|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
OP
|
$88.20
|
|
|
Service Code
|
NDC 00904205159
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna Medicare |
$22.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.56
|
| Rate for Payer: BCBS Complete |
$35.28
|
| Rate for Payer: BCBS MAPPO |
$22.05
|
| Rate for Payer: BCBS Trust/PPO |
$72.51
|
| Rate for Payer: BCN Commercial |
$68.58
|
| Rate for Payer: BCN Medicare Advantage |
$22.05
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.05
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: Nomi Health Commercial |
$72.32
|
| Rate for Payer: PACE Senior Care Partners |
$20.95
|
| Rate for Payer: PACE SWMI |
$22.05
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: PHP Medicare Advantage |
$22.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health HMO/PPO |
$76.73
|
| Rate for Payer: Priority Health Medicare |
$22.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.09
|
| Rate for Payer: Railroad Medicare Medicare |
$22.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.62
|
| Rate for Payer: UHC Core |
$73.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.05
|
| Rate for Payer: UHC Exchange |
$22.05
|
| Rate for Payer: UHC Medicare Advantage |
$22.05
|
| Rate for Payer: VA VA |
$22.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 00904205159
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.33 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: BCBS Trust/PPO |
$72.00
|
| Rate for Payer: BCN Commercial |
$68.16
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: Nomi Health Commercial |
$72.32
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health HMO/PPO |
$76.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.62
|
| Rate for Payer: UHC Core |
$73.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$426.37
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.14 |
| Max. Negotiated Rate |
$383.73 |
| Rate for Payer: Aetna Commercial |
$362.41
|
| Rate for Payer: BCBS Trust/PPO |
$348.05
|
| Rate for Payer: BCN Commercial |
$329.50
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cofinity Commercial |
$366.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.10
|
| Rate for Payer: Healthscope Commercial |
$383.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.41
|
| Rate for Payer: Nomi Health Commercial |
$349.62
|
| Rate for Payer: PHP Commercial |
$362.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.14
|
| Rate for Payer: Priority Health HMO/PPO |
$370.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$285.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$375.21
|
| Rate for Payer: UHC Core |
$356.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.78
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$426.37
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.26 |
| Max. Negotiated Rate |
$383.73 |
| Rate for Payer: Aetna Commercial |
$362.41
|
| Rate for Payer: Aetna Medicare |
$110.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$133.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$133.24
|
| Rate for Payer: BCBS Complete |
$170.55
|
| Rate for Payer: BCBS MAPPO |
$106.59
|
| Rate for Payer: BCBS Trust/PPO |
$350.52
|
| Rate for Payer: BCN Commercial |
$331.50
|
| Rate for Payer: BCN Medicare Advantage |
$106.59
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cofinity Commercial |
$366.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106.59
|
| Rate for Payer: Healthscope Commercial |
$383.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$111.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.41
|
| Rate for Payer: Nomi Health Commercial |
$349.62
|
| Rate for Payer: PACE Senior Care Partners |
$101.26
|
| Rate for Payer: PACE SWMI |
$106.59
|
| Rate for Payer: PHP Commercial |
$362.41
|
| Rate for Payer: PHP Medicare Advantage |
$106.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.14
|
| Rate for Payer: Priority Health HMO/PPO |
$370.94
|
| Rate for Payer: Priority Health Medicare |
$107.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$285.67
|
| Rate for Payer: Railroad Medicare Medicare |
$106.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$375.21
|
| Rate for Payer: UHC Core |
$356.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$106.59
|
| Rate for Payer: UHC Exchange |
$106.59
|
| Rate for Payer: UHC Medicare Advantage |
$106.59
|
| Rate for Payer: VA VA |
$106.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.78
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$13.55
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Aetna Commercial |
$11.52
|
| Rate for Payer: Aetna Medicare |
$3.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.23
|
| Rate for Payer: BCBS Complete |
$5.42
|
| Rate for Payer: BCBS MAPPO |
$3.39
|
| Rate for Payer: BCBS Trust/PPO |
$11.14
|
| Rate for Payer: BCN Commercial |
$10.54
|
| Rate for Payer: BCN Medicare Advantage |
$3.39
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cofinity Commercial |
$11.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.39
|
| Rate for Payer: Healthscope Commercial |
$12.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.52
|
| Rate for Payer: Nomi Health Commercial |
$11.11
|
| Rate for Payer: PACE Senior Care Partners |
$3.22
|
| Rate for Payer: PACE SWMI |
$3.39
|
| Rate for Payer: PHP Commercial |
$11.52
|
| Rate for Payer: PHP Medicare Advantage |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.81
|
| Rate for Payer: Priority Health HMO/PPO |
$11.79
|
| Rate for Payer: Priority Health Medicare |
$3.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.08
|
| Rate for Payer: Railroad Medicare Medicare |
$3.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.92
|
| Rate for Payer: UHC Core |
$11.31
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.39
|
| Rate for Payer: UHC Exchange |
$3.39
|
| Rate for Payer: UHC Medicare Advantage |
$3.39
|
| Rate for Payer: VA VA |
$3.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.16
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$13.55
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Aetna Commercial |
$11.52
|
| Rate for Payer: BCBS Trust/PPO |
$11.06
|
| Rate for Payer: BCN Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cofinity Commercial |
$11.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.84
|
| Rate for Payer: Healthscope Commercial |
$12.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.52
|
| Rate for Payer: Nomi Health Commercial |
$11.11
|
| Rate for Payer: PHP Commercial |
$11.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.81
|
| Rate for Payer: Priority Health HMO/PPO |
$11.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.92
|
| Rate for Payer: UHC Core |
$11.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.16
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: BCBS Trust/PPO |
$1.17
|
| Rate for Payer: BCN Commercial |
$1.11
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.22
|
| Rate for Payer: Nomi Health Commercial |
$1.17
|
| Rate for Payer: PHP Commercial |
$1.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.93
|
| Rate for Payer: Priority Health HMO/PPO |
$1.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.26
|
| Rate for Payer: UHC Core |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$85.68
|
| Rate for Payer: Aetna Medicare |
$26.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.50
|
| Rate for Payer: BCBS Complete |
$40.32
|
| Rate for Payer: BCBS MAPPO |
$25.20
|
| Rate for Payer: BCBS Trust/PPO |
$82.87
|
| Rate for Payer: BCN Commercial |
$78.37
|
| Rate for Payer: BCN Medicare Advantage |
$25.20
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$86.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$90.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.68
|
| Rate for Payer: Nomi Health Commercial |
$82.66
|
| Rate for Payer: PACE Senior Care Partners |
$23.94
|
| Rate for Payer: PACE SWMI |
$25.20
|
| Rate for Payer: PHP Commercial |
$85.68
|
| Rate for Payer: PHP Medicare Advantage |
$25.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.52
|
| Rate for Payer: Priority Health HMO/PPO |
$87.70
|
| Rate for Payer: Priority Health Medicare |
$25.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.54
|
| Rate for Payer: Railroad Medicare Medicare |
$25.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.70
|
| Rate for Payer: UHC Core |
$84.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$25.20
|
| Rate for Payer: UHC Exchange |
$25.20
|
| Rate for Payer: UHC Medicare Advantage |
$25.20
|
| Rate for Payer: VA VA |
$25.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$142.80
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.91 |
| Max. Negotiated Rate |
$128.52 |
| Rate for Payer: Aetna Commercial |
$121.38
|
| Rate for Payer: Aetna Medicare |
$37.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44.62
|
| Rate for Payer: BCBS Complete |
$57.12
|
| Rate for Payer: BCBS MAPPO |
$35.70
|
| Rate for Payer: BCBS Trust/PPO |
$117.40
|
| Rate for Payer: BCN Commercial |
$111.03
|
| Rate for Payer: BCN Medicare Advantage |
$35.70
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$122.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.70
|
| Rate for Payer: Healthscope Commercial |
$128.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$37.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.38
|
| Rate for Payer: Nomi Health Commercial |
$117.10
|
| Rate for Payer: PACE Senior Care Partners |
$33.91
|
| Rate for Payer: PACE SWMI |
$35.70
|
| Rate for Payer: PHP Commercial |
$121.38
|
| Rate for Payer: PHP Medicare Advantage |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.82
|
| Rate for Payer: Priority Health HMO/PPO |
$124.24
|
| Rate for Payer: Priority Health Medicare |
$36.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$95.68
|
| Rate for Payer: Railroad Medicare Medicare |
$35.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.66
|
| Rate for Payer: UHC Core |
$119.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$35.70
|
| Rate for Payer: UHC Exchange |
$35.70
|
| Rate for Payer: UHC Medicare Advantage |
$35.70
|
| Rate for Payer: VA VA |
$35.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$142.80
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.82 |
| Max. Negotiated Rate |
$128.52 |
| Rate for Payer: Aetna Commercial |
$121.38
|
| Rate for Payer: BCBS Trust/PPO |
$116.57
|
| Rate for Payer: BCN Commercial |
$110.36
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$122.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Healthscope Commercial |
$128.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.38
|
| Rate for Payer: Nomi Health Commercial |
$117.10
|
| Rate for Payer: PHP Commercial |
$121.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.82
|
| Rate for Payer: Priority Health HMO/PPO |
$124.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$95.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.66
|
| Rate for Payer: UHC Core |
$119.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.45
|
| Rate for Payer: BCBS Complete |
$0.57
|
| Rate for Payer: BCBS MAPPO |
$0.36
|
| Rate for Payer: BCBS Trust/PPO |
$1.18
|
| Rate for Payer: BCN Commercial |
$1.11
|
| Rate for Payer: BCN Medicare Advantage |
$0.36
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.36
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.22
|
| Rate for Payer: Nomi Health Commercial |
$1.17
|
| Rate for Payer: PACE Senior Care Partners |
$0.34
|
| Rate for Payer: PACE SWMI |
$0.36
|
| Rate for Payer: PHP Commercial |
$1.22
|
| Rate for Payer: PHP Medicare Advantage |
$0.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.93
|
| Rate for Payer: Priority Health HMO/PPO |
$1.24
|
| Rate for Payer: Priority Health Medicare |
$0.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.96
|
| Rate for Payer: Railroad Medicare Medicare |
$0.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.26
|
| Rate for Payer: UHC Core |
$1.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.36
|
| Rate for Payer: UHC Exchange |
$0.36
|
| Rate for Payer: UHC Medicare Advantage |
$0.36
|
| Rate for Payer: VA VA |
$0.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$85.68
|
| Rate for Payer: BCBS Trust/PPO |
$82.28
|
| Rate for Payer: BCN Commercial |
$77.90
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$86.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Healthscope Commercial |
$90.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.68
|
| Rate for Payer: Nomi Health Commercial |
$82.66
|
| Rate for Payer: PHP Commercial |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.52
|
| Rate for Payer: Priority Health HMO/PPO |
$87.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.70
|
| Rate for Payer: UHC Core |
$84.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Medicare |
$3.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.79
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS MAPPO |
$3.03
|
| Rate for Payer: BCBS Trust/PPO |
$9.97
|
| Rate for Payer: BCN Commercial |
$9.43
|
| Rate for Payer: BCN Medicare Advantage |
$3.03
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.03
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: PACE Senior Care Partners |
$2.88
|
| Rate for Payer: PACE SWMI |
$3.03
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Medicare Advantage |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Medicare |
$3.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.13
|
| Rate for Payer: Railroad Medicare Medicare |
$3.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.03
|
| Rate for Payer: UHC Exchange |
$3.03
|
| Rate for Payer: UHC Medicare Advantage |
$3.03
|
| Rate for Payer: VA VA |
$3.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
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 |
$7.88 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: BCBS Trust/PPO |
$9.90
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: BCBS Trust/PPO |
$9.90
|
| Rate for Payer: BCBS Trust/PPO |
$16.86
|
| Rate for Payer: BCBS Trust/PPO |
$11.01
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: BCN Commercial |
$15.96
|
| Rate for Payer: BCN Commercial |
$10.43
|
| Rate for Payer: Cash Price |
$10.79
|
| 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 |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| 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 |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.77
|
| 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 HMO/PPO |
$17.97
|
| Rate for Payer: Priority Health HMO/PPO |
$11.74
|
| Rate for Payer: Priority Health HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.17
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Core |
$11.26
|
| Rate for Payer: UHC Core |
$17.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$5.37
|
| Rate for Payer: Aetna Medicare |
$3.15
|
| Rate for Payer: Aetna Medicare |
$3.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.45
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS MAPPO |
$5.16
|
| Rate for Payer: BCBS MAPPO |
$3.03
|
| Rate for Payer: BCBS MAPPO |
$3.37
|
| Rate for Payer: BCBS Trust/PPO |
$11.09
|
| Rate for Payer: BCBS Trust/PPO |
$9.97
|
| Rate for Payer: BCBS Trust/PPO |
$16.98
|
| Rate for Payer: BCN Commercial |
$10.49
|
| Rate for Payer: BCN Commercial |
$16.06
|
| Rate for Payer: BCN Commercial |
$9.43
|
| Rate for Payer: BCN Medicare Advantage |
$3.03
|
| Rate for Payer: BCN Medicare Advantage |
$3.37
|
| Rate for Payer: BCN Medicare Advantage |
$5.16
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.37
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.03
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.94
|
| 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: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: PACE Senior Care Partners |
$4.90
|
| Rate for Payer: PACE Senior Care Partners |
$2.88
|
| Rate for Payer: PACE Senior Care Partners |
$3.20
|
| Rate for Payer: PACE SWMI |
$3.37
|
| Rate for Payer: PACE SWMI |
$3.03
|
| Rate for Payer: PACE SWMI |
$5.16
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Medicare Advantage |
$3.37
|
| Rate for Payer: PHP Medicare Advantage |
$5.16
|
| Rate for Payer: PHP Medicare Advantage |
$3.03
|
| 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 Cigna Priority Health |
$8.77
|
| Rate for Payer: Priority Health HMO/PPO |
$17.97
|
| Rate for Payer: Priority Health HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health HMO/PPO |
$11.74
|
| Rate for Payer: Priority Health Medicare |
$3.06
|
| Rate for Payer: Priority Health Medicare |
$5.21
|
| Rate for Payer: Priority Health Medicare |
$3.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.13
|
| Rate for Payer: Railroad Medicare Medicare |
$3.37
|
| Rate for Payer: Railroad Medicare Medicare |
$5.16
|
| Rate for Payer: Railroad Medicare Medicare |
$3.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$17.24
|
| Rate for Payer: UHC Core |
$11.26
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.37
|
| Rate for Payer: UHC Exchange |
$3.37
|
| Rate for Payer: UHC Exchange |
$3.03
|
| Rate for Payer: UHC Exchange |
$5.16
|
| Rate for Payer: UHC Medicare Advantage |
$3.03
|
| Rate for Payer: UHC Medicare Advantage |
$3.37
|
| Rate for Payer: UHC Medicare Advantage |
$5.16
|
| Rate for Payer: VA VA |
$3.37
|
| Rate for Payer: VA VA |
$5.16
|
| Rate for Payer: VA VA |
$3.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$20.51
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: BCBS Trust/PPO |
$16.74
|
| Rate for Payer: BCN Commercial |
$15.85
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.41
|
| Rate for Payer: Healthscope Commercial |
$18.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.82
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.33
|
| Rate for Payer: Priority Health HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.05
|
| Rate for Payer: UHC Core |
$17.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.38
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$20.51
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: Aetna Medicare |
$5.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.41
|
| Rate for Payer: BCBS Complete |
$8.20
|
| Rate for Payer: BCBS MAPPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$16.86
|
| Rate for Payer: BCN Commercial |
$15.95
|
| Rate for Payer: BCN Medicare Advantage |
$5.13
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.13
|
| Rate for Payer: Healthscope Commercial |
$18.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.82
|
| Rate for Payer: PACE Senior Care Partners |
$4.87
|
| Rate for Payer: PACE SWMI |
$5.13
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: PHP Medicare Advantage |
$5.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.33
|
| Rate for Payer: Priority Health HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Medicare |
$5.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.74
|
| Rate for Payer: Railroad Medicare Medicare |
$5.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.05
|
| Rate for Payer: UHC Core |
$17.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.13
|
| Rate for Payer: UHC Exchange |
$5.13
|
| Rate for Payer: UHC Medicare Advantage |
$5.13
|
| Rate for Payer: VA VA |
$5.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.38
|
|
|
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 |
$203.11 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: BCBS Trust/PPO |
$255.08
|
| Rate for Payer: BCN Commercial |
$241.48
|
| Rate for Payer: Cash Price |
$249.98
|
| 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: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.98
|
| Rate for Payer: UHC Core |
$260.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
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 |
$74.21 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$81.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$97.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$97.65
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: BCBS MAPPO |
$78.12
|
| Rate for Payer: BCBS Trust/PPO |
$256.89
|
| Rate for Payer: BCN Commercial |
$242.95
|
| Rate for Payer: BCN Medicare Advantage |
$78.12
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: PACE Senior Care Partners |
$74.21
|
| Rate for Payer: PACE SWMI |
$78.12
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: PHP Medicare Advantage |
$78.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Medicare |
$78.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.36
|
| Rate for Payer: Railroad Medicare Medicare |
$78.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.98
|
| Rate for Payer: UHC Core |
$260.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.12
|
| Rate for Payer: UHC Exchange |
$78.12
|
| Rate for Payer: UHC Medicare Advantage |
$78.12
|
| Rate for Payer: VA VA |
$78.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
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 |
$270.37 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: BCBS Trust/PPO |
$339.54
|
| Rate for Payer: BCN Commercial |
$321.45
|
| Rate for Payer: Cash Price |
$332.76
|
| 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: Lakeland Regional Health Systems Commercial |
$311.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Nomi Health Commercial |
$341.08
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.37
|
| Rate for Payer: Priority Health HMO/PPO |
$361.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$278.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.04
|
| Rate for Payer: UHC Core |
$347.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.96
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.43 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: BCBS Trust/PPO |
$240.40
|
| Rate for Payer: BCN Commercial |
$227.59
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.43
|
| Rate for Payer: Priority Health HMO/PPO |
$256.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$197.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$259.16
|
| Rate for Payer: UHC Core |
$245.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.94 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna Medicare |
$76.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$92.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$92.03
|
| Rate for Payer: BCBS Complete |
$117.80
|
| Rate for Payer: BCBS MAPPO |
$73.62
|
| Rate for Payer: BCBS Trust/PPO |
$242.11
|
| Rate for Payer: BCN Commercial |
$228.97
|
| Rate for Payer: BCN Medicare Advantage |
$73.62
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$73.62
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$77.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$84.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: PACE Senior Care Partners |
$69.94
|
| Rate for Payer: PACE SWMI |
$73.62
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: PHP Medicare Advantage |
$73.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.43
|
| Rate for Payer: Priority Health HMO/PPO |
$256.21
|
| Rate for Payer: Priority Health Medicare |
$74.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$197.31
|
| Rate for Payer: Railroad Medicare Medicare |
$73.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$259.16
|
| Rate for Payer: UHC Core |
$245.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$73.62
|
| Rate for Payer: UHC Exchange |
$73.62
|
| Rate for Payer: UHC Medicare Advantage |
$73.62
|
| Rate for Payer: VA VA |
$73.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
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 |
$235.88 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: BCBS Trust/PPO |
$296.24
|
| Rate for Payer: BCN Commercial |
$280.45
|
| Rate for Payer: Cash Price |
$290.32
|
| 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: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$319.35
|
| Rate for Payer: UHC Core |
$303.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
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 |
$86.19 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna Medicare |
$94.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$113.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$113.41
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: BCBS MAPPO |
$90.72
|
| Rate for Payer: BCBS Trust/PPO |
$298.34
|
| Rate for Payer: BCN Commercial |
$282.15
|
| Rate for Payer: BCN Medicare Advantage |
$90.72
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.72
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$95.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: PACE Senior Care Partners |
$86.19
|
| Rate for Payer: PACE SWMI |
$90.72
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: PHP Medicare Advantage |
$90.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Medicare |
$91.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.14
|
| Rate for Payer: Railroad Medicare Medicare |
$90.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$319.35
|
| Rate for Payer: UHC Core |
$303.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.72
|
| Rate for Payer: UHC Exchange |
$90.72
|
| Rate for Payer: UHC Medicare Advantage |
$90.72
|
| Rate for Payer: VA VA |
$90.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
