Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

GLYCERIN ADULT SUPP

Facility

$5.23

Service Code	NDC 713010109
Hospital Charge Code	6022495
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Qualcare PPO/HMO/WC	$0.78

GLYCERIN ADULT SUPP

Facility

$5.23

Service Code	NDC 713010109
Hospital Charge Code	6022495
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$2.62
Rate for Payer: Aetna Commercial	$1.99
Rate for Payer: Aetna Medicare Advantage	$1.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.33
Rate for Payer: Cigna Commercial	$2.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.57
Rate for Payer: Oxford Commercial	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$0.78
Rate for Payer: UnitedHealthcare Commercial	$1.05
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.14

GLYCERIN ADULT SUPP/EACH

Facility

$1.00

Hospital Charge Code	60633052
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

GLYCERIN ADULT SUPP/EACH

Facility

$1.00

Hospital Charge Code	60633051
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

GLYCERIN ADULT SUPP/EACH

Facility

$1.00

Hospital Charge Code	60633051
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.38
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.30
Rate for Payer: Oxford Commercial	$0.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.20
Rate for Payer: UnitedHealthcare Community & State	$0.02
Rate for Payer: Wellpoint Medicaid Managed Care	$0.03

GLYCERIN ADULT SUPP/EACH

Facility

$1.00

Hospital Charge Code	60633052
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.38
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.30
Rate for Payer: Oxford Commercial	$0.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.20
Rate for Payer: UnitedHealthcare Community & State	$0.02
Rate for Payer: Wellpoint Medicaid Managed Care	$0.03

GLYCERIN ORL LQ 50% 177ML

Facility

$95.40

Hospital Charge Code	6002661
Hospital Revenue Code	251
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$14.31
Rate for Payer: Qualcare PPO/HMO/WC	$14.31

GLYCERIN ORL LQ 50% 177ML

Facility

$95.40

Hospital Charge Code	6002661
Hospital Revenue Code	251
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna Commercial	$36.25
Rate for Payer: Aetna Medicare Advantage	$28.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.33
Rate for Payer: Cigna Commercial	$47.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.62
Rate for Payer: Oxford Commercial	$19.08
Rate for Payer: Qualcare PPO/HMO/WC	$14.31
Rate for Payer: UnitedHealthcare Commercial	$19.08
Rate for Payer: UnitedHealthcare Community & State	$2.30
Rate for Payer: Wellpoint Medicaid Managed Care	$2.53

GLYCERIN ORL LQ 75% 120ML

Facility

$82.60

Hospital Charge Code	6002679
Hospital Revenue Code	251
Min. Negotiated Rate	$12.39
Max. Negotiated Rate	$12.39
Rate for Payer: Qualcare PPO/HMO/WC	$12.39

GLYCERIN ORL LQ 75% 120ML

Facility

$82.60

Hospital Charge Code	6002679
Hospital Revenue Code	251
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$41.30
Rate for Payer: Aetna Commercial	$31.39
Rate for Payer: Aetna Medicare Advantage	$24.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.06
Rate for Payer: Cigna Commercial	$41.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.78
Rate for Payer: Oxford Commercial	$16.52
Rate for Payer: Qualcare PPO/HMO/WC	$12.39
Rate for Payer: UnitedHealthcare Commercial	$16.52
Rate for Payer: UnitedHealthcare Community & State	$1.99
Rate for Payer: Wellpoint Medicaid Managed Care	$2.19

GLYCERIN PEDIATRIC SUPP

Facility

$5.09

Service Code	NDC 713010209
Hospital Charge Code	60628129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$1.93
Rate for Payer: Aetna Medicare Advantage	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.30
Rate for Payer: Cigna Commercial	$2.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.53
Rate for Payer: Oxford Commercial	$1.02
Rate for Payer: Qualcare PPO/HMO/WC	$0.76
Rate for Payer: UnitedHealthcare Commercial	$1.02
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

GLYCERIN PEDIATRIC SUPP

Facility

$5.09

Service Code	NDC 713010209
Hospital Charge Code	60628129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$0.76
Rate for Payer: Qualcare PPO/HMO/WC	$0.76

GLYCERIN PEDIATRIC SUPP/1

Facility

$4.00

Hospital Charge Code	60633053
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

GLYCERIN PEDIATRIC SUPP/1

Facility

$4.00

Hospital Charge Code	60633053
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

GLYCERIN PEDIATRIC SUPP/1

Facility

$1.00

Hospital Charge Code	60633054
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

GLYCERIN PEDIATRIC SUPP/1

Facility

$1.00

Hospital Charge Code	60633054
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.38
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.30
Rate for Payer: Oxford Commercial	$0.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.20
Rate for Payer: UnitedHealthcare Community & State	$0.02
Rate for Payer: Wellpoint Medicaid Managed Care	$0.03

GLYCERIN SOL OPH 7.5ML

Facility

$143.40

Hospital Charge Code	6002653
Hospital Revenue Code	251
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

GLYCERIN SOL OPH 7.5ML

Facility

$143.40

Hospital Charge Code	6002653
Hospital Revenue Code	251
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$21.51
Rate for Payer: Qualcare PPO/HMO/WC	$21.51

GLYCERIN USP/40Z

Facility

$15.00

Hospital Charge Code	60634430
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$3.00
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.40

GLYCERIN USP/40Z

Facility

$15.00

Hospital Charge Code	60634430
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

GLYCINE 1.5% 3000ML

Facility

$51.25

Hospital Charge Code	60630176
Hospital Revenue Code	250
Min. Negotiated Rate	$7.69
Max. Negotiated Rate	$7.69
Rate for Payer: Qualcare PPO/HMO/WC	$7.69

GLYCINE 1.5% 3000ML

Facility

$51.25

Hospital Charge Code	60630176
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$25.62
Rate for Payer: Aetna Commercial	$19.48
Rate for Payer: Aetna Medicare Advantage	$15.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.07
Rate for Payer: Cigna Commercial	$25.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.38
Rate for Payer: Oxford Commercial	$10.25
Rate for Payer: Qualcare PPO/HMO/WC	$7.69
Rate for Payer: UnitedHealthcare Commercial	$10.25
Rate for Payer: UnitedHealthcare Community & State	$1.24
Rate for Payer: Wellpoint Medicaid Managed Care	$1.36

GLYCINE 3000 ML **********

Facility

$28.00

Hospital Charge Code	1608256
Hospital Revenue Code	272
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$10.64
Rate for Payer: Aetna Medicare Advantage	$8.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.14
Rate for Payer: Cigna Commercial	$14.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.40
Rate for Payer: Oxford Commercial	$5.60
Rate for Payer: Qualcare PPO/HMO/WC	$4.20
Rate for Payer: UnitedHealthcare Commercial	$5.60
Rate for Payer: UnitedHealthcare Community & State	$0.67
Rate for Payer: Wellpoint Medicaid Managed Care	$0.74

GLYCINE 3000 ML **********

Facility

$28.00

Hospital Charge Code	1608256
Hospital Revenue Code	272
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$4.20
Rate for Payer: Qualcare PPO/HMO/WC	$4.20

GLYCINE IRRIGATION GU ******

Facility

$25.00

Hospital Charge Code	7000474
Hospital Revenue Code	279
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$3.75
Rate for Payer: Qualcare PPO/HMO/WC	$3.75

Know your out-of-pocket cost for care.

All Charges