|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$134.20
|
|
|
Service Code
|
NDC 00450017014
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.74 |
| Max. Negotiated Rate |
$120.78 |
| Rate for Payer: Aetna Commercial |
$114.07
|
| Rate for Payer: Aetna Medicare |
$67.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.23
|
| Rate for Payer: BCBS Complete |
$53.68
|
| 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: MI Amish Medical Board Commercial |
$107.36
|
| 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
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.23
|
| Rate for Payer: UHC Core |
$69.92
|
| Rate for Payer: UHC Exchange |
$52.74
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$119.70
|
|
|
Service Code
|
NDC 904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna Medicare |
$59.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.81
|
| Rate for Payer: BCBS Complete |
$47.88
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Advantage |
$83.79
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health SBD |
$75.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.81
|
| Rate for Payer: UHC Core |
$62.36
|
| Rate for Payer: UHC Exchange |
$47.04
|
|
|
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
|
OP
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna Medicare |
$59.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.81
|
| Rate for Payer: BCBS Complete |
$47.88
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Advantage |
$83.79
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health SBD |
$75.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.81
|
| Rate for Payer: UHC Core |
$62.36
|
| Rate for Payer: UHC Exchange |
$47.04
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.28 |
| Max. Negotiated Rate |
$151.83 |
| Rate for Payer: Aetna Commercial |
$143.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.66
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Advantage |
$118.09
|
| Rate for Payer: Cofinity Commercial |
$145.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$151.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: PHP Commercial |
$143.40
|
| Rate for Payer: Priority Health SBD |
$106.28
|
|
|
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
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$172.70
|
|
|
Service Code
|
NDC 50580022650
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$155.43 |
| Rate for Payer: Aetna Commercial |
$146.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.25
|
| Rate for Payer: Cash Price |
$138.16
|
| Rate for Payer: Cofinity Advantage |
$120.89
|
| Rate for Payer: Cofinity Commercial |
$148.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.16
|
| Rate for Payer: Healthscope Commercial |
$155.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$129.53
|
| Rate for Payer: PHP Commercial |
$146.79
|
| Rate for Payer: Priority Health SBD |
$108.80
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.41 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.81
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Advantage |
$83.79
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health SBD |
$75.41
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$172.70
|
|
|
Service Code
|
NDC 50580022650
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.87 |
| Max. Negotiated Rate |
$155.43 |
| Rate for Payer: Aetna Commercial |
$146.79
|
| Rate for Payer: Aetna Medicare |
$86.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.25
|
| Rate for Payer: BCBS Complete |
$69.08
|
| Rate for Payer: Cash Price |
$138.16
|
| Rate for Payer: Cofinity Advantage |
$120.89
|
| Rate for Payer: Cofinity Commercial |
$148.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.16
|
| Rate for Payer: Healthscope Commercial |
$155.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$138.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$129.53
|
| Rate for Payer: PHP Commercial |
$146.79
|
| Rate for Payer: Priority Health SBD |
$108.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112.25
|
| Rate for Payer: UHC Core |
$89.98
|
| Rate for Payer: UHC Exchange |
$67.87
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna Medicare |
$6.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$14.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cofinity Advantage |
$12.14
|
| Rate for Payer: Cofinity Advantage |
$108.61
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$9.44
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$15.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$14.75
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: Priority Health SBD |
$10.93
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$14.75
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Medicare |
$6.07
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna Medicare |
$77.58
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna Medicare |
$8.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: BCBS Complete |
$62.06
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Complete |
$6.94
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: BCN Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Advantage |
$12.14
|
| Rate for Payer: Cofinity Advantage |
$9.44
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$108.61
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$15.62
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.01
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$14.75
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$10.93
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$1,075.96
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$422.85 |
| Max. Negotiated Rate |
$968.36 |
| Rate for Payer: Aetna Commercial |
$914.57
|
| Rate for Payer: Aetna Medicare |
$537.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.37
|
| Rate for Payer: BCBS Complete |
$430.38
|
| Rate for Payer: Cash Price |
$860.77
|
| Rate for Payer: Cofinity Advantage |
$753.17
|
| Rate for Payer: Cofinity Commercial |
$925.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.77
|
| Rate for Payer: Healthscope Commercial |
$968.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$860.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$806.97
|
| Rate for Payer: PHP Commercial |
$914.57
|
| Rate for Payer: Priority Health SBD |
$677.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$699.37
|
| Rate for Payer: UHC Core |
$560.58
|
| Rate for Payer: UHC Exchange |
$422.85
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.80 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Advantage |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.11
|
| Rate for Payer: UHC Core |
$162.80
|
| Rate for Payer: UHC Exchange |
$122.80
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$1,075.96
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$677.85 |
| Max. Negotiated Rate |
$968.36 |
| Rate for Payer: Aetna Commercial |
$914.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.37
|
| Rate for Payer: Cash Price |
$860.77
|
| Rate for Payer: Cofinity Advantage |
$753.17
|
| Rate for Payer: Cofinity Commercial |
$925.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.77
|
| Rate for Payer: Healthscope Commercial |
$968.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$806.97
|
| Rate for Payer: PHP Commercial |
$914.57
|
| Rate for Payer: Priority Health SBD |
$677.85
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$415.95
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.47 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna Medicare |
$207.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.37
|
| Rate for Payer: BCBS Complete |
$166.38
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Advantage |
$291.17
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$332.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$311.96
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health SBD |
$262.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$270.37
|
| Rate for Payer: UHC Core |
$216.71
|
| Rate for Payer: UHC Exchange |
$163.47
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$415.95
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.37
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Advantage |
$291.17
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$311.96
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health SBD |
$262.05
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.63 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Advantage |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health SBD |
$228.63
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.80 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Advantage |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.11
|
| Rate for Payer: UHC Core |
$162.80
|
| Rate for Payer: UHC Exchange |
$122.80
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.86 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Advantage |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health SBD |
$196.86
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.62 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna Medicare |
$181.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Advantage |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$290.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health SBD |
$228.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.88
|
| Rate for Payer: UHC Core |
$189.07
|
| Rate for Payer: UHC Exchange |
$142.62
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
OP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.68 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna Medicare |
$59.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: BCBS Complete |
$47.51
|
| Rate for Payer: BCBS Trust/PPO |
$72.86
|
| Rate for Payer: BCN Commercial |
$72.86
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Advantage |
$83.15
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.08
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health SBD |
$74.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.21
|
| Rate for Payer: UHC Core |
$61.88
|
| Rate for Payer: UHC Exchange |
$46.68
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
IP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.83 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Advantage |
$83.15
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.08
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health SBD |
$74.83
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.33 |
| Max. Negotiated Rate |
$153.33 |
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.74
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Advantage |
$119.26
|
| Rate for Payer: Cofinity Commercial |
$146.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.30
|
| Rate for Payer: Healthscope Commercial |
$153.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health SBD |
$107.33
|
|
