|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$6.54
|
|
|
Service Code
|
NDC 09900000847
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna American Axle |
$4.25
|
| Rate for Payer: Aetna Commercial |
$5.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.25
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Cofinity Commercial |
$4.58
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.23
|
| Rate for Payer: Healthscope Commercial |
$5.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.56
|
| Rate for Payer: PHP Commercial |
$5.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.25
|
| Rate for Payer: Priority Health SBD |
$4.12
|
| Rate for Payer: UMR Bronson Commercial |
$2.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.91
|
|
|
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 |
$187.60 |
| Max. Negotiated Rate |
$383.73 |
| Rate for Payer: Aetna American Axle |
$277.14
|
| Rate for Payer: Aetna Commercial |
$362.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.14
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cofinity Commercial |
$298.46
|
| Rate for Payer: Cofinity Commercial |
$366.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.10
|
| Rate for Payer: Healthscope Commercial |
$383.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.41
|
| Rate for Payer: PHP Commercial |
$362.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.14
|
| Rate for Payer: Priority Health SBD |
$268.61
|
| Rate for Payer: UMR Bronson Commercial |
$187.60
|
| 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
|
IP
|
$12.15
|
|
|
Service Code
|
NDC 09900000711
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna American Axle |
$7.90
|
| Rate for Payer: Aetna Commercial |
$10.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.90
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cofinity Commercial |
$10.45
|
| Rate for Payer: Cofinity Commercial |
$8.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.72
|
| Rate for Payer: Healthscope Commercial |
$10.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.33
|
| Rate for Payer: PHP Commercial |
$10.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.90
|
| Rate for Payer: Priority Health SBD |
$7.65
|
| Rate for Payer: UMR Bronson Commercial |
$5.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.11
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$12.15
|
|
|
Service Code
|
NDC 09900000711
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna American Axle |
$7.90
|
| Rate for Payer: Aetna Commercial |
$10.33
|
| Rate for Payer: Aetna Medicare |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.90
|
| Rate for Payer: BCBS Complete |
$4.86
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cofinity Commercial |
$10.45
|
| Rate for Payer: Cofinity Commercial |
$8.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.72
|
| Rate for Payer: Healthscope Commercial |
$10.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.33
|
| Rate for Payer: PHP Commercial |
$10.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.90
|
| Rate for Payer: Priority Health SBD |
$7.65
|
| Rate for Payer: UMR Bronson Commercial |
$4.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.11
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$14.31
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Aetna American Axle |
$9.30
|
| Rate for Payer: Aetna American Axle |
$8.81
|
| Rate for Payer: Aetna Commercial |
$11.52
|
| Rate for Payer: Aetna Commercial |
$12.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.30
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cofinity Commercial |
$11.65
|
| Rate for Payer: Cofinity Commercial |
$12.31
|
| Rate for Payer: Cofinity Commercial |
$10.02
|
| Rate for Payer: Cofinity Commercial |
$9.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.84
|
| Rate for Payer: Healthscope Commercial |
$12.20
|
| Rate for Payer: Healthscope Commercial |
$12.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.16
|
| Rate for Payer: PHP Commercial |
$12.16
|
| Rate for Payer: PHP Commercial |
$11.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.30
|
| Rate for Payer: Priority Health SBD |
$8.54
|
| Rate for Payer: Priority Health SBD |
$9.02
|
| Rate for Payer: UMR Bronson Commercial |
$5.96
|
| Rate for Payer: UMR Bronson Commercial |
$6.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.73
|
|
|
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 |
$5.01 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Aetna American Axle |
$8.81
|
| Rate for Payer: Aetna American Axle |
$9.30
|
| Rate for Payer: Aetna Commercial |
$11.52
|
| Rate for Payer: Aetna Commercial |
$12.16
|
| Rate for Payer: Aetna Medicare |
$6.78
|
| Rate for Payer: Aetna Medicare |
$7.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.30
|
| Rate for Payer: BCBS Complete |
$5.72
|
| Rate for Payer: BCBS Complete |
$5.42
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: Cofinity Commercial |
$9.48
|
| Rate for Payer: Cofinity Commercial |
$11.65
|
| Rate for Payer: Cofinity Commercial |
$10.02
|
| Rate for Payer: Cofinity Commercial |
$12.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.45
|
| Rate for Payer: Healthscope Commercial |
$12.88
|
| Rate for Payer: Healthscope Commercial |
$12.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.16
|
| Rate for Payer: PHP Commercial |
$12.16
|
| Rate for Payer: PHP Commercial |
$11.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.30
|
| Rate for Payer: Priority Health SBD |
$9.02
|
| Rate for Payer: Priority Health SBD |
$8.54
|
| Rate for Payer: UMR Bronson Commercial |
$5.01
|
| Rate for Payer: UMR Bronson Commercial |
$5.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.16
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$178.23
|
|
|
Service Code
|
NDC 54838013570
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.95 |
| Max. Negotiated Rate |
$160.41 |
| Rate for Payer: Aetna American Axle |
$115.85
|
| Rate for Payer: Aetna Commercial |
$151.50
|
| Rate for Payer: Aetna Medicare |
$89.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.85
|
| Rate for Payer: BCBS Complete |
$71.29
|
| Rate for Payer: Cash Price |
$142.58
|
| Rate for Payer: Cofinity Commercial |
$124.76
|
| Rate for Payer: Cofinity Commercial |
$153.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$151.50
|
| Rate for Payer: PHP Commercial |
$151.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.85
|
| Rate for Payer: Priority Health SBD |
$112.28
|
| Rate for Payer: UMR Bronson Commercial |
$65.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.67
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$16.72
|
|
|
Service Code
|
NDC 69339015117
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna American Axle |
$10.87
|
| Rate for Payer: Aetna Commercial |
$14.21
|
| Rate for Payer: Aetna Medicare |
$8.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.87
|
| Rate for Payer: BCBS Complete |
$6.69
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$11.70
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.38
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.21
|
| Rate for Payer: PHP Commercial |
$14.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.87
|
| Rate for Payer: Priority Health SBD |
$10.53
|
| Rate for Payer: UMR Bronson Commercial |
$6.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$61.01
|
|
|
Service Code
|
NDC 70000049201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Aetna American Axle |
$39.66
|
| Rate for Payer: Aetna Commercial |
$51.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.66
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cofinity Commercial |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.71
|
| 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: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.66
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| Rate for Payer: UMR Bronson Commercial |
$26.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.76
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$16.72
|
|
|
Service Code
|
NDC 69339015105
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna American Axle |
$10.87
|
| Rate for Payer: Aetna Commercial |
$14.21
|
| Rate for Payer: Aetna Medicare |
$8.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.87
|
| Rate for Payer: BCBS Complete |
$6.69
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$11.70
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.38
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.21
|
| Rate for Payer: PHP Commercial |
$14.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.87
|
| Rate for Payer: Priority Health SBD |
$10.53
|
| Rate for Payer: UMR Bronson Commercial |
$6.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$266.78
|
|
|
Service Code
|
NDC 58657052816
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.38 |
| Max. Negotiated Rate |
$240.10 |
| Rate for Payer: Aetna American Axle |
$173.41
|
| Rate for Payer: Aetna Commercial |
$226.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.41
|
| Rate for Payer: Cash Price |
$213.42
|
| Rate for Payer: Cofinity Commercial |
$186.75
|
| Rate for Payer: Cofinity Commercial |
$229.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.42
|
| Rate for Payer: Healthscope Commercial |
$240.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.76
|
| Rate for Payer: PHP Commercial |
$226.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.41
|
| Rate for Payer: Priority Health SBD |
$168.07
|
| Rate for Payer: UMR Bronson Commercial |
$117.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.09
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
|
Service Code
|
NDC 68094002262
|
| 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 Medicare |
$7.03
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| 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/5 ML ORAL LIQUID
|
Facility
|
IP
|
$144.51
|
|
|
Service Code
|
NDC 00904698516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.58 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Commercial |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.93
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UMR Bronson Commercial |
$63.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
|
Service Code
|
NDC 68094002259
|
| 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 Medicare |
$7.03
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| 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/5 ML ORAL LIQUID
|
Facility
|
IP
|
$14.06
|
|
|
Service Code
|
NDC 68094002259
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| 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
|
$266.78
|
|
|
Service Code
|
NDC 58657052816
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.71 |
| Max. Negotiated Rate |
$240.10 |
| Rate for Payer: Aetna American Axle |
$173.41
|
| Rate for Payer: Aetna Commercial |
$226.76
|
| Rate for Payer: Aetna Medicare |
$133.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.41
|
| Rate for Payer: BCBS Complete |
$106.71
|
| Rate for Payer: Cash Price |
$213.42
|
| Rate for Payer: Cofinity Commercial |
$186.75
|
| Rate for Payer: Cofinity Commercial |
$229.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.42
|
| Rate for Payer: Healthscope Commercial |
$240.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.76
|
| Rate for Payer: PHP Commercial |
$226.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.41
|
| Rate for Payer: Priority Health SBD |
$168.07
|
| Rate for Payer: UMR Bronson Commercial |
$98.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.09
|
|
|
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 Commercial |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.71
|
| 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: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.66
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| 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
|
$41.83
|
|
|
Service Code
|
NDC 68094002459
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Commercial |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.19
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$178.23
|
|
|
Service Code
|
NDC 54838013570
|
| 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 |
$124.76
|
| Rate for Payer: Cofinity Commercial |
$153.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$151.50
|
| Rate for Payer: PHP Commercial |
$151.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.85
|
| 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
|
OP
|
$144.51
|
|
|
Service Code
|
NDC 00904698516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna Medicare |
$72.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: BCBS Complete |
$57.80
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Commercial |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.93
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UMR Bronson Commercial |
$53.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$14.06
|
|
|
Service Code
|
NDC 68094002262
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| 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
|
$41.83
|
|
|
Service Code
|
NDC 68094002462
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Commercial |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.19
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
|
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 Commercial |
$18.91
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.91
|
| 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: PHP Commercial |
$22.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.56
|
| Rate for Payer: Priority Health SBD |
$17.02
|
| 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
|
$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 Commercial |
$18.91
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.91
|
| 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: PHP Commercial |
$22.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.56
|
| 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 Commercial |
$3.86
|
| Rate for Payer: Cofinity Commercial |
$4.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.86
|
| 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: PHP Commercial |
$4.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.59
|
| 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
|
|
