Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

DIOVAN 80MG TAB

Facility

$60.03

Service Code	NDC 78035834
Hospital Charge Code	6063943098
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$30.02
Rate for Payer: Aetna Commercial	$22.81
Rate for Payer: Aetna Medicare Advantage	$18.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.31
Rate for Payer: Cigna Commercial	$30.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.61
Rate for Payer: Oxford Commercial	$12.01
Rate for Payer: Qualcare PPO/HMO/WC	$9.00
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Community & State	$1.90
Rate for Payer: Wellpoint Medicaid Managed Care	$1.70

DIPHENHYDRAM 25MG/10ML VDCUP

Facility

$11.46

Service Code	NDC 121048905
Hospital Charge Code	60627226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$5.73
Rate for Payer: Aetna Commercial	$4.35
Rate for Payer: Aetna Medicare Advantage	$3.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.92
Rate for Payer: Cigna Commercial	$5.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.98
Rate for Payer: Oxford Commercial	$2.29
Rate for Payer: Qualcare PPO/HMO/WC	$1.72
Rate for Payer: UnitedHealthcare Commercial	$2.29
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.33

DIPHENHYDRAM 25MG/10ML VDCUP

Facility

$11.46

Service Code	NDC 121048905
Hospital Charge Code	60627226
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$1.72
Rate for Payer: Qualcare PPO/HMO/WC	$1.72

DIPHENHYDRAMINE 25 MG CAP

Facility

$4.00

Service Code	NDC 185064801
Hospital Charge Code	6022438
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
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	$1.04
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DIPHENHYDRAMINE 25 MG CAP

Facility

$4.00

Service Code	NDC 185064801
Hospital Charge Code	6022438
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DIPHENHYDRAMINE 25MG CAP

Facility

$100.00

Hospital Charge Code	83652541
Hospital Revenue Code	250
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare Advantage	$30.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$25.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$25.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$25.50
Rate for Payer: Cigna Commercial	$50.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.00
Rate for Payer: Oxford Commercial	$20.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.00
Rate for Payer: UnitedHealthcare Commercial	$20.00
Rate for Payer: UnitedHealthcare Community & State	$3.16
Rate for Payer: Wellpoint Medicaid Managed Care	$2.84

DIPHENHYDRAMINE 25MG CAP

Facility

$100.00

Hospital Charge Code	83652541
Hospital Revenue Code	250
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$15.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.00

DIPHENHYDRAMINE 2%ZINC ACET

Facility

$29.15

Service Code	NDC 904535431
Hospital Charge Code	606390604
Hospital Revenue Code	250
Min. Negotiated Rate	$4.37
Max. Negotiated Rate	$4.37
Rate for Payer: Qualcare PPO/HMO/WC	$4.37

DIPHENHYDRAMINE 2%ZINC ACET

Facility

$29.15

Service Code	NDC 904535431
Hospital Charge Code	606390604
Hospital Revenue Code	250
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$14.57
Rate for Payer: Aetna Commercial	$11.08
Rate for Payer: Aetna Medicare Advantage	$8.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.43
Rate for Payer: Cigna Commercial	$14.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.58
Rate for Payer: Oxford Commercial	$5.83
Rate for Payer: Qualcare PPO/HMO/WC	$4.37
Rate for Payer: UnitedHealthcare Commercial	$5.83
Rate for Payer: UnitedHealthcare Community & State	$0.92
Rate for Payer: Wellpoint Medicaid Managed Care	$0.83

DIPHENHYDRAMINE 50 MG CAP

Facility

$4.00

Service Code	NDC 904205661
Hospital Charge Code	60627884
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
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	$1.04
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DIPHENHYDRAMINE 50 MG CAP

Facility

$4.00

Service Code	NDC 904205661
Hospital Charge Code	60627884
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

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 50 MG/ML INJ

Facility

$6.57

Service Code	HCPCS J1200
Hospital Charge Code	60627229
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna Commercial	$2.50
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	$3.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.59
Rate for Payer: Qualcare PPO/HMO/WC	$0.99
Rate for Payer: UnitedHealthcare Community & State	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

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	$1.33
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	$12.19
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	$1.48
Rate for Payer: Wellpoint Medicaid Managed Care	$1.33

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

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	$0.11
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	$1.04
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

DIPTHERIA TITER

Facility

$390.00

Service Code	HCPCS 86648
Hospital Charge Code	39900501
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DIPTHERIA TITER

Facility

$390.00

Service Code	HCPCS 86648
Hospital Charge Code	39900501
Hospital Revenue Code	302
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$41.37
Rate for Payer: Aetna Medicare Advantage	$49.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.17
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$15.21
Rate for Payer: Clover Medicare Advantage	$14.45
Rate for Payer: EmblemHealth Commercial	$45.63
Rate for Payer: Humana Medicare Advantage	$15.67
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$12.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.21
Rate for Payer: Wellcare Medicare Advantage	$15.21
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

DIPYRIDAMOLE 25 MG TAB

Facility

$9.51

Service Code	NDC 64980013301
Hospital Charge Code	6023279
Hospital Revenue Code	251
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$3.61
Rate for Payer: Aetna Medicare Advantage	$2.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.43
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.47
Rate for Payer: Oxford Commercial	$1.90
Rate for Payer: Qualcare PPO/HMO/WC	$1.43
Rate for Payer: UnitedHealthcare Commercial	$1.90
Rate for Payer: UnitedHealthcare Community & State	$0.30
Rate for Payer: Wellpoint Medicaid Managed Care	$0.27

DIPYRIDAMOLE 25 MG TAB

Facility

$9.51

Service Code	NDC 64980013301
Hospital Charge Code	6023279
Hospital Revenue Code	251
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.43
Rate for Payer: Qualcare PPO/HMO/WC	$1.43

DIPYRIDAMOLE 50 MG TAB

Facility

$10.25

Service Code	NDC 54043525
Hospital Charge Code	60627646
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$5.12
Rate for Payer: Aetna Commercial	$3.90
Rate for Payer: Aetna Medicare Advantage	$3.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.61
Rate for Payer: Cigna Commercial	$5.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.67
Rate for Payer: Oxford Commercial	$2.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.54
Rate for Payer: UnitedHealthcare Commercial	$2.05
Rate for Payer: UnitedHealthcare Community & State	$0.32
Rate for Payer: Wellpoint Medicaid Managed Care	$0.29

DIPYRIDAMOLE 50 MG TAB

Facility

$10.25

Service Code	NDC 54043525
Hospital Charge Code	60627646
Hospital Revenue Code	250
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.54

DIPYRIDAMOLE 5 MG/ML INJ 10 ML

Facility

$35.85

Service Code	HCPCS J1245
Hospital Charge Code	6007447
Hospital Revenue Code	636
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$8.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.68
Rate for Payer: Qualcare PPO/HMO/WC	$5.38

DIPYRIDAMOLE 5 MG/ML INJ 10 ML

Facility

$35.85

Service Code	HCPCS J1245
Hospital Charge Code	6007447
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$17.93
Rate for Payer: Aetna Commercial	$13.62
Rate for Payer: Aetna Medicare Advantage	$10.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.14
Rate for Payer: Cigna Commercial	$17.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.68
Rate for Payer: Qualcare PPO/HMO/WC	$5.38
Rate for Payer: UnitedHealthcare Community & State	$1.13
Rate for Payer: Wellpoint Medicaid Managed Care	$1.02

Know your out-of-pocket cost for care.

All Charges