Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM/100MG

Facility

$574.00

Hospital Charge Code	60633276
Hospital Revenue Code	636
Min. Negotiated Rate	$13.83
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$218.12
Rate for Payer: Aetna Medicare Advantage	$172.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$146.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$146.37
Rate for Payer: Cigna Commercial	$287.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$138.91
Rate for Payer: Qualcare PPO/HMO/WC	$86.10
Rate for Payer: UnitedHealthcare Community & State	$13.83
Rate for Payer: Wellpoint Medicaid Managed Care	$15.21

LEUCOVORIN CALCIUM 100 MG VIAL

Facility

$160.80

Service Code	HCPCS J0640
Hospital Charge Code	60628530
Hospital Revenue Code	636
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$38.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$38.91
Rate for Payer: Qualcare PPO/HMO/WC	$24.12

LEUCOVORIN CALCIUM 100 MG VIAL

Facility

$160.80

Service Code	HCPCS J0640
Hospital Charge Code	60628530
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$80.40
Rate for Payer: Aetna Commercial	$61.10
Rate for Payer: Aetna Medicare Advantage	$48.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.00
Rate for Payer: Cigna Commercial	$80.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$38.91
Rate for Payer: Qualcare PPO/HMO/WC	$24.12
Rate for Payer: UnitedHealthcare Community & State	$3.88
Rate for Payer: Wellpoint Medicaid Managed Care	$4.26

LEUCOVORIN CALCIUM/10MG/1

Facility

$42.00

Hospital Charge Code	60633277
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$15.96
Rate for Payer: Aetna Medicare Advantage	$12.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.71
Rate for Payer: Cigna Commercial	$21.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.60
Rate for Payer: Oxford Commercial	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$6.30
Rate for Payer: UnitedHealthcare Commercial	$8.40
Rate for Payer: UnitedHealthcare Community & State	$1.01
Rate for Payer: Wellpoint Medicaid Managed Care	$1.11

LEUCOVORIN CALCIUM/10MG/1

Facility

$42.00

Hospital Charge Code	60633277
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$6.30
Rate for Payer: Qualcare PPO/HMO/WC	$6.30

LEUCOVORIN CALCIUM 25MG TAB

Facility

$91.72

Service Code	NDC 51079058205
Hospital Charge Code	60629049
Hospital Revenue Code	250
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$13.76
Rate for Payer: Qualcare PPO/HMO/WC	$13.76

LEUCOVORIN CALCIUM 25MG TAB

Facility

$91.72

Service Code	NDC 51079058205
Hospital Charge Code	60629049
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$45.86
Rate for Payer: Aetna Commercial	$34.85
Rate for Payer: Aetna Medicare Advantage	$27.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.39
Rate for Payer: Cigna Commercial	$45.86
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.52
Rate for Payer: Oxford Commercial	$18.34
Rate for Payer: Qualcare PPO/HMO/WC	$13.76
Rate for Payer: UnitedHealthcare Commercial	$18.34
Rate for Payer: UnitedHealthcare Community & State	$2.21
Rate for Payer: Wellpoint Medicaid Managed Care	$2.43

LEUCOVORIN CALCIUM/350MG

Facility

$152.36

Service Code	HCPCS J0640
Hospital Charge Code	60633279
Hospital Revenue Code	636
Min. Negotiated Rate	$22.85
Max. Negotiated Rate	$36.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.87
Rate for Payer: Qualcare PPO/HMO/WC	$22.85

LEUCOVORIN CALCIUM/350MG

Facility

$152.36

Service Code	HCPCS J0640
Hospital Charge Code	60633279
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$76.18
Rate for Payer: Aetna Commercial	$57.90
Rate for Payer: Aetna Medicare Advantage	$45.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.85
Rate for Payer: Cigna Commercial	$76.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.87
Rate for Payer: Qualcare PPO/HMO/WC	$22.85
Rate for Payer: UnitedHealthcare Community & State	$3.67
Rate for Payer: Wellpoint Medicaid Managed Care	$4.04

LEUCOVORIN CALCIUM/50MG

Facility

$52.26

Service Code	HCPCS J0640
Hospital Charge Code	60633275
Hospital Revenue Code	636
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$12.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.65
Rate for Payer: Qualcare PPO/HMO/WC	$7.84

LEUCOVORIN CALCIUM/50MG

Facility

$52.26

Service Code	HCPCS J0640
Hospital Charge Code	60633275
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$26.13
Rate for Payer: Aetna Commercial	$19.86
Rate for Payer: Aetna Medicare Advantage	$15.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.33
Rate for Payer: Cigna Commercial	$26.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.65
Rate for Payer: Qualcare PPO/HMO/WC	$7.84
Rate for Payer: UnitedHealthcare Community & State	$1.26
Rate for Payer: Wellpoint Medicaid Managed Care	$1.38

LEUCOVORIN CALCIUM/5MG

Facility

$7.00

Hospital Charge Code	60633280
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.66
Rate for Payer: Aetna Medicare Advantage	$2.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.78
Rate for Payer: Cigna Commercial	$3.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.69
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

LEUCOVORIN CALCIUM/5MG

Facility

$7.00

Hospital Charge Code	60633280
Hospital Revenue Code	636
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.69
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

LEUCOVORIN CALCIUM/5MG

Facility

$18.00

Hospital Charge Code	60633278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$6.84
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.36
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Community & State	$0.43
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

LEUCOVORIN CALCIUM/5MG

Facility

$18.00

Hospital Charge Code	60633278
Hospital Revenue Code	636
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$4.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.36
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

LEUCOVORIN CALCIUM 5 MG TAB

Facility

$21.78

Service Code	NDC 51079058106
Hospital Charge Code	6008668
Hospital Revenue Code	251
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$10.89
Rate for Payer: Aetna Commercial	$8.28
Rate for Payer: Aetna Medicare Advantage	$6.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.55
Rate for Payer: Cigna Commercial	$10.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.53
Rate for Payer: Oxford Commercial	$4.36
Rate for Payer: Qualcare PPO/HMO/WC	$3.27
Rate for Payer: UnitedHealthcare Commercial	$4.36
Rate for Payer: UnitedHealthcare Community & State	$0.52
Rate for Payer: Wellpoint Medicaid Managed Care	$0.58

LEUCOVORIN CALCIUM 5 MG TAB

Facility

$21.78

Service Code	NDC 51079058106
Hospital Charge Code	6008668
Hospital Revenue Code	251
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$3.27
Rate for Payer: Qualcare PPO/HMO/WC	$3.27

LEUCOVORIN CAL INJ 50MG

Facility

$26.90

Hospital Charge Code	6003222
Hospital Revenue Code	251
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: Qualcare PPO/HMO/WC	$4.04

LEUCOVORIN CAL INJ 50MG

Facility

$26.90

Hospital Charge Code	6003222
Hospital Revenue Code	251
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$13.45
Rate for Payer: Aetna Commercial	$10.22
Rate for Payer: Aetna Medicare Advantage	$8.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.86
Rate for Payer: Cigna Commercial	$13.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.07
Rate for Payer: Oxford Commercial	$5.38
Rate for Payer: Qualcare PPO/HMO/WC	$4.04
Rate for Payer: UnitedHealthcare Commercial	$5.38
Rate for Payer: UnitedHealthcare Community & State	$0.65
Rate for Payer: Wellpoint Medicaid Managed Care	$0.71

LEUCOVORIN TAB 25MG

Facility

$85.15

Hospital Charge Code	60628999
Hospital Revenue Code	250
Min. Negotiated Rate	$12.77
Max. Negotiated Rate	$12.77
Rate for Payer: Qualcare PPO/HMO/WC	$12.77

LEUCOVORIN TAB 25MG

Facility

$85.15

Hospital Charge Code	60628999
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$42.58
Rate for Payer: Aetna Commercial	$32.36
Rate for Payer: Aetna Medicare Advantage	$25.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.71
Rate for Payer: Cigna Commercial	$42.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.55
Rate for Payer: Oxford Commercial	$17.03
Rate for Payer: Qualcare PPO/HMO/WC	$12.77
Rate for Payer: UnitedHealthcare Commercial	$17.03
Rate for Payer: UnitedHealthcare Community & State	$2.05
Rate for Payer: Wellpoint Medicaid Managed Care	$2.26

LEUKEMIA LYMPH EVALUATION

Facility

$144.09

Service Code	HCPCS 88180
Hospital Charge Code	3004398
Hospital Revenue Code	301
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$54.75
Rate for Payer: Aetna Medicare Advantage	$43.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36.74
Rate for Payer: Cigna Commercial	$72.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.23
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.61
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.47
Rate for Payer: Wellpoint Medicaid Managed Care	$3.82

LEUKEMIA LYMPH EVALUATION

Facility

$144.09

Service Code	HCPCS 88180
Hospital Charge Code	3004398
Hospital Revenue Code	301
Min. Negotiated Rate	$21.61
Max. Negotiated Rate	$21.61
Rate for Payer: Qualcare PPO/HMO/WC	$21.61

LEUKEMIA LYMPH EVALUATION*****

Facility

$144.09

Service Code	HCPCS 88180
Hospital Charge Code	3006750
Hospital Revenue Code	301
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$54.75
Rate for Payer: Aetna Medicare Advantage	$43.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36.74
Rate for Payer: Cigna Commercial	$72.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.23
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.61
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.47
Rate for Payer: Wellpoint Medicaid Managed Care	$3.82

LEUKEMIA LYMPH EVALUATION*****

Facility

$144.09

Service Code	HCPCS 88180
Hospital Charge Code	3006750
Hospital Revenue Code	301
Min. Negotiated Rate	$21.61
Max. Negotiated Rate	$21.61
Rate for Payer: Qualcare PPO/HMO/WC	$21.61

Know your out-of-pocket cost for care.

All Charges