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All Charges

Charge

Type

Setting

Price

DILATOR ESOPH CRE 18-20

Facility

OP

$335.00

Service Code	HCPCS C1726
Hospital Charge Code	3259949
Hospital Revenue Code	278
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$318.25
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: Humana Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: UnitedHealthcare Medicaid	$134.00
Rate for Payer: WPPA Medicare Advantage	$201.00

DILATOR ESOPH CRE 18-20

Facility

IP

$335.00

Service Code	HCPCS C1726
Hospital Charge Code	3259949
Hospital Revenue Code	278
Min. Negotiated Rate	$301.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dilator Syringe W/Gauge Used with Esoph Balloon Dilators

Facility

OP

$161.70

Hospital Charge Code	3259936
Hospital Revenue Code	270
Min. Negotiated Rate	$64.68
Max. Negotiated Rate	$153.62
Rate for Payer: Aetna Commercial	$145.53
Rate for Payer: Humana Medicare Advantage	$67.91
Rate for Payer: UnitedHealthcare Commercial	$153.62
Rate for Payer: UnitedHealthcare Medicaid	$64.68
Rate for Payer: WPPA Medicare Advantage	$97.02

Dilator Syringe W/Gauge Used with Esoph Balloon Dilators

Facility

IP

$161.70

Hospital Charge Code	3259936
Hospital Revenue Code	270
Min. Negotiated Rate	$145.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$145.53
Rate for Payer: UnitedHealthcare Commercial	$153.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 120 mg/24 hours ERCap [HMC]

Facility

OP

$7.90

Service Code	NDC 60687019501
Hospital Charge Code	3800345
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$7.11
Rate for Payer: Humana Medicare Advantage	$3.32
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: WPPA Medicare Advantage	$4.74

diltiazem 120 mg/24 hours ERCap [HMC]

Facility

IP

$7.90

Service Code	NDC 60687019501
Hospital Charge Code	3800345
Hospital Revenue Code	250
Min. Negotiated Rate	$7.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.11
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 120 mg/24 hours ERCap [HMC]

Facility

IP

$6.61

Service Code	NDC 00904721761
Hospital Charge Code	3800345
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.95
Rate for Payer: UnitedHealthcare Commercial	$6.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 120 mg/24 hours ERCap [HMC]

Facility

OP

$6.61

Service Code	NDC 00904721761
Hospital Charge Code	3800345
Hospital Revenue Code	250
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$6.28
Rate for Payer: Aetna Commercial	$5.95
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.28
Rate for Payer: UnitedHealthcare Medicaid	$2.64
Rate for Payer: WPPA Medicare Advantage	$3.97

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

IP

$7.90

Service Code	NDC 60687020601
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$7.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.11
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

IP

$6.40

Service Code	NDC 00904721861
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.76
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

IP

$9.31

Service Code	NDC 62584097501
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.38
Rate for Payer: UnitedHealthcare Commercial	$8.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

OP

$9.31

Service Code	NDC 62584097501
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$8.84
Rate for Payer: Aetna Commercial	$8.38
Rate for Payer: Humana Medicare Advantage	$3.91
Rate for Payer: UnitedHealthcare Commercial	$8.84
Rate for Payer: UnitedHealthcare Medicaid	$3.72
Rate for Payer: WPPA Medicare Advantage	$5.59

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

OP

$7.90

Service Code	NDC 60687020601
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$7.11
Rate for Payer: Humana Medicare Advantage	$3.32
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: WPPA Medicare Advantage	$4.74

diltiazem 180 mg/24 hours ERCap [HMC]

Facility

OP

$6.40

Service Code	NDC 00904721861
Hospital Charge Code	3807838
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$6.08
Rate for Payer: Aetna Commercial	$5.76
Rate for Payer: Humana Medicare Advantage	$2.69
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: WPPA Medicare Advantage	$3.84

diltiazem 30 mg Tab [HMC]

Facility

OP

$6.57

Service Code	NDC 60687071701
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$6.24
Rate for Payer: Aetna Commercial	$5.91
Rate for Payer: Humana Medicare Advantage	$2.76
Rate for Payer: UnitedHealthcare Commercial	$6.24
Rate for Payer: UnitedHealthcare Medicaid	$2.63
Rate for Payer: WPPA Medicare Advantage	$3.94

diltiazem 30 mg Tab [HMC]

Facility

IP

$5.53

Service Code	NDC 63739007910
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.98
Rate for Payer: UnitedHealthcare Commercial	$5.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 30 mg Tab [HMC]

Facility

OP

$8.00

Service Code	NDC 00093031801
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.80

diltiazem 30 mg Tab [HMC]

Facility

IP

$6.57

Service Code	NDC 60687071701
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$5.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.91
Rate for Payer: UnitedHealthcare Commercial	$6.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 30 mg Tab [HMC]

Facility

OP

$5.53

Service Code	NDC 63739007910
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$5.25
Rate for Payer: Aetna Commercial	$4.98
Rate for Payer: Humana Medicare Advantage	$2.32
Rate for Payer: UnitedHealthcare Commercial	$5.25
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: WPPA Medicare Advantage	$3.32

diltiazem 30 mg Tab [HMC]

Facility

IP

$8.00

Service Code	NDC 00093031801
Hospital Charge Code	3808702
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 5 mg/mL IV Sol [HMC]

Facility

IP

$33.08

Service Code	NDC 00641921710
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$29.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.77
Rate for Payer: UnitedHealthcare Commercial	$31.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 5 mg/mL IV Sol [HMC]

Facility

OP

$33.08

Service Code	NDC 00641921710
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$31.43
Rate for Payer: Aetna Commercial	$29.77
Rate for Payer: Humana Medicare Advantage	$13.89
Rate for Payer: UnitedHealthcare Commercial	$31.43
Rate for Payer: UnitedHealthcare Medicaid	$13.23
Rate for Payer: WPPA Medicare Advantage	$19.85

diltiazem 5 mg/mL IV Sol [HMC]

Facility

IP

$32.72

Service Code	NDC 00409117101
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$29.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 5 mg/mL IV Sol [HMC]

Facility

OP

$32.72

Service Code	NDC 00409117101
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$31.08
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: UnitedHealthcare Medicaid	$13.09
Rate for Payer: WPPA Medicare Advantage	$19.63

dilTIAZem 5 mg/mL Sol

Facility

OP

$39.50

Service Code	NDC 25021031905
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$37.52
Rate for Payer: Aetna Commercial	$35.55
Rate for Payer: Humana Medicare Advantage	$16.59
Rate for Payer: UnitedHealthcare Commercial	$37.52
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: WPPA Medicare Advantage	$23.70

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