Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

DIAZEPAM (VALIUM) 10MG TAB

Facility

$4.00

Service Code	NDC 51079028620
Hospital Charge Code	60630184
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DIAZEPAM (VALIUM) 10MG TAB

Facility

$4.00

Service Code	NDC 51079028620
Hospital Charge Code	60630184
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DIAZEPAM (VALIUM) 2MG TAB

Facility

$0.28

Hospital Charge Code	60630166
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Qualcare PPO/HMO/WC	$0.04

DIAZEPAM (VALIUM) 2MG TAB

Facility

$0.28

Hospital Charge Code	60630166
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna Commercial	$0.11
Rate for Payer: Aetna Medicare Advantage	$0.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.07
Rate for Payer: Cigna Commercial	$0.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.08
Rate for Payer: Oxford Commercial	$0.06
Rate for Payer: Qualcare PPO/HMO/WC	$0.04
Rate for Payer: UnitedHealthcare Commercial	$0.06
Rate for Payer: UnitedHealthcare Community & State	$0.01
Rate for Payer: Wellpoint Medicaid Managed Care	$0.01

DIAZEPAM VL 5MG/ML

Facility

$10.90

Hospital Charge Code	6008049
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$4.14
Rate for Payer: Aetna Medicare Advantage	$3.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.78
Rate for Payer: Cigna Commercial	$5.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.27
Rate for Payer: Oxford Commercial	$2.18
Rate for Payer: Qualcare PPO/HMO/WC	$1.64
Rate for Payer: UnitedHealthcare Commercial	$2.18
Rate for Payer: UnitedHealthcare Community & State	$0.26
Rate for Payer: Wellpoint Medicaid Managed Care	$0.29

DIAZEPAM VL 5MG/ML

Facility

$10.90

Hospital Charge Code	6008049
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.64

DIAZOXIDE 300 MG/20ML INJ

Facility

$32.35

Hospital Charge Code	60627627
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$16.18
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: Aetna Medicare Advantage	$9.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.25
Rate for Payer: Cigna Commercial	$16.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.71
Rate for Payer: Oxford Commercial	$6.47
Rate for Payer: Qualcare PPO/HMO/WC	$4.85
Rate for Payer: UnitedHealthcare Commercial	$6.47
Rate for Payer: UnitedHealthcare Community & State	$0.78
Rate for Payer: Wellpoint Medicaid Managed Care	$0.86

DIAZOXIDE 300 MG/20ML INJ

Facility

$32.35

Hospital Charge Code	60627627
Hospital Revenue Code	250
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$4.85
Rate for Payer: Qualcare PPO/HMO/WC	$4.85

DIBUCAINE

Facility

$69.65

Service Code	HCPCS 82638
Hospital Charge Code	3035071B
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$33.32
Rate for Payer: Aetna Medicare Advantage	$39.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.25
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	$44.22
Rate for Payer: Cigna Commercial	$34.83
Rate for Payer: Cigna Medicare Advantage	$12.25
Rate for Payer: Clover Medicare Advantage	$11.64
Rate for Payer: EmblemHealth Commercial	$36.75
Rate for Payer: Humana Medicare Advantage	$12.62
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.89
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$10.45
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.25
Rate for Payer: Wellcare Medicare Advantage	$12.25
Rate for Payer: Wellpoint Medicaid Managed Care	$1.85

DIBUCAINE

Facility

$69.65

Service Code	HCPCS 82638
Hospital Charge Code	3035071B
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$10.45
Rate for Payer: Qualcare PPO/HMO/WC	$10.45

DIBUCAINE 1%/28.4GM

Facility

$8.00

Hospital Charge Code	60632831
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

DIBUCAINE 1%/28.4GM

Facility

$8.00

Hospital Charge Code	60632831
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.04
Rate for Payer: Aetna Medicare Advantage	$2.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.04
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.40
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$1.20
Rate for Payer: UnitedHealthcare Commercial	$1.60
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.21

DIBUCAINE 1%/30GM

Facility

$12.00

Hospital Charge Code	60632830
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$4.56
Rate for Payer: Aetna Medicare Advantage	$3.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.06
Rate for Payer: Cigna Commercial	$6.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.60
Rate for Payer: Oxford Commercial	$2.40
Rate for Payer: Qualcare PPO/HMO/WC	$1.80
Rate for Payer: UnitedHealthcare Commercial	$2.40
Rate for Payer: UnitedHealthcare Community & State	$0.29
Rate for Payer: Wellpoint Medicaid Managed Care	$0.32

DIBUCAINE 1%/30GM

Facility

$12.00

Hospital Charge Code	60632830
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$1.80
Rate for Payer: Qualcare PPO/HMO/WC	$1.80

DIBUCAINE 1 % OIN

Facility

$4.00

Service Code	NDC 45802005003
Hospital Charge Code	60628412
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DIBUCAINE 1 % OIN

Facility

$4.00

Service Code	NDC 45802005003
Hospital Charge Code	60628412
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICHLORPHENAMIDE 50 MG TAB

Facility

$3.15

Hospital Charge Code	60628046
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: Qualcare PPO/HMO/WC	$0.47

DICHLORPHENAMIDE 50 MG TAB

Facility

$3.15

Hospital Charge Code	60628046
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.57
Rate for Payer: Aetna Commercial	$1.20
Rate for Payer: Aetna Medicare Advantage	$0.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.80
Rate for Payer: Cigna Commercial	$1.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.95
Rate for Payer: Oxford Commercial	$0.63
Rate for Payer: Qualcare PPO/HMO/WC	$0.47
Rate for Payer: UnitedHealthcare Commercial	$0.63
Rate for Payer: UnitedHealthcare Community & State	$0.08
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

DICLOFENAC EC TAB 25MG

Facility

$7.10

Hospital Charge Code	60627680
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.06
Rate for Payer: Qualcare PPO/HMO/WC	$1.06

DICLOFENAC EC TAB 25MG

Facility

$7.10

Hospital Charge Code	60627680
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.55
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Aetna Medicare Advantage	$2.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.81
Rate for Payer: Cigna Commercial	$3.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.13
Rate for Payer: Oxford Commercial	$1.42
Rate for Payer: Qualcare PPO/HMO/WC	$1.06
Rate for Payer: UnitedHealthcare Commercial	$1.42
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

DICLOFENAC EC TAB 50MG

Facility

$11.25

Hospital Charge Code	60627681
Hospital Revenue Code	250
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.69
Rate for Payer: Qualcare PPO/HMO/WC	$1.69

DICLOFENAC EC TAB 50MG

Facility

$11.25

Hospital Charge Code	60627681
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare Advantage	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.87
Rate for Payer: Cigna Commercial	$5.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.38
Rate for Payer: Oxford Commercial	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$1.69
Rate for Payer: UnitedHealthcare Commercial	$2.25
Rate for Payer: UnitedHealthcare Community & State	$0.27
Rate for Payer: Wellpoint Medicaid Managed Care	$0.30

DICLOXACILLIN 250 MG CAP

Facility

$4.85

Hospital Charge Code	60628603
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: Aetna Medicare Advantage	$1.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.24
Rate for Payer: Cigna Commercial	$2.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.46
Rate for Payer: Oxford Commercial	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.73
Rate for Payer: UnitedHealthcare Commercial	$0.97
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

DICLOXACILLIN 250 MG CAP

Facility

$4.85

Hospital Charge Code	60628603
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.73

DICLOXACILLIN SSP 62.5MG/5ML

Facility

$64.00

Hospital Charge Code	6001895
Hospital Revenue Code	251
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$9.60
Rate for Payer: Qualcare PPO/HMO/WC	$9.60

Know your out-of-pocket cost for care.

All Charges