Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

TOLTERODINE 1 MG TAB

Facility

$41.81

Service Code	NDC 58151009891
Hospital Charge Code	60629012
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$20.91
Rate for Payer: Aetna Commercial	$15.89
Rate for Payer: Aetna Medicare Advantage	$12.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.66
Rate for Payer: Cigna Commercial	$20.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.54
Rate for Payer: Oxford Commercial	$8.36
Rate for Payer: Qualcare PPO/HMO/WC	$6.27
Rate for Payer: UnitedHealthcare Commercial	$8.36
Rate for Payer: UnitedHealthcare Community & State	$1.01
Rate for Payer: Wellpoint Medicaid Managed Care	$1.11

TOLTERODINE 1 MG TAB

Facility

$41.81

Service Code	NDC 58151009891
Hospital Charge Code	60629012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$6.27
Rate for Payer: Qualcare PPO/HMO/WC	$6.27

TOLTERODINE 2 MG TAB

Facility

$43.35

Service Code	NDC 9454401
Hospital Charge Code	60628907
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$6.50
Rate for Payer: Qualcare PPO/HMO/WC	$6.50

TOLTERODINE 2 MG TAB

Facility

$43.35

Service Code	NDC 9454401
Hospital Charge Code	60628907
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$16.47
Rate for Payer: Aetna Medicare Advantage	$13.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.05
Rate for Payer: Cigna Commercial	$21.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.01
Rate for Payer: Oxford Commercial	$8.67
Rate for Payer: Qualcare PPO/HMO/WC	$6.50
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Community & State	$1.04
Rate for Payer: Wellpoint Medicaid Managed Care	$1.15

TOLTERODINE 4 MG ER UD

Facility

$71.82

Service Code	NDC 9519004
Hospital Charge Code	60628968
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$35.91
Rate for Payer: Aetna Commercial	$27.29
Rate for Payer: Aetna Medicare Advantage	$21.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.31
Rate for Payer: Cigna Commercial	$35.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.55
Rate for Payer: Oxford Commercial	$14.36
Rate for Payer: Qualcare PPO/HMO/WC	$10.77
Rate for Payer: UnitedHealthcare Commercial	$14.36
Rate for Payer: UnitedHealthcare Community & State	$1.73
Rate for Payer: Wellpoint Medicaid Managed Care	$1.90

TOLTERODINE 4 MG ER UD

Facility

$71.82

Service Code	NDC 9519004
Hospital Charge Code	60628968
Hospital Revenue Code	250
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$10.77
Rate for Payer: Qualcare PPO/HMO/WC	$10.77

TOLTERODINE LA (DETROL LA) 2MG

Facility

$40.47

Service Code	NDC 58151010393
Hospital Charge Code	60630144
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$20.23
Rate for Payer: Aetna Commercial	$15.38
Rate for Payer: Aetna Medicare Advantage	$12.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.32
Rate for Payer: Cigna Commercial	$20.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.14
Rate for Payer: Oxford Commercial	$8.09
Rate for Payer: Qualcare PPO/HMO/WC	$6.07
Rate for Payer: UnitedHealthcare Commercial	$8.09
Rate for Payer: UnitedHealthcare Community & State	$0.98
Rate for Payer: Wellpoint Medicaid Managed Care	$1.07

TOLTERODINE LA (DETROL LA) 2MG

Facility

$40.47

Service Code	NDC 58151010393
Hospital Charge Code	60630144
Hospital Revenue Code	250
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$6.07
Rate for Payer: Qualcare PPO/HMO/WC	$6.07

TOLVAPTAN 15 MG TAB

Facility

$2,305.07

Service Code	NDC 59148002050
Hospital Charge Code	60630114
Hospital Revenue Code	250
Min. Negotiated Rate	$345.76
Max. Negotiated Rate	$345.76
Rate for Payer: Qualcare PPO/HMO/WC	$345.76

TOLVAPTAN 15 MG TAB

Facility

$2,305.07

Service Code	NDC 59148002050
Hospital Charge Code	60630114
Hospital Revenue Code	250
Min. Negotiated Rate	$55.55
Max. Negotiated Rate	$1,152.54
Rate for Payer: Aetna Commercial	$875.93
Rate for Payer: Aetna Medicare Advantage	$691.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$587.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$587.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$587.79
Rate for Payer: Cigna Commercial	$1,152.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$691.52
Rate for Payer: Oxford Commercial	$461.01
Rate for Payer: Qualcare PPO/HMO/WC	$345.76
Rate for Payer: UnitedHealthcare Commercial	$461.01
Rate for Payer: UnitedHealthcare Community & State	$55.55
Rate for Payer: Wellpoint Medicaid Managed Care	$61.08

TOLVAPTAN 30 MG TAB

Facility

$2,305.07

Service Code	NDC 59148002150
Hospital Charge Code	60630115
Hospital Revenue Code	250
Min. Negotiated Rate	$345.76
Max. Negotiated Rate	$345.76
Rate for Payer: Qualcare PPO/HMO/WC	$345.76

TOLVAPTAN 30 MG TAB

Facility

$2,305.07

Service Code	NDC 59148002150
Hospital Charge Code	60630115
Hospital Revenue Code	250
Min. Negotiated Rate	$55.55
Max. Negotiated Rate	$1,152.54
Rate for Payer: Aetna Commercial	$875.93
Rate for Payer: Aetna Medicare Advantage	$691.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$587.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$587.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$587.79
Rate for Payer: Cigna Commercial	$1,152.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$691.52
Rate for Payer: Oxford Commercial	$461.01
Rate for Payer: Qualcare PPO/HMO/WC	$345.76
Rate for Payer: UnitedHealthcare Commercial	$461.01
Rate for Payer: UnitedHealthcare Community & State	$55.55
Rate for Payer: Wellpoint Medicaid Managed Care	$61.08

TOMO DIAG BREAST BIL

Facility

$4,500.00

Service Code	HCPCS 77062
Hospital Charge Code	94061474
Hospital Revenue Code	401
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$1,710.00
Rate for Payer: Aetna Medicare Advantage	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,147.50
Rate for Payer: Cigna Commercial	$2,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,350.00
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$108.45
Rate for Payer: Wellpoint Medicaid Managed Care	$119.25

TOMO DIAG BREAST BIL

Facility

$4,500.00

Service Code	HCPCS 77062
Hospital Charge Code	94061474
Hospital Revenue Code	401
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$675.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00

TOMO DIAG BREAST UNI

Facility

$4,500.00

Service Code	HCPCS 77061
Hospital Charge Code	94061471
Hospital Revenue Code	401
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$1,710.00
Rate for Payer: Aetna Medicare Advantage	$1,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,147.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,147.50
Rate for Payer: Cigna Commercial	$2,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,350.00
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$108.45
Rate for Payer: Wellpoint Medicaid Managed Care	$119.25

TOMO DIAG BREAST UNI

Facility

$4,500.00

Service Code	HCPCS 77061
Hospital Charge Code	94061471
Hospital Revenue Code	401
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$675.00
Rate for Payer: Qualcare PPO/HMO/WC	$675.00

TOMOSYNTHESIS SCREEN BREAST BI

Facility

$260.20

Service Code	HCPCS 77063
Hospital Charge Code	94061470
Hospital Revenue Code	403
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$98.88
Rate for Payer: Aetna Medicare Advantage	$78.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$66.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$66.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$58.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$66.35
Rate for Payer: Cigna Commercial	$130.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$78.06
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$39.03
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$6.27
Rate for Payer: Wellpoint Medicaid Managed Care	$6.90

TOMOSYNTHESIS SCREEN BREAST BI

Facility

$260.20

Service Code	HCPCS 77063
Hospital Charge Code	94061470
Hospital Revenue Code	403
Min. Negotiated Rate	$39.03
Max. Negotiated Rate	$39.03
Rate for Payer: Qualcare PPO/HMO/WC	$39.03

TOMOSYNTHESIS SCREEN BREST UNI

Facility

$130.10

Service Code	HCPCS 7706352
Hospital Charge Code	94061472
Hospital Revenue Code	403
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$19.52
Rate for Payer: Qualcare PPO/HMO/WC	$19.52

TOMOSYNTHESIS SCREEN BREST UNI

Facility

$130.10

Service Code	HCPCS 7706352
Hospital Charge Code	94061472
Hospital Revenue Code	403
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$49.44
Rate for Payer: Aetna Medicare Advantage	$39.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.18
Rate for Payer: Cigna Commercial	$65.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.03
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.52
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: Wellpoint Medicaid Managed Care	$3.45

TOMOSYNTHESIS SCREEN BRST UNI

Facility

$130.10

Service Code	HCPCS 7706352
Hospital Charge Code	94061473
Hospital Revenue Code	403
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$19.52
Rate for Payer: Qualcare PPO/HMO/WC	$19.52

TOMOSYNTHESIS SCREEN BRST UNI

Facility

$130.10

Service Code	HCPCS 7706352
Hospital Charge Code	94061473
Hospital Revenue Code	403
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$1,916.00
Rate for Payer: Aetna Commercial	$49.44
Rate for Payer: Aetna Medicare Advantage	$39.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.18
Rate for Payer: Cigna Commercial	$65.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.03
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.52
Rate for Payer: UnitedHealthcare Commercial	$1,916.00
Rate for Payer: UnitedHealthcare Community & State	$3.14
Rate for Payer: Wellpoint Medicaid Managed Care	$3.45

TONG LOCKING PLASTIC 7

Facility

$3.55

Hospital Charge Code	27600994
Hospital Revenue Code	270
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.53
Rate for Payer: Qualcare PPO/HMO/WC	$0.53

TONG LOCKING PLASTIC 7

Facility

$3.55

Hospital Charge Code	27600994
Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna Commercial	$1.35
Rate for Payer: Aetna Medicare Advantage	$1.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.91
Rate for Payer: Cigna Commercial	$1.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.06
Rate for Payer: Oxford Commercial	$0.71
Rate for Payer: Qualcare PPO/HMO/WC	$0.53
Rate for Payer: UnitedHealthcare Commercial	$0.71
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.09

TONG LOCKING PLASTIC 7****

Facility

$3.55

Hospital Charge Code	270600994
Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna Commercial	$1.35
Rate for Payer: Aetna Medicare Advantage	$1.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.91
Rate for Payer: Cigna Commercial	$1.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.06
Rate for Payer: Oxford Commercial	$0.71
Rate for Payer: Qualcare PPO/HMO/WC	$0.53
Rate for Payer: UnitedHealthcare Commercial	$0.71
Rate for Payer: UnitedHealthcare Community & State	$0.09
Rate for Payer: Wellpoint Medicaid Managed Care	$0.09

Know your out-of-pocket cost for care.

All Charges