Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TETRACAINE 1% 2ML

Facility

$610.57

Service Code	NDC 17478004532
Hospital Charge Code	6063943310
Hospital Revenue Code	250
Min. Negotiated Rate	$91.59
Max. Negotiated Rate	$91.59
Rate for Payer: Qualcare PPO/HMO/WC	$91.59

TETRACAINE 1% 2ML

Facility

$610.57

Service Code	NDC 17478004532
Hospital Charge Code	6063943310
Hospital Revenue Code	250
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$305.29
Rate for Payer: Aetna Commercial	$232.02
Rate for Payer: Aetna Medicare Advantage	$183.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$155.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$155.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$155.70
Rate for Payer: Cigna Commercial	$305.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$183.17
Rate for Payer: Oxford Commercial	$122.11
Rate for Payer: Qualcare PPO/HMO/WC	$91.59
Rate for Payer: UnitedHealthcare Commercial	$122.11
Rate for Payer: UnitedHealthcare Community & State	$14.71
Rate for Payer: Wellpoint Medicaid Managed Care	$16.18

TETRACAINE/ADRENALIN/COCAINE

Facility

$336.00

Hospital Charge Code	60628561
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna Commercial	$127.68
Rate for Payer: Aetna Medicare Advantage	$100.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$85.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$85.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$85.68
Rate for Payer: Cigna Commercial	$168.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$100.80
Rate for Payer: Oxford Commercial	$67.20
Rate for Payer: Qualcare PPO/HMO/WC	$50.40
Rate for Payer: UnitedHealthcare Commercial	$67.20
Rate for Payer: UnitedHealthcare Community & State	$8.10
Rate for Payer: Wellpoint Medicaid Managed Care	$8.90

TETRACAINE/ADRENALIN/COCAINE

Facility

$336.00

Hospital Charge Code	60628561
Hospital Revenue Code	250
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$50.40
Rate for Payer: Qualcare PPO/HMO/WC	$50.40

TETRACAINE/ADRENALIN/COCAINE

Facility

$420.00

Hospital Charge Code	6062320
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$63.00
Rate for Payer: Qualcare PPO/HMO/WC	$63.00

TETRACAINE/ADRENALIN/COCAINE

Facility

$420.00

Hospital Charge Code	6062320
Hospital Revenue Code	250
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare Advantage	$126.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$107.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$107.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$107.10
Rate for Payer: Cigna Commercial	$210.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$126.00
Rate for Payer: Oxford Commercial	$84.00
Rate for Payer: Qualcare PPO/HMO/WC	$63.00
Rate for Payer: UnitedHealthcare Commercial	$84.00
Rate for Payer: UnitedHealthcare Community & State	$10.12
Rate for Payer: Wellpoint Medicaid Managed Care	$11.13

TETRACAINE INJ 1% 2ML

Facility

$37.80

Hospital Charge Code	6005201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna Commercial	$14.36
Rate for Payer: Aetna Medicare Advantage	$11.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.64
Rate for Payer: Cigna Commercial	$18.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.34
Rate for Payer: Oxford Commercial	$7.56
Rate for Payer: Qualcare PPO/HMO/WC	$5.67
Rate for Payer: UnitedHealthcare Commercial	$7.56
Rate for Payer: UnitedHealthcare Community & State	$0.91
Rate for Payer: Wellpoint Medicaid Managed Care	$1.00

TETRACAINE INJ 1% 2ML

Facility

$37.80

Hospital Charge Code	6005201
Hospital Revenue Code	250
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$5.67
Rate for Payer: Qualcare PPO/HMO/WC	$5.67

TETRACAINE OPH OINT .5% 3.5GM

Facility

$90.90

Hospital Charge Code	6005227
Hospital Revenue Code	251
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$13.63
Rate for Payer: Qualcare PPO/HMO/WC	$13.63

TETRACAINE OPH OINT .5% 3.5GM

Facility

$90.90

Hospital Charge Code	6005227
Hospital Revenue Code	251
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$45.45
Rate for Payer: Aetna Commercial	$34.54
Rate for Payer: Aetna Medicare Advantage	$27.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.18
Rate for Payer: Cigna Commercial	$45.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.27
Rate for Payer: Oxford Commercial	$18.18
Rate for Payer: Qualcare PPO/HMO/WC	$13.63
Rate for Payer: UnitedHealthcare Commercial	$18.18
Rate for Payer: UnitedHealthcare Community & State	$2.19
Rate for Payer: Wellpoint Medicaid Managed Care	$2.41

TETRACAINE OPH SOL .5% 1ML

Facility

$67.00

Service Code	NDC 65074112
Hospital Charge Code	6005235
Hospital Revenue Code	251
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$33.50
Rate for Payer: Aetna Commercial	$25.46
Rate for Payer: Aetna Medicare Advantage	$20.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.09
Rate for Payer: Cigna Commercial	$33.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.10
Rate for Payer: Oxford Commercial	$13.40
Rate for Payer: Qualcare PPO/HMO/WC	$10.05
Rate for Payer: UnitedHealthcare Commercial	$13.40
Rate for Payer: UnitedHealthcare Community & State	$1.61
Rate for Payer: Wellpoint Medicaid Managed Care	$1.78

TETRACAINE OPH SOL .5% 1ML

Facility

$67.00

Service Code	NDC 65074112
Hospital Charge Code	6005235
Hospital Revenue Code	251
Min. Negotiated Rate	$10.05
Max. Negotiated Rate	$10.05
Rate for Payer: Qualcare PPO/HMO/WC	$10.05

TETRACAINE OPHT 0.5% 15ML

Facility

$42.16

Hospital Charge Code	60635809
Hospital Revenue Code	250
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$6.32
Rate for Payer: Qualcare PPO/HMO/WC	$6.32

TETRACAINE OPHT 0.5% 15ML

Facility

$42.16

Hospital Charge Code	60635809
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$21.08
Rate for Payer: Aetna Commercial	$16.02
Rate for Payer: Aetna Medicare Advantage	$12.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.75
Rate for Payer: Cigna Commercial	$21.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.65
Rate for Payer: Oxford Commercial	$8.43
Rate for Payer: Qualcare PPO/HMO/WC	$6.32
Rate for Payer: UnitedHealthcare Commercial	$8.43
Rate for Payer: UnitedHealthcare Community & State	$1.02
Rate for Payer: Wellpoint Medicaid Managed Care	$1.12

TETRACAINE SOL 2% 118ML

Facility

$670.45

Hospital Charge Code	60628424
Hospital Revenue Code	250
Min. Negotiated Rate	$100.57
Max. Negotiated Rate	$100.57
Rate for Payer: Qualcare PPO/HMO/WC	$100.57

TETRACAINE SOL 2% 118ML

Facility

$670.45

Hospital Charge Code	60628424
Hospital Revenue Code	250
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$335.23
Rate for Payer: Aetna Commercial	$254.77
Rate for Payer: Aetna Medicare Advantage	$201.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$170.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$170.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$170.96
Rate for Payer: Cigna Commercial	$335.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$201.13
Rate for Payer: Oxford Commercial	$134.09
Rate for Payer: Qualcare PPO/HMO/WC	$100.57
Rate for Payer: UnitedHealthcare Commercial	$134.09
Rate for Payer: UnitedHealthcare Community & State	$16.16
Rate for Payer: Wellpoint Medicaid Managed Care	$17.77

TETRACAINE TOP 2% 30ML

Facility

$7.25

Hospital Charge Code	6005219
Hospital Revenue Code	251
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$1.09

TETRACAINE TOP 2% 30ML

Facility

$7.25

Hospital Charge Code	6005219
Hospital Revenue Code	251
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna Commercial	$2.75
Rate for Payer: Aetna Medicare Advantage	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.85
Rate for Payer: Cigna Commercial	$3.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.17
Rate for Payer: Oxford Commercial	$1.45
Rate for Payer: Qualcare PPO/HMO/WC	$1.09
Rate for Payer: UnitedHealthcare Commercial	$1.45
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

TETRACYCLINE 250 MG CAP

Facility

$4.00

Service Code	NDC 172241660
Hospital Charge Code	60627319
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

TETRACYCLINE 250 MG CAP

Facility

$4.00

Service Code	NDC 172241660
Hospital Charge Code	60627319
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

TETRACYCLINE/250MG/CAP

Facility

$4.00

Hospital Charge Code	60633998
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

TETRACYCLINE/250MG/CAP

Facility

$4.00

Hospital Charge Code	60633998
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

TETRACYCLINE OINT 3% 28GM

Facility

$95.40

Hospital Charge Code	6005243
Hospital Revenue Code	251
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna Commercial	$36.25
Rate for Payer: Aetna Medicare Advantage	$28.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.33
Rate for Payer: Cigna Commercial	$47.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.62
Rate for Payer: Oxford Commercial	$19.08
Rate for Payer: Qualcare PPO/HMO/WC	$14.31
Rate for Payer: UnitedHealthcare Commercial	$19.08
Rate for Payer: UnitedHealthcare Community & State	$2.30
Rate for Payer: Wellpoint Medicaid Managed Care	$2.53

TETRACYCLINE OINT 3% 28GM

Facility

$95.40

Hospital Charge Code	6005243
Hospital Revenue Code	251
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$14.31
Rate for Payer: Qualcare PPO/HMO/WC	$14.31

TETRACYCLINE OINT OPH 1% 3.5GM

Facility

$95.40

Hospital Charge Code	6005250
Hospital Revenue Code	251
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna Commercial	$36.25
Rate for Payer: Aetna Medicare Advantage	$28.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.33
Rate for Payer: Cigna Commercial	$47.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.62
Rate for Payer: Oxford Commercial	$19.08
Rate for Payer: Qualcare PPO/HMO/WC	$14.31
Rate for Payer: UnitedHealthcare Commercial	$19.08
Rate for Payer: UnitedHealthcare Community & State	$2.30
Rate for Payer: Wellpoint Medicaid Managed Care	$2.53

Know your out-of-pocket cost for care.

All Charges