|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$997.89
|
|
|
Service Code
|
NDC 378609001
|
| Hospital Charge Code |
14101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$748.42 |
| 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 |
$819.47
|
| Rate for Payer: BCN Commercial |
$819.47
|
| 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 |
$967.95
|
| Rate for Payer: Healthscope Whirlpool |
$997.89
|
| 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: Opus (Opus Packaging Group) HMA |
$748.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.14
|
|
|
DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR
|
Facility
|
OP
|
$997.89
|
|
|
Service Code
|
NDC 378609001
|
| Hospital Charge Code |
14101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$369.22 |
| Max. Negotiated Rate |
$997.89 |
| Rate for Payer: Aetna Commercial |
$898.10
|
| Rate for Payer: Aetna Medicare |
$369.22
|
| Rate for Payer: ASR ASR |
$967.95
|
| Rate for Payer: BCBS Complete |
$399.16
|
| Rate for Payer: BCBS Trust/PPO |
$822.76
|
| Rate for Payer: BCN Commercial |
$822.76
|
| 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 |
$967.95
|
| Rate for Payer: Healthscope Whirlpool |
$997.89
|
| Rate for Payer: Mclaren Commercial |
$898.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$798.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.21
|
| Rate for Payer: Nomi Health Commercial |
$818.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$748.42
|
| Rate for Payer: Priority Health Cigna 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
|
|
|
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 |
$18.03 |
| 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 |
$19.74
|
| Rate for Payer: BCN Commercial |
$19.74
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cofinity Commercial |
$22.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.24
|
| Rate for Payer: Healthscope Commercial |
$23.32
|
| Rate for Payer: Healthscope Whirlpool |
$24.04
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.44
|
| Rate for Payer: Nomi Health Commercial |
$19.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.03
|
| 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 |
$0.76 |
| Max. Negotiated Rate |
$24.04 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: Aetna Medicare |
$8.90
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: BCBS Complete |
$9.62
|
| Rate for Payer: BCBS Trust/PPO |
$19.82
|
| Rate for Payer: BCN Commercial |
$19.82
|
| 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 |
$19.24
|
| Rate for Payer: Healthscope Commercial |
$23.32
|
| Rate for Payer: Healthscope Whirlpool |
$24.04
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.44
|
| Rate for Payer: Nomi Health Commercial |
$19.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.95
|
| Rate for Payer: Priority Health Narrow Network |
$0.76
|
| 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 |
$230.22 |
| Max. Negotiated Rate |
$306.96 |
| Rate for Payer: Aetna Commercial |
$276.26
|
| Rate for Payer: ASR ASR |
$297.75
|
| Rate for Payer: BCBS Trust/PPO |
$252.08
|
| Rate for Payer: BCN Commercial |
$252.08
|
| 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 |
$297.75
|
| Rate for Payer: Healthscope Whirlpool |
$306.96
|
| 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: Opus (Opus Packaging Group) HMA |
$230.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$270.13
|
|
|
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 |
$113.58 |
| Max. Negotiated Rate |
$306.96 |
| Rate for Payer: Aetna Commercial |
$276.26
|
| Rate for Payer: Aetna Medicare |
$113.58
|
| Rate for Payer: ASR ASR |
$297.75
|
| Rate for Payer: BCBS Complete |
$122.78
|
| Rate for Payer: BCBS Trust/PPO |
$253.09
|
| Rate for Payer: BCN Commercial |
$253.09
|
| 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 |
$297.75
|
| Rate for Payer: Healthscope Whirlpool |
$306.96
|
| Rate for Payer: Mclaren Commercial |
$276.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Nomi Health Commercial |
$251.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.22
|
| Rate for Payer: Priority Health Cigna 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 |
$270.13
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$16.08
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$16.08 |
| Rate for Payer: Aetna Commercial |
$14.47
|
| Rate for Payer: Aetna Medicare |
$5.95
|
| Rate for Payer: ASR ASR |
$15.59
|
| Rate for Payer: BCBS Complete |
$6.43
|
| Rate for Payer: BCBS Trust/PPO |
$13.26
|
| Rate for Payer: BCN Commercial |
$13.26
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cofinity Commercial |
$15.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Healthscope Whirlpool |
$16.08
|
| Rate for Payer: Mclaren Commercial |
$14.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.67
|
| Rate for Payer: Nomi Health Commercial |
$13.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$14.09
|
| Rate for Payer: Priority Health Narrow Network |
$11.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.15
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$16.08
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$16.08 |
| Rate for Payer: Aetna Commercial |
$14.47
|
| Rate for Payer: ASR ASR |
$15.59
|
| Rate for Payer: BCBS Trust/PPO |
$13.20
|
| Rate for Payer: BCN Commercial |
$13.20
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cofinity Commercial |
$15.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Healthscope Whirlpool |
$16.08
|
| Rate for Payer: Mclaren Commercial |
$14.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.67
|
| Rate for Payer: Nomi Health Commercial |
$13.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.15
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$10.74
|
|
|
Service Code
|
NDC 121086505
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$10.73 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: Aetna Medicare |
$3.97
|
| Rate for Payer: ASR ASR |
$10.41
|
| Rate for Payer: BCBS Complete |
$4.29
|
| Rate for Payer: BCBS Trust/PPO |
$8.85
|
| Rate for Payer: BCN Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Commercial |
$10.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$10.41
|
| Rate for Payer: Healthscope Whirlpool |
$10.73
|
| Rate for Payer: Mclaren Commercial |
$9.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.12
|
| Rate for Payer: Nomi Health Commercial |
$8.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9.41
|
| Rate for Payer: Priority Health Narrow Network |
$7.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.45
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$10.74
|
|
|
Service Code
|
NDC 121086500
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$10.73 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: Aetna Medicare |
$3.97
|
| Rate for Payer: ASR ASR |
$10.41
|
| Rate for Payer: BCBS Complete |
$4.29
|
| Rate for Payer: BCBS Trust/PPO |
$8.85
|
| Rate for Payer: BCN Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Commercial |
$10.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$10.41
|
| Rate for Payer: Healthscope Whirlpool |
$10.73
|
| Rate for Payer: Mclaren Commercial |
$9.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.12
|
| Rate for Payer: Nomi Health Commercial |
$8.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9.41
|
| Rate for Payer: Priority Health Narrow Network |
$7.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.45
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$10.74
|
|
|
Service Code
|
NDC 121086505
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$10.73 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: ASR ASR |
$10.41
|
| Rate for Payer: BCBS Trust/PPO |
$8.82
|
| Rate for Payer: BCN Commercial |
$8.82
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Commercial |
$10.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$10.41
|
| Rate for Payer: Healthscope Whirlpool |
$10.73
|
| Rate for Payer: Mclaren Commercial |
$9.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.12
|
| Rate for Payer: Nomi Health Commercial |
$8.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.45
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$10.74
|
|
|
Service Code
|
NDC 121086500
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$10.73 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: ASR ASR |
$10.41
|
| Rate for Payer: BCBS Trust/PPO |
$8.82
|
| Rate for Payer: BCN Commercial |
$8.82
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Commercial |
$10.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$10.41
|
| Rate for Payer: Healthscope Whirlpool |
$10.73
|
| Rate for Payer: Mclaren Commercial |
$9.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.12
|
| Rate for Payer: Nomi Health Commercial |
$8.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.45
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$119.70
|
|
|
Service Code
|
NDC 904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna Commercial |
$107.73
|
| Rate for Payer: Aetna Medicare |
$44.29
|
| Rate for Payer: ASR ASR |
$116.11
|
| Rate for Payer: BCBS Complete |
$47.88
|
| Rate for Payer: BCBS Trust/PPO |
$98.69
|
| Rate for Payer: BCN Commercial |
$98.69
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Commercial |
$112.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$116.11
|
| Rate for Payer: Healthscope Whirlpool |
$119.70
|
| Rate for Payer: Mclaren Commercial |
$107.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Nomi Health Commercial |
$98.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$104.88
|
| Rate for Payer: Priority Health Narrow Network |
$83.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.34
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: ASR ASR |
$1.64
|
| Rate for Payer: BCBS Trust/PPO |
$1.39
|
| Rate for Payer: BCN Commercial |
$1.39
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.64
|
| Rate for Payer: Healthscope Whirlpool |
$1.69
|
| Rate for Payer: Mclaren Commercial |
$1.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.43
|
| Rate for Payer: Nomi Health Commercial |
$1.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.48
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$119.70
|
|
|
Service Code
|
NDC 904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna Commercial |
$107.73
|
| Rate for Payer: ASR ASR |
$116.11
|
| Rate for Payer: BCBS Trust/PPO |
$98.30
|
| Rate for Payer: BCN Commercial |
$98.30
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Commercial |
$112.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$116.11
|
| Rate for Payer: Healthscope Whirlpool |
$119.70
|
| Rate for Payer: Mclaren Commercial |
$107.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Nomi Health Commercial |
$98.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.34
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Aetna Medicare |
$0.62
|
| Rate for Payer: ASR ASR |
$1.64
|
| Rate for Payer: BCBS Complete |
$0.67
|
| Rate for Payer: BCBS Trust/PPO |
$1.39
|
| Rate for Payer: BCN Commercial |
$1.39
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.64
|
| Rate for Payer: Healthscope Whirlpool |
$1.69
|
| Rate for Payer: Mclaren Commercial |
$1.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.43
|
| Rate for Payer: Nomi Health Commercial |
$1.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.48
|
| Rate for Payer: Priority Health Narrow Network |
$1.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.48
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.42 |
| Max. Negotiated Rate |
$168.70 |
| Rate for Payer: Aetna Commercial |
$151.83
|
| Rate for Payer: Aetna Medicare |
$62.42
|
| Rate for Payer: ASR ASR |
$163.64
|
| Rate for Payer: BCBS Complete |
$67.48
|
| Rate for Payer: BCBS Trust/PPO |
$139.09
|
| Rate for Payer: BCN Commercial |
$139.09
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Commercial |
$158.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$163.64
|
| Rate for Payer: Healthscope Whirlpool |
$168.70
|
| Rate for Payer: Mclaren Commercial |
$151.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Nomi Health Commercial |
$138.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$147.81
|
| Rate for Payer: Priority Health Narrow Network |
$118.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$148.46
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.53 |
| Max. Negotiated Rate |
$168.70 |
| Rate for Payer: Aetna Commercial |
$151.83
|
| Rate for Payer: ASR ASR |
$163.64
|
| Rate for Payer: BCBS Trust/PPO |
$138.54
|
| Rate for Payer: BCN Commercial |
$138.54
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Commercial |
$158.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$163.64
|
| Rate for Payer: Healthscope Whirlpool |
$168.70
|
| Rate for Payer: Mclaren Commercial |
$151.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Nomi Health Commercial |
$138.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$148.46
|
|
|
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 |
$9.26 |
| 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 |
$16.95
|
| Rate for Payer: BCBS Trust/PPO |
$10.14
|
| Rate for Payer: BCN Commercial |
$16.95
|
| Rate for Payer: BCN Commercial |
$10.14
|
| 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 |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Healthscope Commercial |
$11.98
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| 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 |
$10.50
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.48
|
| 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 |
$0.59 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Medicare |
$4.57
|
| Rate for Payer: Aetna Medicare |
$7.64
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: BCBS Complete |
$4.94
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$17.02
|
| Rate for Payer: BCBS Trust/PPO |
$10.18
|
| Rate for Payer: BCN Commercial |
$10.18
|
| Rate for Payer: BCN Commercial |
$17.02
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.88
|
| 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 |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Commercial |
$11.98
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.88
|
| 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: Opus (Opus Packaging Group) HMA |
$9.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| 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
|
$13.49
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Aetna Commercial |
$12.14
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$10.89
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: ASR ASR |
$13.08
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR ASR |
$11.74
|
| Rate for Payer: BCBS Trust/PPO |
$11.07
|
| Rate for Payer: BCBS Trust/PPO |
$9.94
|
| Rate for Payer: BCBS Trust/PPO |
$10.14
|
| Rate for Payer: BCBS Trust/PPO |
$16.95
|
| Rate for Payer: BCN Commercial |
$9.94
|
| Rate for Payer: BCN Commercial |
$16.95
|
| Rate for Payer: BCN Commercial |
$10.14
|
| Rate for Payer: BCN Commercial |
$11.07
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cofinity Commercial |
$12.68
|
| Rate for Payer: Cofinity Commercial |
$11.37
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| 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 |
$9.68
|
| Rate for Payer: Healthscope Commercial |
$13.08
|
| Rate for Payer: Healthscope Commercial |
$11.74
|
| Rate for Payer: Healthscope Commercial |
$11.98
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$13.48
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$12.10
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| Rate for Payer: Mclaren Commercial |
$10.89
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Mclaren Commercial |
$12.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.29
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: Nomi Health Commercial |
$9.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.87
|
| 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
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Commercial |
$11.12
|
| Rate for Payer: Aetna Commercial |
$12.14
|
| Rate for Payer: Aetna Commercial |
$10.89
|
| Rate for Payer: Aetna Medicare |
$4.48
|
| Rate for Payer: Aetna Medicare |
$7.64
|
| Rate for Payer: Aetna Medicare |
$4.99
|
| Rate for Payer: Aetna Medicare |
$4.57
|
| Rate for Payer: ASR ASR |
$13.08
|
| Rate for Payer: ASR ASR |
$11.98
|
| Rate for Payer: ASR ASR |
$11.74
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Complete |
$5.39
|
| Rate for Payer: BCBS Complete |
$4.84
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$4.94
|
| Rate for Payer: BCBS Trust/PPO |
$10.18
|
| Rate for Payer: BCBS Trust/PPO |
$17.02
|
| Rate for Payer: BCBS Trust/PPO |
$11.12
|
| Rate for Payer: BCBS Trust/PPO |
$9.98
|
| Rate for Payer: BCN Commercial |
$17.02
|
| Rate for Payer: BCN Commercial |
$11.12
|
| Rate for Payer: BCN Commercial |
$9.98
|
| Rate for Payer: BCN Commercial |
$10.18
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$9.88
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Cofinity Commercial |
$11.37
|
| Rate for Payer: Cofinity Commercial |
$12.68
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Commercial |
$11.74
|
| Rate for Payer: Healthscope Commercial |
$11.98
|
| Rate for Payer: Healthscope Commercial |
$13.08
|
| Rate for Payer: Healthscope Whirlpool |
$12.10
|
| Rate for Payer: Healthscope Whirlpool |
$13.48
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| Rate for Payer: Mclaren Commercial |
$12.14
|
| Rate for Payer: Mclaren Commercial |
$11.12
|
| Rate for Payer: Mclaren Commercial |
$10.89
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.29
|
| 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 |
$9.92
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$10.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.74
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| Rate for Payer: Priority Health Narrow Network |
$0.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.87
|
|
|
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 |
$15.38 |
| Max. Negotiated Rate |
$20.50 |
| Rate for Payer: Aetna Commercial |
$18.45
|
| Rate for Payer: ASR ASR |
$19.89
|
| Rate for Payer: BCBS Trust/PPO |
$16.84
|
| Rate for Payer: BCN Commercial |
$16.84
|
| 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 |
$19.89
|
| Rate for Payer: Healthscope Whirlpool |
$20.50
|
| Rate for Payer: Mclaren Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.38
|
| 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 |
$7.59 |
| Max. Negotiated Rate |
$20.50 |
| Rate for Payer: Aetna Commercial |
$18.45
|
| Rate for Payer: Aetna Medicare |
$7.59
|
| Rate for Payer: ASR ASR |
$19.89
|
| Rate for Payer: BCBS Complete |
$8.20
|
| Rate for Payer: BCBS Trust/PPO |
$16.91
|
| Rate for Payer: BCN Commercial |
$16.91
|
| 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 |
$19.89
|
| Rate for Payer: Healthscope Whirlpool |
$20.50
|
| Rate for Payer: Mclaren Commercial |
$18.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$17.97
|
| 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
|
$22.83
|
|
|
Service Code
|
NDC 904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$22.83 |
| Rate for Payer: Aetna Commercial |
$20.55
|
| Rate for Payer: Aetna Medicare |
$8.45
|
| Rate for Payer: ASR ASR |
$22.15
|
| Rate for Payer: BCBS Complete |
$9.13
|
| Rate for Payer: BCBS Trust/PPO |
$18.83
|
| Rate for Payer: BCN Commercial |
$18.83
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Commercial |
$21.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$22.15
|
| Rate for Payer: Healthscope Whirlpool |
$22.83
|
| Rate for Payer: Mclaren Commercial |
$20.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Nomi Health Commercial |
$18.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$20.01
|
| Rate for Payer: Priority Health Narrow Network |
$16.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.09
|
|
