Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LACOSAMIDE 100 MG TAB

Facility

$83.75

Service Code	NDC 131247835
Hospital Charge Code	6063943364
Hospital Revenue Code	250
Min. Negotiated Rate	$12.56
Max. Negotiated Rate	$12.56
Rate for Payer: Qualcare PPO/HMO/WC	$12.56

LACOSAMIDE 10 MG/ML INJ (20ML)

Facility

$439.65

Service Code	HCPCS C9254
Hospital Charge Code	6063943362
Hospital Revenue Code	636
Min. Negotiated Rate	$10.60
Max. Negotiated Rate	$219.82
Rate for Payer: Aetna Commercial	$167.07
Rate for Payer: Aetna Medicare Advantage	$131.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.11
Rate for Payer: Cigna Commercial	$219.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$106.40
Rate for Payer: Qualcare PPO/HMO/WC	$65.95
Rate for Payer: UnitedHealthcare Community & State	$10.60
Rate for Payer: Wellpoint Medicaid Managed Care	$11.65

LACOSAMIDE 10 MG/ML INJ (20ML)

Facility

$439.65

Service Code	HCPCS C9254
Hospital Charge Code	6063943362
Hospital Revenue Code	636
Min. Negotiated Rate	$65.95
Max. Negotiated Rate	$106.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$106.40
Rate for Payer: Qualcare PPO/HMO/WC	$65.95

LACOSAMIDE 10MG/ML ORAL SOL

Facility

$44.69

Service Code	NDC 131541071
Hospital Charge Code	6063943367
Hospital Revenue Code	250
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$22.34
Rate for Payer: Aetna Commercial	$16.98
Rate for Payer: Aetna Medicare Advantage	$13.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.40
Rate for Payer: Cigna Commercial	$22.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.41
Rate for Payer: Oxford Commercial	$8.94
Rate for Payer: Qualcare PPO/HMO/WC	$6.70
Rate for Payer: UnitedHealthcare Commercial	$8.94
Rate for Payer: UnitedHealthcare Community & State	$1.08
Rate for Payer: Wellpoint Medicaid Managed Care	$1.18

LACOSAMIDE 10MG/ML ORAL SOL

Facility

$44.69

Service Code	NDC 131541071
Hospital Charge Code	6063943367
Hospital Revenue Code	250
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$6.70
Rate for Payer: Qualcare PPO/HMO/WC	$6.70

LACOSAMIDE 150 MG TAB

Facility

$88.64

Service Code	NDC 131247935
Hospital Charge Code	6063943365
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$13.30
Rate for Payer: Qualcare PPO/HMO/WC	$13.30

LACOSAMIDE 150 MG TAB

Facility

$88.64

Service Code	NDC 131247935
Hospital Charge Code	6063943365
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$44.32
Rate for Payer: Aetna Commercial	$33.68
Rate for Payer: Aetna Medicare Advantage	$26.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.60
Rate for Payer: Cigna Commercial	$44.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.59
Rate for Payer: Oxford Commercial	$17.73
Rate for Payer: Qualcare PPO/HMO/WC	$13.30
Rate for Payer: UnitedHealthcare Commercial	$17.73
Rate for Payer: UnitedHealthcare Community & State	$2.14
Rate for Payer: Wellpoint Medicaid Managed Care	$2.35

LACOSAMIDE 200 MG TAB

Facility

$88.71

Service Code	NDC 131248035
Hospital Charge Code	6063943366
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$44.35
Rate for Payer: Aetna Commercial	$33.71
Rate for Payer: Aetna Medicare Advantage	$26.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.62
Rate for Payer: Cigna Commercial	$44.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.61
Rate for Payer: Oxford Commercial	$17.74
Rate for Payer: Qualcare PPO/HMO/WC	$13.31
Rate for Payer: UnitedHealthcare Commercial	$17.74
Rate for Payer: UnitedHealthcare Community & State	$2.14
Rate for Payer: Wellpoint Medicaid Managed Care	$2.35

LACOSAMIDE 200 MG TAB

Facility

$88.71

Service Code	NDC 131248035
Hospital Charge Code	6063943366
Hospital Revenue Code	250
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$13.31
Rate for Payer: Qualcare PPO/HMO/WC	$13.31

LACOSAMIDE 50 MG TAB

Facility

$58.89

Service Code	NDC 131247735
Hospital Charge Code	6063943363
Hospital Revenue Code	250
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$8.83
Rate for Payer: Qualcare PPO/HMO/WC	$8.83

LACOSAMIDE 50 MG TAB

Facility

$58.89

Service Code	NDC 131247735
Hospital Charge Code	6063943363
Hospital Revenue Code	250
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$29.45
Rate for Payer: Aetna Commercial	$22.38
Rate for Payer: Aetna Medicare Advantage	$17.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.02
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.67
Rate for Payer: Oxford Commercial	$11.78
Rate for Payer: Qualcare PPO/HMO/WC	$8.83
Rate for Payer: UnitedHealthcare Commercial	$11.78
Rate for Payer: UnitedHealthcare Community & State	$1.42
Rate for Payer: Wellpoint Medicaid Managed Care	$1.56

Lacosamide level

Facility

$390.00

Service Code	HCPCS 80299
Hospital Charge Code	39708018
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$50.70
Rate for Payer: Aetna Medicare Advantage	$60.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$67.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$67.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$67.28
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$18.64
Rate for Payer: Clover Medicare Advantage	$17.71
Rate for Payer: EmblemHealth Commercial	$55.92
Rate for Payer: Humana Medicare Advantage	$19.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$18.64
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	$14.91
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.64
Rate for Payer: Wellcare Medicare Advantage	$18.64
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

Lacosamide level

Facility

$390.00

Service Code	HCPCS 80299
Hospital Charge Code	39708018
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LAC REP PALATE OVER 2 CM

Facility

$18,789.72

Service Code	HCPCS 42182
Hospital Charge Code	5780210
Hospital Revenue Code	450
Min. Negotiated Rate	$2,818.46
Max. Negotiated Rate	$2,818.46
Rate for Payer: Qualcare PPO/HMO/WC	$2,818.46

LAC REP PALATE OVER 2 CM

Facility

$18,789.72

Service Code	HCPCS 42182
Hospital Charge Code	5780210
Hospital Revenue Code	450
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$25,386.70
Rate for Payer: Aetna Commercial	$19,129.52
Rate for Payer: Aetna Medicare Advantage	$22,786.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$25,386.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$25,386.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$7,032.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$262.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$25,386.70
Rate for Payer: Cigna Commercial	$14,097.46
Rate for Payer: Cigna Medicare Advantage	$7,032.91
Rate for Payer: Clover Medicare Advantage	$6,681.26
Rate for Payer: EmblemHealth Commercial	$21,098.73
Rate for Payer: Humana Medicare Advantage	$7,243.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$7,032.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,636.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,818.46
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$7,032.91
Rate for Payer: Wellcare Medicare Advantage	$7,032.91
Rate for Payer: Wellpoint Medicaid Managed Care	$497.93

LAC REP PALATE UP TO 2 CM

Facility

$1,453.00

Service Code	HCPCS 42180
Hospital Charge Code	5780205
Hospital Revenue Code	450
Min. Negotiated Rate	$217.95
Max. Negotiated Rate	$217.95
Rate for Payer: Qualcare PPO/HMO/WC	$217.95

LAC REP PALATE UP TO 2 CM

Facility

$1,453.00

Service Code	HCPCS 42180
Hospital Charge Code	5780205
Hospital Revenue Code	450
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$2,312.88
Rate for Payer: Aetna Commercial	$1,742.81
Rate for Payer: Aetna Medicare Advantage	$2,076.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,312.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,312.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$640.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$187.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,312.88
Rate for Payer: Cigna Commercial	$1,284.36
Rate for Payer: Cigna Medicare Advantage	$640.74
Rate for Payer: Clover Medicare Advantage	$608.70
Rate for Payer: EmblemHealth Commercial	$1,922.22
Rate for Payer: Humana Medicare Advantage	$659.96
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$640.74
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$435.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$850.00
Rate for Payer: Qualcare PPO/HMO/WC	$217.95
Rate for Payer: UnitedHealthcare Community & State	$140.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$640.74
Rate for Payer: Wellcare Medicare Advantage	$640.74
Rate for Payer: Wellpoint Medicaid Managed Care	$38.50

LACRILUBE/3.5GM

Facility

$76.31

Service Code	NDC 23031204
Hospital Charge Code	60634565
Hospital Revenue Code	250
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$11.45
Rate for Payer: Qualcare PPO/HMO/WC	$11.45

LACRILUBE/3.5GM

Facility

$76.31

Service Code	NDC 23031204
Hospital Charge Code	60634565
Hospital Revenue Code	250
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$38.16
Rate for Payer: Aetna Commercial	$29.00
Rate for Payer: Aetna Medicare Advantage	$22.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.46
Rate for Payer: Cigna Commercial	$38.16
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$22.89
Rate for Payer: Oxford Commercial	$15.26
Rate for Payer: Qualcare PPO/HMO/WC	$11.45
Rate for Payer: UnitedHealthcare Commercial	$15.26
Rate for Payer: UnitedHealthcare Community & State	$1.84
Rate for Payer: Wellpoint Medicaid Managed Care	$2.02

LACRILUBE DROPPERETTES

Facility

$4.50

Hospital Charge Code	6014039
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.71
Rate for Payer: Aetna Medicare Advantage	$1.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.15
Rate for Payer: Cigna Commercial	$2.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.35
Rate for Payer: Oxford Commercial	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$0.90
Rate for Payer: UnitedHealthcare Community & State	$0.11
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

LACRILUBE DROPPERETTES

Facility

$4.50

Hospital Charge Code	6014039
Hospital Revenue Code	251
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Qualcare PPO/HMO/WC	$0.68

LACTASE TAB 3300U

Facility

$1.95

Hospital Charge Code	60628631
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna Commercial	$0.74
Rate for Payer: Aetna Medicare Advantage	$0.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.50
Rate for Payer: Cigna Commercial	$0.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.59
Rate for Payer: Oxford Commercial	$0.39
Rate for Payer: Qualcare PPO/HMO/WC	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.39
Rate for Payer: UnitedHealthcare Community & State	$0.05
Rate for Payer: Wellpoint Medicaid Managed Care	$0.05

LACTASE TAB 3300U

Facility

$1.95

Hospital Charge Code	60628631
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Qualcare PPO/HMO/WC	$0.29

LACTATE,CSF

Facility

$390.00

Service Code	HCPCS 83605
Hospital Charge Code	39900101
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LACTATE,CSF

Facility

$390.00

Service Code	HCPCS 83605
Hospital Charge Code	39900101
Hospital Revenue Code	301
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$31.47
Rate for Payer: Aetna Medicare Advantage	$37.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.76
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$11.57
Rate for Payer: Clover Medicare Advantage	$10.99
Rate for Payer: EmblemHealth Commercial	$34.71
Rate for Payer: Humana Medicare Advantage	$11.92
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$11.57
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	$9.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.57
Rate for Payer: Wellcare Medicare Advantage	$11.57
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

Know your out-of-pocket cost for care.

All Charges