Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DIGOXIN 125 MCG (0.125 MG) TABLET

Facility

$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 125 MCG (0.125 MG) TABLET

Facility

$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 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION

Facility

$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 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION

Facility

$21.14

Service Code	HCPCS J1160
Hospital Charge Code	108720
Hospital Revenue Code	636
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$19.03
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: 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

$11,565.30

Service Code	HCPCS J1162
Hospital Charge Code	31432
Hospital Revenue Code	636
Min. Negotiated Rate	$2,770.17
Max. Negotiated Rate	$14,548.05
Rate for Payer: Aetna Commercial	$9,830.50
Rate for Payer: Aetna Medicare	$5,374.96
Rate for Payer: Aetna New Business (MI Preferred)	$7,517.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,460.29
Rate for Payer: Amish Plain Church Group Commercial	$6,460.29
Rate for Payer: BCBS Complete	$2,908.68
Rate for Payer: BCBS MAPPO	$5,168.23
Rate for Payer: BCN Medicare Advantage	$5,168.23
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	$5,168.23
Rate for Payer: Healthscope Commercial	$10,408.77
Rate for Payer: Mclaren Medicaid	$2,770.17
Rate for Payer: Mclaren Medicare	$5,168.23
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,426.64
Rate for Payer: Meridian Medicaid	$2,908.68
Rate for Payer: MI Amish Medical Board Commercial	$5,943.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,830.50
Rate for Payer: PACE Medicare	$4,909.82
Rate for Payer: PACE SWMI	$5,168.23
Rate for Payer: PHP Commercial	$9,830.50
Rate for Payer: PHP Medicare Advantage	$5,168.23
Rate for Payer: Priority Health Choice Medicaid	$2,770.17
Rate for Payer: Priority Health Cigna Priority Health	$7,517.44
Rate for Payer: Priority Health Medicare	$5,168.23
Rate for Payer: Priority Health SBD	$7,286.14
Rate for Payer: Railroad Medicare Medicare	$5,168.23
Rate for Payer: UHC All Payor (Choice/PPO)	$14,548.05
Rate for Payer: UHC Dual Complete DSNP	$5,168.23
Rate for Payer: UHC Medicare Advantage	$5,168.23
Rate for Payer: UHCCP Medicaid	$2,909.71
Rate for Payer: VA VA	$5,168.23

DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION

Facility

$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

DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)

Facility

$8,728.81

Service Code	CPT 58120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,662.10
Max. Negotiated Rate	$8,728.81
Rate for Payer: Aetna Medicare	$3,224.97
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,876.16
Rate for Payer: Amish Plain Church Group Commercial	$3,876.16
Rate for Payer: BCBS Complete	$1,745.20
Rate for Payer: BCBS MAPPO	$3,100.93
Rate for Payer: BCN Medicare Advantage	$3,100.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,100.93
Rate for Payer: Mclaren Medicaid	$1,662.10
Rate for Payer: Mclaren Medicare	$3,100.93
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,255.98
Rate for Payer: Meridian Medicaid	$1,745.20
Rate for Payer: MI Amish Medical Board Commercial	$3,566.07
Rate for Payer: PACE Medicare	$2,945.88
Rate for Payer: PACE SWMI	$3,100.93
Rate for Payer: PHP Medicare Advantage	$3,100.93
Rate for Payer: Priority Health Choice Medicaid	$1,662.10
Rate for Payer: Priority Health Medicare	$3,100.93
Rate for Payer: Railroad Medicare Medicare	$3,100.93
Rate for Payer: UHC All Payor (Choice/PPO)	$8,728.81
Rate for Payer: UHC Dual Complete DSNP	$3,100.93
Rate for Payer: UHC Medicare Advantage	$3,100.93
Rate for Payer: UHCCP Medicaid	$1,745.82
Rate for Payer: VA VA	$3,100.93

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

$9,468.51

Service Code	CPT 50436
Hospital Revenue Code	360
Min. Negotiated Rate	$1,802.95
Max. Negotiated Rate	$9,468.51
Rate for Payer: Aetna Medicare	$3,498.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,204.64
Rate for Payer: Amish Plain Church Group Commercial	$4,204.64
Rate for Payer: BCBS Complete	$1,893.10
Rate for Payer: BCBS MAPPO	$3,363.71
Rate for Payer: BCN Medicare Advantage	$3,363.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,363.71
Rate for Payer: Mclaren Medicaid	$1,802.95
Rate for Payer: Mclaren Medicare	$3,363.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,531.90
Rate for Payer: Meridian Medicaid	$1,893.10
Rate for Payer: MI Amish Medical Board Commercial	$3,868.27
Rate for Payer: PACE Medicare	$3,195.52
Rate for Payer: PACE SWMI	$3,363.71
Rate for Payer: PHP Medicare Advantage	$3,363.71
Rate for Payer: Priority Health Choice Medicaid	$1,802.95
Rate for Payer: Priority Health Medicare	$3,363.71
Rate for Payer: Railroad Medicare Medicare	$3,363.71
Rate for Payer: UHC All Payor (Choice/PPO)	$9,468.51
Rate for Payer: UHC Dual Complete DSNP	$3,363.71
Rate for Payer: UHC Medicare Advantage	$3,363.71
Rate for Payer: UHCCP Medicaid	$1,893.77
Rate for Payer: VA VA	$3,363.71

DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL)

Facility

$8,728.81

Service Code	CPT 57400
Hospital Revenue Code	360
Min. Negotiated Rate	$1,662.10
Max. Negotiated Rate	$8,728.81
Rate for Payer: Aetna Medicare	$3,224.97
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,876.16
Rate for Payer: Amish Plain Church Group Commercial	$3,876.16
Rate for Payer: BCBS Complete	$1,745.20
Rate for Payer: BCBS MAPPO	$3,100.93
Rate for Payer: BCN Medicare Advantage	$3,100.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,100.93
Rate for Payer: Mclaren Medicaid	$1,662.10
Rate for Payer: Mclaren Medicare	$3,100.93
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,255.98
Rate for Payer: Meridian Medicaid	$1,745.20
Rate for Payer: MI Amish Medical Board Commercial	$3,566.07
Rate for Payer: PACE Medicare	$2,945.88
Rate for Payer: PACE SWMI	$3,100.93
Rate for Payer: PHP Medicare Advantage	$3,100.93
Rate for Payer: Priority Health Choice Medicaid	$1,662.10
Rate for Payer: Priority Health Medicare	$3,100.93
Rate for Payer: Railroad Medicare Medicare	$3,100.93
Rate for Payer: UHC All Payor (Choice/PPO)	$8,728.81
Rate for Payer: UHC Dual Complete DSNP	$3,100.93
Rate for Payer: UHC Medicare Advantage	$3,100.93
Rate for Payer: UHCCP Medicaid	$1,745.82
Rate for Payer: VA VA	$3,100.93

DILATION SALIVARY DUCT

Facility

$4,066.57

Service Code	CPT 42650
Hospital Revenue Code	360
Min. Negotiated Rate	$774.34
Max. Negotiated Rate	$4,066.57
Rate for Payer: Aetna Medicare	$1,502.45
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,805.83
Rate for Payer: Amish Plain Church Group Commercial	$1,805.83
Rate for Payer: BCBS Complete	$813.05
Rate for Payer: BCBS MAPPO	$1,444.66
Rate for Payer: BCN Medicare Advantage	$1,444.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,444.66
Rate for Payer: Mclaren Medicaid	$774.34
Rate for Payer: Mclaren Medicare	$1,444.66
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,516.89
Rate for Payer: Meridian Medicaid	$813.05
Rate for Payer: MI Amish Medical Board Commercial	$1,661.36
Rate for Payer: PACE Medicare	$1,372.43
Rate for Payer: PACE SWMI	$1,444.66
Rate for Payer: PHP Medicare Advantage	$1,444.66
Rate for Payer: Priority Health Choice Medicaid	$774.34
Rate for Payer: Priority Health Medicare	$1,444.66
Rate for Payer: Railroad Medicare Medicare	$1,444.66
Rate for Payer: UHC All Payor (Choice/PPO)	$4,066.57
Rate for Payer: UHC Dual Complete DSNP	$1,444.66
Rate for Payer: UHC Medicare Advantage	$1,444.66
Rate for Payer: UHCCP Medicaid	$813.34
Rate for Payer: VA VA	$1,444.66

DILTIAZEM 1MG/1 ML INFUSION 125 ML (IV PREMIX)

Facility

$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 1MG/1 ML INFUSION 125 ML (IV PREMIX)

Facility

$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 30 MG TABLET

Facility

$366.70

Service Code	NDC 60687071701
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$146.68
Max. Negotiated Rate	$330.03
Rate for Payer: Aetna Commercial	$311.69
Rate for Payer: Aetna Medicare	$183.35
Rate for Payer: Aetna New Business (MI Preferred)	$238.35
Rate for Payer: BCBS Complete	$146.68
Rate for Payer: Cash Price	$293.36
Rate for Payer: Cofinity Commercial	$256.69
Rate for Payer: Cofinity Commercial	$315.36
Rate for Payer: Cofinity Medicare Advantage	$256.69
Rate for Payer: Encore Health Key Benefits Commercial	$293.36
Rate for Payer: Healthscope Commercial	$330.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.69
Rate for Payer: PHP Commercial	$311.69
Rate for Payer: Priority Health Cigna Priority Health	$238.35
Rate for Payer: Priority Health SBD	$231.02

DILTIAZEM 30 MG TABLET

Facility

$3.67

Service Code	NDC 60687071711
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna Commercial	$3.12
Rate for Payer: Aetna New Business (MI Preferred)	$2.39
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

$326.65

Service Code	NDC 00093031801
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$205.79
Max. Negotiated Rate	$293.99
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	$293.99
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

$373.65

Service Code	NDC 51079074520
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$149.46
Max. Negotiated Rate	$336.29
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	$336.29
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

$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

$326.65

Service Code	NDC 00093031801
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$130.66
Max. Negotiated Rate	$293.99
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	$293.99
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

$373.65

Service Code	NDC 51079074520
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$235.40
Max. Negotiated Rate	$336.29
Rate for Payer: Aetna Commercial	$317.60
Rate for Payer: Aetna New Business (MI Preferred)	$242.87
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	$336.29
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

$366.70

Service Code	NDC 60687071701
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$231.02
Max. Negotiated Rate	$330.03
Rate for Payer: Aetna Commercial	$311.69
Rate for Payer: Aetna New Business (MI Preferred)	$238.35
Rate for Payer: Cash Price	$293.36
Rate for Payer: Cofinity Commercial	$256.69
Rate for Payer: Cofinity Commercial	$315.36
Rate for Payer: Cofinity Medicare Advantage	$256.69
Rate for Payer: Encore Health Key Benefits Commercial	$293.36
Rate for Payer: Healthscope Commercial	$330.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.69
Rate for Payer: PHP Commercial	$311.69
Rate for Payer: Priority Health Cigna Priority Health	$238.35
Rate for Payer: Priority Health SBD	$231.02

DILTIAZEM 30 MG TABLET

Facility

$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

$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	$1.83
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 5 MG/ML INTRAVENOUS SOLUTION

Facility

$48.63

Service Code	NDC 00641921710
Hospital Charge Code	9869
Hospital Revenue Code	250
Min. Negotiated Rate	$19.45
Max. Negotiated Rate	$43.77
Rate for Payer: Aetna Commercial	$41.34
Rate for Payer: Aetna Medicare	$24.32
Rate for Payer: Aetna New Business (MI Preferred)	$31.61
Rate for Payer: BCBS Complete	$19.45
Rate for Payer: Cash Price	$38.90
Rate for Payer: Cofinity Commercial	$34.04
Rate for Payer: Cofinity Commercial	$41.82
Rate for Payer: Cofinity Medicare Advantage	$34.04
Rate for Payer: Encore Health Key Benefits Commercial	$38.90
Rate for Payer: Healthscope Commercial	$43.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.34
Rate for Payer: PHP Commercial	$41.34
Rate for Payer: Priority Health Cigna Priority Health	$31.61
Rate for Payer: Priority Health SBD	$30.64

DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION

Facility

$48.63

Service Code	NDC 00641601301
Hospital Charge Code	9869
Hospital Revenue Code	250
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$43.77
Rate for Payer: Aetna Commercial	$41.34
Rate for Payer: Aetna New Business (MI Preferred)	$31.61
Rate for Payer: Cash Price	$38.90
Rate for Payer: Cofinity Commercial	$34.04
Rate for Payer: Cofinity Commercial	$41.82
Rate for Payer: Cofinity Medicare Advantage	$34.04
Rate for Payer: Encore Health Key Benefits Commercial	$38.90
Rate for Payer: Healthscope Commercial	$43.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.34
Rate for Payer: PHP Commercial	$41.34
Rate for Payer: Priority Health Cigna Priority Health	$31.61
Rate for Payer: Priority Health SBD	$30.64

DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION

Facility

$59.50

Service Code	NDC 17478093710
Hospital Charge Code	9869
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$53.55
Rate for Payer: Aetna Commercial	$50.58
Rate for Payer: Aetna Medicare	$29.75
Rate for Payer: Aetna New Business (MI Preferred)	$38.67
Rate for Payer: BCBS Complete	$23.80
Rate for Payer: Cash Price	$47.60
Rate for Payer: Cofinity Commercial	$41.65
Rate for Payer: Cofinity Commercial	$51.17
Rate for Payer: Cofinity Medicare Advantage	$41.65
Rate for Payer: Encore Health Key Benefits Commercial	$47.60
Rate for Payer: Healthscope Commercial	$53.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$50.58
Rate for Payer: PHP Commercial	$50.58
Rate for Payer: Priority Health Cigna Priority Health	$38.67
Rate for Payer: Priority Health SBD	$37.48

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