Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PERPHENAZINE 2 MG TAB

Facility

$13.13

Service Code	HCPCS Q0175
Hospital Charge Code	60627814
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$3.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.18
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

PERPHENAZINE 4 MG TAB

Facility

$18.02

Service Code	HCPCS Q0175
Hospital Charge Code	60627815
Hospital Revenue Code	636
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$4.36
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.36
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

PERPHENAZINE 4 MG TAB

Facility

$18.02

Service Code	HCPCS Q0175
Hospital Charge Code	60627815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$9.01
Rate for Payer: Aetna Commercial	$6.85
Rate for Payer: Aetna Medicare Advantage	$5.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.60
Rate for Payer: Cigna Commercial	$9.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.36
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Community & State	$0.43
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

PERPHENAZINE 4 MG U/D

Facility

$3.00

Hospital Charge Code	60634406
Hospital Revenue Code	636
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	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Community & State	$0.07
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

PERPHENAZINE 4 MG U/D

Facility

$3.00

Hospital Charge Code	60634406
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PERPHENAZINE 5 MG/ML INJ

Facility

$43.25

Hospital Charge Code	6009948
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$21.62
Rate for Payer: Aetna Commercial	$16.43
Rate for Payer: Aetna Medicare Advantage	$12.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.03
Rate for Payer: Cigna Commercial	$21.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.97
Rate for Payer: Oxford Commercial	$8.65
Rate for Payer: Qualcare PPO/HMO/WC	$6.49
Rate for Payer: UnitedHealthcare Commercial	$8.65
Rate for Payer: UnitedHealthcare Community & State	$1.04
Rate for Payer: Wellpoint Medicaid Managed Care	$1.15

PERPHENAZINE 5 MG/ML INJ

Facility

$43.25

Hospital Charge Code	6009948
Hospital Revenue Code	250
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$6.49
Rate for Payer: Qualcare PPO/HMO/WC	$6.49

PERPHENAZINE 8 MG TAB

Facility

$21.84

Service Code	HCPCS Q0175
Hospital Charge Code	60627816
Hospital Revenue Code	636
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$5.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.29
Rate for Payer: Qualcare PPO/HMO/WC	$3.28

PERPHENAZINE 8 MG TAB

Facility

$21.84

Service Code	HCPCS Q0175
Hospital Charge Code	60627816
Hospital Revenue Code	636
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$10.92
Rate for Payer: Aetna Commercial	$8.30
Rate for Payer: Aetna Medicare Advantage	$6.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.57
Rate for Payer: Cigna Commercial	$10.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.29
Rate for Payer: Qualcare PPO/HMO/WC	$3.28
Rate for Payer: UnitedHealthcare Community & State	$0.53
Rate for Payer: Wellpoint Medicaid Managed Care	$0.58

PERPHENAZINE AMITRIPTL TAB2-10

Facility

$4.00

Hospital Charge Code	60627775
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB2-10

Facility

$4.00

Hospital Charge Code	60627775
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

PERPHENAZINE AMITRIPTL TAB2-25

Facility

$4.85

Hospital Charge Code	60627776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: Aetna Medicare Advantage	$1.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.24
Rate for Payer: Cigna Commercial	$2.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.46
Rate for Payer: Oxford Commercial	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.73
Rate for Payer: UnitedHealthcare Commercial	$0.97
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

PERPHENAZINE AMITRIPTL TAB2-25

Facility

$4.85

Hospital Charge Code	60627776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.73

PERPHENAZINE AMITRIPTL TAB4-10

Facility

$4.00

Hospital Charge Code	60627777
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB4-10

Facility

$4.00

Hospital Charge Code	60627777
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

PERPHENAZINE AMITRIPTL TAB4-25

Facility

$4.00

Hospital Charge Code	60627778
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB4-25

Facility

$4.00

Hospital Charge Code	60627778
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

PERPHENAZINE AMITRIPTL TAB4-50

Facility

$5.65

Hospital Charge Code	60627779
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.15
Rate for Payer: Aetna Medicare Advantage	$1.70
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	$2.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.70
Rate for Payer: Oxford Commercial	$1.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.85
Rate for Payer: UnitedHealthcare Commercial	$1.13
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

PERPHENAZINE AMITRIPTL TAB4-50

Facility

$5.65

Hospital Charge Code	60627779
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

PERPHENAZINE LQ 16ML/5ML

Facility

$4.00

Hospital Charge Code	6009898
Hospital Revenue Code	251
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

PERPHENAZINE LQ 16ML/5ML

Facility

$4.00

Hospital Charge Code	6009898
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	321034713
Hospital Revenue Code	361
Min. Negotiated Rate	$163.52
Max. Negotiated Rate	$3,392.50
Rate for Payer: Aetna Commercial	$2,578.30
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,730.17
Rate for Payer: Cigna Commercial	$3,392.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,035.50
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$163.52
Rate for Payer: Wellpoint Medicaid Managed Care	$179.80

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	411034713
Hospital Revenue Code	360
Min. Negotiated Rate	$163.52
Max. Negotiated Rate	$3,392.50
Rate for Payer: Aetna Commercial	$2,578.30
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,730.17
Rate for Payer: Cigna Commercial	$3,392.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,035.50
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$163.52
Rate for Payer: Wellpoint Medicaid Managed Care	$179.80

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	321034713
Hospital Revenue Code	361
Min. Negotiated Rate	$1,017.75
Max. Negotiated Rate	$1,017.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	404634713
Hospital Revenue Code	361
Min. Negotiated Rate	$163.52
Max. Negotiated Rate	$3,392.50
Rate for Payer: Aetna Commercial	$2,578.30
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,730.17
Rate for Payer: Cigna Commercial	$3,392.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,035.50
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: UnitedHealthcare Commercial	$2,220.00
Rate for Payer: UnitedHealthcare Community & State	$163.52
Rate for Payer: Wellpoint Medicaid Managed Care	$179.80

Know your out-of-pocket cost for care.

All Charges