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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

IP

$0.37

Service Code	HCPCS J3490
Hospital Charge Code	2502131905
Hospital Revenue Code	258
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

IP

$0.82

Service Code	HCPCS J3490
Hospital Charge Code	0641601310
Hospital Revenue Code	258
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

OP

$0.82

Service Code	HCPCS J3490
Hospital Charge Code	0641601301
Hospital Revenue Code	258
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.41
Rate for Payer: Aetna Government	$0.41
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: EmblemHealth Commercial	$0.41
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.53

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

IP

$0.82

Service Code	HCPCS J3490
Hospital Charge Code	0641601301
Hospital Revenue Code	258
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

OP

$0.78

Service Code	HCPCS J3490
Hospital Charge Code	7086030141
Hospital Revenue Code	258
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.39
Rate for Payer: Aetna Government	$0.39
Rate for Payer: Brighton Health Commercial	$0.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.53
Rate for Payer: EmblemHealth Commercial	$0.39
Rate for Payer: Group Health Inc Commercial	$0.39
Rate for Payer: Group Health Inc Medicare	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39
Rate for Payer: Hamaspik Choice Inc Medicare	$0.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.51

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

OP

$0.91

Service Code	HCPCS J3490
Hospital Charge Code	5515042501
Hospital Revenue Code	258
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.46
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

IP

$0.78

Service Code	HCPCS J3490
Hospital Charge Code	7086030141
Hospital Revenue Code	258
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.39

DILTIAZEM HCL 25 MG/5ML IV SOLN

Facility

IP

$0.91

Service Code	HCPCS J3490
Hospital Charge Code	5515042501
Hospital Revenue Code	258
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46

DILTIAZEM HCL 30 MG PO TABS

Facility

IP

$0.53

Service Code	NDC 6068771711
Hospital Charge Code	6068771711
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26

DILTIAZEM HCL 30 MG PO TABS

Facility

OP

$0.53

Service Code	NDC 6068771711
Hospital Charge Code	6068771711
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.26
Rate for Payer: Aetna Government	$0.26
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.36
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

DILTIAZEM HCL 30 MG PO TABS

Facility

IP

$1.00

Service Code	NDC 0093031801
Hospital Charge Code	0093031801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

DILTIAZEM HCL 30 MG PO TABS

Facility

OP

$1.00

Service Code	NDC 0093031801
Hospital Charge Code	0093031801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: EmblemHealth Commercial	$0.50
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

DILTIAZEM HCL 30 MG PO TABS

Facility

IP

$0.98

Service Code	NDC 0093031805
Hospital Charge Code	0093031805
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49

DILTIAZEM HCL 30 MG PO TABS

Facility

OP

$0.98

Service Code	NDC 0093031805
Hospital Charge Code	0093031805
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.49
Rate for Payer: Aetna Government	$0.49
Rate for Payer: Brighton Health Commercial	$0.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.79
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.67
Rate for Payer: EmblemHealth Commercial	$0.49
Rate for Payer: Group Health Inc Commercial	$0.49
Rate for Payer: Group Health Inc Medicare	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.49
Rate for Payer: Hamaspik Choice Inc Medicare	$0.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.64

DILTIAZEM HCL 60 MG PO TABS

Facility

IP

$1.57

Service Code	NDC 0093031901
Hospital Charge Code	0093031901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78

DILTIAZEM HCL 60 MG PO TABS

Facility

OP

$1.54

Service Code	NDC 0093031905
Hospital Charge Code	0093031905
Hospital Revenue Code	250
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.77
Rate for Payer: Aetna Government	$0.77
Rate for Payer: Brighton Health Commercial	$1.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.05
Rate for Payer: EmblemHealth Commercial	$0.77
Rate for Payer: Group Health Inc Commercial	$0.77
Rate for Payer: Group Health Inc Medicare	$0.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.77
Rate for Payer: Hamaspik Choice Inc Medicare	$0.77
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.00

DILTIAZEM HCL 60 MG PO TABS

Facility

OP

$1.57

Service Code	NDC 0093031901
Hospital Charge Code	0093031901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.78
Rate for Payer: Aetna Government	$0.78
Rate for Payer: Brighton Health Commercial	$1.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.07
Rate for Payer: EmblemHealth Commercial	$0.78
Rate for Payer: Group Health Inc Commercial	$0.78
Rate for Payer: Group Health Inc Medicare	$0.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.78
Rate for Payer: Hamaspik Choice Inc Medicare	$0.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.02

DILTIAZEM HCL 60 MG PO TABS

Facility

OP

$0.61

Service Code	NDC 6068772811
Hospital Charge Code	6068772811
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.30
Rate for Payer: Aetna Government	$0.30
Rate for Payer: Brighton Health Commercial	$0.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: EmblemHealth Commercial	$0.30
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.40

DILTIAZEM HCL 60 MG PO TABS

Facility

IP

$1.54

Service Code	NDC 0093031905
Hospital Charge Code	0093031905
Hospital Revenue Code	250
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$0.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.77

DILTIAZEM HCL 60 MG PO TABS

Facility

IP

$0.61

Service Code	NDC 6068772811
Hospital Charge Code	6068772811
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30

DILTIAZEM HCL 90 MG PO TABS

Facility

OP

$2.14

Service Code	NDC 5022848301
Hospital Charge Code	5022848301
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.07
Rate for Payer: Aetna Government	$1.07
Rate for Payer: Brighton Health Commercial	$1.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.46
Rate for Payer: EmblemHealth Commercial	$1.07
Rate for Payer: Group Health Inc Commercial	$1.07
Rate for Payer: Group Health Inc Medicare	$0.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.07
Rate for Payer: Hamaspik Choice Inc Medicare	$1.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.39

DILTIAZEM HCL 90 MG PO TABS

Facility

IP

$2.14

Service Code	NDC 5022848301
Hospital Charge Code	5022848301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.07

DILTIAZEM HCL 90 MG PO TABS

Facility

OP

$2.14

Service Code	NDC 0093032001
Hospital Charge Code	0093032001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.07
Rate for Payer: Aetna Government	$1.07
Rate for Payer: Brighton Health Commercial	$1.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.46
Rate for Payer: EmblemHealth Commercial	$1.07
Rate for Payer: Group Health Inc Commercial	$1.07
Rate for Payer: Group Health Inc Medicare	$0.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.07
Rate for Payer: Hamaspik Choice Inc Medicare	$1.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.39

DILTIAZEM HCL 90 MG PO TABS

Facility

IP

$2.14

Service Code	NDC 0093032001
Hospital Charge Code	0093032001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.07

DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24

Facility

OP

$0.91

Service Code	NDC 2497902607
Hospital Charge Code	2497902607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.45
Rate for Payer: Aetna Government	$0.45
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.72
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.45
Rate for Payer: Group Health Inc Commercial	$0.45
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.45
Rate for Payer: Hamaspik Choice Inc Medicare	$0.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

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