Heights University Hospital

All Charges

Charge

Type

Setting

Price

DICLOXACILLIN SSP 62.5MG/5ML

Facility

$64.00

Hospital Charge Code	6001895
Hospital Revenue Code	251
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$19.20
Rate for Payer: Aetna Medicare Advantage	$19.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16.32
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.32
Rate for Payer: Oxford Commercial	$32.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.60
Rate for Payer: UnitedHealthcare Commercial	$32.00

DICUMAROL TAB 25MG

Facility

$1.95

Hospital Charge Code	60627504
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Qualcare PPO/HMO/WC	$0.29

DICUMAROL TAB 25MG

Facility

$1.95

Hospital Charge Code	60627504
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna Commercial	$0.59
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	$0.25
Rate for Payer: Oxford Commercial	$0.98
Rate for Payer: Qualcare PPO/HMO/WC	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.98

DICYCLOMINE/10MG/5ML

Facility

$4.00

Service Code	NDC 68012516
Hospital Charge Code	60632832
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
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	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

DICYCLOMINE/10MG/5ML

Facility

$4.00

Service Code	NDC 68012516
Hospital Charge Code	60632832
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICYCLOMINE 10 MG CAP

Facility

$4.02

Service Code	NDC 51079011820
Hospital Charge Code	60627429
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICYCLOMINE 10 MG CAP

Facility

$4.02

Service Code	NDC 51079011820
Hospital Charge Code	60627429
Hospital Revenue Code	251
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.01
Rate for Payer: Aetna Commercial	$1.21
Rate for Payer: Aetna Medicare Advantage	$1.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.03
Rate for Payer: Cigna Commercial	$2.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.52
Rate for Payer: Oxford Commercial	$2.01
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.01

DICYCLOMINE/10MG/CAP

Facility

$4.00

Hospital Charge Code	60632836
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
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	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

DICYCLOMINE/10MG/CAP

Facility

$4.00

Hospital Charge Code	60632836
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICYCLOMINE/10MG/CAP

Facility

$4.00

Hospital Charge Code	60632835
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
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	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

DICYCLOMINE/10MG/CAP

Facility

$4.00

Hospital Charge Code	60632835
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICYCLOMINE 20 MG/2ML INJ

Facility

$152.36

Service Code	HCPCS J0500
Hospital Charge Code	60627430
Hospital Revenue Code	636
Min. Negotiated Rate	$22.85
Max. Negotiated Rate	$36.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.87
Rate for Payer: Qualcare PPO/HMO/WC	$22.85

DICYCLOMINE 20 MG/2ML INJ

Facility

$152.36

Service Code	HCPCS J0500
Hospital Charge Code	60627430
Hospital Revenue Code	636
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$45.71
Rate for Payer: Aetna Commercial	$45.71
Rate for Payer: Aetna Medicare Advantage	$45.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.85
Rate for Payer: Cigna Commercial	$9.37
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.87
Rate for Payer: Qualcare PPO/HMO/WC	$22.85

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
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	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632833
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632834
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
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	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632833
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
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	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632834
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DICYCLOMINE/20MG/TAB

Facility

$3.00

Hospital Charge Code	60632837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DICYCLOMINE 20MG TABLET

Facility

$4.02

Service Code	NDC 51079011920
Hospital Charge Code	60632354
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.01
Rate for Payer: Aetna Commercial	$1.21
Rate for Payer: Aetna Medicare Advantage	$1.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.03
Rate for Payer: Cigna Commercial	$2.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.52
Rate for Payer: Oxford Commercial	$2.01
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.01

DICYCLOMINE 20MG TABLET

Facility

$4.02

Service Code	NDC 51079011920
Hospital Charge Code	60632354
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DICYCLOMINE HCL INJ 20MG

Facility

$107.55

Hospital Charge Code	6001903
Hospital Revenue Code	250
Min. Negotiated Rate	$16.13
Max. Negotiated Rate	$16.13
Rate for Payer: Qualcare PPO/HMO/WC	$16.13

DICYCLOMINE HCL INJ 20MG

Facility

$107.55

Hospital Charge Code	6001903
Hospital Revenue Code	250
Min. Negotiated Rate	$13.98
Max. Negotiated Rate	$53.77
Rate for Payer: Aetna Commercial	$32.27
Rate for Payer: Aetna Medicare Advantage	$32.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.43
Rate for Payer: Cigna Commercial	$53.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.98
Rate for Payer: Oxford Commercial	$53.77
Rate for Payer: Qualcare PPO/HMO/WC	$16.13
Rate for Payer: UnitedHealthcare Commercial	$53.77

DICYCLOMINE SY 10MG/5ML 120ML

Facility

$134.45

Hospital Charge Code	60628801
Hospital Revenue Code	250
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$20.17
Rate for Payer: Qualcare PPO/HMO/WC	$20.17

DICYCLOMINE SY 10MG/5ML 120ML

Facility

$134.45

Hospital Charge Code	60628801
Hospital Revenue Code	250
Min. Negotiated Rate	$17.48
Max. Negotiated Rate	$67.22
Rate for Payer: Aetna Commercial	$40.34
Rate for Payer: Aetna Medicare Advantage	$40.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.28
Rate for Payer: Cigna Commercial	$67.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.48
Rate for Payer: Oxford Commercial	$67.22
Rate for Payer: Qualcare PPO/HMO/WC	$20.17
Rate for Payer: UnitedHealthcare Commercial	$67.22

Know your out-of-pocket cost for care.

All Charges