St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$3.61

Service Code	HCPCS J1200
Hospital Charge Code	6332366401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$1.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.81

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	$0.96
Max. Negotiated Rate	$0.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.96

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	$0.34
Max. Negotiated Rate	$0.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$0.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.79
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.67
Rate for Payer: EmblemHealth Commercial	$0.49
Rate for Payer: Group Health Inc Commercial	$0.49
Rate for Payer: Group Health Inc Medicare	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49
Rate for Payer: Hamaspik Choice Inc Medicare	$0.49
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.64

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	0641037621
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

$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

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$3.12

Service Code	HCPCS J1200
Hospital Charge Code	7604510210
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$2.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$2.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.12
Rate for Payer: EmblemHealth Commercial	$1.56
Rate for Payer: Group Health Inc Commercial	$1.56
Rate for Payer: Group Health Inc Medicare	$1.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.56
Rate for Payer: Hamaspik Choice Inc Medicare	$1.56
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.03

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

$3.61

Service Code	HCPCS J1200
Hospital Charge Code	6332366401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$2.89
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$2.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.89
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.46
Rate for Payer: EmblemHealth Commercial	$1.81
Rate for Payer: Group Health Inc Commercial	$1.81
Rate for Payer: Group Health Inc Medicare	$1.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.81
Rate for Payer: Hamaspik Choice Inc Medicare	$1.81
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.35

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN

Facility

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	0641037621
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	$0.95
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

$3.60

Service Code	HCPCS J1200
Hospital Charge Code	7248510105
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$2.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$2.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.45
Rate for Payer: EmblemHealth Commercial	$1.80
Rate for Payer: Group Health Inc Commercial	$1.80
Rate for Payer: Group Health Inc Medicare	$1.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.80
Rate for Payer: Hamaspik Choice Inc Medicare	$1.80
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.34

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 PO CAPS

Facility

$0.06

Service Code	HCPCS Q0163
Hospital Charge Code	0904205661
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	$0.04
Rate for Payer: EmblemHealth Commercial	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.04

DIPHENHYDRAMINE HCL 50 MG PO CAPS

Facility

$0.02

Service Code	HCPCS Q0163
Hospital Charge Code	0904530780
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	$0.01
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	$0.01

DIPHENHYDRAMINE HCL 50 MG PO CAPS

Facility

$0.06

Service Code	HCPCS Q0163
Hospital Charge Code	0904205661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03

DIPHENHYDRAMINE HCL 50 MG PO CAPS

Facility

$0.02

Service Code	HCPCS Q0163
Hospital Charge Code	7139910281
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 50 MG PO CAPS

Facility

$0.02

Service Code	HCPCS Q0163
Hospital Charge Code	0904530780
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 50 MG PO CAPS

Facility

$0.02

Service Code	HCPCS Q0163
Hospital Charge Code	7139910281
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	$0.01

DIPHENHYDRAMINE HCL 50 MG PO TABS

Facility

$0.32

Service Code	NDC 0045023524
Hospital Charge Code	0045023524
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16

DIPHENHYDRAMINE HCL 50 MG PO TABS

Facility

$0.32

Service Code	NDC 0045023524
Hospital Charge Code	0045023524
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.16
Rate for Payer: Aetna Government	$0.16
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: EmblemHealth Commercial	$0.16
Rate for Payer: Group Health Inc Commercial	$0.16
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16
Rate for Payer: Hamaspik Choice Inc Medicare	$0.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

DIPHENHYDRAMINE HCL CHILDRENS 12.5 MG/5ML PO LIQD

Facility

$0.03

Service Code	NDC 0045053402
Hospital Charge Code	0045053402
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 CHILDRENS 12.5 MG/5ML PO LIQD

Facility

$0.03

Service Code	NDC 0045053402
Hospital Charge Code	0045053402
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01

DIPHENHYDRAMINE/MAALOX MOUTHWASH (1:1) - COMPOUNDED

Facility

$0.20

Service Code	NDC 9999123401
Hospital Charge Code	9999123401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10

DIPHENHYDRAMINE/MAALOX MOUTHWASH (1:1) - COMPOUNDED

Facility

$0.20

Service Code	NDC 9999123401
Hospital Charge Code	9999123401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: EmblemHealth Commercial	$0.10
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS

Facility

$0.70

Service Code	NDC 6255949001
Hospital Charge Code	6255949001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS

Facility

$0.70

Service Code	NDC 0406123601
Hospital Charge Code	0406123601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: EmblemHealth Commercial	$0.35
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

Know your out-of-pocket cost for care.

All Charges