Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
Leominster, MA
See all hospitals reporting HCPCS J3490 →Price type
HealthAlliance - Clinton Hospital’s median price of $72 is 50% above the median hospital's median price ($48), higher than 63% of the 1,749 hospitals reporting HCPCS J3490. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 8 payers, 12 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | ||||
|---|---|---|---|---|
| 1 | UnitedHealthcare all uhc rhody partners [271] plans percent of total billed charges · bothfrom % of charges | $36.14 | $142.33 | $0.08 – $6,674 |
| 2 | Cigna all tufts ppo/carelink ha [174] plans percent of total billed charges · bothfrom % of charges | $42.22 | $168.00 | $0.10 – $7,875 |
| 3 | Blue Cross Blue Shield all bc hmo ha [61] plans percent of total billed charges · bothfrom % of charges | $42.73 | $170.02 | $0.10 – $7,969 |
| 4 | Blue Cross Blue Shield all bc ppo ha [58] plans percent of total billed charges · bothfrom % of charges | $43.03 | $171.20 | $0.10 – $8,025 |
| 5 | UnitedHealthcare all uhc ha [125] plans percent of total billed charges · bothfrom % of charges | $57.26 | $225.45 | $0.13 – $10,572 |
| 6 | UnitedHealthcare all uhc surest ha [323] plans percent of total billed charges · bothfrom % of charges | $57.26 | $225.45 | $0.13 – $10,572 |
| 7 | Medicaid all medicaid of maine [283] plans percent of total billed charges · bothfrom % of charges | $54.31 | $228.86 | $0.13 – $10,237 |
| 8 | Aetna all aetna ha [147] plans percent of total billed charges · bothfrom % of charges | $69.73 | $274.57 | $0.16 – $12,875 |
| 9 | First Health all coventry (first health) [83] plans percent of total billed charges · bothfrom % of charges | $79.97 | $314.88 | $0.19 – $14,765 |
| 10 | MultiPlan all multiplan [81] plans percent of total billed charges · bothfrom % of charges | $79.97 | $314.88 | $0.19 – $14,765 |
| 11 | Cigna all cigna ha [46] plans percent of total billed charges · bothfrom % of charges | $101.02 | $397.76 | $0.24 – $18,652 |
| 12 | Optum all optum behavioral health (ubh) ha [248] plans percent of total billed charges · bothfrom % of charges | $106.62 | $419.84 | $0.25 – $19,687 |
Last updated: Mar 26, 2026
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