Heights 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	$0.69
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna Commercial	$1.97
Rate for Payer: Aetna Medicare Advantage	$1.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.68
Rate for Payer: Cigna Commercial	$0.69
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	$4.51
Max. Negotiated Rate	$4.51
Rate for Payer: Qualcare PPO/HMO/WC	$4.51

DIPHENHYDRAMINE CRM 2% 28GM

Facility

$30.10

Hospital Charge Code	6001986
Hospital Revenue Code	257
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna Commercial	$9.03
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	$3.91
Rate for Payer: Oxford Commercial	$15.05
Rate for Payer: Qualcare PPO/HMO/WC	$4.51
Rate for Payer: UnitedHealthcare Commercial	$15.05

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	$0.25
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

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	$1.42
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$3.27
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	$1.42
Rate for Payer: Oxford Commercial	$5.45
Rate for Payer: Qualcare PPO/HMO/WC	$1.64
Rate for Payer: UnitedHealthcare Commercial	$5.45

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$3.20

Hospital Charge Code	6027163
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
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	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

DIPHENHYDRAMINE LQ 12.5MG/5ML

Facility

$7.70

Hospital Charge Code	6027148
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$3.85
Rate for Payer: Aetna Commercial	$2.31
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	$1.00
Rate for Payer: Oxford Commercial	$3.85
Rate for Payer: Qualcare PPO/HMO/WC	$1.16
Rate for Payer: UnitedHealthcare Commercial	$3.85

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	$1.16
Max. Negotiated Rate	$1.16
Rate for Payer: Qualcare PPO/HMO/WC	$1.16

DIPHENHYDRAMINE VL 50MG

Facility

$4.50

Hospital Charge Code	6012462
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.35
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	$0.59
Rate for Payer: Oxford Commercial	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$2.25

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

DIPHENORYLATE ATROPINE DR

Facility

$46.90

Service Code	NDC 54319446
Hospital Charge Code	60634572
Hospital Revenue Code	250
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$23.45
Rate for Payer: Aetna Commercial	$14.07
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	$6.10
Rate for Payer: Oxford Commercial	$23.45
Rate for Payer: Qualcare PPO/HMO/WC	$7.04
Rate for Payer: UnitedHealthcare Commercial	$23.45

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

DIPHENOX ATROP 2.5MG/.025

Facility

$1.95

Hospital Charge Code	6021109
Hospital Revenue Code	251
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

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 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	$2.08
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$4.80
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	$2.08
Rate for Payer: Oxford Commercial	$8.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.40
Rate for Payer: UnitedHealthcare Commercial	$8.00

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	$0.52
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

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	$3.33
Max. Negotiated Rate	$12.80
Rate for Payer: Aetna Commercial	$7.68
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	$3.33
Rate for Payer: Oxford Commercial	$12.80
Rate for Payer: Qualcare PPO/HMO/WC	$3.84
Rate for Payer: UnitedHealthcare Commercial	$12.80

DIPHEN/SUCRALF/LIDO SUSP 120ML

Facility

$194.45

Hospital Charge Code	60628975
Hospital Revenue Code	251
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$97.22
Rate for Payer: Aetna Commercial	$58.34
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	$25.28
Rate for Payer: Oxford Commercial	$97.22
Rate for Payer: Qualcare PPO/HMO/WC	$29.17
Rate for Payer: UnitedHealthcare Commercial	$97.22

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