/HMO/WC	$45.36

CLOTRIMAZOLE 1% VAGINAL CREAM

Facility

$80.40

Service Code	NDC 472022041
Hospital Charge Code	60628963
Hospital Revenue Code	251
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$40.20
Rate for Payer: Aetna Commercial	$30.55
Rate for Payer: Aetna Medicare Advantage	$24.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.50
Rate for Payer: Cigna Commercial	$40.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.12
Rate for Payer: Oxford Commercial	$16.08
Rate for Payer: Qualcare PPO/HMO/WC	$12.06
Rate for Payer: UnitedHealthcare Commercial	$16.08
Rate for Payer: UnitedHealthcare Community & State	$1.94
Rate for Payer: Wellpoint Medicaid Managed Care	$2.13

CLOTRIMAZOLE 1% VAGINAL CREAM

Facility

$80.40

Service Code	NDC 472022041
Hospital Charge Code	60628963
Hospital Revenue Code	251
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$12.06
Rate for Payer: Qualcare PPO/HMO/WC	$12.06

CLOTRIMAZOLE 30 GM

Facility

$8.40

Hospital Charge Code	60628334W
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$4.20
Rate for Payer: Aetna Commercial	$3.19
Rate for Payer: Aetna Medicare Advantage	$2.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.14
Rate for Payer: Cigna Commercial	$4.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.52
Rate for Payer: Oxford Commercial	$1.68
Rate for Payer: Qualcare PPO/HMO/WC	$1.26
Rate for Payer: UnitedHealthcare Commercial	$1.68
Rate for Payer: UnitedHealthcare Community & State	$0.20
Rate for Payer: Wellpoint Medicaid Managed Care	$0.22

CLOTRIMAZOLE 30 GM

Facility

$8.40

Hospital Charge Code	60628334W
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.26
Rate for Payer: Qualcare PPO/HMO/WC	$1.26

CLOTRIMAZOLE CRM 30GM

Facility

$131.85

Hospital Charge Code	6001317
Hospital Revenue Code	251
Min. Negotiated Rate	$19.78
Max. Negotiated Rate	$19.78
Rate for Payer: Qualcare PPO/HMO/WC	$19.78

CLOTRIMAZOLE CRM 30GM

Facility

$131.85

Hospital Charge Code	6001317
Hospital Revenue Code	251
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$65.92
Rate for Payer: Aetna Commercial	$50.10
Rate for Payer: Aetna Medicare Advantage	$39.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.62
Rate for Payer: Cigna Commercial	$65.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.55
Rate for Payer: Oxford Commercial	$26.37
Rate for Payer: Qualcare PPO/HMO/WC	$19.78
Rate for Payer: UnitedHealthcare Commercial	$26.37
Rate for Payer: UnitedHealthcare Community & State	$3.18
Rate for Payer: Wellpoint Medicaid Managed Care	$3.49

CLOTRIMAZOLE CRM VAG 45GM

Facility

$122.25

Hospital Charge Code	6001291
Hospital Revenue Code	251
Min. Negotiated Rate	$18.34
Max. Negotiated Rate	$18.34
Rate for Payer: Qualcare PPO/HMO/WC	$18.34

CLOTRIMAZOLE CRM VAG 45GM

Facility

$122.25

Hospital Charge Code	6001291
Hospital Revenue Code	251
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$61.12
Rate for Payer: Aetna Commercial	$46.45
Rate for Payer: Aetna Medicare Advantage	$36.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.17
Rate for Payer: Cigna Commercial	$61.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.67
Rate for Payer: Oxford Commercial	$24.45
Rate for Payer: Qualcare PPO/HMO/WC	$18.34
Rate for Payer: UnitedHealthcare Commercial	$24.45
Rate for Payer: UnitedHealthcare Community & State	$2.95
Rate for Payer: Wellpoint Medicaid Managed Care	$3.24

CLOTRIMAZOLE TAB VAG 100MG

Facility

$21.15

Hospital Charge Code	6001309
Hospital Revenue Code	251
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.17
Rate for Payer: Qualcare PPO/HMO/WC	$3.17

Know your out-of-pocket cost for care.

All Charges