|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
NDC 60687020611
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.74
|
| Rate for Payer: Aetna Medicare |
$1.52
|
| Rate for Payer: ASR ASR |
$2.95
|
| Rate for Payer: ASR Commercial |
$2.95
|
| Rate for Payer: BCBS Complete |
$1.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.49
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.43
|
| Rate for Payer: Healthscope Commercial |
$3.04
|
| Rate for Payer: Healthscope Whirlpool |
$2.95
|
| Rate for Payer: Mclaren Commercial |
$2.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.58
|
| Rate for Payer: Nomi Health Commercial |
$2.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.66
|
| Rate for Payer: Priority Health Narrow Network |
$2.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.68
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.60 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Medicare |
$152.00
|
| Rate for Payer: ASR ASR |
$294.88
|
| Rate for Payer: ASR Commercial |
$294.88
|
| Rate for Payer: BCBS Complete |
$121.60
|
| Rate for Payer: BCBS Trust/PPO |
$248.95
|
| Rate for Payer: BCN Commercial |
$235.69
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Commercial |
$285.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$304.00
|
| Rate for Payer: Healthscope Whirlpool |
$294.88
|
| Rate for Payer: Mclaren Commercial |
$273.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.40
|
| Rate for Payer: Nomi Health Commercial |
$249.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$266.36
|
| Rate for Payer: Priority Health Narrow Network |
$213.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$267.52
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
NDC 60687020611
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.74
|
| Rate for Payer: ASR ASR |
$2.95
|
| Rate for Payer: ASR Commercial |
$2.95
|
| Rate for Payer: BCBS Trust/PPO |
$2.48
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.43
|
| Rate for Payer: Healthscope Commercial |
$3.04
|
| Rate for Payer: Healthscope Whirlpool |
$2.95
|
| Rate for Payer: Mclaren Commercial |
$2.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.58
|
| Rate for Payer: Nomi Health Commercial |
$2.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.68
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$273.60
|
|
|
Service Code
|
NDC 00904721861
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.44 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$246.24
|
| Rate for Payer: Aetna Medicare |
$136.80
|
| Rate for Payer: ASR ASR |
$265.39
|
| Rate for Payer: ASR Commercial |
$265.39
|
| Rate for Payer: BCBS Complete |
$109.44
|
| Rate for Payer: BCBS Trust/PPO |
$224.05
|
| Rate for Payer: BCN Commercial |
$212.12
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$257.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Healthscope Whirlpool |
$265.39
|
| Rate for Payer: Mclaren Commercial |
$246.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: Nomi Health Commercial |
$224.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$239.73
|
| Rate for Payer: Priority Health Narrow Network |
$191.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$240.77
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$2.54
|
|
|
Service Code
|
NDC 60687021711
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.29
|
| Rate for Payer: ASR ASR |
$2.46
|
| Rate for Payer: ASR Commercial |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.07
|
| Rate for Payer: BCN Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.03
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Healthscope Whirlpool |
$2.46
|
| Rate for Payer: Mclaren Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.16
|
| Rate for Payer: Nomi Health Commercial |
$2.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.24
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$424.65
|
|
|
Service Code
|
NDC 63739001610
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$276.02 |
| Max. Negotiated Rate |
$424.65 |
| Rate for Payer: Aetna Commercial |
$382.18
|
| Rate for Payer: ASR ASR |
$411.91
|
| Rate for Payer: ASR Commercial |
$411.91
|
| Rate for Payer: BCBS Trust/PPO |
$346.05
|
| Rate for Payer: BCN Commercial |
$329.23
|
| Rate for Payer: Cash Price |
$339.72
|
| Rate for Payer: Cofinity Commercial |
$399.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.72
|
| Rate for Payer: Healthscope Commercial |
$424.65
|
| Rate for Payer: Healthscope Whirlpool |
$411.91
|
| Rate for Payer: Mclaren Commercial |
$382.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.95
|
| Rate for Payer: Nomi Health Commercial |
$348.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$373.69
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$253.92
|
|
|
Service Code
|
NDC 60687021701
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.57 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$228.53
|
| Rate for Payer: Aetna Medicare |
$126.96
|
| Rate for Payer: ASR ASR |
$246.30
|
| Rate for Payer: ASR Commercial |
$246.30
|
| Rate for Payer: BCBS Complete |
$101.57
|
| Rate for Payer: BCBS Trust/PPO |
$207.94
|
| Rate for Payer: BCN Commercial |
$196.86
|
| Rate for Payer: Cash Price |
$203.14
|
| Rate for Payer: Cofinity Commercial |
$238.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.14
|
| Rate for Payer: Healthscope Commercial |
$253.92
|
| Rate for Payer: Healthscope Whirlpool |
$246.30
|
| Rate for Payer: Mclaren Commercial |
$228.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.83
|
| Rate for Payer: Nomi Health Commercial |
$208.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.48
|
| Rate for Payer: Priority Health Narrow Network |
$178.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.45
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$424.65
|
|
|
Service Code
|
NDC 63739001610
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.86 |
| Max. Negotiated Rate |
$424.65 |
| Rate for Payer: Aetna Commercial |
$382.18
|
| Rate for Payer: Aetna Medicare |
$212.32
|
| Rate for Payer: ASR ASR |
$411.91
|
| Rate for Payer: ASR Commercial |
$411.91
|
| Rate for Payer: BCBS Complete |
$169.86
|
| Rate for Payer: BCBS Trust/PPO |
$347.75
|
| Rate for Payer: BCN Commercial |
$329.23
|
| Rate for Payer: Cash Price |
$339.72
|
| Rate for Payer: Cofinity Commercial |
$399.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.72
|
| Rate for Payer: Healthscope Commercial |
$424.65
|
| Rate for Payer: Healthscope Whirlpool |
$411.91
|
| Rate for Payer: Mclaren Commercial |
$382.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.95
|
| Rate for Payer: Nomi Health Commercial |
$348.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$372.08
|
| Rate for Payer: Priority Health Narrow Network |
$297.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$373.69
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$2.54
|
|
|
Service Code
|
NDC 60687021711
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.29
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: ASR ASR |
$2.46
|
| Rate for Payer: ASR Commercial |
$2.46
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$2.08
|
| Rate for Payer: BCN Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.03
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Healthscope Whirlpool |
$2.46
|
| Rate for Payer: Mclaren Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.16
|
| Rate for Payer: Nomi Health Commercial |
$2.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.23
|
| Rate for Payer: Priority Health Narrow Network |
$1.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.24
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$253.92
|
|
|
Service Code
|
NDC 60687021701
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.05 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$228.53
|
| Rate for Payer: ASR ASR |
$246.30
|
| Rate for Payer: ASR Commercial |
$246.30
|
| Rate for Payer: BCBS Trust/PPO |
$206.92
|
| Rate for Payer: BCN Commercial |
$196.86
|
| Rate for Payer: Cash Price |
$203.14
|
| Rate for Payer: Cofinity Commercial |
$238.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.14
|
| Rate for Payer: Healthscope Commercial |
$253.92
|
| Rate for Payer: Healthscope Whirlpool |
$246.30
|
| Rate for Payer: Mclaren Commercial |
$228.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.83
|
| Rate for Payer: Nomi Health Commercial |
$208.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.45
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR
|
Facility
|
OP
|
$997.89
|
|
|
Service Code
|
NDC 00378609001
|
| Hospital Charge Code |
14101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.16 |
| Max. Negotiated Rate |
$997.89 |
| Rate for Payer: Aetna Commercial |
$898.10
|
| Rate for Payer: Aetna Medicare |
$498.94
|
| Rate for Payer: ASR ASR |
$967.95
|
| Rate for Payer: ASR Commercial |
$967.95
|
| Rate for Payer: BCBS Complete |
$399.16
|
| Rate for Payer: BCBS Trust/PPO |
$817.17
|
| Rate for Payer: BCN Commercial |
$773.66
|
| Rate for Payer: Cash Price |
$798.31
|
| Rate for Payer: Cofinity Commercial |
$938.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.31
|
| Rate for Payer: Healthscope Commercial |
$997.89
|
| Rate for Payer: Healthscope Whirlpool |
$967.95
|
| Rate for Payer: Mclaren Commercial |
$898.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.21
|
| Rate for Payer: Nomi Health Commercial |
$818.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$874.35
|
| Rate for Payer: Priority Health Narrow Network |
$699.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.14
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$997.89
|
|
|
Service Code
|
NDC 00378609001
|
| Hospital Charge Code |
14101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$648.63 |
| Max. Negotiated Rate |
$997.89 |
| Rate for Payer: Aetna Commercial |
$898.10
|
| Rate for Payer: ASR ASR |
$967.95
|
| Rate for Payer: ASR Commercial |
$967.95
|
| Rate for Payer: BCBS Trust/PPO |
$813.18
|
| Rate for Payer: BCN Commercial |
$773.66
|
| Rate for Payer: Cash Price |
$798.31
|
| Rate for Payer: Cofinity Commercial |
$938.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.31
|
| Rate for Payer: Healthscope Commercial |
$997.89
|
| Rate for Payer: Healthscope Whirlpool |
$967.95
|
| Rate for Payer: Mclaren Commercial |
$898.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.21
|
| Rate for Payer: Nomi Health Commercial |
$818.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.14
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.04
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$24.04 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: ASR Commercial |
$23.32
|
| Rate for Payer: BCBS Trust/PPO |
$19.59
|
| Rate for Payer: BCN Commercial |
$18.64
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cofinity Commercial |
$22.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.23
|
| Rate for Payer: Healthscope Commercial |
$24.04
|
| Rate for Payer: Healthscope Whirlpool |
$23.32
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.16
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.04
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$24.04 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: Aetna Medicare |
$12.02
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: ASR Commercial |
$23.32
|
| Rate for Payer: BCBS Complete |
$9.62
|
| Rate for Payer: BCBS Trust/PPO |
$19.69
|
| Rate for Payer: BCN Commercial |
$18.64
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cofinity Commercial |
$22.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.23
|
| Rate for Payer: Healthscope Commercial |
$24.04
|
| Rate for Payer: Healthscope Whirlpool |
$23.32
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.66
|
| Rate for Payer: Priority Health Narrow Network |
$6.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.16
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$306.96
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.52 |
| Max. Negotiated Rate |
$306.96 |
| Rate for Payer: Aetna Commercial |
$276.26
|
| Rate for Payer: ASR ASR |
$297.75
|
| Rate for Payer: ASR Commercial |
$297.75
|
| Rate for Payer: BCBS Trust/PPO |
$250.14
|
| Rate for Payer: BCN Commercial |
$237.99
|
| Rate for Payer: Cash Price |
$245.57
|
| Rate for Payer: Cofinity Commercial |
$288.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.57
|
| Rate for Payer: Healthscope Commercial |
$306.96
|
| Rate for Payer: Healthscope Whirlpool |
$297.75
|
| Rate for Payer: Mclaren Commercial |
$276.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Nomi Health Commercial |
$251.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$270.12
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$306.96
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.78 |
| Max. Negotiated Rate |
$306.96 |
| Rate for Payer: Aetna Commercial |
$276.26
|
| Rate for Payer: Aetna Medicare |
$153.48
|
| Rate for Payer: ASR ASR |
$297.75
|
| Rate for Payer: ASR Commercial |
$297.75
|
| Rate for Payer: BCBS Complete |
$122.78
|
| Rate for Payer: BCBS Trust/PPO |
$251.37
|
| Rate for Payer: BCN Commercial |
$237.99
|
| Rate for Payer: Cash Price |
$245.57
|
| Rate for Payer: Cofinity Commercial |
$288.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.57
|
| Rate for Payer: Healthscope Commercial |
$306.96
|
| Rate for Payer: Healthscope Whirlpool |
$297.75
|
| Rate for Payer: Mclaren Commercial |
$276.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Nomi Health Commercial |
$251.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$268.96
|
| Rate for Payer: Priority Health Narrow Network |
$215.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$270.12
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$14.30
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: Aetna Commercial |
$12.87
|
| Rate for Payer: Aetna Medicare |
$7.15
|
| Rate for Payer: ASR ASR |
$13.87
|
| Rate for Payer: ASR Commercial |
$13.87
|
| Rate for Payer: BCBS Complete |
$5.72
|
| Rate for Payer: BCBS Trust/PPO |
$11.71
|
| Rate for Payer: BCN Commercial |
$11.09
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: Cofinity Commercial |
$13.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.44
|
| Rate for Payer: Healthscope Commercial |
$14.30
|
| Rate for Payer: Healthscope Whirlpool |
$13.87
|
| Rate for Payer: Mclaren Commercial |
$12.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.16
|
| Rate for Payer: Nomi Health Commercial |
$11.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.53
|
| Rate for Payer: Priority Health Narrow Network |
$10.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.58
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$14.30
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: Aetna Commercial |
$12.87
|
| Rate for Payer: ASR ASR |
$13.87
|
| Rate for Payer: ASR Commercial |
$13.87
|
| Rate for Payer: BCBS Trust/PPO |
$11.65
|
| Rate for Payer: BCN Commercial |
$11.09
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: Cofinity Commercial |
$13.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.44
|
| Rate for Payer: Healthscope Commercial |
$14.30
|
| Rate for Payer: Healthscope Whirlpool |
$13.87
|
| Rate for Payer: Mclaren Commercial |
$12.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.16
|
| Rate for Payer: Nomi Health Commercial |
$11.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.58
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$9.79
|
|
|
Service Code
|
NDC 00121086505
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: Aetna Medicare |
$4.90
|
| Rate for Payer: ASR ASR |
$9.50
|
| Rate for Payer: ASR Commercial |
$9.50
|
| Rate for Payer: BCBS Complete |
$3.92
|
| Rate for Payer: BCBS Trust/PPO |
$8.02
|
| Rate for Payer: BCN Commercial |
$7.59
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$9.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Healthscope Whirlpool |
$9.50
|
| Rate for Payer: Mclaren Commercial |
$8.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.58
|
| Rate for Payer: Priority Health Narrow Network |
$6.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.62
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
NDC 00121086505
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: ASR ASR |
$9.50
|
| Rate for Payer: ASR Commercial |
$9.50
|
| Rate for Payer: BCBS Trust/PPO |
$7.98
|
| Rate for Payer: BCN Commercial |
$7.59
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$9.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Healthscope Whirlpool |
$9.50
|
| Rate for Payer: Mclaren Commercial |
$8.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.62
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
NDC 00121086500
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: ASR ASR |
$9.50
|
| Rate for Payer: ASR Commercial |
$9.50
|
| Rate for Payer: BCBS Trust/PPO |
$7.98
|
| Rate for Payer: BCN Commercial |
$7.59
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$9.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Healthscope Whirlpool |
$9.50
|
| Rate for Payer: Mclaren Commercial |
$8.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.62
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$9.79
|
|
|
Service Code
|
NDC 00121086500
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: Aetna Medicare |
$4.90
|
| Rate for Payer: ASR ASR |
$9.50
|
| Rate for Payer: ASR Commercial |
$9.50
|
| Rate for Payer: BCBS Complete |
$3.92
|
| Rate for Payer: BCBS Trust/PPO |
$8.02
|
| Rate for Payer: BCN Commercial |
$7.59
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$9.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Healthscope Whirlpool |
$9.50
|
| Rate for Payer: Mclaren Commercial |
$8.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.58
|
| Rate for Payer: Priority Health Narrow Network |
$6.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.62
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: ASR ASR |
$1.39
|
| Rate for Payer: ASR Commercial |
$1.39
|
| Rate for Payer: BCBS Trust/PPO |
$1.17
|
| Rate for Payer: BCN Commercial |
$1.11
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Healthscope Commercial |
$1.43
|
| Rate for Payer: Healthscope Whirlpool |
$1.39
|
| Rate for Payer: Mclaren Commercial |
$1.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.22
|
| Rate for Payer: Nomi Health Commercial |
$1.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.26
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$142.80
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.12 |
| Max. Negotiated Rate |
$142.80 |
| Rate for Payer: Aetna Commercial |
$128.52
|
| Rate for Payer: Aetna Medicare |
$71.40
|
| Rate for Payer: ASR ASR |
$138.52
|
| Rate for Payer: ASR Commercial |
$138.52
|
| Rate for Payer: BCBS Complete |
$57.12
|
| Rate for Payer: BCBS Trust/PPO |
$116.94
|
| Rate for Payer: BCN Commercial |
$110.71
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$134.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Healthscope Commercial |
$142.80
|
| Rate for Payer: Healthscope Whirlpool |
$138.52
|
| Rate for Payer: Mclaren Commercial |
$128.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.38
|
| Rate for Payer: Nomi Health Commercial |
$117.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$125.12
|
| Rate for Payer: Priority Health Narrow Network |
$100.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.66
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: ASR ASR |
$97.78
|
| Rate for Payer: ASR Commercial |
$97.78
|
| Rate for Payer: BCBS Complete |
$40.32
|
| Rate for Payer: BCBS Trust/PPO |
$82.55
|
| Rate for Payer: BCN Commercial |
$78.15
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Healthscope Commercial |
$100.80
|
| Rate for Payer: Healthscope Whirlpool |
$97.78
|
| Rate for Payer: Mclaren Commercial |
$90.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.68
|
| Rate for Payer: Nomi Health Commercial |
$82.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88.32
|
| Rate for Payer: Priority Health Narrow Network |
$70.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.70
|
|
