|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 51079074501
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 51079074501
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$1.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 60687056211
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna American Axle |
$2.66
|
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.66
|
| Rate for Payer: Cash Price |
$3.27
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.27
|
| Rate for Payer: Healthscope Commercial |
$3.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.48
|
| Rate for Payer: PHP Commercial |
$3.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.66
|
| Rate for Payer: Priority Health SBD |
$2.58
|
| Rate for Payer: UMR Bronson Commercial |
$1.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.07
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$131.60
|
|
|
Service Code
|
NDC 50228048101
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna Medicare |
$65.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: BCBS Complete |
$52.64
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$48.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 00093031801
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 51079074520
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.56
|
| Rate for Payer: Aetna American Axle |
$242.87
|
| 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: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$138.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$131.60
|
|
|
Service Code
|
NDC 50228048101
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.90 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$57.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 00378002301
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 51079074520
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| 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 |
$336.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$164.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$88.75
|
|
|
Service Code
|
NDC 00641601401
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$79.88 |
| Rate for Payer: Aetna American Axle |
$57.69
|
| 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: Cofinity Medicare Advantage |
$62.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.00
|
| Rate for Payer: Healthscope Commercial |
$79.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.44
|
| Rate for Payer: PHP Commercial |
$75.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.69
|
| Rate for Payer: Priority Health SBD |
$55.91
|
| Rate for Payer: UMR Bronson Commercial |
$39.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$129.38
|
|
|
Service Code
|
NDC 00641921901
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna Medicare |
$64.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: BCBS Complete |
$51.75
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$47.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 00641601501
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$59.50
|
|
|
Service Code
|
NDC 17478093710
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.02 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Aetna American Axle |
$38.68
|
| Rate for Payer: Aetna Commercial |
$50.58
|
| Rate for Payer: Aetna Medicare |
$29.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.68
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$41.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.62
|
| 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 |
$38.68
|
| Rate for Payer: Priority Health SBD |
$37.48
|
| Rate for Payer: UMR Bronson Commercial |
$22.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.62
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 00641601510
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$71.75
|
|
|
Service Code
|
NDC 55150042510
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.57 |
| Max. Negotiated Rate |
$64.58 |
| Rate for Payer: Aetna American Axle |
$46.64
|
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.64
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cofinity Commercial |
$50.22
|
| Rate for Payer: Cofinity Commercial |
$61.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.40
|
| Rate for Payer: Healthscope Commercial |
$64.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.99
|
| Rate for Payer: PHP Commercial |
$60.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.64
|
| Rate for Payer: Priority Health SBD |
$45.20
|
| Rate for Payer: UMR Bronson Commercial |
$31.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.81
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$48.63
|
|
|
Service Code
|
NDC 00641601310
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.99 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Aetna American Axle |
$31.61
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$34.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.47
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$17.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.47
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$59.50
|
|
|
Service Code
|
NDC 17478093710
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.18 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Aetna American Axle |
$38.68
|
| Rate for Payer: Aetna Commercial |
$50.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.68
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$41.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.62
|
| 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 |
$38.68
|
| Rate for Payer: Priority Health SBD |
$37.48
|
| Rate for Payer: UMR Bronson Commercial |
$26.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.62
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$88.75
|
|
|
Service Code
|
NDC 00641601410
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$79.88 |
| Rate for Payer: Aetna American Axle |
$57.69
|
| 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: Cofinity Medicare Advantage |
$62.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.00
|
| Rate for Payer: Healthscope Commercial |
$79.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.44
|
| Rate for Payer: PHP Commercial |
$75.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.69
|
| Rate for Payer: Priority Health SBD |
$55.91
|
| Rate for Payer: UMR Bronson Commercial |
$39.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 00641921910
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$129.38
|
|
|
Service Code
|
NDC 00641921910
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna Medicare |
$64.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: BCBS Complete |
$51.75
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$47.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$71.75
|
|
|
Service Code
|
NDC 55150042510
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$64.58 |
| Rate for Payer: Aetna American Axle |
$46.64
|
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Aetna Medicare |
$35.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.64
|
| Rate for Payer: BCBS Complete |
$28.70
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cofinity Commercial |
$50.22
|
| Rate for Payer: Cofinity Commercial |
$61.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.40
|
| Rate for Payer: Healthscope Commercial |
$64.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.99
|
| Rate for Payer: PHP Commercial |
$60.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.64
|
| Rate for Payer: Priority Health SBD |
$45.20
|
| Rate for Payer: UMR Bronson Commercial |
$26.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.81
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$61.50
|
|
|
Service Code
|
NDC 70860030142
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.06 |
| Max. Negotiated Rate |
$55.35 |
| Rate for Payer: Aetna American Axle |
$39.98
|
| Rate for Payer: Aetna Commercial |
$52.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.98
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cofinity Commercial |
$43.05
|
| Rate for Payer: Cofinity Commercial |
$52.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.20
|
| Rate for Payer: Healthscope Commercial |
$55.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.28
|
| Rate for Payer: PHP Commercial |
$52.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.98
|
| Rate for Payer: Priority Health SBD |
$38.74
|
| Rate for Payer: UMR Bronson Commercial |
$27.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.12
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$253.75
|
|
|
Service Code
|
NDC 17478093726
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$228.38 |
| Rate for Payer: Aetna American Axle |
$164.94
|
| Rate for Payer: Aetna Commercial |
$215.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.94
|
| Rate for Payer: Cash Price |
$203.00
|
| Rate for Payer: Cofinity Commercial |
$177.62
|
| Rate for Payer: Cofinity Commercial |
$218.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.00
|
| Rate for Payer: Healthscope Commercial |
$228.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.69
|
| Rate for Payer: PHP Commercial |
$215.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.94
|
| Rate for Payer: Priority Health SBD |
$159.86
|
| Rate for Payer: UMR Bronson Commercial |
$111.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.31
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$61.50
|
|
|
Service Code
|
NDC 70860030110
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$55.35 |
| Rate for Payer: Aetna American Axle |
$39.98
|
| Rate for Payer: Aetna Commercial |
$52.28
|
| Rate for Payer: Aetna Medicare |
$30.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.98
|
| Rate for Payer: BCBS Complete |
$24.60
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cofinity Commercial |
$43.05
|
| Rate for Payer: Cofinity Commercial |
$52.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.20
|
| Rate for Payer: Healthscope Commercial |
$55.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.28
|
| Rate for Payer: PHP Commercial |
$52.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.98
|
| Rate for Payer: Priority Health SBD |
$38.74
|
| Rate for Payer: UMR Bronson Commercial |
$22.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.12
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$48.63
|
|
|
Service Code
|
NDC 00641601301
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.99 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Aetna American Axle |
$31.61
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$34.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.47
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$17.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.47
|
|
