Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE VISC 2% 100ML

Facility

$88.44

Service Code	NDC 54350049
Hospital Charge Code	60628414
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$44.22
Rate for Payer: Aetna Commercial	$33.61
Rate for Payer: Aetna Medicare Advantage	$26.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.55
Rate for Payer: Cigna Commercial	$44.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.53
Rate for Payer: Oxford Commercial	$17.69
Rate for Payer: Qualcare PPO/HMO/WC	$13.27
Rate for Payer: UnitedHealthcare Commercial	$17.69
Rate for Payer: UnitedHealthcare Community & State	$2.13
Rate for Payer: Wellpoint Medicaid Managed Care	$2.34

LIDOCAINE VISC 2% 30ML

Facility

$6.37

Service Code	NDC 63739069457
Hospital Charge Code	60628415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$0.96
Rate for Payer: Qualcare PPO/HMO/WC	$0.96

LIDOCAINE VISC 2% 30ML

Facility

$6.37

Service Code	NDC 63739069457
Hospital Charge Code	60628415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$3.19
Rate for Payer: Aetna Commercial	$2.42
Rate for Payer: Aetna Medicare Advantage	$1.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.62
Rate for Payer: Cigna Commercial	$3.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.91
Rate for Payer: Oxford Commercial	$1.27
Rate for Payer: Qualcare PPO/HMO/WC	$0.96
Rate for Payer: UnitedHealthcare Commercial	$1.27
Rate for Payer: UnitedHealthcare Community & State	$0.15
Rate for Payer: Wellpoint Medicaid Managed Care	$0.17

LIDOCAINE VISCOUS 2%/100M

Facility

$15.00

Hospital Charge Code	60633305
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

LIDOCAINE VISCOUS 2%/100M

Facility

$15.00

Hospital Charge Code	60633305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$3.00
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.40

LIDOCAINE VL 1% 30ML

Facility

$4.00

Hospital Charge Code	6012728
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LIDOCAINE VL 1% 30ML

Facility

$4.00

Hospital Charge Code	6012728
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

LIDOCAINE VL 2% 30ML

Facility

$3.85

Hospital Charge Code	6022636
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.93
Rate for Payer: Aetna Commercial	$1.46
Rate for Payer: Aetna Medicare Advantage	$1.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.98
Rate for Payer: Cigna Commercial	$1.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.16
Rate for Payer: Oxford Commercial	$0.77
Rate for Payer: Qualcare PPO/HMO/WC	$0.58
Rate for Payer: UnitedHealthcare Commercial	$0.77
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.10

LIDOCAINE VL 2% 30ML

Facility

$3.85

Hospital Charge Code	6022636
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: Qualcare PPO/HMO/WC	$0.58

LIDOCAINE VL 2% 30ML

Facility

$3.85

Hospital Charge Code	6014120
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.93
Rate for Payer: Aetna Commercial	$1.46
Rate for Payer: Aetna Medicare Advantage	$1.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.98
Rate for Payer: Cigna Commercial	$1.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.16
Rate for Payer: Oxford Commercial	$0.77
Rate for Payer: Qualcare PPO/HMO/WC	$0.58
Rate for Payer: UnitedHealthcare Commercial	$0.77
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.10

LIDOCAINE VL 2% 30ML

Facility

$3.85

Hospital Charge Code	6014120
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: Qualcare PPO/HMO/WC	$0.58

LIDOCAINE W/EPI INJ 2%

Facility

$15.00

Hospital Charge Code	60634278
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$3.00
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.40

LIDOCAINE W/EPI INJ 2%

Facility

$15.00

Hospital Charge Code	60634278
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

LIDOCAINE W/EPINPH 2% 1.8ML

Facility

$3.20

Hospital Charge Code	6022644
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

LIDOCAINE W/EPINPH 2% 1.8ML

Facility

$3.20

Hospital Charge Code	6022644
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

LIDOCAINE W/EPINPH INJ 1%

Facility

$7.20

Hospital Charge Code	60628275
Hospital Revenue Code	250
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.08
Rate for Payer: Qualcare PPO/HMO/WC	$1.08

LIDOCAINE W/EPINPH INJ 1%

Facility

$7.20

Hospital Charge Code	60628275
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna Commercial	$2.74
Rate for Payer: Aetna Medicare Advantage	$2.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.84
Rate for Payer: Cigna Commercial	$3.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.16
Rate for Payer: Oxford Commercial	$1.44
Rate for Payer: Qualcare PPO/HMO/WC	$1.08
Rate for Payer: UnitedHealthcare Commercial	$1.44
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

LIDOCAINE W/EPINPH INJ 1.5%

Facility

$110.45

Hospital Charge Code	60628276
Hospital Revenue Code	250
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$55.23
Rate for Payer: Aetna Commercial	$41.97
Rate for Payer: Aetna Medicare Advantage	$33.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.16
Rate for Payer: Cigna Commercial	$55.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.13
Rate for Payer: Oxford Commercial	$22.09
Rate for Payer: Qualcare PPO/HMO/WC	$16.57
Rate for Payer: UnitedHealthcare Commercial	$22.09
Rate for Payer: UnitedHealthcare Community & State	$2.66
Rate for Payer: Wellpoint Medicaid Managed Care	$2.93

LIDOCAINE W/EPINPH INJ 1.5%

Facility

$110.45

Hospital Charge Code	60628276
Hospital Revenue Code	250
Min. Negotiated Rate	$16.57
Max. Negotiated Rate	$16.57
Rate for Payer: Qualcare PPO/HMO/WC	$16.57

LIDOCAINE W/EPINPH INJ1.5%30ML

Facility

$70.40

Hospital Charge Code	6012736
Hospital Revenue Code	250
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$10.56
Rate for Payer: Qualcare PPO/HMO/WC	$10.56

LIDOCAINE W/EPINPH INJ1.5%30ML

Facility

$70.40

Hospital Charge Code	6012736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$35.20
Rate for Payer: Aetna Commercial	$26.75
Rate for Payer: Aetna Medicare Advantage	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.95
Rate for Payer: Cigna Commercial	$35.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.12
Rate for Payer: Oxford Commercial	$14.08
Rate for Payer: Qualcare PPO/HMO/WC	$10.56
Rate for Payer: UnitedHealthcare Commercial	$14.08
Rate for Payer: UnitedHealthcare Community & State	$1.70
Rate for Payer: Wellpoint Medicaid Managed Care	$1.87

LIDOCAINE W/EPINPH INJ 2%

Facility

$47.50

Service Code	NDC 63323048257
Hospital Charge Code	60628277
Hospital Revenue Code	250
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$23.75
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare Advantage	$14.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.11
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.25
Rate for Payer: Oxford Commercial	$9.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.12
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: UnitedHealthcare Community & State	$1.14
Rate for Payer: Wellpoint Medicaid Managed Care	$1.26

LIDOCAINE W/EPINPH INJ 2%

Facility

$47.50

Service Code	NDC 63323048257
Hospital Charge Code	60628277
Hospital Revenue Code	250
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$7.12
Rate for Payer: Qualcare PPO/HMO/WC	$7.12

LIDOCAINE W/EPINPH VL 1% 30ML

Facility

$7.70

Hospital Charge Code	6014104
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.16
Rate for Payer: Qualcare PPO/HMO/WC	$1.16

LIDOCAINE W/EPINPH VL 1% 30ML

Facility

$7.70

Hospital Charge Code	6014104
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$3.85
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare Advantage	$2.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.96
Rate for Payer: Cigna Commercial	$3.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.31
Rate for Payer: Oxford Commercial	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.16
Rate for Payer: UnitedHealthcare Commercial	$1.54
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.20

Know your out-of-pocket cost for care.

All Charges