|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: ASR ASR |
$97.78
|
| Rate for Payer: ASR Commercial |
$97.78
|
| Rate for Payer: BCBS Trust/PPO |
$82.14
|
| 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: UHC All Payor (Choice/PPO) + Core |
$88.70
|
|
|
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
|
$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
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.42 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR Commercial |
$11.98
|
| Rate for Payer: ASR Commercial |
$20.03
|
| Rate for Payer: BCBS Trust/PPO |
$10.06
|
| Rate for Payer: BCBS Trust/PPO |
$16.83
|
| Rate for Payer: BCN Commercial |
$16.01
|
| Rate for Payer: BCN Commercial |
$9.57
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$12.35
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$11.98
|
| Rate for Payer: Healthscope Whirlpool |
$20.03
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Medicare |
$6.18
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR Commercial |
$11.98
|
| Rate for Payer: ASR Commercial |
$20.03
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$4.94
|
| Rate for Payer: BCBS Trust/PPO |
$16.91
|
| Rate for Payer: BCBS Trust/PPO |
$10.11
|
| Rate for Payer: BCN Commercial |
$9.57
|
| Rate for Payer: BCN Commercial |
$16.01
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| Rate for Payer: Healthscope Commercial |
$12.35
|
| Rate for Payer: Healthscope Whirlpool |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$11.98
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.50
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.69
|
| Rate for Payer: Priority Health Narrow Network |
$0.55
|
| Rate for Payer: Priority Health Narrow Network |
$0.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$13.48
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Aetna Commercial |
$12.13
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR ASR |
$13.08
|
| Rate for Payer: ASR Commercial |
$11.98
|
| Rate for Payer: ASR Commercial |
$20.03
|
| Rate for Payer: ASR Commercial |
$13.08
|
| Rate for Payer: BCBS Trust/PPO |
$10.98
|
| Rate for Payer: BCBS Trust/PPO |
$10.06
|
| Rate for Payer: BCBS Trust/PPO |
$16.83
|
| Rate for Payer: BCN Commercial |
$9.57
|
| Rate for Payer: BCN Commercial |
$10.45
|
| Rate for Payer: BCN Commercial |
$16.01
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$12.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.78
|
| Rate for Payer: Healthscope Commercial |
$13.48
|
| Rate for Payer: Healthscope Commercial |
$12.35
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$11.98
|
| Rate for Payer: Healthscope Whirlpool |
$13.08
|
| Rate for Payer: Healthscope Whirlpool |
$20.03
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$12.13
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Nomi Health Commercial |
$11.05
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.86
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$12.35
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$12.13
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna Medicare |
$6.18
|
| Rate for Payer: Aetna Medicare |
$6.74
|
| Rate for Payer: ASR ASR |
$13.08
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR Commercial |
$13.08
|
| Rate for Payer: ASR Commercial |
$11.98
|
| Rate for Payer: ASR Commercial |
$20.03
|
| Rate for Payer: BCBS Complete |
$4.94
|
| Rate for Payer: BCBS Complete |
$5.39
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$16.91
|
| Rate for Payer: BCBS Trust/PPO |
$10.11
|
| Rate for Payer: BCBS Trust/PPO |
$11.04
|
| Rate for Payer: BCN Commercial |
$10.45
|
| Rate for Payer: BCN Commercial |
$16.01
|
| Rate for Payer: BCN Commercial |
$9.57
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$12.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.78
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| Rate for Payer: Healthscope Commercial |
$13.48
|
| Rate for Payer: Healthscope Commercial |
$12.35
|
| Rate for Payer: Healthscope Whirlpool |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$13.08
|
| Rate for Payer: Healthscope Whirlpool |
$11.98
|
| Rate for Payer: Mclaren Commercial |
$12.13
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.50
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$11.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.69
|
| Rate for Payer: Priority Health Narrow Network |
$0.55
|
| Rate for Payer: Priority Health Narrow Network |
$0.55
|
| Rate for Payer: Priority Health Narrow Network |
$0.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.32 |
| Max. Negotiated Rate |
$20.50 |
| Rate for Payer: Aetna Commercial |
$18.45
|
| Rate for Payer: ASR ASR |
$19.88
|
| Rate for Payer: ASR Commercial |
$19.88
|
| Rate for Payer: BCBS Trust/PPO |
$16.71
|
| Rate for Payer: BCN Commercial |
$15.89
|
| Rate for Payer: Cash Price |
$16.40
|
| Rate for Payer: Cofinity Commercial |
$19.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.40
|
| Rate for Payer: Healthscope Commercial |
$20.50
|
| Rate for Payer: Healthscope Whirlpool |
$19.88
|
| Rate for Payer: Mclaren Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.42
|
| Rate for Payer: Nomi Health Commercial |
$16.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.04
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$20.50
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$20.50 |
| Rate for Payer: Aetna Commercial |
$18.45
|
| Rate for Payer: Aetna Medicare |
$10.25
|
| Rate for Payer: ASR ASR |
$19.88
|
| Rate for Payer: ASR Commercial |
$19.88
|
| Rate for Payer: BCBS Complete |
$8.20
|
| Rate for Payer: BCBS Trust/PPO |
$16.79
|
| Rate for Payer: BCN Commercial |
$15.89
|
| Rate for Payer: Cash Price |
$16.40
|
| Rate for Payer: Cofinity Commercial |
$19.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.40
|
| Rate for Payer: Healthscope Commercial |
$20.50
|
| Rate for Payer: Healthscope Whirlpool |
$19.88
|
| Rate for Payer: Mclaren Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.42
|
| Rate for Payer: Nomi Health Commercial |
$16.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.96
|
| Rate for Payer: Priority Health Narrow Network |
$14.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.04
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$19.43
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.77 |
| Max. Negotiated Rate |
$19.43 |
| Rate for Payer: Aetna Commercial |
$17.49
|
| Rate for Payer: Aetna Medicare |
$9.72
|
| Rate for Payer: ASR ASR |
$18.85
|
| Rate for Payer: ASR Commercial |
$18.85
|
| Rate for Payer: BCBS Complete |
$7.77
|
| Rate for Payer: BCBS Trust/PPO |
$15.91
|
| Rate for Payer: BCN Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$18.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.54
|
| Rate for Payer: Healthscope Commercial |
$19.43
|
| Rate for Payer: Healthscope Whirlpool |
$18.85
|
| Rate for Payer: Mclaren Commercial |
$17.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.52
|
| Rate for Payer: Nomi Health Commercial |
$15.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.02
|
| Rate for Payer: Priority Health Narrow Network |
$13.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.10
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: ASR ASR |
$14.02
|
| Rate for Payer: ASR Commercial |
$14.02
|
| Rate for Payer: BCBS Trust/PPO |
$11.78
|
| Rate for Payer: BCN Commercial |
$11.20
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$13.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Healthscope Whirlpool |
$14.02
|
| Rate for Payer: Mclaren Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Nomi Health Commercial |
$11.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.72
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Medicare |
$7.22
|
| Rate for Payer: ASR ASR |
$14.02
|
| Rate for Payer: ASR Commercial |
$14.02
|
| Rate for Payer: BCBS Complete |
$5.78
|
| Rate for Payer: BCBS Trust/PPO |
$11.83
|
| Rate for Payer: BCN Commercial |
$11.20
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$13.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Healthscope Whirlpool |
$14.02
|
| Rate for Payer: Mclaren Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Nomi Health Commercial |
$11.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.66
|
| Rate for Payer: Priority Health Narrow Network |
$10.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.72
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.43
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$19.43 |
| Rate for Payer: Aetna Commercial |
$17.49
|
| Rate for Payer: ASR ASR |
$18.85
|
| Rate for Payer: ASR Commercial |
$18.85
|
| Rate for Payer: BCBS Trust/PPO |
$15.83
|
| Rate for Payer: BCN Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$18.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.54
|
| Rate for Payer: Healthscope Commercial |
$19.43
|
| Rate for Payer: Healthscope Whirlpool |
$18.85
|
| Rate for Payer: Mclaren Commercial |
$17.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.52
|
| Rate for Payer: Nomi Health Commercial |
$15.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.10
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.80 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Aetna Commercial |
$265.05
|
| Rate for Payer: Aetna Medicare |
$147.25
|
| Rate for Payer: ASR ASR |
$285.66
|
| Rate for Payer: ASR Commercial |
$285.66
|
| Rate for Payer: BCBS Complete |
$117.80
|
| Rate for Payer: BCBS Trust/PPO |
$241.17
|
| Rate for Payer: BCN Commercial |
$228.33
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$276.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$294.50
|
| Rate for Payer: Healthscope Whirlpool |
$285.66
|
| Rate for Payer: Mclaren Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$258.04
|
| Rate for Payer: Priority Health Narrow Network |
$206.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$259.16
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.11 |
| Max. Negotiated Rate |
$312.48 |
| Rate for Payer: Aetna Commercial |
$281.23
|
| Rate for Payer: ASR ASR |
$303.11
|
| Rate for Payer: ASR Commercial |
$303.11
|
| Rate for Payer: BCBS Trust/PPO |
$254.64
|
| Rate for Payer: BCN Commercial |
$242.27
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$293.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$312.48
|
| Rate for Payer: Healthscope Whirlpool |
$303.11
|
| Rate for Payer: Mclaren Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$274.98
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.99 |
| Max. Negotiated Rate |
$312.48 |
| Rate for Payer: Aetna Commercial |
$281.23
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: ASR ASR |
$303.11
|
| Rate for Payer: ASR Commercial |
$303.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: BCBS Trust/PPO |
$255.89
|
| Rate for Payer: BCN Commercial |
$242.27
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$293.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$312.48
|
| Rate for Payer: Healthscope Whirlpool |
$303.11
|
| Rate for Payer: Mclaren Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$273.79
|
| Rate for Payer: Priority Health Narrow Network |
$219.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$274.98
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.42 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Aetna Commercial |
$265.05
|
| Rate for Payer: ASR ASR |
$285.66
|
| Rate for Payer: ASR Commercial |
$285.66
|
| Rate for Payer: BCBS Trust/PPO |
$239.99
|
| Rate for Payer: BCN Commercial |
$228.33
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$276.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$294.50
|
| Rate for Payer: Healthscope Whirlpool |
$285.66
|
| Rate for Payer: Mclaren Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$259.16
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.88 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna Commercial |
$326.61
|
| Rate for Payer: ASR ASR |
$352.01
|
| Rate for Payer: ASR Commercial |
$352.01
|
| Rate for Payer: BCBS Trust/PPO |
$295.73
|
| Rate for Payer: BCN Commercial |
$281.36
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$341.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$362.90
|
| Rate for Payer: Healthscope Whirlpool |
$352.01
|
| Rate for Payer: Mclaren Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$319.35
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.16 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna Commercial |
$326.61
|
| Rate for Payer: Aetna Medicare |
$181.45
|
| Rate for Payer: ASR ASR |
$352.01
|
| Rate for Payer: ASR Commercial |
$352.01
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: BCBS Trust/PPO |
$297.18
|
| Rate for Payer: BCN Commercial |
$281.36
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$341.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$362.90
|
| Rate for Payer: Healthscope Whirlpool |
$352.01
|
| Rate for Payer: Mclaren Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$317.97
|
| Rate for Payer: Priority Health Narrow Network |
$254.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$319.35
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$94.87
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
118045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.67 |
| Max. Negotiated Rate |
$94.87 |
| Rate for Payer: Aetna Commercial |
$85.38
|
| Rate for Payer: ASR ASR |
$92.02
|
| Rate for Payer: ASR Commercial |
$92.02
|
| Rate for Payer: BCBS Trust/PPO |
$77.31
|
| Rate for Payer: BCN Commercial |
$73.55
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cofinity Commercial |
$89.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.90
|
| Rate for Payer: Healthscope Commercial |
$94.87
|
| Rate for Payer: Healthscope Whirlpool |
$92.02
|
| Rate for Payer: Mclaren Commercial |
$85.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.64
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.49
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$94.87
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
118045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$94.87 |
| Rate for Payer: Aetna Commercial |
$85.38
|
| Rate for Payer: Aetna Medicare |
$47.44
|
| Rate for Payer: ASR ASR |
$92.02
|
| Rate for Payer: ASR Commercial |
$92.02
|
| Rate for Payer: BCBS Complete |
$37.95
|
| Rate for Payer: BCBS Trust/PPO |
$77.69
|
| Rate for Payer: BCN Commercial |
$73.55
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cofinity Commercial |
$89.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.90
|
| Rate for Payer: Healthscope Commercial |
$94.87
|
| Rate for Payer: Healthscope Whirlpool |
$92.02
|
| Rate for Payer: Mclaren Commercial |
$85.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.64
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.31
|
| Rate for Payer: Priority Health Narrow Network |
$26.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.49
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.70 |
| Max. Negotiated Rate |
$165.70 |
| Rate for Payer: Aetna Commercial |
$149.13
|
| Rate for Payer: ASR ASR |
$160.73
|
| Rate for Payer: ASR Commercial |
$160.73
|
| Rate for Payer: BCBS Trust/PPO |
$135.03
|
| Rate for Payer: BCN Commercial |
$128.47
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$155.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$165.70
|
| Rate for Payer: Healthscope Whirlpool |
$160.73
|
| Rate for Payer: Mclaren Commercial |
$149.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: Nomi Health Commercial |
$135.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$145.82
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$165.70 |
| Rate for Payer: Aetna Commercial |
$149.13
|
| Rate for Payer: Aetna Medicare |
$82.85
|
| Rate for Payer: ASR ASR |
$160.73
|
| Rate for Payer: ASR Commercial |
$160.73
|
| Rate for Payer: BCBS Complete |
$66.28
|
| Rate for Payer: BCBS Trust/PPO |
$135.69
|
| Rate for Payer: BCN Commercial |
$128.47
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$155.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$165.70
|
| Rate for Payer: Healthscope Whirlpool |
$160.73
|
| Rate for Payer: Mclaren Commercial |
$149.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: Nomi Health Commercial |
$135.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.15
|
| Rate for Payer: Priority Health Narrow Network |
$44.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$145.82
|
|
|
DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$196.04
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
166805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$196.04 |
| Rate for Payer: Aetna Commercial |
$176.44
|
| Rate for Payer: Aetna Medicare |
$98.02
|
| Rate for Payer: ASR ASR |
$190.16
|
| Rate for Payer: ASR Commercial |
$190.16
|
| Rate for Payer: BCBS Complete |
$78.42
|
| Rate for Payer: BCBS Trust/PPO |
$160.54
|
| Rate for Payer: BCN Commercial |
$151.99
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cofinity Commercial |
$184.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.83
|
| Rate for Payer: Healthscope Commercial |
$196.04
|
| Rate for Payer: Healthscope Whirlpool |
$190.16
|
| Rate for Payer: Mclaren Commercial |
$176.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.63
|
| Rate for Payer: Nomi Health Commercial |
$160.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.15
|
| Rate for Payer: Priority Health Narrow Network |
$44.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.52
|
|
|
DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$196.04
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
166805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.43 |
| Max. Negotiated Rate |
$196.04 |
| Rate for Payer: Aetna Commercial |
$176.44
|
| Rate for Payer: ASR ASR |
$190.16
|
| Rate for Payer: ASR Commercial |
$190.16
|
| Rate for Payer: BCBS Trust/PPO |
$159.75
|
| Rate for Payer: BCN Commercial |
$151.99
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cofinity Commercial |
$184.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.83
|
| Rate for Payer: Healthscope Commercial |
$196.04
|
| Rate for Payer: Healthscope Whirlpool |
$190.16
|
| Rate for Payer: Mclaren Commercial |
$176.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.63
|
| Rate for Payer: Nomi Health Commercial |
$160.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.52
|
|
