Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TOLECTIN DS/400MG/CAP

Facility

$3.00

Hospital Charge Code	60634402
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

TOLERANCE TEST #1

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419B
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$1.97
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

TOLERANCE TEST #1

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419B
Hospital Revenue Code	301
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Aetna Medicare Advantage	$12.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.15
Rate for Payer: Cigna Commercial	$6.55
Rate for Payer: Cigna Medicare Advantage	$3.92
Rate for Payer: Clover Medicare Advantage	$3.72
Rate for Payer: EmblemHealth Commercial	$11.76
Rate for Payer: Humana Medicare Advantage	$4.04
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.93
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.92
Rate for Payer: Wellcare Medicare Advantage	$3.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.35

TOLERANCE TEST #2

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419C
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$1.97
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

TOLERANCE TEST #2

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419C
Hospital Revenue Code	301
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Aetna Medicare Advantage	$12.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.15
Rate for Payer: Cigna Commercial	$6.55
Rate for Payer: Cigna Medicare Advantage	$3.92
Rate for Payer: Clover Medicare Advantage	$3.72
Rate for Payer: EmblemHealth Commercial	$11.76
Rate for Payer: Humana Medicare Advantage	$4.04
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.93
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.92
Rate for Payer: Wellcare Medicare Advantage	$3.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.35

TOLERANCE TEST #3

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419D
Hospital Revenue Code	301
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Aetna Medicare Advantage	$12.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.15
Rate for Payer: Cigna Commercial	$6.55
Rate for Payer: Cigna Medicare Advantage	$3.92
Rate for Payer: Clover Medicare Advantage	$3.72
Rate for Payer: EmblemHealth Commercial	$11.76
Rate for Payer: Humana Medicare Advantage	$4.04
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.93
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.92
Rate for Payer: Wellcare Medicare Advantage	$3.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.35

TOLERANCE TEST #3

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419D
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$1.97
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

TOLERANCE TEST #4

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419E
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$1.97
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

TOLERANCE TEST #4

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419E
Hospital Revenue Code	301
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Aetna Medicare Advantage	$12.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.15
Rate for Payer: Cigna Commercial	$6.55
Rate for Payer: Cigna Medicare Advantage	$3.92
Rate for Payer: Clover Medicare Advantage	$3.72
Rate for Payer: EmblemHealth Commercial	$11.76
Rate for Payer: Humana Medicare Advantage	$4.04
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.93
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.92
Rate for Payer: Wellcare Medicare Advantage	$3.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.35

TOLERANCE TEST #5

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419F
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$1.97
Rate for Payer: Qualcare PPO/HMO/WC	$1.97

TOLERANCE TEST #5

Facility

$13.10

Service Code	HCPCS 82952
Hospital Charge Code	3001419F
Hospital Revenue Code	301
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Aetna Medicare Advantage	$12.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.15
Rate for Payer: Cigna Commercial	$6.55
Rate for Payer: Cigna Medicare Advantage	$3.92
Rate for Payer: Clover Medicare Advantage	$3.72
Rate for Payer: EmblemHealth Commercial	$11.76
Rate for Payer: Humana Medicare Advantage	$4.04
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.93
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.92
Rate for Payer: Wellcare Medicare Advantage	$3.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.35

TOLINASE/100MG/TAB

Facility

$3.00

Hospital Charge Code	60634234
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

TOLINASE/100MG/TAB

Facility

$3.00

Hospital Charge Code	60634234
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

TOLINASE/250MG/TAB

Facility

$6.00

Hospital Charge Code	60634040
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

TOLINASE/250MG/TAB

Facility

$6.00

Hospital Charge Code	60634040
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

TOLMETIN 200 MG TAB

Facility

$9.65

Hospital Charge Code	60627699
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.45
Rate for Payer: Qualcare PPO/HMO/WC	$1.45

TOLMETIN 200 MG TAB

Facility

$9.65

Hospital Charge Code	60627699
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$4.83
Rate for Payer: Aetna Commercial	$3.67
Rate for Payer: Aetna Medicare Advantage	$2.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.46
Rate for Payer: Cigna Commercial	$4.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.90
Rate for Payer: Oxford Commercial	$1.93
Rate for Payer: Qualcare PPO/HMO/WC	$1.45
Rate for Payer: UnitedHealthcare Commercial	$1.93
Rate for Payer: UnitedHealthcare Community & State	$0.23
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

TOLNAFTATE 1%/15GM

Facility

$6.00

Hospital Charge Code	60634041
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

TOLNAFTATE 1%/15GM

Facility

$6.00

Hospital Charge Code	60634041
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

TOLNAFTATE 1%/15ML

Facility

$6.00

Hospital Charge Code	60634042
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

TOLNAFTATE 1%/15ML

Facility

$6.00

Hospital Charge Code	60634042
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

TOLNAFTATE 1 % CRE

Facility

$2.45

Hospital Charge Code	6010078
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Qualcare PPO/HMO/WC	$0.37

TOLNAFTATE 1 % CRE

Facility

$2.45

Hospital Charge Code	6010078
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna Commercial	$0.93
Rate for Payer: Aetna Medicare Advantage	$0.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.62
Rate for Payer: Cigna Commercial	$1.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.74
Rate for Payer: Oxford Commercial	$0.49
Rate for Payer: Qualcare PPO/HMO/WC	$0.37
Rate for Payer: UnitedHealthcare Commercial	$0.49
Rate for Payer: UnitedHealthcare Community & State	$0.06
Rate for Payer: Wellpoint Medicaid Managed Care	$0.06

TOLNAFTATE TOPICAL 1% SOLN

Facility

$23.00

Hospital Charge Code	60628347
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna Commercial	$8.74
Rate for Payer: Aetna Medicare Advantage	$6.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.87
Rate for Payer: Cigna Commercial	$11.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.90
Rate for Payer: Oxford Commercial	$4.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.45
Rate for Payer: UnitedHealthcare Commercial	$4.60
Rate for Payer: UnitedHealthcare Community & State	$0.55
Rate for Payer: Wellpoint Medicaid Managed Care	$0.61

TOLNAFTATE TOPICAL 1% SOLN

Facility

$23.00

Hospital Charge Code	60628347
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$3.45
Rate for Payer: Qualcare PPO/HMO/WC	$3.45

Know your out-of-pocket cost for care.

All Charges