Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

DIPROLENE 0.05% GEL/45GM

Facility

$238.00

Hospital Charge Code	60634722
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$35.70
Rate for Payer: Qualcare PPO/HMO/WC	$35.70

DIPTHERIA ANTITOXOID

Facility

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3000494
Hospital Revenue Code	302
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Qualcare PPO/HMO/WC	$19.69

DIPTHERIA ANTITOXOID

Facility

$131.25

Service Code	HCPCS 86317
Hospital Charge Code	3000494
Hospital Revenue Code	302
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Aetna Medicare Advantage	$48.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$54.11
Rate for Payer: Cigna Commercial	$65.62
Rate for Payer: Cigna Medicare Advantage	$14.99
Rate for Payer: Clover Medicare Advantage	$14.24
Rate for Payer: EmblemHealth Commercial	$44.97
Rate for Payer: Humana Medicare Advantage	$15.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.38
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.69
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.48

DIPTHERIA TITER

Facility

$390.00

Service Code	HCPCS 86648
Hospital Charge Code	39900501
Hospital Revenue Code	302
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$41.37
Rate for Payer: Aetna Medicare Advantage	$49.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.21
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	$54.90
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$15.21
Rate for Payer: Clover Medicare Advantage	$14.45
Rate for Payer: EmblemHealth Commercial	$45.63
Rate for Payer: Humana Medicare Advantage	$15.67
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.21
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	$12.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.21
Rate for Payer: Wellcare Medicare Advantage	$15.21
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

DIPTHERIA TITER

Facility

$390.00

Service Code	HCPCS 86648
Hospital Charge Code	39900501
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DIPUFRIN HCL SOL OPH .1% 10ML

Facility

$143.40

Hospital Charge Code	6002034
Hospital Revenue Code	250
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$21.51
Rate for Payer: Qualcare PPO/HMO/WC	$21.51

DIPUFRIN HCL SOL OPH .1% 10ML

Facility

$143.40

Hospital Charge Code	6002034
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$71.70
Rate for Payer: Aetna Commercial	$54.49
Rate for Payer: Aetna Medicare Advantage	$43.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36.57
Rate for Payer: Cigna Commercial	$71.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.02
Rate for Payer: Oxford Commercial	$28.68
Rate for Payer: Qualcare PPO/HMO/WC	$21.51
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Community & State	$3.46
Rate for Payer: Wellpoint Medicaid Managed Care	$3.80

DIPYRIDAMOLE 25 MG TAB

Facility

$9.51

Service Code	NDC 64980013301
Hospital Charge Code	6023279
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$3.61
Rate for Payer: Aetna Medicare Advantage	$2.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.43
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.85
Rate for Payer: Oxford Commercial	$1.90
Rate for Payer: Qualcare PPO/HMO/WC	$1.43
Rate for Payer: UnitedHealthcare Commercial	$1.90
Rate for Payer: UnitedHealthcare Community & State	$0.23
Rate for Payer: Wellpoint Medicaid Managed Care	$0.25

DIPYRIDAMOLE 25 MG TAB

Facility

$9.51

Service Code	NDC 64980013301
Hospital Charge Code	6023279
Hospital Revenue Code	251
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.43
Rate for Payer: Qualcare PPO/HMO/WC	$1.43

DIPYRIDAMOLE/25MG/TAB

Facility

$3.00

Hospital Charge Code	60632867
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DIPYRIDAMOLE/25MG/TAB

Facility

$3.00

Hospital Charge Code	60632867
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
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

DIPYRIDAMOLE 50 MG TAB

Facility

$10.25

Service Code	NDC 54043525
Hospital Charge Code	60627646
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$5.12
Rate for Payer: Aetna Commercial	$3.90
Rate for Payer: Aetna Medicare Advantage	$3.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.61
Rate for Payer: Cigna Commercial	$5.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.08
Rate for Payer: Oxford Commercial	$2.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.54
Rate for Payer: UnitedHealthcare Commercial	$2.05
Rate for Payer: UnitedHealthcare Community & State	$0.25
Rate for Payer: Wellpoint Medicaid Managed Care	$0.27

DIPYRIDAMOLE 50 MG TAB

Facility

$10.25

Service Code	NDC 54043525
Hospital Charge Code	60627646
Hospital Revenue Code	250
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.54

DIPYRIDAMOLE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632868
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DIPYRIDAMOLE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632868
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
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

DIPYRIDAMOLE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632866
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
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

DIPYRIDAMOLE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632866
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DIPYRIDAMOLE 5 MG/ML INJ 10 ML

Facility

$35.85

Service Code	HCPCS J1245
Hospital Charge Code	6007447
Hospital Revenue Code	636
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$17.93
Rate for Payer: Aetna Commercial	$13.62
Rate for Payer: Aetna Medicare Advantage	$10.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.14
Rate for Payer: Cigna Commercial	$17.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.68
Rate for Payer: Qualcare PPO/HMO/WC	$5.38
Rate for Payer: UnitedHealthcare Community & State	$0.86
Rate for Payer: Wellpoint Medicaid Managed Care	$0.95

DIPYRIDAMOLE 5 MG/ML INJ 10 ML

Facility

$35.85

Service Code	HCPCS J1245
Hospital Charge Code	6007447
Hospital Revenue Code	636
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$8.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.68
Rate for Payer: Qualcare PPO/HMO/WC	$5.38

DIPYRIDAMOLE/75MG/TAB

Facility

$3.00

Hospital Charge Code	60632869
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DIPYRIDAMOLE/75MG/TAB

Facility

$3.00

Hospital Charge Code	60632869
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
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

DIPYRIDAMOLE/75MG/TAB

Facility

$3.00

Hospital Charge Code	60632865
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$1.14
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.90
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

DIPYRIDAMOLE/75MG/TAB

Facility

$3.00

Hospital Charge Code	60632865
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DIPYRIDAMOLE/ASPIRIN 200/25 MG

Facility

$51.52

Service Code	NDC 597000160
Hospital Charge Code	60628983
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$25.76
Rate for Payer: Aetna Commercial	$19.58
Rate for Payer: Aetna Medicare Advantage	$15.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.14
Rate for Payer: Cigna Commercial	$25.76
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.46
Rate for Payer: Oxford Commercial	$10.30
Rate for Payer: Qualcare PPO/HMO/WC	$7.73
Rate for Payer: UnitedHealthcare Commercial	$10.30
Rate for Payer: UnitedHealthcare Community & State	$1.24
Rate for Payer: Wellpoint Medicaid Managed Care	$1.37

DIPYRIDAMOLE/ASPIRIN 200/25 MG

Facility

$51.52

Service Code	NDC 597000160
Hospital Charge Code	60628983
Hospital Revenue Code	250
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$7.73
Rate for Payer: Qualcare PPO/HMO/WC	$7.73

Know your out-of-pocket cost for care.

All Charges