St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.91

Service Code	NDC 0121048900
Hospital Charge Code	0121048900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.46
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.45

Service Code	NDC 0121097800
Hospital Charge Code	0121097800
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.45

Service Code	NDC 0121097800
Hospital Charge Code	0121097800
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Brighton Health Commercial	$0.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.23
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.91

Service Code	NDC 0121048905
Hospital Charge Code	0121048905
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.91

Service Code	NDC 0121048905
Hospital Charge Code	0121048905
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.46
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX

Facility

$0.91

Service Code	NDC 0121048900
Hospital Charge Code	0121048900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.02

Service Code	NDC 0904698520
Hospital Charge Code	0904698520
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: EmblemHealth Commercial	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.02

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.29

Service Code	NDC 6933915217
Hospital Charge Code	6933915217
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: EmblemHealth Commercial	$0.15
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.19

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.02

Service Code	NDC 0904698520
Hospital Charge Code	0904698520
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.17

Service Code	NDC 0121173010
Hospital Charge Code	0121173010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: EmblemHealth Commercial	$0.08
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.11

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.29

Service Code	NDC 6933915217
Hospital Charge Code	6933915217
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15

DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD

Facility

$0.17

Service Code	NDC 0121173010
Hospital Charge Code	0121173010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08

DIPHENHYDRAMINE HCL 25 MG/10ML PO LIQD

Facility

$0.27

Service Code	NDC 5723731811
Hospital Charge Code	5723731811
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

DIPHENHYDRAMINE HCL 25 MG/10ML PO LIQD

Facility

$0.27

Service Code	NDC 5723731811
Hospital Charge Code	5723731811
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13

DIPHENHYDRAMINE HCL 25 MG PO CAPS

Facility

$0.05

Service Code	HCPCS Q0163
Hospital Charge Code	0904723761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: EmblemHealth Commercial	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

DIPHENHYDRAMINE HCL 25 MG PO CAPS

Facility

$0.05

Service Code	HCPCS Q0163
Hospital Charge Code	0904723761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02

DIPHENHYDRAMINE HCL 25 MG PO TABS

Facility

$0.26

Service Code	NDC 6809401859
Hospital Charge Code	6809401859
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13

DIPHENHYDRAMINE HCL 25 MG PO TABS

Facility

$0.26

Service Code	NDC 6809401861
Hospital Charge Code	6809401861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

DIPHENHYDRAMINE HCL 25 MG PO TABS

Facility

$0.26

Service Code	NDC 6809401861
Hospital Charge Code	6809401861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13

DIPHENHYDRAMINE HCL 25 MG PO TABS

Facility

$0.26

Service Code	NDC 6809401859
Hospital Charge Code	6809401859
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$3.60

Service Code	HCPCS J1200
Hospital Charge Code	7248510105
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$1.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.80

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$1.41

Service Code	HCPCS J1200
Hospital Charge Code	0641037625
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$0.98

Service Code	HCPCS J1200
Hospital Charge Code	6332366416
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$1.41

Service Code	HCPCS J1200
Hospital Charge Code	0641037625
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.96
Rate for Payer: EmblemHealth Commercial	$0.70
Rate for Payer: Group Health Inc Commercial	$0.70
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.91

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$1.92

Service Code	HCPCS J1200
Hospital Charge Code	7248510125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.31
Rate for Payer: EmblemHealth Commercial	$0.96
Rate for Payer: Group Health Inc Commercial	$0.96
Rate for Payer: Group Health Inc Medicare	$0.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.96
Rate for Payer: Hamaspik Choice Inc Medicare	$0.96
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.25

Know your out-of-pocket cost for care.

All Charges