Heights University Hospital

All Charges

Charge

Type

Setting

Price

DONEPEZIL 5 MG TAB

Facility

$52.19

Service Code	NDC 13668010290
Hospital Charge Code	60628610
Hospital Revenue Code	250
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$7.83
Rate for Payer: Qualcare PPO/HMO/WC	$7.83

DONEPEZIL 5 MG TAB

Facility

$52.19

Service Code	NDC 13668010290
Hospital Charge Code	60628610
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$26.09
Rate for Payer: Aetna Commercial	$15.66
Rate for Payer: Aetna Medicare Advantage	$15.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.31
Rate for Payer: Cigna Commercial	$26.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.78
Rate for Payer: Oxford Commercial	$26.09
Rate for Payer: Qualcare PPO/HMO/WC	$7.83
Rate for Payer: UnitedHealthcare Commercial	$26.09

DONEPEZIL HCL TAB 5MG

Facility

$26.90

Hospital Charge Code	6017826
Hospital Revenue Code	252
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: Qualcare PPO/HMO/WC	$4.04

DONEPEZIL HCL TAB 5MG

Facility

$26.90

Hospital Charge Code	6017826
Hospital Revenue Code	252
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$13.45
Rate for Payer: Aetna Commercial	$8.07
Rate for Payer: Aetna Medicare Advantage	$8.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.86
Rate for Payer: Cigna Commercial	$13.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.50
Rate for Payer: Oxford Commercial	$13.45
Rate for Payer: Qualcare PPO/HMO/WC	$4.04
Rate for Payer: UnitedHealthcare Commercial	$13.45

DONEPEZIL HYDROCHLORIDE 10 MG

Facility

$58.02

Service Code	NDC 68382034706
Hospital Charge Code	6063943262
Hospital Revenue Code	250
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$8.70

DONEPEZIL HYDROCHLORIDE 10 MG

Facility

$58.02

Service Code	NDC 68382034706
Hospital Charge Code	6063943262
Hospital Revenue Code	250
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$29.01
Rate for Payer: Aetna Commercial	$17.41
Rate for Payer: Aetna Medicare Advantage	$17.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.80
Rate for Payer: Cigna Commercial	$29.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.54
Rate for Payer: Oxford Commercial	$29.01
Rate for Payer: Qualcare PPO/HMO/WC	$8.70
Rate for Payer: UnitedHealthcare Commercial	$29.01

DONEPEZIL HYDROCHLORIDE 5 MG O

Facility

$58.02

Service Code	NDC 68382034606
Hospital Charge Code	6063943263
Hospital Revenue Code	250
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$8.70

DONEPEZIL HYDROCHLORIDE 5 MG O

Facility

$58.02

Service Code	NDC 68382034606
Hospital Charge Code	6063943263
Hospital Revenue Code	250
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$29.01
Rate for Payer: Aetna Commercial	$17.41
Rate for Payer: Aetna Medicare Advantage	$17.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.80
Rate for Payer: Cigna Commercial	$29.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.54
Rate for Payer: Oxford Commercial	$29.01
Rate for Payer: Qualcare PPO/HMO/WC	$8.70
Rate for Payer: UnitedHealthcare Commercial	$29.01

DONNAGEL/120ML

Facility

$4.00

Hospital Charge Code	60632886
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

DONNAGEL/120ML

Facility

$4.00

Hospital Charge Code	60632886
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DONNAGEL-PG/180ML

Facility

$38.00

Hospital Charge Code	60632887
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$5.70
Rate for Payer: Qualcare PPO/HMO/WC	$5.70

DONNAGEL-PG/180ML

Facility

$38.00

Hospital Charge Code	60632887
Hospital Revenue Code	250
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare Advantage	$11.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.69
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.94
Rate for Payer: Oxford Commercial	$19.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.70
Rate for Payer: UnitedHealthcare Commercial	$19.00

DONNATAL/16.2MG/5ML

Facility

$5.00

Hospital Charge Code	60632889
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.65
Rate for Payer: Oxford Commercial	$2.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$2.50

DONNATAL/16.2MG/5ML

Facility

$9.00

Hospital Charge Code	60632888
Hospital Revenue Code	250
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Aetna Medicare Advantage	$2.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.29
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.17
Rate for Payer: Oxford Commercial	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$1.35
Rate for Payer: UnitedHealthcare Commercial	$4.50

DONNATAL/16.2MG/5ML

Facility

$5.00

Hospital Charge Code	60632889
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

DONNATAL/16.2MG/5ML

Facility

$26.00

Hospital Charge Code	60632890
Hospital Revenue Code	250
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$3.90
Rate for Payer: Qualcare PPO/HMO/WC	$3.90

DONNATAL/16.2MG/5ML

Facility

$26.00

Hospital Charge Code	60632890
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Aetna Medicare Advantage	$7.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.63
Rate for Payer: Cigna Commercial	$13.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.38
Rate for Payer: Oxford Commercial	$13.00
Rate for Payer: Qualcare PPO/HMO/WC	$3.90
Rate for Payer: UnitedHealthcare Commercial	$13.00

DONNATAL/16.2MG/5ML

Facility

$9.00

Hospital Charge Code	60632888
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: Qualcare PPO/HMO/WC	$1.35

DONNATAL/16.2MG/TAB

Facility

$4.00

Hospital Charge Code	60632891
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

DONNATAL/16.2MG/TAB

Facility

$4.00

Hospital Charge Code	60632891
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DONNATAL/16.2MG/TAB

Facility

$4.00

Hospital Charge Code	60632892
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

DONNATAL/16.2MG/TAB

Facility

$4.00

Hospital Charge Code	60632892
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DONNAZYME/TAB

Facility

$3.00

Hospital Charge Code	60632893
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

DONNAZYME/TAB

Facility

$3.00

Hospital Charge Code	60632893
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

DONNOTAL LIQUID U/D

Facility

$4.00

Hospital Charge Code	60634965
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

Know your out-of-pocket cost for care.

All Charges