|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$275.37 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$90.29
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$81.26 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna Commercial |
$235.89
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: Aetna Medicare |
$13.76
|
| Rate for Payer: Aetna Medicare |
$45.14
|
| Rate for Payer: Aetna Medicare |
$138.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.39
|
| Rate for Payer: BCBS Complete |
$16.56
|
| Rate for Payer: BCBS Complete |
$36.12
|
| Rate for Payer: BCBS Complete |
$111.01
|
| Rate for Payer: BCBS Complete |
$11.01
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Commercial |
$194.26
|
| Rate for Payer: Cofinity Commercial |
$19.26
|
| Rate for Payer: Cofinity Commercial |
$23.67
|
| Rate for Payer: Cofinity Commercial |
$238.67
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$63.20
|
| Rate for Payer: Cofinity Commercial |
$77.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Healthscope Commercial |
$249.77
|
| Rate for Payer: Healthscope Commercial |
$81.26
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Healthscope Commercial |
$24.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.75
|
| Rate for Payer: PHP Commercial |
$76.75
|
| Rate for Payer: PHP Commercial |
$235.89
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: PHP Commercial |
$23.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.39
|
| Rate for Payer: Priority Health SBD |
$56.88
|
| Rate for Payer: Priority Health SBD |
$174.84
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$26.08
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna Commercial |
$235.89
|
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.69
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cofinity Commercial |
$19.26
|
| Rate for Payer: Cofinity Commercial |
$77.65
|
| Rate for Payer: Cofinity Commercial |
$63.20
|
| Rate for Payer: Cofinity Commercial |
$194.26
|
| Rate for Payer: Cofinity Commercial |
$238.67
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$23.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.23
|
| Rate for Payer: Healthscope Commercial |
$249.77
|
| Rate for Payer: Healthscope Commercial |
$24.77
|
| Rate for Payer: Healthscope Commercial |
$81.26
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.39
|
| Rate for Payer: PHP Commercial |
$23.39
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: PHP Commercial |
$235.89
|
| Rate for Payer: PHP Commercial |
$76.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.69
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$26.08
|
| Rate for Payer: Priority Health SBD |
$174.84
|
| Rate for Payer: Priority Health SBD |
$56.88
|
|
|
DICYCLOMINE 20 MG TABLET
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$44.83 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna Commercial |
$329.46
|
| Rate for Payer: Aetna Medicare |
$212.80
|
| Rate for Payer: Aetna Medicare |
$170.38
|
| Rate for Payer: Aetna Medicare |
$2.13
|
| Rate for Payer: Aetna Medicare |
$193.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.94
|
| Rate for Payer: BCBS Complete |
$170.24
|
| Rate for Payer: BCBS Complete |
$1.70
|
| Rate for Payer: BCBS Complete |
$155.04
|
| Rate for Payer: BCBS Complete |
$136.30
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCBS Trust/PPO |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: BCN Commercial |
$44.83
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$271.32
|
| Rate for Payer: Cofinity Commercial |
$238.52
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Cofinity Commercial |
$333.34
|
| Rate for Payer: Cofinity Commercial |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$3.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.08
|
| Rate for Payer: Healthscope Commercial |
$348.84
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.62
|
| Rate for Payer: PHP Commercial |
$3.62
|
| Rate for Payer: PHP Commercial |
$329.46
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.94
|
| Rate for Payer: Priority Health SBD |
$2.68
|
| Rate for Payer: Priority Health SBD |
$244.19
|
| Rate for Payer: Priority Health SBD |
$214.67
|
| Rate for Payer: Priority Health SBD |
$268.13
|
|
|
DICYCLOMINE 20 MG TABLET
|
Facility
|
IP
|
$425.60
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$268.13 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna Commercial |
$329.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.77
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cofinity Commercial |
$238.52
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Cofinity Commercial |
$271.32
|
| Rate for Payer: Cofinity Commercial |
$333.34
|
| Rate for Payer: Cofinity Commercial |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$3.66
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.41
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Healthscope Commercial |
$348.84
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.46
|
| Rate for Payer: PHP Commercial |
$329.46
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: PHP Commercial |
$3.62
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.64
|
| Rate for Payer: Priority Health SBD |
$214.67
|
| Rate for Payer: Priority Health SBD |
$268.13
|
| Rate for Payer: Priority Health SBD |
$244.19
|
| Rate for Payer: Priority Health SBD |
$2.68
|
|
|
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$454.72
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
9853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.47 |
| Max. Negotiated Rate |
$409.25 |
| Rate for Payer: Aetna Commercial |
$386.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.57
|
| Rate for Payer: Cash Price |
$363.78
|
| Rate for Payer: Cofinity Commercial |
$318.30
|
| Rate for Payer: Cofinity Commercial |
$391.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$318.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.78
|
| Rate for Payer: Healthscope Commercial |
$409.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$386.51
|
| Rate for Payer: PHP Commercial |
$386.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.57
|
| Rate for Payer: Priority Health SBD |
$286.47
|
|
|
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$454.72
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
9853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.39 |
| Max. Negotiated Rate |
$409.25 |
| Rate for Payer: Aetna Commercial |
$386.51
|
| Rate for Payer: Aetna Medicare |
$227.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.57
|
| Rate for Payer: BCBS Complete |
$181.89
|
| Rate for Payer: BCBS Trust/PPO |
$44.39
|
| Rate for Payer: BCN Commercial |
$44.39
|
| Rate for Payer: Cash Price |
$363.78
|
| Rate for Payer: Cash Price |
$363.78
|
| Rate for Payer: Cofinity Commercial |
$318.30
|
| Rate for Payer: Cofinity Commercial |
$391.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$318.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.78
|
| Rate for Payer: Healthscope Commercial |
$409.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$386.51
|
| Rate for Payer: PHP Commercial |
$386.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.57
|
| Rate for Payer: Priority Health SBD |
$286.47
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
OP
|
$426.72
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.69 |
| Max. Negotiated Rate |
$384.05 |
| Rate for Payer: Aetna Commercial |
$362.71
|
| Rate for Payer: Aetna Medicare |
$213.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.37
|
| Rate for Payer: BCBS Complete |
$170.69
|
| Rate for Payer: Cash Price |
$341.38
|
| Rate for Payer: Cofinity Commercial |
$298.70
|
| Rate for Payer: Cofinity Commercial |
$366.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.38
|
| Rate for Payer: Healthscope Commercial |
$384.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.71
|
| Rate for Payer: PHP Commercial |
$362.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.37
|
| Rate for Payer: Priority Health SBD |
$268.83
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
IP
|
$426.72
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.83 |
| Max. Negotiated Rate |
$384.05 |
| Rate for Payer: Aetna Commercial |
$362.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.37
|
| Rate for Payer: Cash Price |
$341.38
|
| Rate for Payer: Cofinity Commercial |
$298.70
|
| Rate for Payer: Cofinity Commercial |
$366.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.38
|
| Rate for Payer: Healthscope Commercial |
$384.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.71
|
| Rate for Payer: PHP Commercial |
$362.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.37
|
| Rate for Payer: Priority Health SBD |
$268.83
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$21.14
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
108720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$44.39 |
| Rate for Payer: Aetna Commercial |
$17.97
|
| Rate for Payer: Aetna Medicare |
$10.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.74
|
| Rate for Payer: BCBS Complete |
$8.46
|
| Rate for Payer: BCBS Trust/PPO |
$44.39
|
| Rate for Payer: BCN Commercial |
$44.39
|
| Rate for Payer: Cash Price |
$16.91
|
| Rate for Payer: Cash Price |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$18.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.91
|
| Rate for Payer: Healthscope Commercial |
$19.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.97
|
| Rate for Payer: PHP Commercial |
$17.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.74
|
| Rate for Payer: Priority Health SBD |
$13.32
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$21.14
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
108720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.32 |
| Max. Negotiated Rate |
$19.03 |
| Rate for Payer: Aetna Commercial |
$17.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.74
|
| Rate for Payer: Cash Price |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$18.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.91
|
| Rate for Payer: Healthscope Commercial |
$19.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.97
|
| Rate for Payer: PHP Commercial |
$17.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.74
|
| Rate for Payer: Priority Health SBD |
$13.32
|
|
|
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$11,565.30
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
31432
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,286.14 |
| Max. Negotiated Rate |
$10,408.77 |
| Rate for Payer: Aetna Commercial |
$9,830.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,517.44
|
| Rate for Payer: Cash Price |
$9,252.24
|
| Rate for Payer: Cofinity Commercial |
$8,095.71
|
| Rate for Payer: Cofinity Commercial |
$9,946.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,095.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,252.24
|
| Rate for Payer: Healthscope Commercial |
$10,408.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,830.50
|
| Rate for Payer: PHP Commercial |
$9,830.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,517.44
|
| Rate for Payer: Priority Health SBD |
$7,286.14
|
|
|
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$11,565.30
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
31432
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,717.51 |
| Max. Negotiated Rate |
$15,209.94 |
| Rate for Payer: Aetna Commercial |
$9,830.50
|
| Rate for Payer: Aetna Medicare |
$5,272.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,517.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,337.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,337.48
|
| Rate for Payer: BCBS Complete |
$2,853.38
|
| Rate for Payer: BCBS MAPPO |
$5,069.98
|
| Rate for Payer: BCBS Trust/PPO |
$14,321.74
|
| Rate for Payer: BCN Commercial |
$14,321.74
|
| Rate for Payer: BCN Medicare Advantage |
$5,069.98
|
| Rate for Payer: Cash Price |
$9,252.24
|
| Rate for Payer: Cash Price |
$9,252.24
|
| Rate for Payer: Cofinity Commercial |
$9,946.16
|
| Rate for Payer: Cofinity Commercial |
$8,095.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,095.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,252.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,069.98
|
| Rate for Payer: Healthscope Commercial |
$10,408.77
|
| Rate for Payer: Mclaren Medicaid |
$2,717.51
|
| Rate for Payer: Mclaren Medicare |
$5,069.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,323.48
|
| Rate for Payer: Meridian Medicaid |
$2,853.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,830.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,830.50
|
| Rate for Payer: Nomi Health Commercial |
$15,209.94
|
| Rate for Payer: PACE Medicare |
$4,816.48
|
| Rate for Payer: PACE SWMI |
$5,069.98
|
| Rate for Payer: PHP Commercial |
$9,830.50
|
| Rate for Payer: PHP Medicare Advantage |
$5,069.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,717.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,517.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,068.05
|
| Rate for Payer: Priority Health Medicare |
$5,069.98
|
| Rate for Payer: Priority Health Narrow Network |
$11,254.44
|
| Rate for Payer: Priority Health SBD |
$7,286.14
|
| Rate for Payer: Railroad Medicare Medicare |
$5,069.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,271.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,069.98
|
| Rate for Payer: UHC Medicare Advantage |
$5,069.98
|
| Rate for Payer: UHCCP Medicaid |
$2,854.40
|
| Rate for Payer: VA VA |
$5,069.98
|
|
|
DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 58120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$248.83 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,404.28
|
| Rate for Payer: BCN Commercial |
$1,404.28
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.83
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;
|
Facility
|
OP
|
$10,620.87
|
|
|
Service Code
|
CPT 50436
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$155.36 |
| Max. Negotiated Rate |
$10,620.87 |
| Rate for Payer: Aetna Medicare |
$3,514.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,224.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,224.04
|
| Rate for Payer: BCBS Complete |
$1,901.83
|
| Rate for Payer: BCBS MAPPO |
$3,379.23
|
| Rate for Payer: BCBS Trust/PPO |
$802.05
|
| Rate for Payer: BCN Commercial |
$802.05
|
| Rate for Payer: BCN Medicare Advantage |
$3,379.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,379.23
|
| Rate for Payer: Mclaren Medicaid |
$1,811.27
|
| Rate for Payer: Mclaren Medicare |
$3,379.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,548.19
|
| Rate for Payer: Meridian Medicaid |
$1,901.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,886.11
|
| Rate for Payer: Nomi Health Commercial |
$7,096.38
|
| Rate for Payer: PACE Medicare |
$3,210.27
|
| Rate for Payer: PACE SWMI |
$3,379.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,379.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,811.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,620.87
|
| Rate for Payer: Priority Health Medicare |
$3,379.23
|
| Rate for Payer: Priority Health Narrow Network |
$8,496.70
|
| Rate for Payer: Railroad Medicare Medicare |
$3,379.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.36
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,379.23
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,379.23
|
| Rate for Payer: UHCCP Medicaid |
$1,902.51
|
| Rate for Payer: VA VA |
$3,379.23
|
|
|
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 57400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$139.26 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$953.12
|
| Rate for Payer: BCN Commercial |
$953.12
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$139.26
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
DILATION SALIVARY DUCT
|
Facility
|
OP
|
$4,561.52
|
|
|
Service Code
|
CPT 42650
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$41.42 |
| Max. Negotiated Rate |
$4,561.52 |
| Rate for Payer: Aetna Medicare |
$1,509.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,814.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,814.16
|
| Rate for Payer: BCBS Complete |
$816.81
|
| Rate for Payer: BCBS MAPPO |
$1,451.33
|
| Rate for Payer: BCBS Trust/PPO |
$41.42
|
| Rate for Payer: BCN Commercial |
$41.42
|
| Rate for Payer: BCN Medicare Advantage |
$1,451.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,451.33
|
| Rate for Payer: Mclaren Medicaid |
$777.91
|
| Rate for Payer: Mclaren Medicare |
$1,451.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,523.90
|
| Rate for Payer: Meridian Medicaid |
$816.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,669.03
|
| Rate for Payer: Nomi Health Commercial |
$3,047.79
|
| Rate for Payer: PACE Medicare |
$1,378.76
|
| Rate for Payer: PACE SWMI |
$1,451.33
|
| Rate for Payer: PHP Medicare Advantage |
$1,451.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$777.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,561.52
|
| Rate for Payer: Priority Health Medicare |
$1,451.33
|
| Rate for Payer: Priority Health Narrow Network |
$3,649.22
|
| Rate for Payer: Railroad Medicare Medicare |
$1,451.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.91
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,451.33
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,451.33
|
| Rate for Payer: UHCCP Medicaid |
$817.10
|
| Rate for Payer: VA VA |
$1,451.33
|
|
|
DILTIAZEM 1MG/1 ML INFUSION 125 ML (IV PREMIX)
|
Facility
|
IP
|
$156.25
|
|
|
Service Code
|
NDC 09900000302
|
| Hospital Charge Code |
155072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.44 |
| Max. Negotiated Rate |
$140.62 |
| Rate for Payer: Aetna Commercial |
$132.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.56
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cofinity Commercial |
$109.38
|
| Rate for Payer: Cofinity Commercial |
$134.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.00
|
| Rate for Payer: Healthscope Commercial |
$140.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.81
|
| Rate for Payer: PHP Commercial |
$132.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.56
|
| Rate for Payer: Priority Health SBD |
$98.44
|
|
|
DILTIAZEM 1MG/1 ML INFUSION 125 ML (IV PREMIX)
|
Facility
|
OP
|
$156.25
|
|
|
Service Code
|
NDC 09900000302
|
| Hospital Charge Code |
155072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$140.62 |
| Rate for Payer: Aetna Commercial |
$132.81
|
| Rate for Payer: Aetna Medicare |
$78.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.56
|
| Rate for Payer: BCBS Complete |
$62.50
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cofinity Commercial |
$109.38
|
| Rate for Payer: Cofinity Commercial |
$134.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.00
|
| Rate for Payer: Healthscope Commercial |
$140.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.81
|
| Rate for Payer: PHP Commercial |
$132.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.56
|
| Rate for Payer: Priority Health SBD |
$98.44
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 51079074501
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 51079074520
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.46 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna Medicare |
$186.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: BCBS Complete |
$149.46
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.87
|
| Rate for Payer: Priority Health SBD |
$235.40
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$326.65
|
|
|
Service Code
|
NDC 00093031801
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.66 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna Medicare |
$163.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: BCBS Complete |
$130.66
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.32
|
| Rate for Payer: Priority Health SBD |
$205.79
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$3.67
|
|
|
Service Code
|
NDC 60687071711
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna Commercial |
$3.12
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.39
|
| Rate for Payer: BCBS Complete |
$1.47
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cofinity Commercial |
$2.57
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.94
|
| Rate for Payer: Healthscope Commercial |
$3.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.12
|
| Rate for Payer: PHP Commercial |
$3.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.39
|
| Rate for Payer: Priority Health SBD |
$2.31
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 51079074501
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 00093031801
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.79 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.32
|
| Rate for Payer: Priority Health SBD |
$205.79
|
|
