Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DICYCLOMINE 10 MG CAPSULE

Facility

$395.20

Service Code	NDC 60687-369-01
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$248.98
Max. Negotiated Rate	$355.68
Rate for Payer: Aetna Commercial	$335.92
Rate for Payer: Aetna New Business (MI Preferred)	$256.88
Rate for Payer: Cash Price	$316.16
Rate for Payer: Cofinity Commercial	$276.64
Rate for Payer: Cofinity Commercial	$339.87
Rate for Payer: Healthscope Commercial	$355.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$335.92
Rate for Payer: PHP Commercial	$335.92
Rate for Payer: Priority Health Cigna Priority Health	$276.64
Rate for Payer: Priority Health SBD	$248.98

DICYCLOMINE 10 MG CAPSULE

Facility

$3.82

Service Code	NDC 51079-118-01
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna Commercial	$3.25
Rate for Payer: Aetna New Business (MI Preferred)	$2.48
Rate for Payer: Cash Price	$3.06
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Cofinity Commercial	$3.29
Rate for Payer: Healthscope Commercial	$3.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.25
Rate for Payer: PHP Commercial	$3.25
Rate for Payer: Priority Health Cigna Priority Health	$2.67
Rate for Payer: Priority Health SBD	$2.41

DICYCLOMINE 10 MG CAPSULE

Facility

$3.96

Service Code	NDC 60687-369-11
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna Commercial	$3.37
Rate for Payer: Aetna New Business (MI Preferred)	$2.57
Rate for Payer: Cash Price	$3.17
Rate for Payer: Cofinity Commercial	$3.41
Rate for Payer: Cofinity Commercial	$2.77
Rate for Payer: Healthscope Commercial	$3.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.37
Rate for Payer: PHP Commercial	$3.37
Rate for Payer: Priority Health Cigna Priority Health	$2.77
Rate for Payer: Priority Health SBD	$2.49

DICYCLOMINE 10 MG CAPSULE

Facility

$381.90

Service Code	NDC 51079-118-20
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$240.60
Max. Negotiated Rate	$343.71
Rate for Payer: Aetna Commercial	$324.62
Rate for Payer: Aetna New Business (MI Preferred)	$248.24
Rate for Payer: Cash Price	$305.52
Rate for Payer: Cofinity Commercial	$267.33
Rate for Payer: Cofinity Commercial	$328.43
Rate for Payer: Healthscope Commercial	$343.71
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$324.62
Rate for Payer: PHP Commercial	$324.62
Rate for Payer: Priority Health Cigna Priority Health	$267.33
Rate for Payer: Priority Health SBD	$240.60

DICYCLOMINE 10 MG CAPSULE

Facility

$437.10

Service Code	NDC 0591-0794-01
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: Healthscope Commercial	$393.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$371.54
Rate for Payer: PHP Commercial	$371.54
Rate for Payer: Priority Health Cigna Priority Health	$305.97
Rate for Payer: Priority Health SBD	$275.37

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION

Facility

$53.81

Service Code	HCPCS J0500
Hospital Charge Code	2417
Hospital Revenue Code	636
Min. Negotiated Rate	$33.90
Max. Negotiated Rate	$48.43
Rate for Payer: Aetna Commercial	$45.74
Rate for Payer: Aetna Commercial	$23.39
Rate for Payer: Aetna Commercial	$235.89
Rate for Payer: Aetna Commercial	$76.75
Rate for Payer: Aetna New Business (MI Preferred)	$180.39
Rate for Payer: Aetna New Business (MI Preferred)	$34.98
Rate for Payer: Aetna New Business (MI Preferred)	$58.69
Rate for Payer: Aetna New Business (MI Preferred)	$17.89
Rate for Payer: Cash Price	$22.02
Rate for Payer: Cash Price	$43.05
Rate for Payer: Cash Price	$72.23
Rate for Payer: Cash Price	$222.02
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	$46.28
Rate for Payer: Cofinity Commercial	$194.26
Rate for Payer: Cofinity Commercial	$238.67
Rate for Payer: Cofinity Commercial	$37.67
Rate for Payer: Cofinity Commercial	$23.67
Rate for Payer: Healthscope Commercial	$81.26
Rate for Payer: Healthscope Commercial	$24.77
Rate for Payer: Healthscope Commercial	$249.77
Rate for Payer: Healthscope Commercial	$48.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$235.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$45.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.75
Rate for Payer: PHP Commercial	$235.89
Rate for Payer: PHP Commercial	$76.75
Rate for Payer: PHP Commercial	$23.39
Rate for Payer: PHP Commercial	$45.74
Rate for Payer: Priority Health Cigna Priority Health	$63.20
Rate for Payer: Priority Health Cigna Priority Health	$37.67
Rate for Payer: Priority Health Cigna Priority Health	$19.26
Rate for Payer: Priority Health Cigna Priority Health	$194.26
Rate for Payer: Priority Health SBD	$56.88
Rate for Payer: Priority Health SBD	$17.34
Rate for Payer: Priority Health SBD	$174.84
Rate for Payer: Priority Health SBD	$33.90

DICYCLOMINE 20 MG TABLET

Facility

$381.90

Service Code	HCPCS J0500
Hospital Charge Code	2420
Hospital Revenue Code	636
Min. Negotiated Rate	$240.60
Max. Negotiated Rate	$343.71
Rate for Payer: Aetna Commercial	$324.62
Rate for Payer: Aetna Commercial	$3.35
Rate for Payer: Aetna Commercial	$208.34
Rate for Payer: Aetna Commercial	$334.30
Rate for Payer: Aetna New Business (MI Preferred)	$248.24
Rate for Payer: Aetna New Business (MI Preferred)	$159.32
Rate for Payer: Aetna New Business (MI Preferred)	$2.56
Rate for Payer: Aetna New Business (MI Preferred)	$255.64
Rate for Payer: Cash Price	$196.08
Rate for Payer: Cash Price	$314.64
Rate for Payer: Cash Price	$305.52
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cofinity Commercial	$275.31
Rate for Payer: Cofinity Commercial	$171.57
Rate for Payer: Cofinity Commercial	$210.79
Rate for Payer: Cofinity Commercial	$267.33
Rate for Payer: Cofinity Commercial	$328.43
Rate for Payer: Cofinity Commercial	$338.24
Rate for Payer: Cofinity Commercial	$2.76
Rate for Payer: Cofinity Commercial	$3.39
Rate for Payer: Healthscope Commercial	$343.71
Rate for Payer: Healthscope Commercial	$3.55
Rate for Payer: Healthscope Commercial	$220.59
Rate for Payer: Healthscope Commercial	$353.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$334.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$324.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$208.34
Rate for Payer: PHP Commercial	$208.34
Rate for Payer: PHP Commercial	$334.30
Rate for Payer: PHP Commercial	$324.62
Rate for Payer: PHP Commercial	$3.35
Rate for Payer: Priority Health Cigna Priority Health	$267.33
Rate for Payer: Priority Health Cigna Priority Health	$2.76
Rate for Payer: Priority Health Cigna Priority Health	$171.57
Rate for Payer: Priority Health Cigna Priority Health	$275.31
Rate for Payer: Priority Health SBD	$154.41
Rate for Payer: Priority Health SBD	$240.60
Rate for Payer: Priority Health SBD	$2.48
Rate for Payer: Priority Health SBD	$247.78

DIGESTIVE MALIGNANCY WITH CC

Facility

$18,278.87

Service Code	MS-DRG 375
Min. Negotiated Rate	$8,666.50
Max. Negotiated Rate	$18,278.87
Rate for Payer: Aetna Medicare	$9,487.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,403.29
Rate for Payer: Amish Plain Church Group Commercial	$11,403.29
Rate for Payer: BCBS MAPPO	$9,122.63
Rate for Payer: BCBS Trust/PPO	$17,753.85
Rate for Payer: BCN Medicare Advantage	$9,122.63
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,122.63
Rate for Payer: Mclaren Medicare	$9,122.63
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,578.76
Rate for Payer: MI Amish Medical Board Commercial	$10,491.02
Rate for Payer: PACE Medicare	$8,666.50
Rate for Payer: PACE SWMI	$9,122.63
Rate for Payer: PHP Medicare Advantage	$9,122.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17,195.51
Rate for Payer: Priority Health Medicare	$9,122.63
Rate for Payer: Priority Health Narrow Network	$13,756.41
Rate for Payer: Railroad Medicare Medicare	$9,122.63
Rate for Payer: UHC All Payor (Choice/PPO)	$18,278.87
Rate for Payer: UHC Core	$11,216.09
Rate for Payer: UHC Dual Complete DSNP	$9,122.63
Rate for Payer: UHC Exchange	$12,012.96
Rate for Payer: UHC Medicare Advantage	$9,396.31
Rate for Payer: VA VA	$9,122.63

DIGESTIVE MALIGNANCY WITH MCC

Facility

$32,018.15

Service Code	MS-DRG 374
Min. Negotiated Rate	$14,828.84
Max. Negotiated Rate	$32,018.15
Rate for Payer: Aetna Medicare	$16,233.67
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,511.62
Rate for Payer: Amish Plain Church Group Commercial	$19,511.62
Rate for Payer: BCBS MAPPO	$15,609.30
Rate for Payer: BCBS Trust/PPO	$30,573.52
Rate for Payer: BCN Medicare Advantage	$15,609.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,609.30
Rate for Payer: Mclaren Medicare	$15,609.30
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,389.76
Rate for Payer: MI Amish Medical Board Commercial	$17,950.70
Rate for Payer: PACE Medicare	$14,828.84
Rate for Payer: PACE SWMI	$15,609.30
Rate for Payer: PHP Medicare Advantage	$15,609.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30,120.48
Rate for Payer: Priority Health Medicare	$15,609.30
Rate for Payer: Priority Health Narrow Network	$24,096.38
Rate for Payer: Railroad Medicare Medicare	$15,609.30
Rate for Payer: UHC All Payor (Choice/PPO)	$32,018.15
Rate for Payer: UHC Core	$19,646.64
Rate for Payer: UHC Dual Complete DSNP	$15,609.30
Rate for Payer: UHC Exchange	$21,042.48
Rate for Payer: UHC Medicare Advantage	$16,077.58
Rate for Payer: VA VA	$15,609.30

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$13,597.42

Service Code	MS-DRG 376
Min. Negotiated Rate	$6,566.78
Max. Negotiated Rate	$13,597.42
Rate for Payer: Aetna Medicare	$7,188.90
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,640.50
Rate for Payer: Amish Plain Church Group Commercial	$8,640.50
Rate for Payer: BCBS MAPPO	$6,912.40
Rate for Payer: BCBS Trust/PPO	$13,208.34
Rate for Payer: BCN Medicare Advantage	$6,912.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,912.40
Rate for Payer: Mclaren Medicare	$6,912.40
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7,258.02
Rate for Payer: MI Amish Medical Board Commercial	$7,949.26
Rate for Payer: PACE Medicare	$6,566.78
Rate for Payer: PACE SWMI	$6,912.40
Rate for Payer: PHP Medicare Advantage	$6,912.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12,791.52
Rate for Payer: Priority Health Medicare	$6,912.40
Rate for Payer: Priority Health Narrow Network	$10,233.22
Rate for Payer: Railroad Medicare Medicare	$6,912.40
Rate for Payer: UHC All Payor (Choice/PPO)	$13,597.42
Rate for Payer: UHC Core	$8,343.50
Rate for Payer: UHC Dual Complete DSNP	$6,912.40
Rate for Payer: UHC Exchange	$8,936.29
Rate for Payer: UHC Medicare Advantage	$7,119.77
Rate for Payer: VA VA	$6,912.40

DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION

Facility

$417.18

Service Code	HCPCS J1160
Hospital Charge Code	9853
Hospital Revenue Code	636
Min. Negotiated Rate	$262.82
Max. Negotiated Rate	$375.46
Rate for Payer: Aetna Commercial	$354.60
Rate for Payer: Aetna New Business (MI Preferred)	$271.17
Rate for Payer: Cash Price	$333.74
Rate for Payer: Cofinity Commercial	$292.03
Rate for Payer: Cofinity Commercial	$358.77
Rate for Payer: Healthscope Commercial	$375.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$354.60
Rate for Payer: PHP Commercial	$354.60
Rate for Payer: Priority Health Cigna Priority Health	$292.03
Rate for Payer: Priority Health SBD	$262.82

DIGOXIN 125 MCG (0.125 MG) TABLET

Facility

$403.20

Service Code	NDC 0904-5921-61
Hospital Charge Code	2444
Hospital Revenue Code	637
Min. Negotiated Rate	$254.02
Max. Negotiated Rate	$362.88
Rate for Payer: Aetna Commercial	$342.72
Rate for Payer: Aetna New Business (MI Preferred)	$262.08
Rate for Payer: Cash Price	$322.56
Rate for Payer: Cofinity Commercial	$282.24
Rate for Payer: Cofinity Commercial	$346.75
Rate for Payer: Healthscope Commercial	$362.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$342.72
Rate for Payer: PHP Commercial	$342.72
Rate for Payer: Priority Health Cigna Priority Health	$282.24
Rate for Payer: Priority Health SBD	$254.02

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: Healthscope Commercial	$19.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.97
Rate for Payer: PHP Commercial	$17.97
Rate for Payer: Priority Health Cigna Priority Health	$14.80
Rate for Payer: Priority Health SBD	$13.32

DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION

Facility

$11,120.39

Service Code	HCPCS J1162
Hospital Charge Code	31432
Hospital Revenue Code	636
Min. Negotiated Rate	$7,005.85
Max. Negotiated Rate	$10,008.35
Rate for Payer: Aetna Commercial	$9,452.33
Rate for Payer: Aetna New Business (MI Preferred)	$7,228.25
Rate for Payer: Cash Price	$8,896.31
Rate for Payer: Cofinity Commercial	$7,784.27
Rate for Payer: Cofinity Commercial	$9,563.54
Rate for Payer: Healthscope Commercial	$10,008.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$9,452.33
Rate for Payer: PHP Commercial	$9,452.33
Rate for Payer: Priority Health Cigna Priority Health	$7,784.27
Rate for Payer: Priority Health SBD	$7,005.85

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

Facility

$4,155.00

Service Code	CPT 58120
Hospital Revenue Code	360
Min. Negotiated Rate	$231.17
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,363.71
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$254.29
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$231.17
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

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

$9,573.02

Service Code	CPT 50436
Hospital Revenue Code	360
Min. Negotiated Rate	$143.42
Max. Negotiated Rate	$9,573.02
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$778.87
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,573.02
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Priority Health Narrow Network	$7,658.42
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$157.76
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$143.42
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

DILATION SALIVARY DUCT

Facility

$3,138.00

Service Code	CPT 42650
Hospital Revenue Code	360
Min. Negotiated Rate	$40.22
Max. Negotiated Rate	$3,138.00
Rate for Payer: Aetna Medicare	$1,411.25
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,696.21
Rate for Payer: Amish Plain Church Group Commercial	$1,696.21
Rate for Payer: BCBS Complete	$779.44
Rate for Payer: BCBS MAPPO	$1,356.97
Rate for Payer: BCBS Trust/PPO	$40.22
Rate for Payer: BCN Medicare Advantage	$1,356.97
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,356.97
Rate for Payer: Mclaren Medicaid	$742.26
Rate for Payer: Mclaren Medicare	$1,356.97
Rate for Payer: Meridian Medicaid	$779.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,424.82
Rate for Payer: MI Amish Medical Board Commercial	$1,560.52
Rate for Payer: PACE Medicare	$1,289.12
Rate for Payer: PACE SWMI	$1,356.97
Rate for Payer: PHP Medicare Advantage	$1,356.97
Rate for Payer: Priority Health Choice Medicaid	$742.26
Rate for Payer: Priority Health Medicare	$1,356.97
Rate for Payer: Railroad Medicare Medicare	$1,356.97
Rate for Payer: UHC All Payor (Choice/PPO)	$64.11
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,356.97
Rate for Payer: UHC Exchange	$58.28
Rate for Payer: UHC Medicare Advantage	$1,397.68
Rate for Payer: VA VA	$1,356.97

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

Facility

$156.25

Service Code	NDC 9900-0003-02
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: Healthscope Commercial	$140.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$132.81
Rate for Payer: PHP Commercial	$132.81
Rate for Payer: Priority Health Cigna Priority Health	$109.38
Rate for Payer: Priority Health SBD	$98.44

DILTIAZEM 30 MG TABLET

Facility

$307.85

Service Code	NDC 63739-079-10
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$193.95
Max. Negotiated Rate	$277.06
Rate for Payer: Aetna Commercial	$261.67
Rate for Payer: Aetna New Business (MI Preferred)	$200.10
Rate for Payer: Cash Price	$246.28
Rate for Payer: Cofinity Commercial	$215.50
Rate for Payer: Cofinity Commercial	$264.75
Rate for Payer: Healthscope Commercial	$277.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$261.67
Rate for Payer: PHP Commercial	$261.67
Rate for Payer: Priority Health Cigna Priority Health	$215.50
Rate for Payer: Priority Health SBD	$193.95

DILTIAZEM 30 MG TABLET

Facility

$347.70

Service Code	NDC 60687-717-01
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$219.05
Max. Negotiated Rate	$312.93
Rate for Payer: Aetna Commercial	$295.54
Rate for Payer: Aetna New Business (MI Preferred)	$226.00
Rate for Payer: Cash Price	$278.16
Rate for Payer: Cofinity Commercial	$243.39
Rate for Payer: Cofinity Commercial	$299.02
Rate for Payer: Healthscope Commercial	$312.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$295.54
Rate for Payer: PHP Commercial	$295.54
Rate for Payer: Priority Health Cigna Priority Health	$243.39
Rate for Payer: Priority Health SBD	$219.05

DILTIAZEM 30 MG TABLET

Facility

$3.74

Service Code	NDC 51079-745-01
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: Healthscope Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.18
Rate for Payer: PHP Commercial	$3.18
Rate for Payer: Priority Health Cigna Priority Health	$2.62
Rate for Payer: Priority Health SBD	$2.36

DILTIAZEM 30 MG TABLET

Facility

$3.48

Service Code	NDC 60687-717-11
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna Commercial	$2.96
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Commercial	$2.44
Rate for Payer: Cofinity Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.96
Rate for Payer: PHP Commercial	$2.96
Rate for Payer: Priority Health Cigna Priority Health	$2.44
Rate for Payer: Priority Health SBD	$2.19

DILTIAZEM 30 MG TABLET

Facility

$373.65

Service Code	NDC 51079-745-20
Hospital Charge Code	2475
Hospital Revenue Code	637
Min. Negotiated Rate	$235.40
Max. Negotiated Rate	$336.28
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: Healthscope Commercial	$336.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$317.60
Rate for Payer: PHP Commercial	$317.60
Rate for Payer: Priority Health Cigna Priority Health	$261.56
Rate for Payer: Priority Health SBD	$235.40

DILTIAZEM 30 MG TABLET

Facility

$326.65

Service Code	NDC 0093-0318-01
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: Healthscope Commercial	$293.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$277.65
Rate for Payer: PHP Commercial	$277.65
Rate for Payer: Priority Health Cigna Priority Health	$228.66
Rate for Payer: Priority Health SBD	$205.79

DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION

Facility

$88.75

Service Code	NDC 0641-6014-10
Hospital Charge Code	9869
Hospital Revenue Code	250
Min. Negotiated Rate	$55.91
Max. Negotiated Rate	$79.88
Rate for Payer: Aetna Commercial	$75.44
Rate for Payer: Aetna New Business (MI Preferred)	$57.69
Rate for Payer: Cash Price	$71.00
Rate for Payer: Cofinity Commercial	$62.12
Rate for Payer: Cofinity Commercial	$76.32
Rate for Payer: Healthscope Commercial	$79.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$75.44
Rate for Payer: PHP Commercial	$75.44
Rate for Payer: Priority Health Cigna Priority Health	$62.12
Rate for Payer: Priority Health SBD	$55.91

Know your out-of-pocket cost for care.

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