Heights University Hospital

All Charges

Charge

Type

Setting

Price

IMIPRAMINE 50 MG TAB

Facility

$7.03

Hospital Charge Code	6063943207
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna Commercial	$2.11
Rate for Payer: Aetna Medicare Advantage	$2.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.79
Rate for Payer: Cigna Commercial	$3.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.91
Rate for Payer: Oxford Commercial	$3.52
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$3.52

IMIPRAMINE CAP 100MG

Facility

$10.90

Hospital Charge Code	6009674
Hospital Revenue Code	251
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.64

IMIPRAMINE CAP 100MG

Facility

$10.90

Hospital Charge Code	6009674
Hospital Revenue Code	251
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

IMIPRAMINE, SERUM

Facility

$56.00

Service Code	HCPCS 80335
Hospital Charge Code	3004300
Hospital Revenue Code	301
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$8.40

IMIPRAMINE, SERUM

Facility

$56.00

Service Code	HCPCS 80335
Hospital Charge Code	3004300
Hospital Revenue Code	301
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$16.80
Rate for Payer: Aetna Medicare Advantage	$16.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.28
Rate for Payer: Cigna Commercial	$28.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.28
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$8.40
Rate for Payer: UnitedHealthcare Commercial	$114.00

IMIPRAMINE TAB 10MG

Facility

$4.00

Service Code	NDC 49884005401
Hospital Charge Code	60627767
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

IMIPRAMINE TAB 10MG

Facility

$4.00

Service Code	NDC 49884005401
Hospital Charge Code	60627767
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

IMIPRAMINE TAB 25MG

Facility

$5.83

Service Code	NDC 781176413
Hospital Charge Code	60627768
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.87

IMIPRAMINE TAB 25MG

Facility

$5.83

Service Code	NDC 781176413
Hospital Charge Code	60627768
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna Commercial	$1.75
Rate for Payer: Aetna Medicare Advantage	$1.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.49
Rate for Payer: Cigna Commercial	$2.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.76
Rate for Payer: Oxford Commercial	$2.92
Rate for Payer: Qualcare PPO/HMO/WC	$0.87
Rate for Payer: UnitedHealthcare Commercial	$2.92

IMIPRAMINE TAB 50MG

Facility

$9.78

Service Code	NDC 781176613
Hospital Charge Code	60627769
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.47
Rate for Payer: Qualcare PPO/HMO/WC	$1.47

IMIPRAMINE TAB 50MG

Facility

$9.78

Service Code	NDC 781176613
Hospital Charge Code	60627769
Hospital Revenue Code	250
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare Advantage	$2.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.49
Rate for Payer: Cigna Commercial	$4.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.27
Rate for Payer: Oxford Commercial	$4.89
Rate for Payer: Qualcare PPO/HMO/WC	$1.47
Rate for Payer: UnitedHealthcare Commercial	$4.89

IMIPRAMINE (TOFRANIL)

Facility

$193.00

Service Code	HCPCS 80335
Hospital Charge Code	38472485
Hospital Revenue Code	301
Min. Negotiated Rate	$25.09
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$57.90
Rate for Payer: Aetna Medicare Advantage	$57.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.22
Rate for Payer: Cigna Commercial	$96.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.09
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.95
Rate for Payer: UnitedHealthcare Commercial	$114.00

IMIPRAMINE (TOFRANIL)

Facility

$193.00

Service Code	HCPCS 80335
Hospital Charge Code	38472485
Hospital Revenue Code	301
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$28.95
Rate for Payer: Qualcare PPO/HMO/WC	$28.95

IMITREX INJECTION

Facility

$217.00

Hospital Charge Code	60634877
Hospital Revenue Code	636
Min. Negotiated Rate	$32.55
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$65.10
Rate for Payer: Aetna Medicare Advantage	$65.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.34
Rate for Payer: Cigna Commercial	$108.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.51
Rate for Payer: Qualcare PPO/HMO/WC	$32.55

IMITREX INJECTION

Facility

$217.00

Hospital Charge Code	60634877
Hospital Revenue Code	636
Min. Negotiated Rate	$32.55
Max. Negotiated Rate	$52.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$52.51
Rate for Payer: Qualcare PPO/HMO/WC	$32.55

IMM.ADM BY NASAL/ORAL @ADDN'L

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	73050855
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM.ADM BY NASAL/ORAL @ADDN'L

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	73050855
Hospital Revenue Code	771
Min. Negotiated Rate	$13.82
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$13.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.28
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM ADM BY NASL/ORAL @ ADDTL

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	87502415
Hospital Revenue Code	771
Min. Negotiated Rate	$13.82
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$13.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.28
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM ADM BY NASL/ORAL @ ADDTL

Facility

$156.00

Service Code	HCPCS 90474
Hospital Charge Code	87502415
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	87502395
Hospital Revenue Code	771
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$171.47
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$171.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.28
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	87502395
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	83652299
Hospital Revenue Code	771
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$171.47
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$171.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.28
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM ADM INTRANASAL/ORAL VACC

Facility

$156.00

Service Code	HCPCS 90473
Hospital Charge Code	83652299
Hospital Revenue Code	771
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	83652293
Hospital Revenue Code	771
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$4.65
Rate for Payer: Qualcare PPO/HMO/WC	$4.65

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	73050810
Hospital Revenue Code	771
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$9.30
Rate for Payer: Aetna Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.91
Rate for Payer: Cigna Commercial	$9.46
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.03
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.65
Rate for Payer: UnitedHealthcare Commercial	$103.00

Know your out-of-pocket cost for care.

All Charges