|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$131.88
|
|
|
Service Code
|
NDC 0641-9219-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.32 |
| Max. Negotiated Rate |
$131.88 |
| Rate for Payer: Aetna Commercial |
$118.69
|
| Rate for Payer: ASR ASR |
$127.92
|
| Rate for Payer: BCBS Trust/PPO |
$102.25
|
| Rate for Payer: BCN Commercial |
$102.25
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cofinity Commercial |
$123.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.50
|
| Rate for Payer: Healthscope Commercial |
$131.88
|
| Rate for Payer: Healthscope Whirlpool |
$127.92
|
| Rate for Payer: Mclaren Commercial |
$118.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$116.05
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 0409-1171-02
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.80 |
| Max. Negotiated Rate |
$74.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: ASR ASR |
$71.78
|
| Rate for Payer: BCBS Trust/PPO |
$57.37
|
| Rate for Payer: BCN Commercial |
$57.37
|
| Rate for Payer: Cash Price |
$59.20
|
| Rate for Payer: Cofinity Commercial |
$69.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.20
|
| Rate for Payer: Healthscope Commercial |
$74.00
|
| Rate for Payer: Healthscope Whirlpool |
$71.78
|
| Rate for Payer: Mclaren Commercial |
$66.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.12
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$49.62
|
|
|
Service Code
|
NDC 0641-9217-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.73 |
| Max. Negotiated Rate |
$49.62 |
| Rate for Payer: Aetna Commercial |
$44.66
|
| Rate for Payer: ASR ASR |
$48.13
|
| Rate for Payer: BCBS Trust/PPO |
$38.47
|
| Rate for Payer: BCN Commercial |
$38.47
|
| Rate for Payer: Cash Price |
$39.70
|
| Rate for Payer: Cofinity Commercial |
$46.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.70
|
| Rate for Payer: Healthscope Commercial |
$49.62
|
| Rate for Payer: Healthscope Whirlpool |
$48.13
|
| Rate for Payer: Mclaren Commercial |
$44.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$42.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$43.67
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$59.50
|
|
|
Service Code
|
NDC 17478-937-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna Commercial |
$53.55
|
| Rate for Payer: ASR ASR |
$57.72
|
| Rate for Payer: BCBS Trust/PPO |
$46.13
|
| Rate for Payer: BCN Commercial |
$46.13
|
| Rate for Payer: Cash Price |
$47.60
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.60
|
| Rate for Payer: Healthscope Commercial |
$59.50
|
| Rate for Payer: Healthscope Whirlpool |
$57.72
|
| Rate for Payer: Mclaren Commercial |
$53.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.36
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$65.25
|
|
|
Service Code
|
NDC 17478-937-05
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.68 |
| Max. Negotiated Rate |
$65.25 |
| Rate for Payer: Aetna Commercial |
$58.72
|
| Rate for Payer: ASR ASR |
$63.29
|
| Rate for Payer: BCBS Trust/PPO |
$50.59
|
| Rate for Payer: BCN Commercial |
$50.59
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cofinity Commercial |
$61.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.20
|
| Rate for Payer: Healthscope Commercial |
$65.25
|
| Rate for Payer: Healthscope Whirlpool |
$63.29
|
| Rate for Payer: Mclaren Commercial |
$58.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.42
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$90.50
|
|
|
Service Code
|
NDC 0641-6014-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$90.50 |
| Rate for Payer: Aetna Commercial |
$81.45
|
| Rate for Payer: ASR ASR |
$87.78
|
| Rate for Payer: BCBS Trust/PPO |
$70.16
|
| Rate for Payer: BCN Commercial |
$70.16
|
| Rate for Payer: Cash Price |
$72.40
|
| Rate for Payer: Cofinity Commercial |
$85.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.40
|
| Rate for Payer: Healthscope Commercial |
$90.50
|
| Rate for Payer: Healthscope Whirlpool |
$87.78
|
| Rate for Payer: Mclaren Commercial |
$81.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$79.64
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 60687-195-01
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.92 |
| Max. Negotiated Rate |
$428.45 |
| Rate for Payer: Aetna Commercial |
$385.60
|
| Rate for Payer: ASR ASR |
$415.60
|
| Rate for Payer: BCBS Trust/PPO |
$332.18
|
| Rate for Payer: BCN Commercial |
$332.18
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$402.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$428.45
|
| Rate for Payer: Healthscope Whirlpool |
$415.60
|
| Rate for Payer: Mclaren Commercial |
$385.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$377.04
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$329.65
|
|
|
Service Code
|
NDC 0904-7217-61
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.76 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Aetna Commercial |
$296.68
|
| Rate for Payer: ASR ASR |
$319.76
|
| Rate for Payer: BCBS Trust/PPO |
$255.58
|
| Rate for Payer: BCN Commercial |
$255.58
|
| Rate for Payer: Cash Price |
$263.72
|
| Rate for Payer: Cofinity Commercial |
$309.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.72
|
| Rate for Payer: Healthscope Commercial |
$329.65
|
| Rate for Payer: Healthscope Whirlpool |
$319.76
|
| Rate for Payer: Mclaren Commercial |
$296.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$280.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$290.09
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 60687-195-11
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: ASR ASR |
$4.15
|
| Rate for Payer: BCBS Trust/PPO |
$3.32
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Healthscope Whirlpool |
$4.15
|
| Rate for Payer: Mclaren Commercial |
$3.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.77
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$305.90
|
|
|
Service Code
|
NDC 60687-206-01
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.13 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Aetna Commercial |
$275.31
|
| Rate for Payer: ASR ASR |
$296.72
|
| Rate for Payer: BCBS Trust/PPO |
$237.16
|
| Rate for Payer: BCN Commercial |
$237.16
|
| Rate for Payer: Cash Price |
$244.72
|
| Rate for Payer: Cofinity Commercial |
$287.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.72
|
| Rate for Payer: Healthscope Commercial |
$305.90
|
| Rate for Payer: Healthscope Whirlpool |
$296.72
|
| Rate for Payer: Mclaren Commercial |
$275.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$260.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$269.19
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$268.85
|
|
|
Service Code
|
NDC 0904-7218-61
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.20 |
| Max. Negotiated Rate |
$268.85 |
| Rate for Payer: Aetna Commercial |
$241.96
|
| Rate for Payer: ASR ASR |
$260.78
|
| Rate for Payer: BCBS Trust/PPO |
$208.44
|
| Rate for Payer: BCN Commercial |
$208.44
|
| Rate for Payer: Cash Price |
$215.08
|
| Rate for Payer: Cofinity Commercial |
$252.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.08
|
| Rate for Payer: Healthscope Commercial |
$268.85
|
| Rate for Payer: Healthscope Whirlpool |
$260.78
|
| Rate for Payer: Mclaren Commercial |
$241.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$228.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$236.59
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 60687-206-11
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: ASR ASR |
$2.97
|
| Rate for Payer: BCBS Trust/PPO |
$2.37
|
| Rate for Payer: BCN Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$2.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.45
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Healthscope Whirlpool |
$2.97
|
| Rate for Payer: Mclaren Commercial |
$2.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.69
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 60687-217-11
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: ASR ASR |
$2.47
|
| Rate for Payer: BCBS Trust/PPO |
$1.98
|
| Rate for Payer: BCN Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.55
|
| Rate for Payer: Healthscope Whirlpool |
$2.47
|
| Rate for Payer: Mclaren Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| 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 63739-016-10
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$297.26 |
| Max. Negotiated Rate |
$424.65 |
| Rate for Payer: Aetna Commercial |
$382.18
|
| Rate for Payer: ASR ASR |
$411.91
|
| Rate for Payer: BCBS Trust/PPO |
$329.23
|
| 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 Multiplan/Beech St/PHCS |
$360.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$373.69
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$254.88
|
|
|
Service Code
|
NDC 60687-217-01
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.42 |
| Max. Negotiated Rate |
$254.88 |
| Rate for Payer: Aetna Commercial |
$229.39
|
| Rate for Payer: ASR ASR |
$247.23
|
| Rate for Payer: BCBS Trust/PPO |
$197.61
|
| Rate for Payer: BCN Commercial |
$197.61
|
| Rate for Payer: Cash Price |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$239.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.90
|
| Rate for Payer: Healthscope Commercial |
$254.88
|
| Rate for Payer: Healthscope Whirlpool |
$247.23
|
| Rate for Payer: Mclaren Commercial |
$229.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.29
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$997.89
|
|
|
Service Code
|
NDC 0378-6090-01
|
| Hospital Charge Code |
14101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$698.52 |
| Max. Negotiated Rate |
$997.89 |
| Rate for Payer: Aetna Commercial |
$898.10
|
| Rate for Payer: ASR ASR |
$967.95
|
| Rate for Payer: BCBS Trust/PPO |
$773.66
|
| 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 Multiplan/Beech St/PHCS |
$848.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$698.52
|
| 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 |
$16.83 |
| Max. Negotiated Rate |
$24.04 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: BCBS Trust/PPO |
$18.64
|
| 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 Multiplan/Beech St/PHCS |
$20.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.16
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$13.04
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$13.04 |
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: ASR ASR |
$12.65
|
| Rate for Payer: BCBS Trust/PPO |
$10.11
|
| Rate for Payer: BCN Commercial |
$10.11
|
| Rate for Payer: Cash Price |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$12.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.43
|
| Rate for Payer: Healthscope Commercial |
$13.04
|
| Rate for Payer: Healthscope Whirlpool |
$12.65
|
| Rate for Payer: Mclaren Commercial |
$11.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.48
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 68094-018-59
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: ASR ASR |
$1.39
|
| Rate for Payer: BCBS Trust/PPO |
$1.11
|
| 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 Multiplan/Beech St/PHCS |
$1.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.26
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$142.80
|
|
|
Service Code
|
NDC 68094-018-61
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.96 |
| Max. Negotiated Rate |
$142.80 |
| Rate for Payer: Aetna Commercial |
$128.52
|
| Rate for Payer: ASR ASR |
$138.52
|
| Rate for Payer: BCBS Trust/PPO |
$110.71
|
| 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 Multiplan/Beech St/PHCS |
$121.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.66
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 0904-5551-59
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: ASR ASR |
$97.78
|
| Rate for Payer: BCBS Trust/PPO |
$78.15
|
| 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 Multiplan/Beech St/PHCS |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.70
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$12.35
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$12.35 |
| 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: BCBS Trust/PPO |
$9.57
|
| Rate for Payer: BCBS Trust/PPO |
$16.01
|
| 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 |
$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 |
$12.35
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$11.98
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
|
|
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 |
$9.44 |
| 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 |
$13.08
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Trust/PPO |
$9.57
|
| Rate for Payer: BCBS Trust/PPO |
$16.01
|
| Rate for Payer: BCBS Trust/PPO |
$10.45
|
| Rate for Payer: BCN Commercial |
$10.45
|
| 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 |
$10.79
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$12.67
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.78
|
| 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 |
$13.48
|
| Rate for Payer: Healthscope Commercial |
$12.35
|
| Rate for Payer: Healthscope Commercial |
$20.65
|
| 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 |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$12.13
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| 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 1254717162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$20.50 |
| Rate for Payer: Aetna Commercial |
$18.45
|
| Rate for Payer: ASR ASR |
$19.88
|
| Rate for Payer: BCBS Trust/PPO |
$15.89
|
| 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 Multiplan/Beech St/PHCS |
$17.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.04
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
NDC 0904-5354-31
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$14.80
|
| Rate for Payer: BCN Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$19.09
|
| Rate for Payer: Healthscope Whirlpool |
$18.52
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
