Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LEVEL V SP GROSS&MICROSCOPIC

Facility

$1,099.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005300
Hospital Revenue Code	310
Min. Negotiated Rate	$26.49
Max. Negotiated Rate	$549.50
Rate for Payer: Aetna Commercial	$417.62
Rate for Payer: Aetna Medicare Advantage	$329.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$280.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$280.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$280.25
Rate for Payer: Cigna Commercial	$549.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$329.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$164.85
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$26.49
Rate for Payer: Wellpoint Medicaid Managed Care	$29.12

LEVEL V SP GROSS&MICROSCOPIC

Facility

$1,099.00

Service Code	HCPCS 88307TC
Hospital Charge Code	3005300
Hospital Revenue Code	310
Min. Negotiated Rate	$164.85
Max. Negotiated Rate	$164.85
Rate for Payer: Qualcare PPO/HMO/WC	$164.85

LEVEL V SP GROSS&MICROSCOPIC**

Facility

$39.00

Service Code	HCPCS 8830759
Hospital Charge Code	3005300A
Hospital Revenue Code	312
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$5.85
Rate for Payer: Qualcare PPO/HMO/WC	$5.85

LEVEL V SP GROSS&MICROSCOPIC**

Facility

$39.00

Service Code	HCPCS 8830759
Hospital Charge Code	3005300A
Hospital Revenue Code	312
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$14.82
Rate for Payer: Aetna Medicare Advantage	$11.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.95
Rate for Payer: Cigna Commercial	$19.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.85
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$0.94
Rate for Payer: Wellpoint Medicaid Managed Care	$1.03

LEVETIRACETAM

Facility

$390.00

Service Code	HCPCS 80177
Hospital Charge Code	39900013
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LEVETIRACETAM

Facility

$390.00

Service Code	HCPCS 80177
Hospital Charge Code	39900013
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$36.04
Rate for Payer: Aetna Medicare Advantage	$42.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$14.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.83
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.25
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.25
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	$10.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Medicare Advantage	$13.25
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

LEVETIRACETAM

Facility

$256.00

Service Code	HCPCS 82542
Hospital Charge Code	3003457
Hospital Revenue Code	301
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$128.00
Rate for Payer: Aetna Commercial	$65.52
Rate for Payer: Aetna Medicare Advantage	$78.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$86.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$86.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$24.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$86.96
Rate for Payer: Cigna Commercial	$128.00
Rate for Payer: Cigna Medicare Advantage	$24.09
Rate for Payer: Clover Medicare Advantage	$22.89
Rate for Payer: EmblemHealth Commercial	$72.27
Rate for Payer: Humana Medicare Advantage	$24.81
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$24.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$76.80
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$38.40
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$19.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.09
Rate for Payer: Wellcare Medicare Advantage	$24.09
Rate for Payer: Wellpoint Medicaid Managed Care	$6.78

LEVETIRACETAM

Facility

$256.00

Service Code	HCPCS 82542
Hospital Charge Code	3003457
Hospital Revenue Code	301
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$38.40
Rate for Payer: Qualcare PPO/HMO/WC	$38.40

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$199.43
Rate for Payer: Aetna Commercial	$151.56
Rate for Payer: Aetna Medicare Advantage	$119.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$101.71
Rate for Payer: Cigna Commercial	$199.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83
Rate for Payer: UnitedHealthcare Community & State	$9.61
Rate for Payer: Wellpoint Medicaid Managed Care	$10.57

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$59.83
Max. Negotiated Rate	$96.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$42.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$87.83
Rate for Payer: Aetna Commercial	$66.75
Rate for Payer: Aetna Medicare Advantage	$52.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.80
Rate for Payer: Cigna Commercial	$87.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35
Rate for Payer: UnitedHealthcare Community & State	$4.23
Rate for Payer: Wellpoint Medicaid Managed Care	$4.66

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$8.68
Rate for Payer: Aetna Commercial	$6.59
Rate for Payer: Aetna Medicare Advantage	$5.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.42
Rate for Payer: Cigna Commercial	$8.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.21
Rate for Payer: Oxford Commercial	$3.47
Rate for Payer: Qualcare PPO/HMO/WC	$2.60
Rate for Payer: UnitedHealthcare Commercial	$3.47
Rate for Payer: UnitedHealthcare Community & State	$0.42
Rate for Payer: Wellpoint Medicaid Managed Care	$0.46

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$2.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.60

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$119.66
Rate for Payer: Aetna Commercial	$90.94
Rate for Payer: Aetna Medicare Advantage	$71.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$61.03
Rate for Payer: Cigna Commercial	$119.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90
Rate for Payer: UnitedHealthcare Community & State	$5.77
Rate for Payer: Wellpoint Medicaid Managed Care	$6.34

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$35.90
Max. Negotiated Rate	$57.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$46.63
Max. Negotiated Rate	$75.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$155.44
Rate for Payer: Aetna Commercial	$118.13
Rate for Payer: Aetna Medicare Advantage	$93.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.27
Rate for Payer: Cigna Commercial	$155.44
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63
Rate for Payer: UnitedHealthcare Community & State	$7.49
Rate for Payer: Wellpoint Medicaid Managed Care	$8.24

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$27.84
Rate for Payer: Aetna Commercial	$21.16
Rate for Payer: Aetna Medicare Advantage	$16.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.20
Rate for Payer: Cigna Commercial	$27.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.70
Rate for Payer: Oxford Commercial	$11.14
Rate for Payer: Qualcare PPO/HMO/WC	$8.35
Rate for Payer: UnitedHealthcare Commercial	$11.14
Rate for Payer: UnitedHealthcare Community & State	$1.34
Rate for Payer: Wellpoint Medicaid Managed Care	$1.48

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$8.35
Rate for Payer: Qualcare PPO/HMO/WC	$8.35

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$124.00
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	$55.00
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	$33.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.50
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	$2.92

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$16.50
Rate for Payer: Qualcare PPO/HMO/WC	$16.50

LEVLEUCOVORI FUSILEV 50MG 10ML

Facility

$971.50

Hospital Charge Code	60630110
Hospital Revenue Code	636
Min. Negotiated Rate	$23.41
Max. Negotiated Rate	$485.75
Rate for Payer: Aetna Commercial	$369.17
Rate for Payer: Aetna Medicare Advantage	$291.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$247.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$247.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$247.73
Rate for Payer: Cigna Commercial	$485.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$235.10
Rate for Payer: Qualcare PPO/HMO/WC	$145.72
Rate for Payer: UnitedHealthcare Community & State	$23.41
Rate for Payer: Wellpoint Medicaid Managed Care	$25.74

LEVLEUCOVORI FUSILEV 50MG 10ML

Facility

$971.50

Hospital Charge Code	60630110
Hospital Revenue Code	636
Min. Negotiated Rate	$145.72
Max. Negotiated Rate	$235.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$235.10
Rate for Payer: Qualcare PPO/HMO/WC	$145.72

LEVOBUNOLOL OPH SOL 0.05%

Facility

$93.65

Hospital Charge Code	60628090
Hospital Revenue Code	250
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$14.05
Rate for Payer: Qualcare PPO/HMO/WC	$14.05

Know your out-of-pocket cost for care.

All Charges