Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PRIMIDONE (MYSOLINE)

Facility

$150.45

Service Code	HCPCS 80188
Hospital Charge Code	3003985
Hospital Revenue Code	301
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$22.57
Rate for Payer: Qualcare PPO/HMO/WC	$22.57

PRIMIDONE (MYSOLINE)

Facility

$150.45

Service Code	HCPCS 80188
Hospital Charge Code	3003985
Hospital Revenue Code	301
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$45.12
Rate for Payer: Aetna Medicare Advantage	$53.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$59.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$59.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$38.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$59.88
Rate for Payer: Cigna Commercial	$75.22
Rate for Payer: Cigna Medicare Advantage	$16.59
Rate for Payer: Clover Medicare Advantage	$15.76
Rate for Payer: EmblemHealth Commercial	$49.77
Rate for Payer: Humana Medicare Advantage	$17.09
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.13
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.57
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$13.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.59
Rate for Payer: Wellcare Medicare Advantage	$16.59
Rate for Payer: Wellpoint Medicaid Managed Care	$3.99

PRINCIPEN 125/125MG/5ML

Facility

$15.00

Hospital Charge Code	60633720
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

PRINCIPEN 125/125MG/5ML

Facility

$15.00

Hospital Charge Code	60633720
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

PRINCIPEN 125/125MG/5ML

Facility

$13.00

Hospital Charge Code	60633721
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$4.94
Rate for Payer: Aetna Medicare Advantage	$3.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.31
Rate for Payer: Cigna Commercial	$6.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.90
Rate for Payer: Oxford Commercial	$2.60
Rate for Payer: Qualcare PPO/HMO/WC	$1.95
Rate for Payer: UnitedHealthcare Commercial	$2.60
Rate for Payer: UnitedHealthcare Community & State	$0.31
Rate for Payer: Wellpoint Medicaid Managed Care	$0.34

PRINCIPEN 125/125MG/5ML

Facility

$13.00

Hospital Charge Code	60633721
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$1.95
Rate for Payer: Qualcare PPO/HMO/WC	$1.95

PRINCIPEN 250/250MG/5ML

Facility

$18.00

Hospital Charge Code	60633722
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$2.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

PRINCIPEN 250/250MG/5ML

Facility

$9.00

Hospital Charge Code	60633723
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: Qualcare PPO/HMO/WC	$1.35

PRINCIPEN 250/250MG/5ML

Facility

$9.00

Hospital Charge Code	60633723
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna Commercial	$3.42
Rate for Payer: Aetna Medicare Advantage	$2.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.29
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.70
Rate for Payer: Oxford Commercial	$1.80
Rate for Payer: Qualcare PPO/HMO/WC	$1.35
Rate for Payer: UnitedHealthcare Commercial	$1.80
Rate for Payer: UnitedHealthcare Community & State	$0.22
Rate for Payer: Wellpoint Medicaid Managed Care	$0.24

PRINCIPEN 250/250MG/5ML

Facility

$18.00

Hospital Charge Code	60633722
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$6.84
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.40
Rate for Payer: Oxford Commercial	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Commercial	$3.60
Rate for Payer: UnitedHealthcare Community & State	$0.43
Rate for Payer: Wellpoint Medicaid Managed Care	$0.48

PRINCIPEN 250/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633724
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

PRINCIPEN 250/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633724
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PRINCIPEN 500/500MG/CAP

Facility

$3.00

Hospital Charge Code	60633725
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PRINCIPEN 500/500MG/CAP

Facility

$3.00

Hospital Charge Code	60633725
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

PRINIVIL 10MG

Facility

$6.00

Hospital Charge Code	60635078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.80
Rate for Payer: Oxford Commercial	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$1.20
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

PRINIVIL 10MG

Facility

$6.00

Hospital Charge Code	60635078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

PRINIVIL 10MG U/D

Facility

$5.00

Hospital Charge Code	60635075
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

PRINIVIL 10MG U/D

Facility

$5.00

Hospital Charge Code	60635075
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

PRINIVIL 20MG

Facility

$6.00

Hospital Charge Code	60635079
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.80
Rate for Payer: Oxford Commercial	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$1.20
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

PRINIVIL 20MG

Facility

$6.00

Hospital Charge Code	60635079
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

PRINIVIL 20MG U/D

Facility

$5.00

Hospital Charge Code	60635080
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

PRINIVIL 20MG U/D

Facility

$5.00

Hospital Charge Code	60635080
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

PRINIVIL 5MG

Facility

$6.00

Hospital Charge Code	60635076
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.80
Rate for Payer: Oxford Commercial	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$1.20
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

PRINIVIL 5MG

Facility

$6.00

Hospital Charge Code	60635076
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

PRINIVIL 5MG U/D

Facility

$5.00

Hospital Charge Code	60635077
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

Know your out-of-pocket cost for care.

All Charges