|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
OP
|
$1,893.18
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$744.02 |
| Max. Negotiated Rate |
$1,703.86 |
| Rate for Payer: Aetna Commercial |
$1,609.20
|
| Rate for Payer: Aetna Medicare |
$946.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,230.57
|
| Rate for Payer: BCBS Complete |
$757.27
|
| Rate for Payer: Cash Price |
$1,514.54
|
| Rate for Payer: Cofinity Advantage |
$1,325.23
|
| Rate for Payer: Cofinity Commercial |
$1,628.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,514.54
|
| Rate for Payer: Healthscope Commercial |
$1,703.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,514.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,609.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,419.88
|
| Rate for Payer: PHP Commercial |
$1,609.20
|
| Rate for Payer: Priority Health SBD |
$1,192.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,230.57
|
| Rate for Payer: UHC Core |
$986.35
|
| Rate for Payer: UHC Exchange |
$744.02
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,893.18
|
|
|
Service Code
|
NDC 55566280000
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,192.70 |
| Max. Negotiated Rate |
$1,703.86 |
| Rate for Payer: Aetna Commercial |
$1,609.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,230.57
|
| Rate for Payer: Cash Price |
$1,514.54
|
| Rate for Payer: Cofinity Advantage |
$1,325.23
|
| Rate for Payer: Cofinity Commercial |
$1,628.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,514.54
|
| Rate for Payer: Healthscope Commercial |
$1,703.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,609.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,419.88
|
| Rate for Payer: PHP Commercial |
$1,609.20
|
| Rate for Payer: Priority Health SBD |
$1,192.70
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,893.18
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,192.70 |
| Max. Negotiated Rate |
$1,703.86 |
| Rate for Payer: Aetna Commercial |
$1,609.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,230.57
|
| Rate for Payer: Cash Price |
$1,514.54
|
| Rate for Payer: Cofinity Advantage |
$1,325.23
|
| Rate for Payer: Cofinity Commercial |
$1,628.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,514.54
|
| Rate for Payer: Healthscope Commercial |
$1,703.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,609.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,419.88
|
| Rate for Payer: PHP Commercial |
$1,609.20
|
| Rate for Payer: Priority Health SBD |
$1,192.70
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$12.15
|
|
|
Service Code
|
NDC 09900000711
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.77 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna Commercial |
$10.33
|
| Rate for Payer: Aetna Medicare |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.90
|
| Rate for Payer: BCBS Complete |
$4.86
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cofinity Advantage |
$8.51
|
| Rate for Payer: Cofinity Commercial |
$10.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.72
|
| Rate for Payer: Healthscope Commercial |
$10.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.11
|
| Rate for Payer: PHP Commercial |
$10.33
|
| Rate for Payer: Priority Health SBD |
$7.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.90
|
| Rate for Payer: UHC Core |
$6.33
|
| Rate for Payer: UHC Exchange |
$4.77
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$306.97
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.39 |
| Max. Negotiated Rate |
$276.27 |
| Rate for Payer: Aetna Commercial |
$260.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.53
|
| Rate for Payer: Cash Price |
$245.58
|
| Rate for Payer: Cofinity Advantage |
$214.88
|
| Rate for Payer: Cofinity Commercial |
$263.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.58
|
| Rate for Payer: Healthscope Commercial |
$276.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.23
|
| Rate for Payer: PHP Commercial |
$260.92
|
| Rate for Payer: Priority Health SBD |
$193.39
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$6.54
|
|
|
Service Code
|
NDC 09900000847
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna Commercial |
$5.56
|
| Rate for Payer: Aetna Medicare |
$3.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.25
|
| Rate for Payer: BCBS Complete |
$2.62
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Cofinity Advantage |
$4.58
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.23
|
| Rate for Payer: Healthscope Commercial |
$5.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.91
|
| Rate for Payer: PHP Commercial |
$5.56
|
| Rate for Payer: Priority Health SBD |
$4.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.25
|
| Rate for Payer: UHC Core |
$3.41
|
| Rate for Payer: UHC Exchange |
$2.57
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$12.15
|
|
|
Service Code
|
NDC 09900000711
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna Commercial |
$10.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.90
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cofinity Advantage |
$8.51
|
| Rate for Payer: Cofinity Commercial |
$10.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.72
|
| Rate for Payer: Healthscope Commercial |
$10.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.11
|
| Rate for Payer: PHP Commercial |
$10.33
|
| Rate for Payer: Priority Health SBD |
$7.65
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$6.54
|
|
|
Service Code
|
NDC 09900000847
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna Commercial |
$5.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.25
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Cofinity Advantage |
$4.58
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.23
|
| Rate for Payer: Healthscope Commercial |
$5.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.91
|
| Rate for Payer: PHP Commercial |
$5.56
|
| Rate for Payer: Priority Health SBD |
$4.12
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$306.97
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.64 |
| Max. Negotiated Rate |
$276.27 |
| Rate for Payer: Aetna Commercial |
$260.92
|
| Rate for Payer: Aetna Medicare |
$153.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.53
|
| Rate for Payer: BCBS Complete |
$122.79
|
| Rate for Payer: Cash Price |
$245.58
|
| Rate for Payer: Cofinity Advantage |
$214.88
|
| Rate for Payer: Cofinity Commercial |
$263.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.58
|
| Rate for Payer: Healthscope Commercial |
$276.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.23
|
| Rate for Payer: PHP Commercial |
$260.92
|
| Rate for Payer: Priority Health SBD |
$193.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.53
|
| Rate for Payer: UHC Core |
$159.93
|
| Rate for Payer: UHC Exchange |
$120.64
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$15.51
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$13.96 |
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cofinity Advantage |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.63
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: Priority Health SBD |
$9.77
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$15.51
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$13.96 |
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Medicare |
$7.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: BCBS Complete |
$6.20
|
| Rate for Payer: BCBS Trust/PPO |
$0.20
|
| Rate for Payer: BCN Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cofinity Advantage |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.63
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.34
|
| Rate for Payer: UHC Core |
$2.34
|
| Rate for Payer: UHC Exchange |
$2.34
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$20.33
|
|
|
Service Code
|
NDC 69339015201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$44.42
|
|
|
Service Code
|
NDC 60687083008
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.98 |
| Max. Negotiated Rate |
$39.98 |
| Rate for Payer: Aetna Commercial |
$37.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.87
|
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: Cofinity Advantage |
$31.09
|
| Rate for Payer: Cofinity Commercial |
$38.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.54
|
| Rate for Payer: Healthscope Commercial |
$39.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.31
|
| Rate for Payer: PHP Commercial |
$37.76
|
| Rate for Payer: Priority Health SBD |
$27.98
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$44.42
|
|
|
Service Code
|
NDC 60687083008
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$39.98 |
| Rate for Payer: Aetna Commercial |
$37.76
|
| Rate for Payer: Aetna Medicare |
$22.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.87
|
| Rate for Payer: BCBS Complete |
$17.77
|
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: Cofinity Advantage |
$31.09
|
| Rate for Payer: Cofinity Commercial |
$38.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.54
|
| Rate for Payer: Healthscope Commercial |
$39.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.31
|
| Rate for Payer: PHP Commercial |
$37.76
|
| Rate for Payer: Priority Health SBD |
$27.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.87
|
| Rate for Payer: UHC Core |
$23.14
|
| Rate for Payer: UHC Exchange |
$17.46
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$44.42
|
|
|
Service Code
|
NDC 60687083042
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.98 |
| Max. Negotiated Rate |
$39.98 |
| Rate for Payer: Aetna Commercial |
$37.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.87
|
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: Cofinity Advantage |
$31.09
|
| Rate for Payer: Cofinity Commercial |
$38.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.54
|
| Rate for Payer: Healthscope Commercial |
$39.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.31
|
| Rate for Payer: PHP Commercial |
$37.76
|
| Rate for Payer: Priority Health SBD |
$27.98
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$44.42
|
|
|
Service Code
|
NDC 60687083042
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$39.98 |
| Rate for Payer: Aetna Commercial |
$37.76
|
| Rate for Payer: Aetna Medicare |
$22.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.87
|
| Rate for Payer: BCBS Complete |
$17.77
|
| Rate for Payer: Cash Price |
$35.54
|
| Rate for Payer: Cofinity Advantage |
$31.09
|
| Rate for Payer: Cofinity Commercial |
$38.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.54
|
| Rate for Payer: Healthscope Commercial |
$39.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.31
|
| Rate for Payer: PHP Commercial |
$37.76
|
| Rate for Payer: Priority Health SBD |
$27.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.87
|
| Rate for Payer: UHC Core |
$23.14
|
| Rate for Payer: UHC Exchange |
$17.46
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$20.33
|
|
|
Service Code
|
NDC 69339015217
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$41.83
|
|
|
Service Code
|
NDC 68094002462
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094002459
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.19
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: UHC Exchange |
$16.44
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094002462
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.19
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: UHC Exchange |
$16.44
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$41.83
|
|
|
Service Code
|
NDC 68094002459
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 69339015217
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: BCBS Complete |
$8.13
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.21
|
| Rate for Payer: UHC Core |
$10.59
|
| Rate for Payer: UHC Exchange |
$7.99
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 69339015201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: BCBS Complete |
$8.13
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.21
|
| Rate for Payer: UHC Core |
$10.59
|
| Rate for Payer: UHC Exchange |
$7.99
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Aetna Medicare |
$0.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.10
|
| Rate for Payer: BCBS Complete |
$0.68
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Advantage |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.44
|
| Rate for Payer: Priority Health SBD |
$1.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.10
|
| Rate for Payer: UHC Core |
$0.88
|
| Rate for Payer: UHC Exchange |
$0.66
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$134.20
|
|
|
Service Code
|
NDC 00450017014
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.55 |
| Max. Negotiated Rate |
$120.78 |
| Rate for Payer: Aetna Commercial |
$114.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.23
|
| Rate for Payer: Cash Price |
$107.36
|
| Rate for Payer: Cofinity Advantage |
$93.94
|
| Rate for Payer: Cofinity Commercial |
$115.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.36
|
| Rate for Payer: Healthscope Commercial |
$120.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.65
|
| Rate for Payer: PHP Commercial |
$114.07
|
| Rate for Payer: Priority Health SBD |
$84.55
|
|
