Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LORAZEPAM 2 MG/MLINJ.

Facility

$37.30

Hospital Charge Code	60627847
Hospital Revenue Code	250
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$5.59
Rate for Payer: Qualcare PPO/HMO/WC	$5.59

LORAZEPAM 2 MG/MLINJ.

Facility

$37.30

Hospital Charge Code	60627847
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$18.65
Rate for Payer: Aetna Commercial	$14.17
Rate for Payer: Aetna Medicare Advantage	$11.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.51
Rate for Payer: Cigna Commercial	$18.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.19
Rate for Payer: Oxford Commercial	$7.46
Rate for Payer: Qualcare PPO/HMO/WC	$5.59
Rate for Payer: UnitedHealthcare Commercial	$7.46
Rate for Payer: UnitedHealthcare Community & State	$0.90
Rate for Payer: Wellpoint Medicaid Managed Care	$0.99

LORAZEPAM 2MG/ML INTENSOL

Facility

$124.00

Hospital Charge Code	60635310
Hospital Revenue Code	250
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$18.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.60

LORAZEPAM 2MG/ML INTENSOL

Facility

$124.00

Hospital Charge Code	60635310
Hospital Revenue Code	250
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$47.12
Rate for Payer: Aetna Medicare Advantage	$37.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.62
Rate for Payer: Cigna Commercial	$62.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.20
Rate for Payer: Oxford Commercial	$24.80
Rate for Payer: Qualcare PPO/HMO/WC	$18.60
Rate for Payer: UnitedHealthcare Commercial	$24.80
Rate for Payer: UnitedHealthcare Community & State	$2.99
Rate for Payer: Wellpoint Medicaid Managed Care	$3.29

LORAZEPAM 2 MG/ML SOL

Facility

$40.00

Service Code	HCPCS J2060
Hospital Charge Code	60627845
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$9.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.68
Rate for Payer: Qualcare PPO/HMO/WC	$6.00

LORAZEPAM 2 MG/ML SOL

Facility

$40.00

Service Code	HCPCS J2060
Hospital Charge Code	60627845
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.20
Rate for Payer: Cigna Commercial	$20.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.68
Rate for Payer: Qualcare PPO/HMO/WC	$6.00
Rate for Payer: UnitedHealthcare Community & State	$0.96
Rate for Payer: Wellpoint Medicaid Managed Care	$1.06

LORAZEPAM 4MG/ML SINGLE DOES

Facility

$19.30

Service Code	NDC 641600325
Hospital Charge Code	606390581
Hospital Revenue Code	250
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$2.90
Rate for Payer: Qualcare PPO/HMO/WC	$2.90

LORAZEPAM 4MG/ML SINGLE DOES

Facility

$19.30

Service Code	NDC 641600325
Hospital Charge Code	606390581
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$9.65
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: Aetna Medicare Advantage	$5.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.92
Rate for Payer: Cigna Commercial	$9.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.79
Rate for Payer: Oxford Commercial	$3.86
Rate for Payer: Qualcare PPO/HMO/WC	$2.90
Rate for Payer: UnitedHealthcare Commercial	$3.86
Rate for Payer: UnitedHealthcare Community & State	$0.47
Rate for Payer: Wellpoint Medicaid Managed Care	$0.51

LORAZEPAM (ATIVAN)

Facility

$190.45

Service Code	HCPCS 80300
Hospital Charge Code	3000301
Hospital Revenue Code	301
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$72.37
Rate for Payer: Aetna Medicare Advantage	$57.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.56
Rate for Payer: Cigna Commercial	$95.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$4.59
Rate for Payer: Wellpoint Medicaid Managed Care	$5.05

LORAZEPAM (ATIVAN)

Facility

$190.45

Service Code	HCPCS 80300
Hospital Charge Code	3000301
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

LORAZEPAM (ATIVAN)

Facility

$324.00

Service Code	HCPCS 80346
Hospital Charge Code	38472462
Hospital Revenue Code	301
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna Commercial	$123.12
Rate for Payer: Aetna Medicare Advantage	$97.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$82.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$82.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$82.62
Rate for Payer: Cigna Commercial	$162.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$48.60
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: Wellpoint Medicaid Managed Care	$8.59

LORAZEPAM (ATIVAN)

Facility

$324.00

Service Code	HCPCS 80346
Hospital Charge Code	38472462
Hospital Revenue Code	301
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Qualcare PPO/HMO/WC	$48.60

LORAZEPAM (ATIVAN) 2MG TAB

Facility

$8.84

Service Code	NDC 51079038720
Hospital Charge Code	60630183
Hospital Revenue Code	250
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.33
Rate for Payer: Qualcare PPO/HMO/WC	$1.33

LORAZEPAM (ATIVAN) 2MG TAB

Facility

$8.84

Service Code	NDC 51079038720
Hospital Charge Code	60630183
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$4.42
Rate for Payer: Aetna Commercial	$3.36
Rate for Payer: Aetna Medicare Advantage	$2.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.25
Rate for Payer: Cigna Commercial	$4.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.65
Rate for Payer: Oxford Commercial	$1.77
Rate for Payer: Qualcare PPO/HMO/WC	$1.33
Rate for Payer: UnitedHealthcare Commercial	$1.77
Rate for Payer: UnitedHealthcare Community & State	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.23

LORAZEPAM INJ 2MG/ML

Facility

$70.40

Hospital Charge Code	6010508
Hospital Revenue Code	250
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$10.56
Rate for Payer: Qualcare PPO/HMO/WC	$10.56

LORAZEPAM INJ 2MG/ML

Facility

$70.40

Hospital Charge Code	6010508
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

LORAZEPAM INJ 40MG/10ML

Facility

$74.37

Service Code	HCPCS J2060
Hospital Charge Code	60627848
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$37.19
Rate for Payer: Aetna Commercial	$28.26
Rate for Payer: Aetna Medicare Advantage	$22.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.96
Rate for Payer: Cigna Commercial	$37.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.16
Rate for Payer: UnitedHealthcare Community & State	$1.79
Rate for Payer: Wellpoint Medicaid Managed Care	$1.97

LORAZEPAM INJ 40MG/10ML

Facility

$74.37

Service Code	HCPCS J2060
Hospital Charge Code	60627848
Hospital Revenue Code	636
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$18.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.16

LORDOTIC PEEK 12X12X10

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658053
Hospital Revenue Code	278
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

LORDOTIC PEEK 12X12X10

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658053
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X5

Facility

$13,500.00

Hospital Charge Code	270658066
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X5

Facility

$13,500.00

Hospital Charge Code	270658066
Hospital Revenue Code	278
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

LORDOTIC PEEK 12X12X6

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658065
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X6

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658065
Hospital Revenue Code	278
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$5,130.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,970.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

LORDOTIC PEEK 12x12x6MM

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270667220
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,178.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,980.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

Know your out-of-pocket cost for care.

All Charges