Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE PRES-FREE 1.5%

Facility

$38.00

Hospital Charge Code	60634764
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$5.70
Rate for Payer: Qualcare PPO/HMO/WC	$5.70

LIDOCAINE PRES-FREE 1.5%

Facility

$38.00

Hospital Charge Code	60634764
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$14.44
Rate for Payer: Aetna Medicare Advantage	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.69
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.40
Rate for Payer: Oxford Commercial	$7.60
Rate for Payer: Qualcare PPO/HMO/WC	$5.70
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Community & State	$0.92
Rate for Payer: Wellpoint Medicaid Managed Care	$1.01

LIDOCAINE PRES-FREE 2%AMP

Facility

$7.00

Hospital Charge Code	60634787
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

LIDOCAINE PRES-FREE 2%AMP

Facility

$7.00

Hospital Charge Code	60634787
Hospital Revenue Code	250
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	$2.10
Rate for Payer: Oxford Commercial	$1.40
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$1.40
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

LIDOCAINE/PRILOCAINE 1 CREAM

Facility

$343.25

Hospital Charge Code	60628418
Hospital Revenue Code	250
Min. Negotiated Rate	$51.49
Max. Negotiated Rate	$51.49
Rate for Payer: Qualcare PPO/HMO/WC	$51.49

LIDOCAINE/PRILOCAINE 1 CREAM

Facility

$343.25

Hospital Charge Code	60628418
Hospital Revenue Code	250
Min. Negotiated Rate	$8.27
Max. Negotiated Rate	$171.62
Rate for Payer: Aetna Commercial	$130.44
Rate for Payer: Aetna Medicare Advantage	$102.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$87.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$87.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$87.53
Rate for Payer: Cigna Commercial	$171.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$102.97
Rate for Payer: Oxford Commercial	$68.65
Rate for Payer: Qualcare PPO/HMO/WC	$51.49
Rate for Payer: UnitedHealthcare Commercial	$68.65
Rate for Payer: UnitedHealthcare Community & State	$8.27
Rate for Payer: Wellpoint Medicaid Managed Care	$9.10

LIDOCAINE/PRILOCAINE 2.5 5MG

Facility

$57.08

Service Code	NDC 168035730
Hospital Charge Code	606351010
Hospital Revenue Code	250
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$8.56
Rate for Payer: Qualcare PPO/HMO/WC	$8.56

LIDOCAINE/PRILOCAINE 2.5 5MG

Facility

$57.08

Service Code	NDC 168035730
Hospital Charge Code	606351010
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$28.54
Rate for Payer: Aetna Commercial	$21.69
Rate for Payer: Aetna Medicare Advantage	$17.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.56
Rate for Payer: Cigna Commercial	$28.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.12
Rate for Payer: Oxford Commercial	$11.42
Rate for Payer: Qualcare PPO/HMO/WC	$8.56
Rate for Payer: UnitedHealthcare Commercial	$11.42
Rate for Payer: UnitedHealthcare Community & State	$1.38
Rate for Payer: Wellpoint Medicaid Managed Care	$1.51

LIDOCAINE PRILOCAINE CRM 5GM

Facility

$57.60

Hospital Charge Code	60628419
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$8.64
Rate for Payer: Qualcare PPO/HMO/WC	$8.64

LIDOCAINE PRILOCAINE CRM 5GM

Facility

$57.60

Hospital Charge Code	60628419
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna Commercial	$21.89
Rate for Payer: Aetna Medicare Advantage	$17.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.69
Rate for Payer: Cigna Commercial	$28.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.28
Rate for Payer: Oxford Commercial	$11.52
Rate for Payer: Qualcare PPO/HMO/WC	$8.64
Rate for Payer: UnitedHealthcare Commercial	$11.52
Rate for Payer: UnitedHealthcare Community & State	$1.39
Rate for Payer: Wellpoint Medicaid Managed Care	$1.53

LIDOCAINE RUGBY PATCH 4%

Facility

$187.53

Service Code	NDC 536120207
Hospital Charge Code	606390564
Hospital Revenue Code	250
Min. Negotiated Rate	$28.13
Max. Negotiated Rate	$28.13
Rate for Payer: Qualcare PPO/HMO/WC	$28.13

LIDOCAINE RUGBY PATCH 4%

Facility

$187.53

Service Code	NDC 536120207
Hospital Charge Code	606390564
Hospital Revenue Code	250
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$93.77
Rate for Payer: Aetna Commercial	$71.26
Rate for Payer: Aetna Medicare Advantage	$56.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.82
Rate for Payer: Cigna Commercial	$93.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$56.26
Rate for Payer: Oxford Commercial	$37.51
Rate for Payer: Qualcare PPO/HMO/WC	$28.13
Rate for Payer: UnitedHealthcare Commercial	$37.51
Rate for Payer: UnitedHealthcare Community & State	$4.52
Rate for Payer: Wellpoint Medicaid Managed Care	$4.97

LIDOCAINE (SERUM)

Facility

$128.00

Service Code	HCPCS 80176
Hospital Charge Code	3007572
Hospital Revenue Code	301
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$19.20
Rate for Payer: Qualcare PPO/HMO/WC	$19.20

LIDOCAINE (SERUM)

Facility

$128.00

Service Code	HCPCS 80176
Hospital Charge Code	3007572
Hospital Revenue Code	301
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$39.96
Rate for Payer: Aetna Medicare Advantage	$47.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$34.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.03
Rate for Payer: Cigna Commercial	$64.00
Rate for Payer: Cigna Medicare Advantage	$14.69
Rate for Payer: Clover Medicare Advantage	$13.96
Rate for Payer: EmblemHealth Commercial	$44.07
Rate for Payer: Humana Medicare Advantage	$15.13
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$38.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.20
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.69
Rate for Payer: Wellcare Medicare Advantage	$14.69
Rate for Payer: Wellpoint Medicaid Managed Care	$3.39

LIDOCAINE SYR 100MG/5ML

Facility

$24.59

Service Code	HCPCS J2003
Hospital Charge Code	60627569
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna Commercial	$9.34
Rate for Payer: Aetna Medicare Advantage	$7.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.27
Rate for Payer: Cigna Commercial	$12.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.95
Rate for Payer: Qualcare PPO/HMO/WC	$3.69
Rate for Payer: UnitedHealthcare Community & State	$0.59
Rate for Payer: Wellpoint Medicaid Managed Care	$0.65

LIDOCAINE SYR 100MG/5ML

Facility

$24.59

Service Code	HCPCS J2003
Hospital Charge Code	60627569
Hospital Revenue Code	636
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$5.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.95
Rate for Payer: Qualcare PPO/HMO/WC	$3.69

LIDOCAINE TOP 2% 10ML JELLY

Facility

$11.26

Service Code	NDC 76329301305
Hospital Charge Code	6003271
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$5.63
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare Advantage	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.87
Rate for Payer: Cigna Commercial	$5.63
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.38
Rate for Payer: Oxford Commercial	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$1.69
Rate for Payer: UnitedHealthcare Commercial	$2.25
Rate for Payer: UnitedHealthcare Community & State	$0.27
Rate for Payer: Wellpoint Medicaid Managed Care	$0.30

LIDOCAINE TOP 2% 10ML JELLY

Facility

$11.26

Service Code	NDC 76329301305
Hospital Charge Code	6003271
Hospital Revenue Code	250
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.69
Rate for Payer: Qualcare PPO/HMO/WC	$1.69

LIDOCAINE TOP 4% 50ML

Facility

$68.00

Service Code	HCPCS J2000
Hospital Charge Code	6006738
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$25.84
Rate for Payer: Aetna Medicare Advantage	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.34
Rate for Payer: Cigna Commercial	$34.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.40
Rate for Payer: Oxford Commercial	$13.60
Rate for Payer: Qualcare PPO/HMO/WC	$10.20
Rate for Payer: UnitedHealthcare Commercial	$13.60
Rate for Payer: UnitedHealthcare Community & State	$1.64
Rate for Payer: Wellpoint Medicaid Managed Care	$1.80

LIDOCAINE TOP 4% 50ML

Facility

$68.00

Service Code	HCPCS J2000
Hospital Charge Code	6006738
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$10.20
Rate for Payer: Qualcare PPO/HMO/WC	$10.20

LIDOCAINE UNPRES INJ 1.5%

Facility

$30.69

Service Code	NDC 409477601
Hospital Charge Code	6003297
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$4.60
Rate for Payer: Qualcare PPO/HMO/WC	$4.60

LIDOCAINE UNPRES INJ 1.5%

Facility

$30.69

Service Code	NDC 409477601
Hospital Charge Code	6003297
Hospital Revenue Code	250
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$15.35
Rate for Payer: Aetna Commercial	$11.66
Rate for Payer: Aetna Medicare Advantage	$9.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.83
Rate for Payer: Cigna Commercial	$15.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.21
Rate for Payer: Oxford Commercial	$6.14
Rate for Payer: Qualcare PPO/HMO/WC	$4.60
Rate for Payer: UnitedHealthcare Commercial	$6.14
Rate for Payer: UnitedHealthcare Community & State	$0.74
Rate for Payer: Wellpoint Medicaid Managed Care	$0.81

LIDOCAINE UNPRES INJ 2%

Facility

$21.15

Hospital Charge Code	6003305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$10.57
Rate for Payer: Aetna Commercial	$8.04
Rate for Payer: Aetna Medicare Advantage	$6.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.39
Rate for Payer: Cigna Commercial	$10.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.34
Rate for Payer: Oxford Commercial	$4.23
Rate for Payer: Qualcare PPO/HMO/WC	$3.17
Rate for Payer: UnitedHealthcare Commercial	$4.23
Rate for Payer: UnitedHealthcare Community & State	$0.51
Rate for Payer: Wellpoint Medicaid Managed Care	$0.56

LIDOCAINE UNPRES INJ 2%

Facility

$21.15

Hospital Charge Code	6003305
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.17
Rate for Payer: Qualcare PPO/HMO/WC	$3.17

LIDOCAINE VISC 2% 100ML

Facility

$88.44

Service Code	NDC 54350049
Hospital Charge Code	60628414
Hospital Revenue Code	250
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$13.27
Rate for Payer: Qualcare PPO/HMO/WC	$13.27

Know your out-of-pocket cost for care.

All Charges