Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$20.14

Service Code	NDC 69339015217
Hospital Charge Code	12556
Hospital Revenue Code	637
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$18.13
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$10.07
Rate for Payer: Aetna New Business (MI Preferred)	$13.09
Rate for Payer: BCBS Complete	$8.06
Rate for Payer: Cash Price	$16.11
Rate for Payer: Cofinity Commercial	$14.10
Rate for Payer: Cofinity Commercial	$17.32
Rate for Payer: Cofinity Medicare Advantage	$14.10
Rate for Payer: Encore Health Key Benefits Commercial	$16.11
Rate for Payer: Healthscope Commercial	$18.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.12
Rate for Payer: PHP Commercial	$17.12
Rate for Payer: Priority Health Cigna Priority Health	$13.09
Rate for Payer: Priority Health SBD	$12.69

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$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 Commercial	$29.28
Rate for Payer: Cofinity Commercial	$35.97
Rate for Payer: Cofinity Medicare Advantage	$29.28
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: PHP Commercial	$35.56
Rate for Payer: Priority Health Cigna Priority Health	$27.19
Rate for Payer: Priority Health SBD	$26.35

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$41.83

Service Code	NDC 68094002459
Hospital Charge Code	12556
Hospital Revenue Code	637
Min. Negotiated Rate	$16.73
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 Commercial	$29.28
Rate for Payer: Cofinity Commercial	$35.97
Rate for Payer: Cofinity Medicare Advantage	$29.28
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: PHP Commercial	$35.56
Rate for Payer: Priority Health Cigna Priority Health	$27.19
Rate for Payer: Priority Health SBD	$26.35

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$20.14

Service Code	NDC 69339015201
Hospital Charge Code	12556
Hospital Revenue Code	637
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$18.13
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$10.07
Rate for Payer: Aetna New Business (MI Preferred)	$13.09
Rate for Payer: BCBS Complete	$8.06
Rate for Payer: Cash Price	$16.11
Rate for Payer: Cofinity Commercial	$14.10
Rate for Payer: Cofinity Commercial	$17.32
Rate for Payer: Cofinity Medicare Advantage	$14.10
Rate for Payer: Encore Health Key Benefits Commercial	$16.11
Rate for Payer: Healthscope Commercial	$18.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.12
Rate for Payer: PHP Commercial	$17.12
Rate for Payer: Priority Health Cigna Priority Health	$13.09
Rate for Payer: Priority Health SBD	$12.69

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$20.14

Service Code	NDC 69339015201
Hospital Charge Code	12556
Hospital Revenue Code	637
Min. Negotiated Rate	$12.69
Max. Negotiated Rate	$18.13
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna New Business (MI Preferred)	$13.09
Rate for Payer: Cash Price	$16.11
Rate for Payer: Cofinity Commercial	$14.10
Rate for Payer: Cofinity Commercial	$17.32
Rate for Payer: Cofinity Medicare Advantage	$14.10
Rate for Payer: Encore Health Key Benefits Commercial	$16.11
Rate for Payer: Healthscope Commercial	$18.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.12
Rate for Payer: PHP Commercial	$17.12
Rate for Payer: Priority Health Cigna Priority Health	$13.09
Rate for Payer: Priority Health SBD	$12.69

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID

Facility

$41.83

Service Code	NDC 68094002462
Hospital Charge Code	12556
Hospital Revenue Code	637
Min. Negotiated Rate	$16.73
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 Commercial	$29.28
Rate for Payer: Cofinity Commercial	$35.97
Rate for Payer: Cofinity Medicare Advantage	$29.28
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: PHP Commercial	$35.56
Rate for Payer: Priority Health Cigna Priority Health	$27.19
Rate for Payer: Priority Health SBD	$26.35

DIPHENHYDRAMINE 25 MG TABLET

Facility

$134.20

Service Code	NDC 00450017014
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$53.68
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 Commercial	$115.41
Rate for Payer: Cofinity Commercial	$93.94
Rate for Payer: Cofinity Medicare Advantage	$93.94
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: PHP Commercial	$114.07
Rate for Payer: Priority Health Cigna Priority Health	$87.23
Rate for Payer: Priority Health SBD	$84.55

DIPHENHYDRAMINE 25 MG TABLET

Facility

$142.80

Service Code	NDC 68094001861
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$128.52
Rate for Payer: Aetna Commercial	$121.38
Rate for Payer: Aetna Medicare	$71.40
Rate for Payer: Aetna New Business (MI Preferred)	$92.82
Rate for Payer: BCBS Complete	$57.12
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cofinity Commercial	$122.81
Rate for Payer: Cofinity Commercial	$99.96
Rate for Payer: Cofinity Medicare Advantage	$99.96
Rate for Payer: Encore Health Key Benefits Commercial	$114.24
Rate for Payer: Healthscope Commercial	$128.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$121.38
Rate for Payer: PHP Commercial	$121.38
Rate for Payer: Priority Health Cigna Priority Health	$92.82
Rate for Payer: Priority Health SBD	$89.96

DIPHENHYDRAMINE 25 MG TABLET

Facility

$1.43

Service Code	NDC 68094001859
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna Commercial	$1.22
Rate for Payer: Aetna Medicare	$0.72
Rate for Payer: Aetna New Business (MI Preferred)	$0.93
Rate for Payer: BCBS Complete	$0.57
Rate for Payer: Cash Price	$1.14
Rate for Payer: Cofinity Commercial	$1.00
Rate for Payer: Cofinity Commercial	$1.23
Rate for Payer: Cofinity Medicare Advantage	$1.00
Rate for Payer: Encore Health Key Benefits Commercial	$1.14
Rate for Payer: Healthscope Commercial	$1.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.22
Rate for Payer: PHP Commercial	$1.22
Rate for Payer: Priority Health Cigna Priority Health	$0.93
Rate for Payer: Priority Health SBD	$0.90

DIPHENHYDRAMINE 25 MG TABLET

Facility

$1.43

Service Code	NDC 68094001859
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna Commercial	$1.22
Rate for Payer: Aetna New Business (MI Preferred)	$0.93
Rate for Payer: Cash Price	$1.14
Rate for Payer: Cofinity Commercial	$1.00
Rate for Payer: Cofinity Commercial	$1.23
Rate for Payer: Cofinity Medicare Advantage	$1.00
Rate for Payer: Encore Health Key Benefits Commercial	$1.14
Rate for Payer: Healthscope Commercial	$1.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.22
Rate for Payer: PHP Commercial	$1.22
Rate for Payer: Priority Health Cigna Priority Health	$0.93
Rate for Payer: Priority Health SBD	$0.90

DIPHENHYDRAMINE 25 MG TABLET

Facility

$100.80

Service Code	NDC 00904555159
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$90.72
Rate for Payer: Aetna Commercial	$85.68
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: Aetna New Business (MI Preferred)	$65.52
Rate for Payer: BCBS Complete	$40.32
Rate for Payer: Cash Price	$80.64
Rate for Payer: Cofinity Commercial	$70.56
Rate for Payer: Cofinity Commercial	$86.69
Rate for Payer: Cofinity Medicare Advantage	$70.56
Rate for Payer: Encore Health Key Benefits Commercial	$80.64
Rate for Payer: Healthscope Commercial	$90.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$85.68
Rate for Payer: PHP Commercial	$85.68
Rate for Payer: Priority Health Cigna Priority Health	$65.52
Rate for Payer: Priority Health SBD	$63.50

DIPHENHYDRAMINE 25 MG TABLET

Facility

$142.80

Service Code	NDC 68094001861
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$128.52
Rate for Payer: Aetna Commercial	$121.38
Rate for Payer: Aetna New Business (MI Preferred)	$92.82
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cofinity Commercial	$122.81
Rate for Payer: Cofinity Commercial	$99.96
Rate for Payer: Cofinity Medicare Advantage	$99.96
Rate for Payer: Encore Health Key Benefits Commercial	$114.24
Rate for Payer: Healthscope Commercial	$128.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$121.38
Rate for Payer: PHP Commercial	$121.38
Rate for Payer: Priority Health Cigna Priority Health	$92.82
Rate for Payer: Priority Health SBD	$89.96

DIPHENHYDRAMINE 25 MG TABLET

Facility

$100.80

Service Code	NDC 00904555159
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$63.50
Max. Negotiated Rate	$90.72
Rate for Payer: Aetna Commercial	$85.68
Rate for Payer: Aetna New Business (MI Preferred)	$65.52
Rate for Payer: Cash Price	$80.64
Rate for Payer: Cofinity Commercial	$70.56
Rate for Payer: Cofinity Commercial	$86.69
Rate for Payer: Cofinity Medicare Advantage	$70.56
Rate for Payer: Encore Health Key Benefits Commercial	$80.64
Rate for Payer: Healthscope Commercial	$90.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$85.68
Rate for Payer: PHP Commercial	$85.68
Rate for Payer: Priority Health Cigna Priority Health	$65.52
Rate for Payer: Priority Health SBD	$63.50

DIPHENHYDRAMINE 25 MG TABLET

Facility

$162.80

Service Code	NDC 50580022650
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$146.52
Rate for Payer: Aetna Commercial	$138.38
Rate for Payer: Aetna Medicare	$81.40
Rate for Payer: Aetna New Business (MI Preferred)	$105.82
Rate for Payer: BCBS Complete	$65.12
Rate for Payer: Cash Price	$130.24
Rate for Payer: Cofinity Commercial	$113.96
Rate for Payer: Cofinity Commercial	$140.01
Rate for Payer: Cofinity Medicare Advantage	$113.96
Rate for Payer: Encore Health Key Benefits Commercial	$130.24
Rate for Payer: Healthscope Commercial	$146.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.38
Rate for Payer: PHP Commercial	$138.38
Rate for Payer: Priority Health Cigna Priority Health	$105.82
Rate for Payer: Priority Health SBD	$102.56

DIPHENHYDRAMINE 25 MG TABLET

Facility

$162.80

Service Code	NDC 50580022650
Hospital Charge Code	2505
Hospital Revenue Code	637
Min. Negotiated Rate	$102.56
Max. Negotiated Rate	$146.52
Rate for Payer: Aetna Commercial	$138.38
Rate for Payer: Aetna New Business (MI Preferred)	$105.82
Rate for Payer: Cash Price	$130.24
Rate for Payer: Cofinity Commercial	$113.96
Rate for Payer: Cofinity Commercial	$140.01
Rate for Payer: Cofinity Medicare Advantage	$113.96
Rate for Payer: Encore Health Key Benefits Commercial	$130.24
Rate for Payer: Healthscope Commercial	$146.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.38
Rate for Payer: PHP Commercial	$138.38
Rate for Payer: Priority Health Cigna Priority Health	$105.82
Rate for Payer: Priority Health SBD	$102.56

DIPHENHYDRAMINE 25 MG TABLET

Facility

$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 Commercial	$115.41
Rate for Payer: Cofinity Commercial	$93.94
Rate for Payer: Cofinity Medicare Advantage	$93.94
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: PHP Commercial	$114.07
Rate for Payer: Priority Health Cigna Priority Health	$87.23
Rate for Payer: Priority Health SBD	$84.55

DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)

Facility

$20.65

Service Code	HCPCS J1200
Hospital Charge Code	163710
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	$10.31
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 Commercial	$10.43
Rate for Payer: Cofinity Commercial	$14.46
Rate for Payer: Cofinity Commercial	$17.76
Rate for Payer: Cofinity Commercial	$8.49
Rate for Payer: Cofinity Medicare Advantage	$14.46
Rate for Payer: Cofinity Medicare Advantage	$8.49
Rate for Payer: Encore Health Key Benefits Commercial	$9.70
Rate for Payer: Encore Health Key Benefits Commercial	$16.52
Rate for Payer: Healthscope Commercial	$10.92
Rate for Payer: Healthscope Commercial	$18.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.55
Rate for Payer: PHP Commercial	$10.31
Rate for Payer: PHP Commercial	$17.55
Rate for Payer: Priority Health Cigna Priority Health	$13.42
Rate for Payer: Priority Health Cigna Priority Health	$7.88
Rate for Payer: Priority Health SBD	$13.01
Rate for Payer: Priority Health SBD	$7.64

DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)

Facility

$20.65

Service Code	HCPCS J1200
Hospital Charge Code	163710
Hospital Revenue Code	636
Min. Negotiated Rate	$8.26
Max. Negotiated Rate	$18.59
Rate for Payer: Aetna Commercial	$17.55
Rate for Payer: Aetna Commercial	$10.31
Rate for Payer: Aetna Medicare	$6.07
Rate for Payer: Aetna Medicare	$10.32
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: Cash Price	$9.70
Rate for Payer: Cash Price	$16.52
Rate for Payer: Cofinity Commercial	$10.43
Rate for Payer: Cofinity Commercial	$14.46
Rate for Payer: Cofinity Commercial	$17.76
Rate for Payer: Cofinity Commercial	$8.49
Rate for Payer: Cofinity Medicare Advantage	$14.46
Rate for Payer: Cofinity Medicare Advantage	$8.49
Rate for Payer: Encore Health Key Benefits Commercial	$9.70
Rate for Payer: Encore Health Key Benefits Commercial	$16.52
Rate for Payer: Healthscope Commercial	$10.92
Rate for Payer: Healthscope Commercial	$18.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.55
Rate for Payer: PHP Commercial	$17.55
Rate for Payer: PHP Commercial	$10.31
Rate for Payer: Priority Health Cigna Priority Health	$7.88
Rate for Payer: Priority Health Cigna Priority Health	$13.42
Rate for Payer: Priority Health SBD	$13.01
Rate for Payer: Priority Health SBD	$7.64

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION

Facility

$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	$10.31
Rate for Payer: Aetna Commercial	$131.88
Rate for Payer: Aetna Commercial	$11.47
Rate for Payer: Aetna New Business (MI Preferred)	$8.77
Rate for Payer: Aetna New Business (MI Preferred)	$7.88
Rate for Payer: Aetna New Business (MI Preferred)	$13.42
Rate for Payer: Aetna New Business (MI Preferred)	$100.85
Rate for Payer: Cash Price	$16.52
Rate for Payer: Cash Price	$9.70
Rate for Payer: Cash Price	$124.12
Rate for Payer: Cash Price	$10.79
Rate for Payer: Cofinity Commercial	$17.76
Rate for Payer: Cofinity Commercial	$8.49
Rate for Payer: Cofinity Commercial	$108.61
Rate for Payer: Cofinity Commercial	$11.60
Rate for Payer: Cofinity Commercial	$9.44
Rate for Payer: Cofinity Commercial	$10.43
Rate for Payer: Cofinity Commercial	$133.43
Rate for Payer: Cofinity Commercial	$14.46
Rate for Payer: Cofinity Medicare Advantage	$14.46
Rate for Payer: Cofinity Medicare Advantage	$8.49
Rate for Payer: Cofinity Medicare Advantage	$9.44
Rate for Payer: Cofinity Medicare Advantage	$108.61
Rate for Payer: Encore Health Key Benefits Commercial	$124.12
Rate for Payer: Encore Health Key Benefits Commercial	$10.79
Rate for Payer: Encore Health Key Benefits Commercial	$9.70
Rate for Payer: Encore Health Key Benefits Commercial	$16.52
Rate for Payer: Healthscope Commercial	$12.14
Rate for Payer: Healthscope Commercial	$139.63
Rate for Payer: Healthscope Commercial	$18.59
Rate for Payer: Healthscope Commercial	$10.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$131.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.31
Rate for Payer: PHP Commercial	$11.47
Rate for Payer: PHP Commercial	$131.88
Rate for Payer: PHP Commercial	$17.55
Rate for Payer: PHP Commercial	$10.31
Rate for Payer: Priority Health Cigna Priority Health	$8.77
Rate for Payer: Priority Health Cigna Priority Health	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$7.88
Rate for Payer: Priority Health Cigna Priority Health	$13.42
Rate for Payer: Priority Health SBD	$13.01
Rate for Payer: Priority Health SBD	$8.50
Rate for Payer: Priority Health SBD	$97.74
Rate for Payer: Priority Health SBD	$7.64

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION

Facility

$155.15

Service Code	HCPCS J1200
Hospital Charge Code	2508
Hospital Revenue Code	636
Min. Negotiated Rate	$62.06
Max. Negotiated Rate	$139.63
Rate for Payer: Aetna Commercial	$131.88
Rate for Payer: Aetna Commercial	$11.47
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	$77.58
Rate for Payer: Aetna Medicare	$6.75
Rate for Payer: Aetna Medicare	$6.07
Rate for Payer: Aetna New Business (MI Preferred)	$100.85
Rate for Payer: Aetna New Business (MI Preferred)	$7.88
Rate for Payer: Aetna New Business (MI Preferred)	$8.77
Rate for Payer: Aetna New Business (MI Preferred)	$13.42
Rate for Payer: BCBS Complete	$4.85
Rate for Payer: BCBS Complete	$8.26
Rate for Payer: BCBS Complete	$5.40
Rate for Payer: BCBS Complete	$62.06
Rate for Payer: Cash Price	$16.52
Rate for Payer: Cash Price	$10.79
Rate for Payer: Cash Price	$124.12
Rate for Payer: Cash Price	$9.70
Rate for Payer: Cofinity Commercial	$9.44
Rate for Payer: Cofinity Commercial	$17.76
Rate for Payer: Cofinity Commercial	$108.61
Rate for Payer: Cofinity Commercial	$14.46
Rate for Payer: Cofinity Commercial	$133.43
Rate for Payer: Cofinity Commercial	$10.43
Rate for Payer: Cofinity Commercial	$8.49
Rate for Payer: Cofinity Commercial	$11.60
Rate for Payer: Cofinity Medicare Advantage	$108.61
Rate for Payer: Cofinity Medicare Advantage	$8.49
Rate for Payer: Cofinity Medicare Advantage	$9.44
Rate for Payer: Cofinity Medicare Advantage	$14.46
Rate for Payer: Encore Health Key Benefits Commercial	$124.12
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	$10.92
Rate for Payer: Healthscope Commercial	$18.59
Rate for Payer: Healthscope Commercial	$12.14
Rate for Payer: Healthscope Commercial	$139.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$131.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.31
Rate for Payer: PHP Commercial	$11.47
Rate for Payer: PHP Commercial	$17.55
Rate for Payer: PHP Commercial	$131.88
Rate for Payer: PHP Commercial	$10.31
Rate for Payer: Priority Health Cigna Priority Health	$8.77
Rate for Payer: Priority Health Cigna Priority Health	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$7.88
Rate for Payer: Priority Health Cigna Priority Health	$13.42
Rate for Payer: Priority Health SBD	$7.64
Rate for Payer: Priority Health SBD	$97.74
Rate for Payer: Priority Health SBD	$8.50
Rate for Payer: Priority Health SBD	$13.01

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID

Facility

$312.48

Service Code	NDC 00054319446
Hospital Charge Code	2515
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 Commercial	$218.74
Rate for Payer: Cofinity Commercial	$268.73
Rate for Payer: Cofinity Medicare Advantage	$218.74
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: PHP Commercial	$265.61
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: Priority Health SBD	$196.86

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID

Facility

$312.48

Service Code	NDC 00054319446
Hospital Charge Code	2515
Hospital Revenue Code	637
Min. Negotiated Rate	$124.99
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 Commercial	$218.74
Rate for Payer: Cofinity Commercial	$268.73
Rate for Payer: Cofinity Medicare Advantage	$218.74
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: PHP Commercial	$265.61
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: Priority Health SBD	$196.86

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$312.48

Service Code	NDC 00378041501
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$124.99
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 Commercial	$218.74
Rate for Payer: Cofinity Commercial	$268.73
Rate for Payer: Cofinity Medicare Advantage	$218.74
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: PHP Commercial	$265.61
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: Priority Health SBD	$196.86

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$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 Commercial	$254.03
Rate for Payer: Cofinity Commercial	$312.09
Rate for Payer: Cofinity Medicare Advantage	$254.03
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: PHP Commercial	$308.46
Rate for Payer: Priority Health Cigna Priority Health	$235.88
Rate for Payer: Priority Health SBD	$228.63

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$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 Commercial	$218.74
Rate for Payer: Cofinity Commercial	$268.73
Rate for Payer: Cofinity Medicare Advantage	$218.74
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: PHP Commercial	$265.61
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: Priority Health SBD	$196.86

Know your out-of-pocket cost for care.

All Charges