Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

IM INS BREAST PROSTH S/P M

Facility

$42,601.70

Service Code	HCPCS 19340
Hospital Charge Code	16000665
Hospital Revenue Code	360
Min. Negotiated Rate	$6,390.26
Max. Negotiated Rate	$6,390.26
Rate for Payer: Qualcare PPO/HMO/WC	$6,390.26

IMIPEN4MG/CILAST4MG/RELEBAC2MG

Facility

$1,846.05

Service Code	HCPCS J0742
Hospital Charge Code	606390434
Hospital Revenue Code	636
Min. Negotiated Rate	$276.91
Max. Negotiated Rate	$446.74
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$446.74
Rate for Payer: Qualcare PPO/HMO/WC	$276.91

IMIPEN4MG/CILAST4MG/RELEBAC2MG

Facility

$1,846.05

Service Code	HCPCS J0742
Hospital Charge Code	606390434
Hospital Revenue Code	636
Min. Negotiated Rate	$44.49
Max. Negotiated Rate	$923.02
Rate for Payer: Aetna Commercial	$701.50
Rate for Payer: Aetna Medicare Advantage	$553.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$470.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$470.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$470.74
Rate for Payer: Cigna Commercial	$923.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$446.74
Rate for Payer: Qualcare PPO/HMO/WC	$276.91
Rate for Payer: UnitedHealthcare Community & State	$44.49
Rate for Payer: Wellpoint Medicaid Managed Care	$48.92

IMIPRAMINE/10MG/TAB

Facility

$3.00

Hospital Charge Code	60633159
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

IMIPRAMINE/10MG/TAB

Facility

$3.00

Hospital Charge Code	60633158
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

IMIPRAMINE/10MG/TAB

Facility

$3.00

Hospital Charge Code	60633158
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

IMIPRAMINE/10MG/TAB

Facility

$3.00

Hospital Charge Code	60633159
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

IMIPRAMINE 50 MG TAB

Facility

$7.03

Hospital Charge Code	6063943207
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

IMIPRAMINE 50 MG TAB

Facility

$7.03

Hospital Charge Code	6063943207
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna Commercial	$2.67
Rate for Payer: Aetna Medicare Advantage	$2.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.79
Rate for Payer: Cigna Commercial	$3.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.11
Rate for Payer: Oxford Commercial	$1.41
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$1.41
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

IMIPRAMINE CAP 100MG

Facility

$10.90

Hospital Charge Code	6009674
Hospital Revenue Code	251
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.64

IMIPRAMINE CAP 100MG

Facility

$10.90

Hospital Charge Code	6009674
Hospital Revenue Code	251
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

IMIPRAMINE, SERUM

Facility

$56.00

Service Code	HCPCS 80335
Hospital Charge Code	3004300
Hospital Revenue Code	301
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$8.40

IMIPRAMINE, SERUM

Facility

$56.00

Service Code	HCPCS 80335
Hospital Charge Code	3004300
Hospital Revenue Code	301
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$21.28
Rate for Payer: Aetna Medicare Advantage	$16.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.28
Rate for Payer: Cigna Commercial	$28.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$8.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$1.48

IMIPRAMINE TAB 10MG

Facility

$4.00

Service Code	NDC 49884005401
Hospital Charge Code	60627767
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

IMIPRAMINE TAB 10MG

Facility

$4.00

Service Code	NDC 49884005401
Hospital Charge Code	60627767
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

IMIPRAMINE TAB 25MG

Facility

$5.83

Service Code	NDC 781176413
Hospital Charge Code	60627768
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna Commercial	$2.22
Rate for Payer: Aetna Medicare Advantage	$1.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.49
Rate for Payer: Cigna Commercial	$2.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.75
Rate for Payer: Oxford Commercial	$1.17
Rate for Payer: Qualcare PPO/HMO/WC	$0.87
Rate for Payer: UnitedHealthcare Commercial	$1.17
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

IMIPRAMINE TAB 25MG

Facility

$5.83

Service Code	NDC 781176413
Hospital Charge Code	60627768
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.87

IMIPRAMINE TAB 50MG

Facility

$9.78

Service Code	NDC 781176613
Hospital Charge Code	60627769
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.47
Rate for Payer: Qualcare PPO/HMO/WC	$1.47

IMIPRAMINE TAB 50MG

Facility

$9.78

Service Code	NDC 781176613
Hospital Charge Code	60627769
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna Medicare Advantage	$2.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.49
Rate for Payer: Cigna Commercial	$4.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.93
Rate for Payer: Oxford Commercial	$1.96
Rate for Payer: Qualcare PPO/HMO/WC	$1.47
Rate for Payer: UnitedHealthcare Commercial	$1.96
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

IMIPRAMINE (TOFRANIL)

Facility

$193.00

Service Code	HCPCS 80335
Hospital Charge Code	38472485
Hospital Revenue Code	301
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$28.95
Rate for Payer: Qualcare PPO/HMO/WC	$28.95

IMIPRAMINE (TOFRANIL)

Facility

$193.00

Service Code	HCPCS 80335
Hospital Charge Code	38472485
Hospital Revenue Code	301
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$73.34
Rate for Payer: Aetna Medicare Advantage	$57.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.22
Rate for Payer: Cigna Commercial	$96.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.90
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.95
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$16.66
Rate for Payer: Wellpoint Medicaid Managed Care	$5.11

IMITREX INJECTION

Facility

$217.00

Hospital Charge Code	60634877
Hospital Revenue Code	636
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$82.46
Rate for Payer: Aetna Medicare Advantage	$65.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.34
Rate for Payer: Cigna Commercial	$108.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.51
Rate for Payer: Qualcare PPO/HMO/WC	$32.55
Rate for Payer: UnitedHealthcare Community & State	$5.23
Rate for Payer: Wellpoint Medicaid Managed Care	$5.75

IMITREX INJECTION

Facility

$217.00

Hospital Charge Code	60634877
Hospital Revenue Code	636
Min. Negotiated Rate	$32.55
Max. Negotiated Rate	$52.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.51
Rate for Payer: Qualcare PPO/HMO/WC	$32.55

IMM.ADM BY NASAL/ORAL @ADDN'L

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	73050855
Hospital Revenue Code	771
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$59.28
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$78.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$46.80
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$159.00
Rate for Payer: UnitedHealthcare Community & State	$3.76
Rate for Payer: Wellpoint Medicaid Managed Care	$4.13

IMM.ADM BY NASAL/ORAL @ADDN'L

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	73050855
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

Know your out-of-pocket cost for care.

All Charges