|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$19.62
|
|
|
Service Code
|
NDC 69339015105
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$17.66 |
| Rate for Payer: Aetna American Axle |
$12.75
|
| Rate for Payer: Aetna Commercial |
$16.68
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Advantage |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.71
|
| Rate for Payer: PHP Commercial |
$16.68
|
| Rate for Payer: Priority Health SBD |
$12.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.75
|
| Rate for Payer: UHC Core |
$10.22
|
| Rate for Payer: UHC Exchange |
$7.71
|
| Rate for Payer: UMR Bronson Commercial |
$7.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.71
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$61.01
|
|
|
Service Code
|
NDC 70000049201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.57 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Aetna American Axle |
$39.66
|
| Rate for Payer: Aetna Commercial |
$51.86
|
| Rate for Payer: Aetna Medicare |
$30.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.66
|
| Rate for Payer: BCBS Complete |
$24.40
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cofinity Advantage |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.81
|
| Rate for Payer: Healthscope Commercial |
$54.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.76
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.66
|
| Rate for Payer: UHC Core |
$31.79
|
| Rate for Payer: UHC Exchange |
$23.98
|
| Rate for Payer: UMR Bronson Commercial |
$22.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.76
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 69339015217
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna American Axle |
$13.21
|
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: BCBS Complete |
$8.13
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.21
|
| Rate for Payer: UHC Core |
$10.59
|
| Rate for Payer: UHC Exchange |
$7.99
|
| Rate for Payer: UMR Bronson Commercial |
$7.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.25
|
|
|
DIPHENHYDRAMINE 12.5 MG CHEWABLE TABLET
|
Facility
|
OP
|
$27.01
|
|
|
Service Code
|
NDC 00450055320
|
| Hospital Charge Code |
15539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$24.31 |
| Rate for Payer: Aetna American Axle |
$17.56
|
| Rate for Payer: Aetna Commercial |
$22.96
|
| Rate for Payer: Aetna Medicare |
$13.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.56
|
| Rate for Payer: BCBS Complete |
$10.80
|
| Rate for Payer: Cash Price |
$21.61
|
| Rate for Payer: Cofinity Advantage |
$18.91
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.61
|
| Rate for Payer: Healthscope Commercial |
$24.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.26
|
| Rate for Payer: PHP Commercial |
$22.96
|
| Rate for Payer: Priority Health SBD |
$17.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.56
|
| Rate for Payer: UHC Core |
$14.07
|
| Rate for Payer: UHC Exchange |
$10.61
|
| Rate for Payer: UMR Bronson Commercial |
$9.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.26
|
|
|
DIPHENHYDRAMINE 12.5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$22.12
|
|
|
Service Code
|
NDC 50026066040
|
| Hospital Charge Code |
15539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.73 |
| Max. Negotiated Rate |
$19.91 |
| Rate for Payer: Aetna American Axle |
$14.38
|
| Rate for Payer: Aetna Commercial |
$18.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.38
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cofinity Advantage |
$15.48
|
| Rate for Payer: Cofinity Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.70
|
| Rate for Payer: Healthscope Commercial |
$19.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.59
|
| Rate for Payer: PHP Commercial |
$18.80
|
| Rate for Payer: Priority Health SBD |
$13.94
|
| Rate for Payer: UMR Bronson Commercial |
$9.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.59
|
|
|
DIPHENHYDRAMINE 12.5 MG CHEWABLE TABLET
|
Facility
|
OP
|
$22.12
|
|
|
Service Code
|
NDC 50026066040
|
| Hospital Charge Code |
15539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$19.91 |
| Rate for Payer: Aetna American Axle |
$14.38
|
| Rate for Payer: Aetna Commercial |
$18.80
|
| Rate for Payer: Aetna Medicare |
$11.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.38
|
| Rate for Payer: BCBS Complete |
$8.85
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cofinity Advantage |
$15.48
|
| Rate for Payer: Cofinity Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.70
|
| Rate for Payer: Healthscope Commercial |
$19.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.59
|
| Rate for Payer: PHP Commercial |
$18.80
|
| Rate for Payer: Priority Health SBD |
$13.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.38
|
| Rate for Payer: UHC Core |
$11.52
|
| Rate for Payer: UHC Exchange |
$8.69
|
| Rate for Payer: UMR Bronson Commercial |
$8.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.59
|
|
|
DIPHENHYDRAMINE 12.5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$27.01
|
|
|
Service Code
|
NDC 00450055320
|
| Hospital Charge Code |
15539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$24.31 |
| Rate for Payer: Aetna American Axle |
$17.56
|
| Rate for Payer: Aetna Commercial |
$22.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.56
|
| Rate for Payer: Cash Price |
$21.61
|
| Rate for Payer: Cofinity Advantage |
$18.91
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.61
|
| Rate for Payer: Healthscope Commercial |
$24.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.26
|
| Rate for Payer: PHP Commercial |
$22.96
|
| Rate for Payer: Priority Health SBD |
$17.02
|
| Rate for Payer: UMR Bronson Commercial |
$11.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.26
|
|
|
DIPHENHYDRAMINE 12.5 MG CUSTOM TAB
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
NDC 09900000982
|
| 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 Medicare |
$2.76
|
| 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 Advantage |
$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: MI Amish Medical Board Commercial |
$4.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.14
|
| Rate for Payer: PHP Commercial |
$4.69
|
| Rate for Payer: Priority Health SBD |
$3.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.59
|
| Rate for Payer: UHC Core |
$2.88
|
| Rate for Payer: UHC Exchange |
$2.17
|
| 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 09900000982
|
| 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 Advantage |
$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 Commercial |
$4.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.14
|
| Rate for Payer: PHP Commercial |
$4.69
|
| 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
|
$89.30
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Advantage |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.97
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.04 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna Medicare |
$44.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: BCBS Complete |
$35.72
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Advantage |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.97
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.05
|
| Rate for Payer: UHC Core |
$46.53
|
| Rate for Payer: UHC Exchange |
$35.09
|
| Rate for Payer: UMR Bronson Commercial |
$33.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$170.10
|
|
|
Service Code
|
NDC 96295012933
|
| 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 |
$144.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.56
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Cofinity Advantage |
$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 Commercial |
$144.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.58
|
| Rate for Payer: PHP Commercial |
$144.59
|
| 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
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna American Axle |
$77.81
|
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.81
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Advantage |
$83.79
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health SBD |
$75.41
|
| Rate for Payer: UMR Bronson Commercial |
$52.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.78
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$170.10
|
|
|
Service Code
|
NDC 96295012933
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.94 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna American Axle |
$110.56
|
| Rate for Payer: Aetna Commercial |
$144.59
|
| Rate for Payer: Aetna Medicare |
$85.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.56
|
| Rate for Payer: BCBS Complete |
$68.04
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$136.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.58
|
| Rate for Payer: PHP Commercial |
$144.59
|
| Rate for Payer: Priority Health SBD |
$107.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$110.56
|
| Rate for Payer: UHC Core |
$88.62
|
| Rate for Payer: UHC Exchange |
$66.85
|
| Rate for Payer: UMR Bronson Commercial |
$62.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.58
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna American Axle |
$1.10
|
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.10
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Advantage |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.44
|
| Rate for Payer: Priority Health SBD |
$1.06
|
| Rate for Payer: UMR Bronson Commercial |
$0.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.27
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna American Axle |
$1.10
|
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Aetna Medicare |
$0.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.10
|
| Rate for Payer: BCBS Complete |
$0.68
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Advantage |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.44
|
| Rate for Payer: Priority Health SBD |
$1.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.10
|
| Rate for Payer: UHC Core |
$0.88
|
| Rate for Payer: UHC Exchange |
$0.66
|
| Rate for Payer: UMR Bronson Commercial |
$0.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.27
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna American Axle |
$77.81
|
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna Medicare |
$59.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.81
|
| Rate for Payer: BCBS Complete |
$47.88
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Advantage |
$83.79
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health SBD |
$75.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.81
|
| Rate for Payer: UHC Core |
$62.36
|
| Rate for Payer: UHC Exchange |
$47.04
|
| Rate for Payer: UMR Bronson Commercial |
$44.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.78
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.42 |
| Max. Negotiated Rate |
$151.83 |
| Rate for Payer: Aetna American Axle |
$109.66
|
| Rate for Payer: Aetna Commercial |
$143.40
|
| Rate for Payer: Aetna Medicare |
$84.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.66
|
| Rate for Payer: BCBS Complete |
$67.48
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Advantage |
$118.09
|
| Rate for Payer: Cofinity Commercial |
$145.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$151.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: PHP Commercial |
$143.40
|
| Rate for Payer: Priority Health SBD |
$106.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.66
|
| Rate for Payer: UHC Core |
$87.89
|
| Rate for Payer: UHC Exchange |
$66.30
|
| Rate for Payer: UMR Bronson Commercial |
$62.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.53
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.23 |
| Max. Negotiated Rate |
$151.83 |
| Rate for Payer: Aetna American Axle |
$109.66
|
| Rate for Payer: Aetna Commercial |
$143.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.66
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Advantage |
$118.09
|
| Rate for Payer: Cofinity Commercial |
$145.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$151.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: PHP Commercial |
$143.40
|
| Rate for Payer: Priority Health SBD |
$106.28
|
| Rate for Payer: UMR Bronson Commercial |
$74.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.53
|
|
|
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 |
$1.17 |
| 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 |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| 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: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$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: 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: MI Amish Medical Board Commercial |
$9.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| 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
|
|
|
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 |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| 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 Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health SBD |
$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
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna American Axle |
$100.85
|
| Rate for Payer: Aetna American Axle |
$11.28
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$14.75
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Medicare |
$8.68
|
| Rate for Payer: Aetna Medicare |
$77.58
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| 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) |
$13.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.28
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Complete |
$62.06
|
| Rate for Payer: BCBS Complete |
$6.94
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.29
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Advantage |
$12.14
|
| Rate for Payer: Cofinity Advantage |
$108.61
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.88
|
| 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: Healthscope Commercial |
$15.62
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$14.75
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: Priority Health SBD |
$10.93
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Core |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UMR Bronson Commercial |
$7.64
|
| Rate for Payer: UMR Bronson Commercial |
$4.49
|
| Rate for Payer: UMR Bronson Commercial |
$57.41
|
| Rate for Payer: UMR Bronson Commercial |
$6.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.36
|
| 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
|
IP
|
$17.35
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna American Axle |
$11.28
|
| Rate for Payer: Aetna American Axle |
$100.85
|
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$14.75
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cofinity Advantage |
$108.61
|
| Rate for Payer: Cofinity Advantage |
$8.49
|
| Rate for Payer: Cofinity Advantage |
$12.14
|
| Rate for Payer: Cofinity Advantage |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$15.62
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$14.75
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$10.93
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: UMR Bronson Commercial |
$68.27
|
| Rate for Payer: UMR Bronson Commercial |
$7.63
|
| 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 |
$13.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
|
DIPHENHYDRAMINE (BULK) POWDER
|
Facility
|
IP
|
$43.20
|
|
|
Service Code
|
NDC 38779028202
|
| Hospital Charge Code |
12308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$38.88 |
| Rate for Payer: Aetna American Axle |
$28.08
|
| Rate for Payer: Aetna Commercial |
$36.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.08
|
| Rate for Payer: Cash Price |
$34.56
|
| Rate for Payer: Cofinity Advantage |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$37.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.56
|
| Rate for Payer: Healthscope Commercial |
$38.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.40
|
| Rate for Payer: PHP Commercial |
$36.72
|
| Rate for Payer: Priority Health SBD |
$27.22
|
| Rate for Payer: UMR Bronson Commercial |
$19.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.40
|
|
|
DIPHENHYDRAMINE (BULK) POWDER
|
Facility
|
OP
|
$43.20
|
|
|
Service Code
|
NDC 38779028202
|
| Hospital Charge Code |
12308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$38.88 |
| Rate for Payer: Aetna American Axle |
$28.08
|
| Rate for Payer: Aetna Commercial |
$36.72
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.08
|
| Rate for Payer: BCBS Complete |
$17.28
|
| Rate for Payer: Cash Price |
$34.56
|
| Rate for Payer: Cofinity Advantage |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$37.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.56
|
| Rate for Payer: Healthscope Commercial |
$38.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.40
|
| Rate for Payer: PHP Commercial |
$36.72
|
| Rate for Payer: Priority Health SBD |
$27.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.08
|
| Rate for Payer: UHC Core |
$22.51
|
| Rate for Payer: UHC Exchange |
$16.98
|
| Rate for Payer: UMR Bronson Commercial |
$15.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.40
|
|
