Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE 50 MG/ML INJ

Facility

$6.57

Service Code	HCPCS J1200
Hospital Charge Code	60627229
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.59
Rate for Payer: Qualcare PPO/HMO/WC	$0.99

DIPHENHYDRAMINE CRM 2% 28GM

Facility

$30.10

Hospital Charge Code	6001986
Hospital Revenue Code	257
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna Commercial	$11.44
Rate for Payer: Aetna Medicare Advantage	$9.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.68
Rate for Payer: Cigna Commercial	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.03
Rate for Payer: Oxford Commercial	$6.02
Rate for Payer: Qualcare PPO/HMO/WC	$4.51
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Community & State	$0.73
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

DIPHENHYDRAMINE CRM 2% 28GM

Facility

$30.10

Hospital Charge Code	6001986
Hospital Revenue Code	257
Min. Negotiated Rate	$4.51
Max. Negotiated Rate	$4.51
Rate for Payer: Qualcare PPO/HMO/WC	$4.51

DIPHENHYDRAMINE ELX 12.5MG/5ML

Facility

$1.95

Hospital Charge Code	60627228
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Qualcare PPO/HMO/WC	$0.29

DIPHENHYDRAMINE ELX 12.5MG/5ML

Facility

$1.95

Hospital Charge Code	60627228
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna Commercial	$0.74
Rate for Payer: Aetna Medicare Advantage	$0.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.50
Rate for Payer: Cigna Commercial	$0.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.59
Rate for Payer: Oxford Commercial	$0.39
Rate for Payer: Qualcare PPO/HMO/WC	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.39
Rate for Payer: UnitedHealthcare Community & State	$0.05
Rate for Payer: Wellpoint Medicaid Managed Care	$0.05

DIPHENHYDRAMINE INJ 50M/ML

Facility

$10.90

Hospital Charge Code	6001978
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.64

DIPHENHYDRAMINE INJ 50M/ML

Facility

$10.90

Hospital Charge Code	6001978
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$4.14
Rate for Payer: Aetna Medicare Advantage	$3.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.78
Rate for Payer: Cigna Commercial	$5.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.27
Rate for Payer: Oxford Commercial	$2.18
Rate for Payer: Qualcare PPO/HMO/WC	$1.64
Rate for Payer: UnitedHealthcare Commercial	$2.18
Rate for Payer: UnitedHealthcare Community & State	$0.26
Rate for Payer: Wellpoint Medicaid Managed Care	$0.29

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$3.20

Hospital Charge Code	6027163
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$1.22
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.96
Rate for Payer: Oxford Commercial	$0.64
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$0.64
Rate for Payer: UnitedHealthcare Community & State	$0.08
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$7.70

Hospital Charge Code	6027148
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.16
Rate for Payer: Qualcare PPO/HMO/WC	$1.16

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$3.20

Hospital Charge Code	6027163
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$7.70

Hospital Charge Code	6027148
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$3.85
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare Advantage	$2.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.96
Rate for Payer: Cigna Commercial	$3.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.31
Rate for Payer: Oxford Commercial	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.16
Rate for Payer: UnitedHealthcare Commercial	$1.54
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.20

DIPHENHYDRAMINE VL 50MG

Facility

$4.50

Hospital Charge Code	6012462
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Qualcare PPO/HMO/WC	$0.68

DIPHENHYDRAMINE VL 50MG

Facility

$4.50

Hospital Charge Code	6012462
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.71
Rate for Payer: Aetna Medicare Advantage	$1.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.15
Rate for Payer: Cigna Commercial	$2.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.35
Rate for Payer: Oxford Commercial	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$0.90
Rate for Payer: UnitedHealthcare Community & State	$0.11
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

DIPHENORYLATE ATROPINE DR

Facility

$46.90

Service Code	NDC 54319446
Hospital Charge Code	60634572
Hospital Revenue Code	250
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$7.04
Rate for Payer: Qualcare PPO/HMO/WC	$7.04

DIPHENORYLATE ATROPINE DR

Facility

$46.90

Service Code	NDC 54319446
Hospital Charge Code	60634572
Hospital Revenue Code	250
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$23.45
Rate for Payer: Aetna Commercial	$17.82
Rate for Payer: Aetna Medicare Advantage	$14.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.96
Rate for Payer: Cigna Commercial	$23.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.07
Rate for Payer: Oxford Commercial	$9.38
Rate for Payer: Qualcare PPO/HMO/WC	$7.04
Rate for Payer: UnitedHealthcare Commercial	$9.38
Rate for Payer: UnitedHealthcare Community & State	$1.13
Rate for Payer: Wellpoint Medicaid Managed Care	$1.24

DIPHENOX ATROP 2.5MG/.025

Facility

$1.95

Hospital Charge Code	6021109
Hospital Revenue Code	251
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Qualcare PPO/HMO/WC	$0.29

DIPHENOX ATROP 2.5MG/.025

Facility

$1.95

Hospital Charge Code	6021109
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna Commercial	$0.74
Rate for Payer: Aetna Medicare Advantage	$0.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.50
Rate for Payer: Cigna Commercial	$0.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.59
Rate for Payer: Oxford Commercial	$0.39
Rate for Payer: Qualcare PPO/HMO/WC	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.39
Rate for Payer: UnitedHealthcare Community & State	$0.05
Rate for Payer: Wellpoint Medicaid Managed Care	$0.05

DIPHENOX ATROP LQ

Facility

$16.00

Hospital Charge Code	60628116
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.40

DIPHENOX ATROP LQ

Facility

$16.00

Hospital Charge Code	60628116
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$6.08
Rate for Payer: Aetna Medicare Advantage	$4.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.08
Rate for Payer: Cigna Commercial	$8.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.80
Rate for Payer: Oxford Commercial	$3.20
Rate for Payer: Qualcare PPO/HMO/WC	$2.40
Rate for Payer: UnitedHealthcare Commercial	$3.20
Rate for Payer: UnitedHealthcare Community & State	$0.39
Rate for Payer: Wellpoint Medicaid Managed Care	$0.42

DIPHENOX ATROP TAB 2.5/0.025MG

Facility

$4.00

Service Code	NDC 25006131
Hospital Charge Code	60628115
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

DIPHENOX ATROP TAB 2.5/0.025MG

Facility

$4.00

Service Code	NDC 25006131
Hospital Charge Code	60628115
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DIPHENOXYLATE 2.5MG/AIR .025MG

Facility

$25.60

Hospital Charge Code	6009468
Hospital Revenue Code	251
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$3.84
Rate for Payer: Qualcare PPO/HMO/WC	$3.84

DIPHENOXYLATE 2.5MG/AIR .025MG

Facility

$25.60

Hospital Charge Code	6009468
Hospital Revenue Code	251
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$12.80
Rate for Payer: Aetna Commercial	$9.73
Rate for Payer: Aetna Medicare Advantage	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.53
Rate for Payer: Cigna Commercial	$12.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.68
Rate for Payer: Oxford Commercial	$5.12
Rate for Payer: Qualcare PPO/HMO/WC	$3.84
Rate for Payer: UnitedHealthcare Commercial	$5.12
Rate for Payer: UnitedHealthcare Community & State	$0.62
Rate for Payer: Wellpoint Medicaid Managed Care	$0.68

DIPHEN/SUCRALF/LIDO SUSP 120ML

Facility

$194.45

Hospital Charge Code	60628975
Hospital Revenue Code	251
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$97.22
Rate for Payer: Aetna Commercial	$73.89
Rate for Payer: Aetna Medicare Advantage	$58.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.58
Rate for Payer: Cigna Commercial	$97.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$58.34
Rate for Payer: Oxford Commercial	$38.89
Rate for Payer: Qualcare PPO/HMO/WC	$29.17
Rate for Payer: UnitedHealthcare Commercial	$38.89
Rate for Payer: UnitedHealthcare Community & State	$4.69
Rate for Payer: Wellpoint Medicaid Managed Care	$5.15

DIPHEN/SUCRALF/LIDO SUSP 120ML

Facility

$194.45

Hospital Charge Code	60628975
Hospital Revenue Code	251
Min. Negotiated Rate	$29.17
Max. Negotiated Rate	$29.17
Rate for Payer: Qualcare PPO/HMO/WC	$29.17

Know your out-of-pocket cost for care.

All Charges