Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

DIHYDROTERTOSTERONE 1-2

Facility

$179.00

Service Code	HCPCS 80327
Hospital Charge Code	3000602
Hospital Revenue Code	301
Min. Negotiated Rate	$26.85
Max. Negotiated Rate	$26.85
Rate for Payer: Qualcare PPO/HMO/WC	$26.85

DIHYDROTESTOSTERONE

Facility

$182.80

Service Code	HCPCS 80327
Hospital Charge Code	38472937
Hospital Revenue Code	301
Min. Negotiated Rate	$27.42
Max. Negotiated Rate	$27.42
Rate for Payer: Qualcare PPO/HMO/WC	$27.42

DIHYDROTESTOSTERONE

Facility

$182.80

Service Code	HCPCS 80327
Hospital Charge Code	38472937
Hospital Revenue Code	301
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$69.46
Rate for Payer: Aetna Medicare Advantage	$54.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.61
Rate for Payer: Cigna Commercial	$91.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$54.84
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.42
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$4.84

DIHYDROTESTOSTERONE,LC/MS

Facility

$390.00

Service Code	HCPCS 80327
Hospital Charge Code	39900072
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare Advantage	$117.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$195.00
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	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

DIHYDROTESTOSTERONE,LC/MS

Facility

$390.00

Service Code	HCPCS 80327
Hospital Charge Code	39900072
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DILANTIN-125/125MG/5ML

Facility

$5.00

Hospital Charge Code	60632846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

DILANTIN-125/125MG/5ML

Facility

$5.00

Hospital Charge Code	60632846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

DILANTIN/50MG/1ML

Facility

$17.00

Hospital Charge Code	60632844
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Qualcare PPO/HMO/WC	$2.55

DILANTIN/50MG/1ML

Facility

$17.00

Hospital Charge Code	60632844
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna Commercial	$6.46
Rate for Payer: Aetna Medicare Advantage	$5.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.33
Rate for Payer: Cigna Commercial	$8.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.10
Rate for Payer: Oxford Commercial	$3.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.55
Rate for Payer: UnitedHealthcare Commercial	$3.40
Rate for Payer: UnitedHealthcare Community & State	$0.41
Rate for Payer: Wellpoint Medicaid Managed Care	$0.45

DILANTIN KAPSEAL/100MG/1C

Facility

$4.00

Hospital Charge Code	60632845
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DILANTIN KAPSEAL/100MG/1C

Facility

$4.00

Hospital Charge Code	60632845
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

DILANTIN (PHENYTOIN)

Facility

$303.00

Service Code	HCPCS 80185
Hospital Charge Code	38472536
Hospital Revenue Code	301
Min. Negotiated Rate	$45.45
Max. Negotiated Rate	$45.45
Rate for Payer: Qualcare PPO/HMO/WC	$45.45

DILANTIN (PHENYTOIN)

Facility

$303.00

Service Code	HCPCS 80185
Hospital Charge Code	38472536
Hospital Revenue Code	301
Min. Negotiated Rate	$8.03
Max. Negotiated Rate	$151.50
Rate for Payer: Aetna Commercial	$36.04
Rate for Payer: Aetna Medicare Advantage	$42.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.83
Rate for Payer: Cigna Commercial	$151.50
Rate for Payer: Cigna Medicare Advantage	$13.25
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$90.90
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$45.45
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Medicare Advantage	$13.25
Rate for Payer: Wellpoint Medicaid Managed Care	$8.03

DILANTIN PHENYTOIN

Facility

$390.00

Service Code	HCPCS 80185
Hospital Charge Code	3003977
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DILANTIN PHENYTOIN

Facility

$390.00

Service Code	HCPCS 80185
Hospital Charge Code	3003977
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$36.04
Rate for Payer: Aetna Medicare Advantage	$42.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.83
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.25
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.25
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	$10.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Medicare Advantage	$13.25
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

DILANTIN (PHENYTOIN) FREE

Facility

$133.65

Service Code	HCPCS 80186
Hospital Charge Code	3003978
Hospital Revenue Code	301
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$37.43
Rate for Payer: Aetna Medicare Advantage	$44.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$36.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.67
Rate for Payer: Cigna Commercial	$66.83
Rate for Payer: Cigna Medicare Advantage	$13.76
Rate for Payer: Clover Medicare Advantage	$13.07
Rate for Payer: EmblemHealth Commercial	$41.28
Rate for Payer: Humana Medicare Advantage	$14.17
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.76
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.09
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.76
Rate for Payer: Wellcare Medicare Advantage	$13.76
Rate for Payer: Wellpoint Medicaid Managed Care	$3.54

DILANTIN (PHENYTOIN) FREE

Facility

$133.65

Service Code	HCPCS 80186
Hospital Charge Code	3003978
Hospital Revenue Code	301
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$20.05
Rate for Payer: Qualcare PPO/HMO/WC	$20.05

DILANTIN SUSP 30/8OZ

Facility

$17.00

Hospital Charge Code	60634580
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Qualcare PPO/HMO/WC	$2.55

DILANTIN SUSP 30/8OZ

Facility

$17.00

Hospital Charge Code	60634580
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna Commercial	$6.46
Rate for Payer: Aetna Medicare Advantage	$5.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.33
Rate for Payer: Cigna Commercial	$8.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.10
Rate for Payer: Oxford Commercial	$3.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.55
Rate for Payer: UnitedHealthcare Commercial	$3.40
Rate for Payer: UnitedHealthcare Community & State	$0.41
Rate for Payer: Wellpoint Medicaid Managed Care	$0.45

DILANTIN SYSP 125/18OZ

Facility

$16.00

Hospital Charge Code	60634579
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$6.08
Rate for Payer: Aetna Medicare Advantage	$4.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.08
Rate for Payer: Cigna Commercial	$8.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.80
Rate for Payer: Oxford Commercial	$3.20
Rate for Payer: Qualcare PPO/HMO/WC	$2.40
Rate for Payer: UnitedHealthcare Commercial	$3.20
Rate for Payer: UnitedHealthcare Community & State	$0.39
Rate for Payer: Wellpoint Medicaid Managed Care	$0.42

DILANTIN SYSP 125/18OZ

Facility

$16.00

Hospital Charge Code	60634579
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.40

DILATE ANAL SPHINCTER UNDER AN

Facility

$17,147.43

Service Code	HCPCS 45905
Hospital Charge Code	16000748
Hospital Revenue Code	360
Min. Negotiated Rate	$2,572.11
Max. Negotiated Rate	$2,572.11
Rate for Payer: Qualcare PPO/HMO/WC	$2,572.11

DILATE ANAL SPHINCTER UNDER AN

Facility

$17,147.43

Service Code	HCPCS 45905
Hospital Charge Code	16000748
Hospital Revenue Code	360
Min. Negotiated Rate	$413.25
Max. Negotiated Rate	$5,311.00
Rate for Payer: Aetna Commercial	$3,866.86
Rate for Payer: Aetna Medicare Advantage	$4,606.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,421.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,131.69
Rate for Payer: Cigna Commercial	$2,849.67
Rate for Payer: Cigna Medicare Advantage	$1,421.64
Rate for Payer: Clover Medicare Advantage	$1,350.56
Rate for Payer: EmblemHealth Commercial	$4,264.92
Rate for Payer: Humana Medicare Advantage	$1,464.29
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,421.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,144.23
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,572.11
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$413.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,421.64
Rate for Payer: Wellcare Medicare Advantage	$1,421.64
Rate for Payer: Wellpoint Medicaid Managed Care	$454.41

DILATE BILIARY DUCT/AMPULLA

Facility

$8,460.00

Service Code	HCPCS 47543
Hospital Charge Code	321047543
Hospital Revenue Code	361
Min. Negotiated Rate	$1,269.00
Max. Negotiated Rate	$1,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,269.00

DILATE BILIARY DUCT/AMPULLA

Facility

$8,460.00

Service Code	HCPCS 47543
Hospital Charge Code	321047543
Hospital Revenue Code	361
Min. Negotiated Rate	$203.89
Max. Negotiated Rate	$4,230.00
Rate for Payer: Aetna Commercial	$3,214.80
Rate for Payer: Aetna Medicare Advantage	$2,538.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,157.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,157.30
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	$2,157.30
Rate for Payer: Cigna Commercial	$4,230.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,538.00
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,269.00
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$203.89
Rate for Payer: Wellpoint Medicaid Managed Care	$224.19

Know your out-of-pocket cost for care.

All Charges