Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

AMITRIPTYLINE/25MG/TAB

Facility

$3.00

Hospital Charge Code	60632440
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

AMITRIPTYLINE/25MG/TAB

Facility

$3.00

Hospital Charge Code	60632440
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

AMITRIPTYLINE/25MG/TAB

Facility

$3.00

Hospital Charge Code	60632441
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

AMITRIPTYLINE 50MG

Facility

$21.00

Hospital Charge Code	60635387
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.15
Rate for Payer: Qualcare PPO/HMO/WC	$3.15

AMITRIPTYLINE 50MG

Facility

$21.00

Hospital Charge Code	60635387
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: Aetna Medicare Advantage	$6.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.36
Rate for Payer: Cigna Commercial	$10.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.30
Rate for Payer: Oxford Commercial	$4.20
Rate for Payer: Qualcare PPO/HMO/WC	$3.15
Rate for Payer: UnitedHealthcare Commercial	$4.20
Rate for Payer: UnitedHealthcare Community & State	$0.51
Rate for Payer: Wellpoint Medicaid Managed Care	$0.56

AMITRIPTYLINE 50 MG TAB

Facility

$7.10

Service Code	NDC 51079013320
Hospital Charge Code	60627755
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

AMITRIPTYLINE 50 MG TAB

Facility

$7.10

Service Code	NDC 51079013320
Hospital Charge Code	60627755
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.06
Rate for Payer: Qualcare PPO/HMO/WC	$1.06

AMITRIPTYLINE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632439
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

AMITRIPTYLINE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632439
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

AMITRIPTYLINE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632443
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

AMITRIPTYLINE/50MG/TAB

Facility

$3.00

Hospital Charge Code	60632443
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

AMITRIPTYLINE (ELAVIL)

Facility

$360.00

Service Code	HCPCS 80335
Hospital Charge Code	38472673
Hospital Revenue Code	301
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare Advantage	$108.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$91.80
Rate for Payer: Cigna Commercial	$180.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$108.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$54.00
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$9.54

AMITRIPTYLINE (ELAVIL)

Facility

$360.00

Service Code	HCPCS 80335
Hospital Charge Code	38472673
Hospital Revenue Code	301
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Qualcare PPO/HMO/WC	$54.00

AMITRIPTYLINE & METABOLITE

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3035122
Hospital Revenue Code	301
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$58.39
Rate for Payer: Aetna Medicare Advantage	$46.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$76.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$46.09
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$4.07

AMITRIPTYLINE & METABOLITE

Facility

$153.65

Service Code	HCPCS 80335
Hospital Charge Code	3035122
Hospital Revenue Code	301
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$23.05
Rate for Payer: Qualcare PPO/HMO/WC	$23.05

AMITRIPTYLINE/NORTRIP, URINE

Facility

$190.45

Service Code	HCPCS 80335
Hospital Charge Code	3006996
Hospital Revenue Code	301
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$72.37
Rate for Payer: Aetna Medicare Advantage	$57.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.56
Rate for Payer: Cigna Commercial	$95.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$5.05

AMITRIPTYLINE/NORTRIP, URINE

Facility

$190.45

Service Code	HCPCS 80335
Hospital Charge Code	3006996
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

AMITRIPTYLINE VL 10MG/ML 10ML

Facility

$80.65

Hospital Charge Code	6009344
Hospital Revenue Code	250
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$12.10
Rate for Payer: Qualcare PPO/HMO/WC	$12.10

AMITRIPTYLINE VL 10MG/ML 10ML

Facility

$80.65

Hospital Charge Code	6009344
Hospital Revenue Code	250
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$40.33
Rate for Payer: Aetna Commercial	$30.65
Rate for Payer: Aetna Medicare Advantage	$24.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.57
Rate for Payer: Cigna Commercial	$40.33
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.20
Rate for Payer: Oxford Commercial	$16.13
Rate for Payer: Qualcare PPO/HMO/WC	$12.10
Rate for Payer: UnitedHealthcare Commercial	$16.13
Rate for Payer: UnitedHealthcare Community & State	$1.94
Rate for Payer: Wellpoint Medicaid Managed Care	$2.14

AMLODIPINE 10 MG TAB

Facility

$41.74

Service Code	NDC 69154041
Hospital Charge Code	60029064
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$20.87
Rate for Payer: Aetna Commercial	$15.86
Rate for Payer: Aetna Medicare Advantage	$12.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.64
Rate for Payer: Cigna Commercial	$20.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.52
Rate for Payer: Oxford Commercial	$8.35
Rate for Payer: Qualcare PPO/HMO/WC	$6.26
Rate for Payer: UnitedHealthcare Commercial	$8.35
Rate for Payer: UnitedHealthcare Community & State	$1.01
Rate for Payer: Wellpoint Medicaid Managed Care	$1.11

AMLODIPINE 10 MG TAB

Facility

$41.74

Service Code	NDC 69154041
Hospital Charge Code	60029064
Hospital Revenue Code	250
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$6.26
Rate for Payer: Qualcare PPO/HMO/WC	$6.26

AMLODIPINE 2.5 MG TAB

Facility

$30.42

Service Code	NDC 58151035377
Hospital Charge Code	6008841
Hospital Revenue Code	250
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$4.56
Rate for Payer: Qualcare PPO/HMO/WC	$4.56

AMLODIPINE 2.5 MG TAB

Facility

$30.42

Service Code	NDC 58151035377
Hospital Charge Code	6008841
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$15.21
Rate for Payer: Aetna Commercial	$11.56
Rate for Payer: Aetna Medicare Advantage	$9.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.76
Rate for Payer: Cigna Commercial	$15.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.13
Rate for Payer: Oxford Commercial	$6.08
Rate for Payer: Qualcare PPO/HMO/WC	$4.56
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: UnitedHealthcare Community & State	$0.73
Rate for Payer: Wellpoint Medicaid Managed Care	$0.81

AMLODIPINE 5MG/BENAZEPRILIO MG

Facility

$10.85

Hospital Charge Code	60629293
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna Commercial	$4.12
Rate for Payer: Aetna Medicare Advantage	$3.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.77
Rate for Payer: Cigna Commercial	$5.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.25
Rate for Payer: Oxford Commercial	$2.17
Rate for Payer: Qualcare PPO/HMO/WC	$1.63
Rate for Payer: UnitedHealthcare Commercial	$2.17
Rate for Payer: UnitedHealthcare Community & State	$0.26
Rate for Payer: Wellpoint Medicaid Managed Care	$0.29

AMLODIPINE 5MG/BENAZEPRILIO MG

Facility

$10.85

Hospital Charge Code	60629293
Hospital Revenue Code	250
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$1.63
Rate for Payer: Qualcare PPO/HMO/WC	$1.63

Know your out-of-pocket cost for care.

All Charges