DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$178.23
|
|
Service Code
|
NDC 54838-135-70
|
Hospital Charge Code |
12556
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$78.42 |
Max. Negotiated Rate |
$160.41 |
Rate for Payer: Aetna American Axle |
$115.85
|
Rate for Payer: Aetna Commercial |
$151.50
|
Rate for Payer: Aetna New Business (MI Preferred) |
$115.85
|
Rate for Payer: Cash Price |
$142.58
|
Rate for Payer: Cofinity Commercial |
$153.28
|
Rate for Payer: Cofinity Commercial |
$124.76
|
Rate for Payer: Encore Health Key Benefits Commercial |
$142.58
|
Rate for Payer: Healthscope Commercial |
$160.41
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.76
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.67
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.50
|
Rate for Payer: PHP Commercial |
$151.50
|
Rate for Payer: Priority Health Cigna Priority Health |
$124.76
|
Rate for Payer: Priority Health SBD |
$112.28
|
Rate for Payer: UMR Bronson Commercial |
$78.42
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.67
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$14.06
|
|
Service Code
|
NDC 68094-022-62
|
Hospital Charge Code |
12556
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$6.19 |
Max. Negotiated Rate |
$12.65 |
Rate for Payer: Aetna American Axle |
$9.14
|
Rate for Payer: Aetna Commercial |
$11.95
|
Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
Rate for Payer: Cash Price |
$11.25
|
Rate for Payer: Cofinity Commercial |
$12.09
|
Rate for Payer: Cofinity Commercial |
$9.84
|
Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
Rate for Payer: Healthscope Commercial |
$12.65
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.95
|
Rate for Payer: PHP Commercial |
$11.95
|
Rate for Payer: Priority Health Cigna Priority Health |
$9.84
|
Rate for Payer: Priority Health SBD |
$8.86
|
Rate for Payer: UMR Bronson Commercial |
$6.19
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$16.53
|
|
Service Code
|
NDC 69339-151-05
|
Hospital Charge Code |
12556
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$6.12 |
Max. Negotiated Rate |
$14.88 |
Rate for Payer: Aetna American Axle |
$10.74
|
Rate for Payer: Aetna Commercial |
$14.05
|
Rate for Payer: Aetna New Business (MI Preferred) |
$10.74
|
Rate for Payer: BCBS Complete |
$6.61
|
Rate for Payer: Cash Price |
$13.22
|
Rate for Payer: Cofinity Commercial |
$11.57
|
Rate for Payer: Cofinity Commercial |
$14.22
|
Rate for Payer: Encore Health Key Benefits Commercial |
$13.22
|
Rate for Payer: Healthscope Commercial |
$14.88
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.57
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.40
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.05
|
Rate for Payer: PHP Commercial |
$14.05
|
Rate for Payer: Priority Health Cigna Priority Health |
$11.57
|
Rate for Payer: Priority Health SBD |
$10.41
|
Rate for Payer: UMR Bronson Commercial |
$6.12
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.40
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
Service Code
|
NDC 68094-022-59
|
Hospital Charge Code |
12556
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$5.20 |
Max. Negotiated Rate |
$12.65 |
Rate for Payer: Aetna American Axle |
$9.14
|
Rate for Payer: Aetna Commercial |
$11.95
|
Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
Rate for Payer: BCBS Complete |
$5.62
|
Rate for Payer: Cash Price |
$11.25
|
Rate for Payer: Cofinity Commercial |
$12.09
|
Rate for Payer: Cofinity Commercial |
$9.84
|
Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
Rate for Payer: Healthscope Commercial |
$12.65
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.95
|
Rate for Payer: PHP Commercial |
$11.95
|
Rate for Payer: Priority Health Cigna Priority Health |
$9.84
|
Rate for Payer: Priority Health SBD |
$8.86
|
Rate for Payer: UMR Bronson Commercial |
$5.20
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
DIPHENHYDRAMINE 12.5 MG CUSTOM TAB
|
Facility
|
OP
|
$5.52
|
|
Service Code
|
NDC 9900-0009-82
|
Hospital Charge Code |
181103
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2.04 |
Max. Negotiated Rate |
$4.97 |
Rate for Payer: Aetna American Axle |
$3.59
|
Rate for Payer: Aetna Commercial |
$4.69
|
Rate for Payer: Aetna New Business (MI Preferred) |
$3.59
|
Rate for Payer: BCBS Complete |
$2.21
|
Rate for Payer: Cash Price |
$4.42
|
Rate for Payer: Cofinity Commercial |
$3.86
|
Rate for Payer: Cofinity Commercial |
$4.75
|
Rate for Payer: Encore Health Key Benefits Commercial |
$4.42
|
Rate for Payer: Healthscope Commercial |
$4.97
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.86
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.14
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.69
|
Rate for Payer: PHP Commercial |
$4.69
|
Rate for Payer: Priority Health Cigna Priority Health |
$3.86
|
Rate for Payer: Priority Health SBD |
$3.48
|
Rate for Payer: UMR Bronson Commercial |
$2.04
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.14
|
|
DIPHENHYDRAMINE 12.5 MG CUSTOM TAB
|
Facility
|
IP
|
$5.52
|
|
Service Code
|
NDC 9900-0009-82
|
Hospital Charge Code |
181103
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2.43 |
Max. Negotiated Rate |
$4.97 |
Rate for Payer: Aetna American Axle |
$3.59
|
Rate for Payer: Aetna Commercial |
$4.69
|
Rate for Payer: Aetna New Business (MI Preferred) |
$3.59
|
Rate for Payer: Cash Price |
$4.42
|
Rate for Payer: Cofinity Commercial |
$3.86
|
Rate for Payer: Cofinity Commercial |
$4.75
|
Rate for Payer: Encore Health Key Benefits Commercial |
$4.42
|
Rate for Payer: Healthscope Commercial |
$4.97
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.86
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.14
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.69
|
Rate for Payer: PHP Commercial |
$4.69
|
Rate for Payer: Priority Health Cigna Priority Health |
$3.86
|
Rate for Payer: Priority Health SBD |
$3.48
|
Rate for Payer: UMR Bronson Commercial |
$2.43
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.14
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$7.52
|
|
Service Code
|
NDC 0904-5306-61
|
Hospital Charge Code |
2509
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$3.31 |
Max. Negotiated Rate |
$6.77 |
Rate for Payer: Aetna American Axle |
$4.89
|
Rate for Payer: Aetna Commercial |
$6.39
|
Rate for Payer: Aetna New Business (MI Preferred) |
$4.89
|
Rate for Payer: Cash Price |
$6.02
|
Rate for Payer: Cofinity Commercial |
$5.26
|
Rate for Payer: Cofinity Commercial |
$6.47
|
Rate for Payer: Encore Health Key Benefits Commercial |
$6.02
|
Rate for Payer: Healthscope Commercial |
$6.77
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.26
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.64
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.39
|
Rate for Payer: PHP Commercial |
$6.39
|
Rate for Payer: Priority Health Cigna Priority Health |
$5.26
|
Rate for Payer: Priority Health SBD |
$4.74
|
Rate for Payer: UMR Bronson Commercial |
$3.31
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.64
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
OP
|
$7.52
|
|
Service Code
|
NDC 0904-5306-61
|
Hospital Charge Code |
2509
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2.78 |
Max. Negotiated Rate |
$6.77 |
Rate for Payer: Aetna American Axle |
$4.89
|
Rate for Payer: Aetna Commercial |
$6.39
|
Rate for Payer: Aetna New Business (MI Preferred) |
$4.89
|
Rate for Payer: BCBS Complete |
$3.01
|
Rate for Payer: Cash Price |
$6.02
|
Rate for Payer: Cofinity Commercial |
$5.26
|
Rate for Payer: Cofinity Commercial |
$6.47
|
Rate for Payer: Encore Health Key Benefits Commercial |
$6.02
|
Rate for Payer: Healthscope Commercial |
$6.77
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.26
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.64
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.39
|
Rate for Payer: PHP Commercial |
$6.39
|
Rate for Payer: Priority Health Cigna Priority Health |
$5.26
|
Rate for Payer: Priority Health SBD |
$4.74
|
Rate for Payer: UMR Bronson Commercial |
$2.78
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.64
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
OP
|
$84.60
|
|
Service Code
|
NDC 0904-7237-61
|
Hospital Charge Code |
2509
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$31.30 |
Max. Negotiated Rate |
$76.14 |
Rate for Payer: Aetna American Axle |
$54.99
|
Rate for Payer: Aetna Commercial |
$71.91
|
Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
Rate for Payer: BCBS Complete |
$33.84
|
Rate for Payer: Cash Price |
$67.68
|
Rate for Payer: Cofinity Commercial |
$72.76
|
Rate for Payer: Cofinity Commercial |
$59.22
|
Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
Rate for Payer: Healthscope Commercial |
$76.14
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
Rate for Payer: PHP Commercial |
$71.91
|
Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
Rate for Payer: Priority Health SBD |
$53.30
|
Rate for Payer: UMR Bronson Commercial |
$31.30
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$84.60
|
|
Service Code
|
NDC 0904-7237-61
|
Hospital Charge Code |
2509
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$37.22 |
Max. Negotiated Rate |
$76.14 |
Rate for Payer: Aetna American Axle |
$54.99
|
Rate for Payer: Aetna Commercial |
$71.91
|
Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
Rate for Payer: Cash Price |
$67.68
|
Rate for Payer: Cofinity Commercial |
$59.22
|
Rate for Payer: Cofinity Commercial |
$72.76
|
Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
Rate for Payer: Healthscope Commercial |
$76.14
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
Rate for Payer: PHP Commercial |
$71.91
|
Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
Rate for Payer: Priority Health SBD |
$53.30
|
Rate for Payer: UMR Bronson Commercial |
$37.22
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
Service Code
|
NDC 0904-5551-59
|
Hospital Charge Code |
2505
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$44.35 |
Max. Negotiated Rate |
$90.72 |
Rate for Payer: Aetna American Axle |
$65.52
|
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: Encore Health Key Benefits Commercial |
$80.64
|
Rate for Payer: Healthscope Commercial |
$90.72
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.56
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.68
|
Rate for Payer: PHP Commercial |
$85.68
|
Rate for Payer: Priority Health Cigna Priority Health |
$70.56
|
Rate for Payer: Priority Health SBD |
$63.50
|
Rate for Payer: UMR Bronson Commercial |
$44.35
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
Service Code
|
NDC 68094-018-59
|
Hospital Charge Code |
2505
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.63 |
Max. Negotiated Rate |
$1.29 |
Rate for Payer: Aetna American Axle |
$0.93
|
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: Encore Health Key Benefits Commercial |
$1.14
|
Rate for Payer: Healthscope Commercial |
$1.29
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.00
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.22
|
Rate for Payer: PHP Commercial |
$1.22
|
Rate for Payer: Priority Health Cigna Priority Health |
$1.00
|
Rate for Payer: Priority Health SBD |
$0.90
|
Rate for Payer: UMR Bronson Commercial |
$0.63
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$170.10
|
|
Service Code
|
NDC 9629512933
|
Hospital Charge Code |
2505
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$74.84 |
Max. Negotiated Rate |
$153.09 |
Rate for Payer: Aetna American Axle |
$110.56
|
Rate for Payer: Aetna Commercial |
$144.58
|
Rate for Payer: Aetna New Business (MI Preferred) |
$110.56
|
Rate for Payer: Cash Price |
$136.08
|
Rate for Payer: Cofinity Commercial |
$119.07
|
Rate for Payer: Cofinity Commercial |
$146.29
|
Rate for Payer: Encore Health Key Benefits Commercial |
$136.08
|
Rate for Payer: Healthscope Commercial |
$153.09
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.07
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.58
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.58
|
Rate for Payer: PHP Commercial |
$144.58
|
Rate for Payer: Priority Health Cigna Priority Health |
$119.07
|
Rate for Payer: Priority Health SBD |
$107.16
|
Rate for Payer: UMR Bronson Commercial |
$74.84
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.58
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$142.80
|
|
Service Code
|
NDC 68094-018-61
|
Hospital Charge Code |
2505
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$62.83 |
Max. Negotiated Rate |
$128.52 |
Rate for Payer: Aetna American Axle |
$92.82
|
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: Encore Health Key Benefits Commercial |
$114.24
|
Rate for Payer: Healthscope Commercial |
$128.52
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.96
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.38
|
Rate for Payer: PHP Commercial |
$121.38
|
Rate for Payer: Priority Health Cigna Priority Health |
$99.96
|
Rate for Payer: Priority Health SBD |
$89.96
|
Rate for Payer: UMR Bronson Commercial |
$62.83
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
DIPHENHYDRAMINE 50 MG CAPSULE
|
Facility
|
OP
|
$98.70
|
|
Service Code
|
HCPCS Q0163
|
Hospital Charge Code |
2510
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.32 |
Max. Negotiated Rate |
$88.83 |
Rate for Payer: Aetna American Axle |
$64.16
|
Rate for Payer: Aetna Commercial |
$83.90
|
Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
Rate for Payer: BCBS Complete |
$39.48
|
Rate for Payer: BCBS Trust/PPO |
$0.32
|
Rate for Payer: Cash Price |
$78.96
|
Rate for Payer: Cash Price |
$78.96
|
Rate for Payer: Cofinity Commercial |
$69.09
|
Rate for Payer: Cofinity Commercial |
$84.88
|
Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
Rate for Payer: Healthscope Commercial |
$88.83
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
Rate for Payer: PHP Commercial |
$83.90
|
Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
Rate for Payer: Priority Health SBD |
$62.18
|
Rate for Payer: UMR Bronson Commercial |
$36.52
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
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 |
$5.34 |
Max. Negotiated Rate |
$10.92 |
Rate for Payer: Aetna American Axle |
$7.88
|
Rate for Payer: Aetna American Axle |
$13.42
|
Rate for Payer: Aetna Commercial |
$17.55
|
Rate for Payer: Aetna Commercial |
$10.31
|
Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
Rate for Payer: Cash Price |
$16.52
|
Rate for Payer: Cash Price |
$9.70
|
Rate for Payer: Cofinity Commercial |
$14.46
|
Rate for Payer: Cofinity Commercial |
$17.76
|
Rate for Payer: Cofinity Commercial |
$10.43
|
Rate for Payer: Cofinity Commercial |
$8.49
|
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 |
$18.58
|
Rate for Payer: Healthscope Commercial |
$10.92
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.31
|
Rate for Payer: PHP Commercial |
$10.31
|
Rate for Payer: PHP Commercial |
$17.55
|
Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
Rate for Payer: Priority Health Cigna Priority Health |
$8.49
|
Rate for Payer: Priority Health SBD |
$13.01
|
Rate for Payer: Priority Health SBD |
$7.64
|
Rate for Payer: UMR Bronson Commercial |
$5.34
|
Rate for Payer: UMR Bronson Commercial |
$9.09
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
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 |
$2.57 |
Max. Negotiated Rate |
$10.92 |
Rate for Payer: Aetna American Axle |
$7.88
|
Rate for Payer: Aetna American Axle |
$70.31
|
Rate for Payer: Aetna American Axle |
$13.42
|
Rate for Payer: Aetna Commercial |
$91.94
|
Rate for Payer: Aetna Commercial |
$10.31
|
Rate for Payer: Aetna Commercial |
$17.55
|
Rate for Payer: Aetna New Business (MI Preferred) |
$70.31
|
Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
Rate for Payer: BCBS Complete |
$4.85
|
Rate for Payer: BCBS Complete |
$43.27
|
Rate for Payer: BCBS Complete |
$8.26
|
Rate for Payer: BCBS Trust/PPO |
$2.57
|
Rate for Payer: BCBS Trust/PPO |
$2.57
|
Rate for Payer: BCBS Trust/PPO |
$2.57
|
Rate for Payer: Cash Price |
$9.70
|
Rate for Payer: Cash Price |
$86.54
|
Rate for Payer: Cash Price |
$86.54
|
Rate for Payer: Cash Price |
$16.52
|
Rate for Payer: Cash Price |
$16.52
|
Rate for Payer: Cash Price |
$9.70
|
Rate for Payer: Cofinity Commercial |
$8.49
|
Rate for Payer: Cofinity Commercial |
$75.72
|
Rate for Payer: Cofinity Commercial |
$93.03
|
Rate for Payer: Cofinity Commercial |
$10.43
|
Rate for Payer: Cofinity Commercial |
$14.46
|
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 |
$86.54
|
Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
Rate for Payer: Healthscope Commercial |
$97.35
|
Rate for Payer: Healthscope Commercial |
$18.58
|
Rate for Payer: Healthscope Commercial |
$10.92
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.72
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.13
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.31
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.94
|
Rate for Payer: PHP Commercial |
$91.94
|
Rate for Payer: PHP Commercial |
$10.31
|
Rate for Payer: PHP Commercial |
$17.55
|
Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
Rate for Payer: Priority Health Cigna Priority Health |
$8.49
|
Rate for Payer: Priority Health Cigna Priority Health |
$75.72
|
Rate for Payer: Priority Health SBD |
$68.15
|
Rate for Payer: Priority Health SBD |
$7.64
|
Rate for Payer: Priority Health SBD |
$13.01
|
Rate for Payer: UMR Bronson Commercial |
$40.02
|
Rate for Payer: UMR Bronson Commercial |
$4.49
|
Rate for Payer: UMR Bronson Commercial |
$7.64
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.13
|
|
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 |
$5.34 |
Max. Negotiated Rate |
$10.92 |
Rate for Payer: Aetna American Axle |
$7.88
|
Rate for Payer: Aetna American Axle |
$70.31
|
Rate for Payer: Aetna American Axle |
$13.42
|
Rate for Payer: Aetna Commercial |
$17.55
|
Rate for Payer: Aetna Commercial |
$10.31
|
Rate for Payer: Aetna Commercial |
$91.94
|
Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
Rate for Payer: Aetna New Business (MI Preferred) |
$70.31
|
Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
Rate for Payer: Cash Price |
$9.70
|
Rate for Payer: Cash Price |
$86.54
|
Rate for Payer: Cash Price |
$16.52
|
Rate for Payer: Cofinity Commercial |
$14.46
|
Rate for Payer: Cofinity Commercial |
$10.43
|
Rate for Payer: Cofinity Commercial |
$75.72
|
Rate for Payer: Cofinity Commercial |
$17.76
|
Rate for Payer: Cofinity Commercial |
$93.03
|
Rate for Payer: Cofinity Commercial |
$8.49
|
Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
Rate for Payer: Encore Health Key Benefits Commercial |
$86.54
|
Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
Rate for Payer: Healthscope Commercial |
$97.35
|
Rate for Payer: Healthscope Commercial |
$18.58
|
Rate for Payer: Healthscope Commercial |
$10.92
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.72
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.13
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.31
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.94
|
Rate for Payer: PHP Commercial |
$17.55
|
Rate for Payer: PHP Commercial |
$91.94
|
Rate for Payer: PHP Commercial |
$10.31
|
Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
Rate for Payer: Priority Health Cigna Priority Health |
$8.49
|
Rate for Payer: Priority Health Cigna Priority Health |
$75.72
|
Rate for Payer: Priority Health SBD |
$68.15
|
Rate for Payer: Priority Health SBD |
$7.64
|
Rate for Payer: Priority Health SBD |
$13.01
|
Rate for Payer: UMR Bronson Commercial |
$9.09
|
Rate for Payer: UMR Bronson Commercial |
$5.34
|
Rate for Payer: UMR Bronson Commercial |
$47.59
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.13
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
DIPHENHYDRAMINE (BULK) POWDER
|
Facility
|
IP
|
$37.80
|
|
Service Code
|
NDC 38779-0282-2
|
Hospital Charge Code |
12308
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$16.63 |
Max. Negotiated Rate |
$34.02 |
Rate for Payer: Aetna American Axle |
$24.57
|
Rate for Payer: Aetna Commercial |
$32.13
|
Rate for Payer: Aetna New Business (MI Preferred) |
$24.57
|
Rate for Payer: Cash Price |
$30.24
|
Rate for Payer: Cofinity Commercial |
$26.46
|
Rate for Payer: Cofinity Commercial |
$32.51
|
Rate for Payer: Encore Health Key Benefits Commercial |
$30.24
|
Rate for Payer: Healthscope Commercial |
$34.02
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.46
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.35
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.13
|
Rate for Payer: PHP Commercial |
$32.13
|
Rate for Payer: Priority Health Cigna Priority Health |
$26.46
|
Rate for Payer: Priority Health SBD |
$23.81
|
Rate for Payer: UMR Bronson Commercial |
$16.63
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.35
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$55.56
|
|
Service Code
|
NDC 1254717167
|
Hospital Charge Code |
16299
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$24.45 |
Max. Negotiated Rate |
$50.00 |
Rate for Payer: Aetna American Axle |
$36.11
|
Rate for Payer: Aetna Commercial |
$47.23
|
Rate for Payer: Aetna New Business (MI Preferred) |
$36.11
|
Rate for Payer: Cash Price |
$44.45
|
Rate for Payer: Cofinity Commercial |
$38.89
|
Rate for Payer: Cofinity Commercial |
$47.78
|
Rate for Payer: Encore Health Key Benefits Commercial |
$44.45
|
Rate for Payer: Healthscope Commercial |
$50.00
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.89
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.67
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.23
|
Rate for Payer: PHP Commercial |
$47.23
|
Rate for Payer: Priority Health Cigna Priority Health |
$38.89
|
Rate for Payer: Priority Health SBD |
$35.00
|
Rate for Payer: UMR Bronson Commercial |
$24.45
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.67
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.09
|
|
Service Code
|
NDC 0904-5354-31
|
Hospital Charge Code |
16299
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$8.40 |
Max. Negotiated Rate |
$17.18 |
Rate for Payer: Aetna American Axle |
$12.41
|
Rate for Payer: Aetna Commercial |
$16.23
|
Rate for Payer: Aetna New Business (MI Preferred) |
$12.41
|
Rate for Payer: Cash Price |
$15.27
|
Rate for Payer: Cofinity Commercial |
$13.36
|
Rate for Payer: Cofinity Commercial |
$16.42
|
Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
Rate for Payer: Healthscope Commercial |
$17.18
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.36
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.32
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.23
|
Rate for Payer: PHP Commercial |
$16.23
|
Rate for Payer: Priority Health Cigna Priority Health |
$13.36
|
Rate for Payer: Priority Health SBD |
$12.03
|
Rate for Payer: UMR Bronson Commercial |
$8.40
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.32
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$14.45
|
|
Service Code
|
NDC 70000-0388-1
|
Hospital Charge Code |
16299
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$6.36 |
Max. Negotiated Rate |
$13.00 |
Rate for Payer: Aetna American Axle |
$9.39
|
Rate for Payer: Aetna Commercial |
$12.28
|
Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
Rate for Payer: Cash Price |
$11.56
|
Rate for Payer: Cofinity Commercial |
$10.12
|
Rate for Payer: Cofinity Commercial |
$12.43
|
Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
Rate for Payer: Healthscope Commercial |
$13.00
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.12
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.84
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.28
|
Rate for Payer: PHP Commercial |
$12.28
|
Rate for Payer: Priority Health Cigna Priority Health |
$10.12
|
Rate for Payer: Priority Health SBD |
$9.10
|
Rate for Payer: UMR Bronson Commercial |
$6.36
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.84
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$20.84
|
|
Service Code
|
NDC 45802-358-03
|
Hospital Charge Code |
16299
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$9.17 |
Max. Negotiated Rate |
$18.76 |
Rate for Payer: Aetna American Axle |
$13.55
|
Rate for Payer: Aetna Commercial |
$17.71
|
Rate for Payer: Aetna New Business (MI Preferred) |
$13.55
|
Rate for Payer: Cash Price |
$16.67
|
Rate for Payer: Cofinity Commercial |
$14.59
|
Rate for Payer: Cofinity Commercial |
$17.92
|
Rate for Payer: Encore Health Key Benefits Commercial |
$16.67
|
Rate for Payer: Healthscope Commercial |
$18.76
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.59
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.63
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.71
|
Rate for Payer: PHP Commercial |
$17.71
|
Rate for Payer: Priority Health Cigna Priority Health |
$14.59
|
Rate for Payer: Priority Health SBD |
$13.13
|
Rate for Payer: UMR Bronson Commercial |
$9.17
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.63
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$273.89
|
|
Service Code
|
NDC 0054-3194-46
|
Hospital Charge Code |
2515
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$120.51 |
Max. Negotiated Rate |
$246.50 |
Rate for Payer: Aetna American Axle |
$178.03
|
Rate for Payer: Aetna Commercial |
$232.81
|
Rate for Payer: Aetna New Business (MI Preferred) |
$178.03
|
Rate for Payer: Cash Price |
$219.11
|
Rate for Payer: Cofinity Commercial |
$191.72
|
Rate for Payer: Cofinity Commercial |
$235.55
|
Rate for Payer: Encore Health Key Benefits Commercial |
$219.11
|
Rate for Payer: Healthscope Commercial |
$246.50
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.72
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.42
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$232.81
|
Rate for Payer: PHP Commercial |
$232.81
|
Rate for Payer: Priority Health Cigna Priority Health |
$191.72
|
Rate for Payer: Priority Health SBD |
$172.55
|
Rate for Payer: UMR Bronson Commercial |
$120.51
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.42
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$26.21
|
|
Service Code
|
NDC 9900-0009-66
|
Hospital Charge Code |
2515
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$11.53 |
Max. Negotiated Rate |
$23.59 |
Rate for Payer: Aetna American Axle |
$17.04
|
Rate for Payer: Aetna Commercial |
$22.28
|
Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
Rate for Payer: Cash Price |
$20.97
|
Rate for Payer: Cofinity Commercial |
$18.35
|
Rate for Payer: Cofinity Commercial |
$22.54
|
Rate for Payer: Encore Health Key Benefits Commercial |
$20.97
|
Rate for Payer: Healthscope Commercial |
$23.59
|
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.28
|
Rate for Payer: PHP Commercial |
$22.28
|
Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
Rate for Payer: Priority Health SBD |
$16.51
|
Rate for Payer: UMR Bronson Commercial |
$11.53
|
Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|