|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$48.63
|
|
|
Service Code
|
NDC 0641-9217-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.66 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: BCBS Trust/PPO |
$37.58
|
| Rate for Payer: BCN Commercial |
$37.58
|
| Rate for Payer: Cash Price |
$38.90
|
| Rate for Payer: Cofinity Commercial |
$41.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.90
|
| Rate for Payer: Healthscope Commercial |
$43.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$29.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.79
|
| Rate for Payer: UHC Core |
$40.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.47
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$65.25
|
|
|
Service Code
|
NDC 17478-937-05
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.80 |
| Max. Negotiated Rate |
$58.72 |
| Rate for Payer: Aetna Commercial |
$55.46
|
| Rate for Payer: BCBS Trust/PPO |
$50.43
|
| Rate for Payer: BCN Commercial |
$50.43
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cofinity Commercial |
$56.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.20
|
| Rate for Payer: Healthscope Commercial |
$58.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.46
|
| Rate for Payer: PHP Commercial |
$55.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$56.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.42
|
| Rate for Payer: UHC Core |
$54.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.94
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$253.75
|
|
|
Service Code
|
NDC 17478-937-26
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$154.76 |
| Max. Negotiated Rate |
$228.38 |
| Rate for Payer: Aetna Commercial |
$215.69
|
| Rate for Payer: BCBS Trust/PPO |
$196.10
|
| Rate for Payer: BCN Commercial |
$196.10
|
| Rate for Payer: Cash Price |
$203.00
|
| Rate for Payer: Cofinity Commercial |
$218.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.00
|
| Rate for Payer: Healthscope Commercial |
$228.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$215.69
|
| Rate for Payer: PHP Commercial |
$215.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$220.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$223.30
|
| Rate for Payer: UHC Core |
$211.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.31
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 0641-6015-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.91 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: BCBS Trust/PPO |
$99.98
|
| Rate for Payer: BCN Commercial |
$99.98
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$112.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$113.85
|
| Rate for Payer: UHC Core |
$108.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 60 MG TABLET
|
Facility
|
IP
|
$208.05
|
|
|
Service Code
|
NDC 0093-0319-01
|
| Hospital Charge Code |
2476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.89 |
| Max. Negotiated Rate |
$187.24 |
| Rate for Payer: Aetna Commercial |
$176.84
|
| Rate for Payer: BCBS Trust/PPO |
$160.78
|
| Rate for Payer: BCN Commercial |
$160.78
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Cofinity Commercial |
$178.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.44
|
| Rate for Payer: Healthscope Commercial |
$187.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.84
|
| Rate for Payer: PHP Commercial |
$176.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$181.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$126.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.08
|
| Rate for Payer: UHC Core |
$173.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.04
|
|
|
DILTIAZEM 60 MG TABLET
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 51079-746-01
|
| Hospital Charge Code |
2476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna Commercial |
$1.71
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.61
|
| Rate for Payer: Healthscope Commercial |
$1.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.71
|
| Rate for Payer: PHP Commercial |
$1.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.77
|
| Rate for Payer: UHC Core |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.51
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 60687-195-11
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: BCBS Trust/PPO |
$3.32
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cofinity Commercial |
$3.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.43
|
| Rate for Payer: Healthscope Commercial |
$3.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.65
|
| Rate for Payer: PHP Commercial |
$3.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.78
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.22
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 60687-195-01
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.31 |
| Max. Negotiated Rate |
$385.60 |
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: BCBS Trust/PPO |
$331.11
|
| Rate for Payer: BCN Commercial |
$331.11
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$372.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$261.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$377.04
|
| Rate for Payer: UHC Core |
$357.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.34
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 60687-206-11
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.60
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$2.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.45
|
| Rate for Payer: Healthscope Commercial |
$2.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.60
|
| Rate for Payer: PHP Commercial |
$2.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.69
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.30
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$305.90
|
|
|
Service Code
|
NDC 60687-206-01
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.57 |
| Max. Negotiated Rate |
$275.31 |
| Rate for Payer: Aetna Commercial |
$260.02
|
| Rate for Payer: BCBS Trust/PPO |
$236.40
|
| Rate for Payer: BCN Commercial |
$236.40
|
| Rate for Payer: Cash Price |
$244.72
|
| Rate for Payer: Cofinity Commercial |
$263.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.72
|
| Rate for Payer: Healthscope Commercial |
$275.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$229.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$260.02
|
| Rate for Payer: PHP Commercial |
$260.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$266.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$186.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$269.19
|
| Rate for Payer: UHC Core |
$255.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$229.42
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 63739-015-10
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.25 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: BCBS Trust/PPO |
$154.91
|
| Rate for Payer: BCN Commercial |
$154.91
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$122.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.40
|
| Rate for Payer: UHC Core |
$167.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.34
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$333.45
|
|
|
Service Code
|
NDC 0904-7219-61
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.37 |
| Max. Negotiated Rate |
$300.10 |
| Rate for Payer: Aetna Commercial |
$283.43
|
| Rate for Payer: BCBS Trust/PPO |
$257.69
|
| Rate for Payer: BCN Commercial |
$257.69
|
| Rate for Payer: Cash Price |
$266.76
|
| Rate for Payer: Cofinity Commercial |
$286.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.76
|
| Rate for Payer: Healthscope Commercial |
$300.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.43
|
| Rate for Payer: PHP Commercial |
$283.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$290.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.44
|
| Rate for Payer: UHC Core |
$278.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.09
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$424.65
|
|
|
Service Code
|
NDC 63739-016-10
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.99 |
| Max. Negotiated Rate |
$382.18 |
| Rate for Payer: Aetna Commercial |
$360.95
|
| Rate for Payer: BCBS Trust/PPO |
$328.17
|
| Rate for Payer: BCN Commercial |
$328.17
|
| Rate for Payer: Cash Price |
$339.72
|
| Rate for Payer: Cofinity Commercial |
$365.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.72
|
| Rate for Payer: Healthscope Commercial |
$382.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$360.95
|
| Rate for Payer: PHP Commercial |
$360.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$258.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$373.69
|
| Rate for Payer: UHC Core |
$354.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.49
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$254.88
|
|
|
Service Code
|
NDC 60687-217-01
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.45 |
| Max. Negotiated Rate |
$229.39 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: BCBS Trust/PPO |
$196.97
|
| Rate for Payer: BCN Commercial |
$196.97
|
| Rate for Payer: Cash Price |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$219.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.90
|
| Rate for Payer: Healthscope Commercial |
$229.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.65
|
| Rate for Payer: PHP Commercial |
$216.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$221.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.29
|
| Rate for Payer: UHC Core |
$212.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.16
|
|
|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 60687-217-11
|
| Hospital Charge Code |
29274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: BCBS Trust/PPO |
$1.97
|
| Rate for Payer: BCN Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.24
|
| Rate for Payer: UHC Core |
$2.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
DILTIAZEM ER (XR/XT) 180 MG CAPSULE,EXTENDED RELEASE 24 HR, CONTROLLED
|
Facility
|
IP
|
$403.75
|
|
|
Service Code
|
NDC 60505-0015-6
|
| Hospital Charge Code |
29347
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$246.25 |
| Max. Negotiated Rate |
$363.38 |
| Rate for Payer: Aetna Commercial |
$343.19
|
| Rate for Payer: BCBS Trust/PPO |
$312.02
|
| Rate for Payer: BCN Commercial |
$312.02
|
| Rate for Payer: Cash Price |
$323.00
|
| Rate for Payer: Cofinity Commercial |
$347.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.00
|
| Rate for Payer: Healthscope Commercial |
$363.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$302.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.19
|
| Rate for Payer: PHP Commercial |
$343.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$351.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$246.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.30
|
| Rate for Payer: UHC Core |
$337.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$302.81
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.01
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: BCBS Trust/PPO |
$18.55
|
| Rate for Payer: BCN Commercial |
$18.55
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.41
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.13
|
| Rate for Payer: UHC Core |
$20.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$14.52
|
|
|
Service Code
|
NDC 96295-20033
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$13.07 |
| Rate for Payer: Aetna Commercial |
$12.34
|
| Rate for Payer: BCBS Trust/PPO |
$11.22
|
| Rate for Payer: BCN Commercial |
$11.22
|
| Rate for Payer: Cash Price |
$11.62
|
| Rate for Payer: Cofinity Commercial |
$12.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.62
|
| Rate for Payer: Healthscope Commercial |
$13.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.34
|
| Rate for Payer: PHP Commercial |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.78
|
| Rate for Payer: UHC Core |
$12.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.89
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 0904-2051-59
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.79 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: BCBS Trust/PPO |
$68.16
|
| Rate for Payer: BCN Commercial |
$68.16
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.62
|
| Rate for Payer: UHC Core |
$73.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$407.29
|
|
|
Service Code
|
NDC 65628-050-01
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.41 |
| Max. Negotiated Rate |
$366.56 |
| Rate for Payer: Aetna Commercial |
$346.20
|
| Rate for Payer: BCBS Trust/PPO |
$314.75
|
| Rate for Payer: BCN Commercial |
$314.75
|
| Rate for Payer: Cash Price |
$325.83
|
| Rate for Payer: Cofinity Commercial |
$350.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.83
|
| Rate for Payer: Healthscope Commercial |
$366.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$346.20
|
| Rate for Payer: PHP Commercial |
$346.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$354.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$358.42
|
| Rate for Payer: UHC Core |
$340.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.47
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: BCBS Trust/PPO |
$10.01
|
| Rate for Payer: BCN Commercial |
$10.01
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.40
|
| Rate for Payer: UHC Core |
$10.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$142.80
|
|
|
Service Code
|
NDC 68094-018-61
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.09 |
| Max. Negotiated Rate |
$128.52 |
| Rate for Payer: Aetna Commercial |
$121.38
|
| Rate for Payer: BCBS Trust/PPO |
$110.36
|
| Rate for Payer: BCN Commercial |
$110.36
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$122.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Healthscope Commercial |
$128.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.38
|
| Rate for Payer: PHP Commercial |
$121.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$124.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$87.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.66
|
| Rate for Payer: UHC Core |
$119.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 0904-5551-59
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.48 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$85.68
|
| Rate for Payer: BCBS Trust/PPO |
$77.90
|
| Rate for Payer: BCN Commercial |
$77.90
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$86.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Healthscope Commercial |
$90.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.68
|
| Rate for Payer: PHP Commercial |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$87.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.70
|
| Rate for Payer: UHC Core |
$84.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 68094-018-59
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: BCBS Trust/PPO |
$1.11
|
| Rate for Payer: BCN Commercial |
$1.11
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.22
|
| Rate for Payer: PHP Commercial |
$1.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.26
|
| Rate for Payer: UHC Core |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: BCBS Trust/PPO |
$9.37
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.31
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
