|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
NDC 60687060711
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Aetna Medicare |
$4.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.00
|
| Rate for Payer: Cash Price |
$8.53
|
| Rate for Payer: Centivo All Commercial |
$7.73
|
| Rate for Payer: Cigna All Commercial |
$12.26
|
| Rate for Payer: CORVEL All Commercial |
$13.22
|
| Rate for Payer: Coventry All Commercial |
$12.50
|
| Rate for Payer: Encore All Commercial |
$13.08
|
| Rate for Payer: Frontpath All Commercial |
$13.07
|
| Rate for Payer: Humana ChoiceCare |
$12.27
|
| Rate for Payer: Humana Medicare |
$4.55
|
| Rate for Payer: Lucent All Commercial |
$7.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.79
|
| Rate for Payer: PHCS All Commercial |
$10.66
|
| Rate for Payer: PHP All Commercial |
$10.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.54
|
| Rate for Payer: Sagamore Health Network All Products |
$10.97
|
| Rate for Payer: Signature Care EPO |
$11.79
|
| Rate for Payer: Signature Care PPO |
$12.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.08
|
| Rate for Payer: United Healthcare Commercial |
$11.20
|
| Rate for Payer: United Healthcare Medicare |
$4.55
|
|
|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
NDC 60687060721
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Aetna Medicare |
$4.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.00
|
| Rate for Payer: Cash Price |
$8.53
|
| Rate for Payer: Centivo All Commercial |
$7.73
|
| Rate for Payer: Cigna All Commercial |
$12.26
|
| Rate for Payer: CORVEL All Commercial |
$13.22
|
| Rate for Payer: Coventry All Commercial |
$12.50
|
| Rate for Payer: Encore All Commercial |
$13.08
|
| Rate for Payer: Frontpath All Commercial |
$13.07
|
| Rate for Payer: Humana ChoiceCare |
$12.27
|
| Rate for Payer: Humana Medicare |
$4.55
|
| Rate for Payer: Lucent All Commercial |
$7.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.79
|
| Rate for Payer: PHCS All Commercial |
$10.66
|
| Rate for Payer: PHP All Commercial |
$10.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.54
|
| Rate for Payer: Sagamore Health Network All Products |
$10.97
|
| Rate for Payer: Signature Care EPO |
$11.79
|
| Rate for Payer: Signature Care PPO |
$12.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.08
|
| Rate for Payer: United Healthcare Commercial |
$11.20
|
| Rate for Payer: United Healthcare Medicare |
$4.55
|
|
|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
NDC 60687060711
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Cash Price |
$8.53
|
| Rate for Payer: Cigna All Commercial |
$12.26
|
| Rate for Payer: CORVEL All Commercial |
$13.22
|
| Rate for Payer: Coventry All Commercial |
$12.50
|
| Rate for Payer: Encore All Commercial |
$13.08
|
| Rate for Payer: Frontpath All Commercial |
$13.07
|
| Rate for Payer: Humana ChoiceCare |
$12.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.79
|
| Rate for Payer: PHCS All Commercial |
$10.66
|
| Rate for Payer: PHP All Commercial |
$10.78
|
| Rate for Payer: Sagamore Health Network All Products |
$10.97
|
| Rate for Payer: Signature Care EPO |
$11.79
|
| Rate for Payer: Signature Care PPO |
$12.50
|
| Rate for Payer: United Healthcare Commercial |
$11.20
|
|
|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
NDC 60687060721
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Cash Price |
$8.53
|
| Rate for Payer: Cigna All Commercial |
$12.26
|
| Rate for Payer: CORVEL All Commercial |
$13.22
|
| Rate for Payer: Coventry All Commercial |
$12.50
|
| Rate for Payer: Encore All Commercial |
$13.08
|
| Rate for Payer: Frontpath All Commercial |
$13.07
|
| Rate for Payer: Humana ChoiceCare |
$12.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.79
|
| Rate for Payer: PHCS All Commercial |
$10.66
|
| Rate for Payer: PHP All Commercial |
$10.78
|
| Rate for Payer: Sagamore Health Network All Products |
$10.97
|
| Rate for Payer: Signature Care EPO |
$11.79
|
| Rate for Payer: Signature Care PPO |
$12.50
|
| Rate for Payer: United Healthcare Commercial |
$11.20
|
|
|
DEXAMETHASONE 24 MG/ML OTIC SOLUTION - CLINIC ADMINISTRATION
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
13060023212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$295.40
|
| Rate for Payer: Aetna Medicare |
$112.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$128.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$123.20
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Centivo All Commercial |
$190.40
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Humana Medicare |
$112.00
|
| Rate for Payer: Lucent All Commercial |
$190.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.50
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$297.50
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
| Rate for Payer: United Healthcare Medicare |
$112.00
|
|
|
DEXAMETHASONE 24 MG/ML OTIC SOLUTION - CLINIC ADMINISTRATION
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
13060023212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$302.40
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
|
|
DEXAMETHASONE 4 MG/ML INJ *FOR ORAL USE ONLY*
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4082332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXAMETHASONE 4 MG/ML INJ *FOR ORAL USE ONLY*
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4082332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
DEXAMETHASONE 4 MG ORAL TAB
|
Facility
|
OP
|
$7.36
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Aetna Commercial |
$6.22
|
| Rate for Payer: Aetna Medicare |
$2.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.59
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Centivo All Commercial |
$4.01
|
| Rate for Payer: Cigna All Commercial |
$6.36
|
| Rate for Payer: CORVEL All Commercial |
$6.85
|
| Rate for Payer: Coventry All Commercial |
$6.48
|
| Rate for Payer: Encore All Commercial |
$6.78
|
| Rate for Payer: Frontpath All Commercial |
$6.77
|
| Rate for Payer: Humana ChoiceCare |
$6.36
|
| Rate for Payer: Humana Medicare |
$2.36
|
| Rate for Payer: Lucent All Commercial |
$4.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.63
|
| Rate for Payer: PHCS All Commercial |
$5.52
|
| Rate for Payer: PHP All Commercial |
$5.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.87
|
| Rate for Payer: Sagamore Health Network All Products |
$5.69
|
| Rate for Payer: Signature Care EPO |
$6.11
|
| Rate for Payer: Signature Care PPO |
$6.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.26
|
| Rate for Payer: United Healthcare Commercial |
$5.80
|
| Rate for Payer: United Healthcare Medicare |
$2.36
|
|
|
DEXAMETHASONE 4 MG ORAL TAB
|
Facility
|
IP
|
$7.36
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$6.85 |
| Rate for Payer: Aetna Commercial |
$6.36
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cigna All Commercial |
$6.36
|
| Rate for Payer: CORVEL All Commercial |
$6.85
|
| Rate for Payer: Coventry All Commercial |
$6.48
|
| Rate for Payer: Encore All Commercial |
$6.78
|
| Rate for Payer: Frontpath All Commercial |
$6.77
|
| Rate for Payer: Humana ChoiceCare |
$6.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.63
|
| Rate for Payer: PHCS All Commercial |
$5.52
|
| Rate for Payer: PHP All Commercial |
$5.58
|
| Rate for Payer: Sagamore Health Network All Products |
$5.69
|
| Rate for Payer: Signature Care EPO |
$6.11
|
| Rate for Payer: Signature Care PPO |
$6.48
|
| Rate for Payer: United Healthcare Commercial |
$5.80
|
|
|
DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$64.04
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
118427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$59.56 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Cash Price |
$38.43
|
| Rate for Payer: Cigna All Commercial |
$55.27
|
| Rate for Payer: CORVEL All Commercial |
$59.56
|
| Rate for Payer: Coventry All Commercial |
$56.36
|
| Rate for Payer: Encore All Commercial |
$58.95
|
| Rate for Payer: Frontpath All Commercial |
$58.92
|
| Rate for Payer: Humana ChoiceCare |
$55.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.64
|
| Rate for Payer: PHCS All Commercial |
$48.03
|
| Rate for Payer: PHP All Commercial |
$48.57
|
| Rate for Payer: Sagamore Health Network All Products |
$49.44
|
| Rate for Payer: Signature Care EPO |
$53.16
|
| Rate for Payer: Signature Care PPO |
$56.36
|
| Rate for Payer: United Healthcare Commercial |
$50.47
|
|
|
DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$64.04
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
118427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$59.56 |
| Rate for Payer: Aetna Commercial |
$54.05
|
| Rate for Payer: Aetna Medicare |
$20.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.54
|
| Rate for Payer: Cash Price |
$38.43
|
| Rate for Payer: Centivo All Commercial |
$34.84
|
| Rate for Payer: Cigna All Commercial |
$55.27
|
| Rate for Payer: CORVEL All Commercial |
$59.56
|
| Rate for Payer: Coventry All Commercial |
$56.36
|
| Rate for Payer: Encore All Commercial |
$58.95
|
| Rate for Payer: Frontpath All Commercial |
$58.92
|
| Rate for Payer: Humana ChoiceCare |
$55.31
|
| Rate for Payer: Humana Medicare |
$20.49
|
| Rate for Payer: Lucent All Commercial |
$34.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.64
|
| Rate for Payer: PHCS All Commercial |
$48.03
|
| Rate for Payer: PHP All Commercial |
$48.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.98
|
| Rate for Payer: Sagamore Health Network All Products |
$49.44
|
| Rate for Payer: Signature Care EPO |
$53.16
|
| Rate for Payer: Signature Care PPO |
$56.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$54.44
|
| Rate for Payer: United Healthcare Commercial |
$50.47
|
| Rate for Payer: United Healthcare Medicare |
$20.49
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 71288050503
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 71288050503
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 71288050502
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 71288050502
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML BOLUS INJECTION
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4080171613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML BOLUS INJECTION
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4080171613
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.00
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 70121138901
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$104.16 |
| Rate for Payer: Aetna Commercial |
$96.77
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna All Commercial |
$96.66
|
| Rate for Payer: CORVEL All Commercial |
$104.16
|
| Rate for Payer: Coventry All Commercial |
$98.56
|
| Rate for Payer: Encore All Commercial |
$103.10
|
| Rate for Payer: Frontpath All Commercial |
$103.04
|
| Rate for Payer: Humana ChoiceCare |
$96.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.80
|
| Rate for Payer: PHCS All Commercial |
$84.00
|
| Rate for Payer: PHP All Commercial |
$84.94
|
| Rate for Payer: Sagamore Health Network All Products |
$86.46
|
| Rate for Payer: Signature Care EPO |
$92.96
|
| Rate for Payer: Signature Care PPO |
$98.56
|
| Rate for Payer: United Healthcare Commercial |
$88.26
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 70121138907
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$104.16 |
| Rate for Payer: Aetna Commercial |
$94.53
|
| Rate for Payer: Aetna Medicare |
$35.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.42
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Centivo All Commercial |
$60.93
|
| Rate for Payer: Cigna All Commercial |
$96.66
|
| Rate for Payer: CORVEL All Commercial |
$104.16
|
| Rate for Payer: Coventry All Commercial |
$98.56
|
| Rate for Payer: Encore All Commercial |
$103.10
|
| Rate for Payer: Frontpath All Commercial |
$103.04
|
| Rate for Payer: Humana ChoiceCare |
$96.73
|
| Rate for Payer: Humana Medicare |
$35.84
|
| Rate for Payer: Lucent All Commercial |
$60.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.80
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$84.00
|
| Rate for Payer: PHP All Commercial |
$84.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.68
|
| Rate for Payer: Sagamore Health Network All Products |
$86.46
|
| Rate for Payer: Signature Care EPO |
$92.96
|
| Rate for Payer: Signature Care PPO |
$98.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.20
|
| Rate for Payer: United Healthcare Commercial |
$88.26
|
| Rate for Payer: United Healthcare Medicare |
$35.84
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 70121138901
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$104.16 |
| Rate for Payer: Aetna Commercial |
$94.53
|
| Rate for Payer: Aetna Medicare |
$35.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.42
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Centivo All Commercial |
$60.93
|
| Rate for Payer: Cigna All Commercial |
$96.66
|
| Rate for Payer: CORVEL All Commercial |
$104.16
|
| Rate for Payer: Coventry All Commercial |
$98.56
|
| Rate for Payer: Encore All Commercial |
$103.10
|
| Rate for Payer: Frontpath All Commercial |
$103.04
|
| Rate for Payer: Humana ChoiceCare |
$96.73
|
| Rate for Payer: Humana Medicare |
$35.84
|
| Rate for Payer: Lucent All Commercial |
$60.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.80
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$84.00
|
| Rate for Payer: PHP All Commercial |
$84.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.68
|
| Rate for Payer: Sagamore Health Network All Products |
$86.46
|
| Rate for Payer: Signature Care EPO |
$92.96
|
| Rate for Payer: Signature Care PPO |
$98.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.20
|
| Rate for Payer: United Healthcare Commercial |
$88.26
|
| Rate for Payer: United Healthcare Medicare |
$35.84
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 70121138907
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$104.16 |
| Rate for Payer: Aetna Commercial |
$96.77
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna All Commercial |
$96.66
|
| Rate for Payer: CORVEL All Commercial |
$104.16
|
| Rate for Payer: Coventry All Commercial |
$98.56
|
| Rate for Payer: Encore All Commercial |
$103.10
|
| Rate for Payer: Frontpath All Commercial |
$103.04
|
| Rate for Payer: Humana ChoiceCare |
$96.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.80
|
| Rate for Payer: PHCS All Commercial |
$84.00
|
| Rate for Payer: PHP All Commercial |
$84.94
|
| Rate for Payer: Sagamore Health Network All Products |
$86.46
|
| Rate for Payer: Signature Care EPO |
$92.96
|
| Rate for Payer: Signature Care PPO |
$98.56
|
| Rate for Payer: United Healthcare Commercial |
$88.26
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 80 MCG/20 ML (4 MCG/ML) IV SOLN
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
171613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$78.12 |
| Rate for Payer: Aetna Commercial |
$72.58
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna All Commercial |
$72.49
|
| Rate for Payer: CORVEL All Commercial |
$78.12
|
| Rate for Payer: Coventry All Commercial |
$73.92
|
| Rate for Payer: Encore All Commercial |
$77.32
|
| Rate for Payer: Frontpath All Commercial |
$77.28
|
| Rate for Payer: Humana ChoiceCare |
$72.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.60
|
| Rate for Payer: PHCS All Commercial |
$63.00
|
| Rate for Payer: PHP All Commercial |
$63.71
|
| Rate for Payer: Sagamore Health Network All Products |
$64.85
|
| Rate for Payer: Signature Care EPO |
$69.72
|
| Rate for Payer: Signature Care PPO |
$73.92
|
| Rate for Payer: United Healthcare Commercial |
$66.19
|
|
