St. Barnabas Hospital

All Charges

Charge

Type

Price

DIPHENHYDRAMINE 25 MG CAP

Facility OP

$0.12

Service Code	HCPCS Q0163
Hospital Charge Code	41654666
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

DIPHENHYDRAMINE 25 MG CAP

Facility OP

$0.12

Service Code	HCPCS Q0163
Hospital Charge Code	41644666
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

DIPHENHYDRAMINE 25 MG CAP

Facility IP

$0.12

Service Code	HCPCS Q0163
Hospital Charge Code	41654666
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06

DIPHENHYDRAMINE 25 MG CAP

Facility IP

$0.12

Service Code	HCPCS Q0163
Hospital Charge Code	41644666
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06

DIPHENHYDRAMINE 2.5 MG/ML LIQ

Facility IP

$8.08

Service Code	HCPCS Q0163
Hospital Charge Code	41652777
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.04
Rate for Payer: Hamaspik Choice Inc Medicare	$4.04

DIPHENHYDRAMINE 2.5 MG/ML LIQ

Facility OP

$8.08

Service Code	HCPCS Q0163
Hospital Charge Code	41652777
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.65
Rate for Payer: Group Health Inc Commercial	$4.04
Rate for Payer: Group Health Inc Medicare	$2.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.04
Rate for Payer: Hamaspik Choice Inc Medicare	$4.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.25

DIPHENHYDRAMINE 2.5 MG/ML LIQ

Facility IP

$8.08

Service Code	HCPCS Q0163
Hospital Charge Code	41642777
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.04
Rate for Payer: Hamaspik Choice Inc Medicare	$4.04

DIPHENHYDRAMINE 2.5 MG/ML LIQ

Facility OP

$8.08

Service Code	HCPCS Q0163
Hospital Charge Code	41642777
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.65
Rate for Payer: Group Health Inc Commercial	$4.04
Rate for Payer: Group Health Inc Medicare	$2.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.04
Rate for Payer: Hamaspik Choice Inc Medicare	$4.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.25

DIPHENHYDRAMINE 50 MG CAP

Facility IP

$0.07

Service Code	HCPCS Q0163
Hospital Charge Code	41643520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04

DIPHENHYDRAMINE 50 MG CAP

Facility OP

$0.07

Service Code	HCPCS Q0163
Hospital Charge Code	41653520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.05

DIPHENHYDRAMINE 50 MG CAP

Facility IP

$0.07

Service Code	HCPCS Q0163
Hospital Charge Code	41653520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04

DIPHENHYDRAMINE 50 MG CAP

Facility OP

$0.07

Service Code	HCPCS Q0163
Hospital Charge Code	41643520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.05

DIPHENHYDRAMINE 50 MG/ML INJ

Facility IP

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	41654105
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70

DIPHENHYDRAMINE 50 MG/ML INJ

Facility OP

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	41654105
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.06
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: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.96
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	$1.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.87
Rate for Payer: SOMOS Essential	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.91

DIPHENHYDRAMINE 50 MG/ML INJ

Facility OP

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	41644105
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.06
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: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.96
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	$1.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.87
Rate for Payer: SOMOS Essential	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.91

DIPHENHYDRAMINE 50 MG/ML INJ

Facility IP

$1.40

Service Code	HCPCS J1200
Hospital Charge Code	41644105
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70

DIPHENHYDRAMINE 50MG PER ML PEDS

Facility OP

$1.15

Service Code	HCPCS J1200
Hospital Charge Code	41658032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$1.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.96
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.87
Rate for Payer: SOMOS Essential	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.75

DIPHENHYDRAMINE 50MG PER ML PEDS

Facility OP

$1.15

Service Code	HCPCS J1200
Hospital Charge Code	41648032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$1.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.96
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.87
Rate for Payer: SOMOS Essential	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.75

DIPHENHYDRAMINE 50MG PER ML PEDS

Facility IP

$1.15

Service Code	HCPCS J1200
Hospital Charge Code	41648032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58

DIPHENHYDRAMINE 50MG PER ML PEDS

Facility IP

$1.15

Service Code	HCPCS J1200
Hospital Charge Code	41658032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58

DIPHENHYDRAMINE + MAALOX (1

Facility OP

$3.00

Hospital Charge Code	41644736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DIPHENHYDRAMINE + MAALOX (1

Facility OP

$3.00

Hospital Charge Code	41654736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DIPHENHYDRAMINE + MYLANTA + LIDOCAINE LI

Facility OP

$15.00

Hospital Charge Code	41644739
Hospital Revenue Code	250
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$12.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.50
Rate for Payer: Aetna Government	$7.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.20
Rate for Payer: Group Health Inc Commercial	$7.50
Rate for Payer: Group Health Inc Medicare	$5.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.50
Rate for Payer: Hamaspik Choice Inc Medicare	$7.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.75

DIPHENHYDRAMINE + MYLANTA + LIDOCAINE LI

Facility OP

$15.00

Hospital Charge Code	41654739
Hospital Revenue Code	250
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$12.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.50
Rate for Payer: Aetna Government	$7.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.20
Rate for Payer: Group Health Inc Commercial	$7.50
Rate for Payer: Group Health Inc Medicare	$5.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.50
Rate for Payer: Hamaspik Choice Inc Medicare	$7.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.75

DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG

Facility OP

$12.00

Hospital Charge Code	41640800
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$9.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.00
Rate for Payer: Aetna Government	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.16
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

Price Transparency.

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