Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LEVORPHANOL TARTRATE/2MG

Facility

$3.00

Hospital Charge Code	60633284
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

LEVOTHROID/0.2MG/TAB

Facility

$3.00

Hospital Charge Code	60633285
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

LEVOTHROID/0.2MG/TAB

Facility

$3.00

Hospital Charge Code	60633285
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

LEVOTHROID TAB 137MCG

Facility

$4.00

Service Code	NDC 74372790
Hospital Charge Code	60635232
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

LEVOTHROID TAB 137MCG

Facility

$4.00

Service Code	NDC 74372790
Hospital Charge Code	60635232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LEVOTHYROXINE 500 MCG INJ.

Facility

$161.30

Hospital Charge Code	60629127
Hospital Revenue Code	250
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$80.65
Rate for Payer: Aetna Commercial	$61.29
Rate for Payer: Aetna Medicare Advantage	$48.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.13
Rate for Payer: Cigna Commercial	$80.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.39
Rate for Payer: Oxford Commercial	$32.26
Rate for Payer: Qualcare PPO/HMO/WC	$24.20
Rate for Payer: UnitedHealthcare Commercial	$32.26
Rate for Payer: UnitedHealthcare Community & State	$3.89
Rate for Payer: Wellpoint Medicaid Managed Care	$4.27

LEVOTHYROXINE 500 MCG INJ.

Facility

$161.30

Hospital Charge Code	60629127
Hospital Revenue Code	250
Min. Negotiated Rate	$24.20
Max. Negotiated Rate	$24.20
Rate for Payer: Qualcare PPO/HMO/WC	$24.20

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$55.71
Rate for Payer: Qualcare PPO/HMO/WC	$55.71

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$185.69
Rate for Payer: Aetna Commercial	$141.12
Rate for Payer: Aetna Medicare Advantage	$111.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$94.70
Rate for Payer: Cigna Commercial	$185.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$111.41
Rate for Payer: Oxford Commercial	$74.28
Rate for Payer: Qualcare PPO/HMO/WC	$55.71
Rate for Payer: UnitedHealthcare Commercial	$74.28
Rate for Payer: UnitedHealthcare Community & State	$8.95
Rate for Payer: Wellpoint Medicaid Managed Care	$9.84

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$221.10
Rate for Payer: Aetna Commercial	$168.04
Rate for Payer: Aetna Medicare Advantage	$132.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.76
Rate for Payer: Cigna Commercial	$221.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$132.66
Rate for Payer: Oxford Commercial	$88.44
Rate for Payer: Qualcare PPO/HMO/WC	$66.33
Rate for Payer: UnitedHealthcare Commercial	$88.44
Rate for Payer: UnitedHealthcare Community & State	$10.66
Rate for Payer: Wellpoint Medicaid Managed Care	$11.72

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$66.33
Max. Negotiated Rate	$66.33
Rate for Payer: Qualcare PPO/HMO/WC	$66.33

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna Commercial	$2.14
Rate for Payer: Aetna Medicare Advantage	$1.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.44
Rate for Payer: Cigna Commercial	$2.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.69
Rate for Payer: Oxford Commercial	$1.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.84
Rate for Payer: UnitedHealthcare Commercial	$1.13
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$0.84
Rate for Payer: Qualcare PPO/HMO/WC	$0.84

LEVOTHYROXINE TAB 100MCG

Facility

$8.51

Service Code	NDC 74662411
Hospital Charge Code	60628249
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna Commercial	$3.23
Rate for Payer: Aetna Medicare Advantage	$2.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.17
Rate for Payer: Cigna Commercial	$4.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.55
Rate for Payer: Oxford Commercial	$1.70
Rate for Payer: Qualcare PPO/HMO/WC	$1.28
Rate for Payer: UnitedHealthcare Commercial	$1.70
Rate for Payer: UnitedHealthcare Community & State	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.23

LEVOTHYROXINE TAB 100MCG

Facility

$8.51

Service Code	NDC 74662411
Hospital Charge Code	60628249
Hospital Revenue Code	250
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.28
Rate for Payer: Qualcare PPO/HMO/WC	$1.28

LEVOTHYROXINE TAB 112MCG

Facility

$4.36

Service Code	NDC 378181177
Hospital Charge Code	60628250
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.65
Rate for Payer: Qualcare PPO/HMO/WC	$0.65

LEVOTHYROXINE TAB 112MCG

Facility

$4.36

Service Code	NDC 378181177
Hospital Charge Code	60628250
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$1.66
Rate for Payer: Aetna Medicare Advantage	$1.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.11
Rate for Payer: Cigna Commercial	$2.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.31
Rate for Payer: Oxford Commercial	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.65
Rate for Payer: UnitedHealthcare Commercial	$0.87
Rate for Payer: UnitedHealthcare Community & State	$0.11
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

LEVOTHYROXINE TAB 125MCG

Facility

$4.00

Service Code	NDC 74706811
Hospital Charge Code	60628251
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LEVOTHYROXINE TAB 125MCG

Facility

$4.00

Service Code	NDC 74706811
Hospital Charge Code	60628251
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

LEVOTHYROXINE TAB 150MCG

Facility

$4.09

Service Code	NDC 74706990
Hospital Charge Code	60628252
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna Commercial	$1.55
Rate for Payer: Aetna Medicare Advantage	$1.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.04
Rate for Payer: Cigna Commercial	$2.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.23
Rate for Payer: Oxford Commercial	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.61
Rate for Payer: UnitedHealthcare Commercial	$0.82
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

LEVOTHYROXINE TAB 150MCG

Facility

$4.09

Service Code	NDC 74706990
Hospital Charge Code	60628252
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.61
Rate for Payer: Qualcare PPO/HMO/WC	$0.61

LEVOTHYROXINE TAB 175MCG

Facility

$5.43

Service Code	NDC 378181701
Hospital Charge Code	60628253
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$0.81
Rate for Payer: Qualcare PPO/HMO/WC	$0.81

LEVOTHYROXINE TAB 175MCG

Facility

$5.43

Service Code	NDC 378181701
Hospital Charge Code	60628253
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$2.71
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: Aetna Medicare Advantage	$1.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.38
Rate for Payer: Cigna Commercial	$2.71
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.63
Rate for Payer: Oxford Commercial	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$0.81
Rate for Payer: UnitedHealthcare Commercial	$1.09
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.14

LEVOTHYROXINE TAB 200MCG

Facility

$3.20

Hospital Charge Code	60628254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

LEVOTHYROXINE TAB 200MCG

Facility

$3.20

Hospital Charge Code	60628254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$1.22
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.96
Rate for Payer: Oxford Commercial	$0.64
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$0.64
Rate for Payer: UnitedHealthcare Community & State	$0.08
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

Know your out-of-pocket cost for care.

All Charges