|
DEXTROSE 5 %-LACTATED RINGERS IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
9788
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
DEXTROSE 5 %-LACTATED RINGERS IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
9788
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
|
|
DIATRIZOATE AND IODIPAMIDE MEG 52.7-26.8 % INJ SOLN
|
Facility
|
OP
|
$322.74
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9822
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$300.15 |
| Rate for Payer: Aetna Commercial |
$272.39
|
| Rate for Payer: Aetna Medicare |
$103.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$118.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.60
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Centivo All Commercial |
$175.57
|
| Rate for Payer: Cigna All Commercial |
$278.52
|
| Rate for Payer: CORVEL All Commercial |
$300.15
|
| Rate for Payer: Coventry All Commercial |
$284.01
|
| Rate for Payer: Encore All Commercial |
$297.08
|
| Rate for Payer: Frontpath All Commercial |
$296.92
|
| Rate for Payer: Humana ChoiceCare |
$278.75
|
| Rate for Payer: Humana Medicare |
$103.28
|
| Rate for Payer: Lucent All Commercial |
$175.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$290.47
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$242.06
|
| Rate for Payer: PHP All Commercial |
$244.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$125.87
|
| Rate for Payer: Sagamore Health Network All Products |
$249.16
|
| Rate for Payer: Signature Care EPO |
$267.87
|
| Rate for Payer: Signature Care PPO |
$284.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$274.33
|
| Rate for Payer: United Healthcare Commercial |
$254.32
|
| Rate for Payer: United Healthcare Medicare |
$103.28
|
|
|
DIATRIZOATE AND IODIPAMIDE MEG 52.7-26.8 % INJ SOLN
|
Facility
|
IP
|
$322.74
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9822
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.06 |
| Max. Negotiated Rate |
$300.15 |
| Rate for Payer: Aetna Commercial |
$278.85
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cigna All Commercial |
$278.52
|
| Rate for Payer: CORVEL All Commercial |
$300.15
|
| Rate for Payer: Coventry All Commercial |
$284.01
|
| Rate for Payer: Encore All Commercial |
$297.08
|
| Rate for Payer: Frontpath All Commercial |
$296.92
|
| Rate for Payer: Humana ChoiceCare |
$278.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$290.47
|
| Rate for Payer: PHCS All Commercial |
$242.06
|
| Rate for Payer: PHP All Commercial |
$244.77
|
| Rate for Payer: Sagamore Health Network All Products |
$249.16
|
| Rate for Payer: Signature Care EPO |
$267.87
|
| Rate for Payer: Signature Care PPO |
$284.01
|
| Rate for Payer: United Healthcare Commercial |
$254.32
|
|
|
DIATRIZOATE MEGLUMINE 18 % URTH SOLN 300ML
|
Facility
|
IP
|
$226.80
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$170.10 |
| Max. Negotiated Rate |
$210.92 |
| Rate for Payer: Aetna Commercial |
$195.96
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Cigna All Commercial |
$195.73
|
| Rate for Payer: CORVEL All Commercial |
$210.92
|
| Rate for Payer: Coventry All Commercial |
$199.58
|
| Rate for Payer: Encore All Commercial |
$208.77
|
| Rate for Payer: Frontpath All Commercial |
$208.66
|
| Rate for Payer: Humana ChoiceCare |
$195.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.12
|
| Rate for Payer: PHCS All Commercial |
$170.10
|
| Rate for Payer: PHP All Commercial |
$172.01
|
| Rate for Payer: Sagamore Health Network All Products |
$175.09
|
| Rate for Payer: Signature Care EPO |
$188.24
|
| Rate for Payer: Signature Care PPO |
$199.58
|
| Rate for Payer: United Healthcare Commercial |
$178.72
|
|
|
DIATRIZOATE MEGLUMINE 18 % URTH SOLN 300ML
|
Facility
|
OP
|
$226.80
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$210.92 |
| Rate for Payer: Aetna Commercial |
$191.42
|
| Rate for Payer: Aetna Medicare |
$72.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$70.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$130.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$83.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$79.83
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Centivo All Commercial |
$123.38
|
| Rate for Payer: Cigna All Commercial |
$195.73
|
| Rate for Payer: CORVEL All Commercial |
$210.92
|
| Rate for Payer: Coventry All Commercial |
$199.58
|
| Rate for Payer: Encore All Commercial |
$208.77
|
| Rate for Payer: Frontpath All Commercial |
$208.66
|
| Rate for Payer: Humana ChoiceCare |
$195.89
|
| Rate for Payer: Humana Medicare |
$72.58
|
| Rate for Payer: Lucent All Commercial |
$123.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.12
|
| Rate for Payer: PHCS All Commercial |
$170.10
|
| Rate for Payer: PHP All Commercial |
$172.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$88.45
|
| Rate for Payer: Sagamore Health Network All Products |
$175.09
|
| Rate for Payer: Signature Care EPO |
$188.24
|
| Rate for Payer: Signature Care PPO |
$199.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$192.78
|
| Rate for Payer: United Healthcare Commercial |
$178.72
|
| Rate for Payer: United Healthcare Medicare |
$72.58
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN 120 ML *MULTI-DOSE* BTL
|
Facility
|
IP
|
$460.08
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$345.06 |
| Max. Negotiated Rate |
$427.87 |
| Rate for Payer: Aetna Commercial |
$397.51
|
| Rate for Payer: Cash Price |
$276.05
|
| Rate for Payer: Cigna All Commercial |
$397.05
|
| Rate for Payer: CORVEL All Commercial |
$427.87
|
| Rate for Payer: Coventry All Commercial |
$404.87
|
| Rate for Payer: Encore All Commercial |
$423.50
|
| Rate for Payer: Frontpath All Commercial |
$423.27
|
| Rate for Payer: Humana ChoiceCare |
$397.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.07
|
| Rate for Payer: PHCS All Commercial |
$345.06
|
| Rate for Payer: PHP All Commercial |
$348.92
|
| Rate for Payer: Sagamore Health Network All Products |
$355.18
|
| Rate for Payer: Signature Care EPO |
$381.87
|
| Rate for Payer: Signature Care PPO |
$404.87
|
| Rate for Payer: United Healthcare Commercial |
$362.54
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN 120 ML *MULTI-DOSE* BTL
|
Facility
|
OP
|
$460.08
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.62 |
| Max. Negotiated Rate |
$427.87 |
| Rate for Payer: Aetna Commercial |
$388.31
|
| Rate for Payer: Aetna Medicare |
$147.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$142.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$264.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$287.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$169.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$161.95
|
| Rate for Payer: Cash Price |
$276.05
|
| Rate for Payer: Centivo All Commercial |
$250.28
|
| Rate for Payer: Cigna All Commercial |
$397.05
|
| Rate for Payer: CORVEL All Commercial |
$427.87
|
| Rate for Payer: Coventry All Commercial |
$404.87
|
| Rate for Payer: Encore All Commercial |
$423.50
|
| Rate for Payer: Frontpath All Commercial |
$423.27
|
| Rate for Payer: Humana ChoiceCare |
$397.37
|
| Rate for Payer: Humana Medicare |
$147.23
|
| Rate for Payer: Lucent All Commercial |
$250.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.07
|
| Rate for Payer: PHCS All Commercial |
$345.06
|
| Rate for Payer: PHP All Commercial |
$348.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$179.43
|
| Rate for Payer: Sagamore Health Network All Products |
$355.18
|
| Rate for Payer: Signature Care EPO |
$381.87
|
| Rate for Payer: Signature Care PPO |
$404.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$391.07
|
| Rate for Payer: United Healthcare Commercial |
$362.54
|
| Rate for Payer: United Healthcare Medicare |
$147.23
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN PER ML BOTTLE
|
Facility
|
OP
|
$460.08
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
14019828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.62 |
| Max. Negotiated Rate |
$427.87 |
| Rate for Payer: Aetna Commercial |
$388.31
|
| Rate for Payer: Aetna Medicare |
$147.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$142.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$264.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$287.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$169.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$161.95
|
| Rate for Payer: Cash Price |
$276.05
|
| Rate for Payer: Centivo All Commercial |
$250.28
|
| Rate for Payer: Cigna All Commercial |
$397.05
|
| Rate for Payer: CORVEL All Commercial |
$427.87
|
| Rate for Payer: Coventry All Commercial |
$404.87
|
| Rate for Payer: Encore All Commercial |
$423.50
|
| Rate for Payer: Frontpath All Commercial |
$423.27
|
| Rate for Payer: Humana ChoiceCare |
$397.37
|
| Rate for Payer: Humana Medicare |
$147.23
|
| Rate for Payer: Lucent All Commercial |
$250.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.07
|
| Rate for Payer: PHCS All Commercial |
$345.06
|
| Rate for Payer: PHP All Commercial |
$348.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$179.43
|
| Rate for Payer: Sagamore Health Network All Products |
$355.18
|
| Rate for Payer: Signature Care EPO |
$381.87
|
| Rate for Payer: Signature Care PPO |
$404.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$391.07
|
| Rate for Payer: United Healthcare Commercial |
$362.54
|
| Rate for Payer: United Healthcare Medicare |
$147.23
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN PER ML BOTTLE
|
Facility
|
IP
|
$460.08
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
14019828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$345.06 |
| Max. Negotiated Rate |
$427.87 |
| Rate for Payer: Aetna Commercial |
$397.51
|
| Rate for Payer: Cash Price |
$276.05
|
| Rate for Payer: Cigna All Commercial |
$397.05
|
| Rate for Payer: CORVEL All Commercial |
$427.87
|
| Rate for Payer: Coventry All Commercial |
$404.87
|
| Rate for Payer: Encore All Commercial |
$423.50
|
| Rate for Payer: Frontpath All Commercial |
$423.27
|
| Rate for Payer: Humana ChoiceCare |
$397.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.07
|
| Rate for Payer: PHCS All Commercial |
$345.06
|
| Rate for Payer: PHP All Commercial |
$348.92
|
| Rate for Payer: Sagamore Health Network All Products |
$355.18
|
| Rate for Payer: Signature Care EPO |
$381.87
|
| Rate for Payer: Signature Care PPO |
$404.87
|
| Rate for Payer: United Healthcare Commercial |
$362.54
|
|
|
DIAZEPAM 5 MG/ML INJ SYRG
|
Facility
|
IP
|
$185.19
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
106278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.89 |
| Max. Negotiated Rate |
$172.23 |
| Rate for Payer: Aetna Commercial |
$160.01
|
| Rate for Payer: Cash Price |
$111.12
|
| Rate for Payer: Cigna All Commercial |
$159.82
|
| Rate for Payer: CORVEL All Commercial |
$172.23
|
| Rate for Payer: Coventry All Commercial |
$162.97
|
| Rate for Payer: Encore All Commercial |
$170.47
|
| Rate for Payer: Frontpath All Commercial |
$170.38
|
| Rate for Payer: Humana ChoiceCare |
$159.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.67
|
| Rate for Payer: PHCS All Commercial |
$138.89
|
| Rate for Payer: PHP All Commercial |
$140.45
|
| Rate for Payer: Sagamore Health Network All Products |
$142.97
|
| Rate for Payer: Signature Care EPO |
$153.71
|
| Rate for Payer: Signature Care PPO |
$162.97
|
| Rate for Payer: United Healthcare Commercial |
$145.93
|
|
|
DIAZEPAM 5 MG/ML INJ SYRG
|
Facility
|
OP
|
$185.19
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
106278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.41 |
| Max. Negotiated Rate |
$172.23 |
| Rate for Payer: Aetna Commercial |
$156.30
|
| Rate for Payer: Aetna Medicare |
$59.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$106.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$115.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.19
|
| Rate for Payer: Cash Price |
$111.12
|
| Rate for Payer: Centivo All Commercial |
$100.74
|
| Rate for Payer: Cigna All Commercial |
$159.82
|
| Rate for Payer: CORVEL All Commercial |
$172.23
|
| Rate for Payer: Coventry All Commercial |
$162.97
|
| Rate for Payer: Encore All Commercial |
$170.47
|
| Rate for Payer: Frontpath All Commercial |
$170.38
|
| Rate for Payer: Humana ChoiceCare |
$159.95
|
| Rate for Payer: Humana Medicare |
$59.26
|
| Rate for Payer: Lucent All Commercial |
$100.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.67
|
| Rate for Payer: PHCS All Commercial |
$138.89
|
| Rate for Payer: PHP All Commercial |
$140.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.22
|
| Rate for Payer: Sagamore Health Network All Products |
$142.97
|
| Rate for Payer: Signature Care EPO |
$153.71
|
| Rate for Payer: Signature Care PPO |
$162.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$157.41
|
| Rate for Payer: United Healthcare Commercial |
$145.93
|
| Rate for Payer: United Healthcare Medicare |
$59.26
|
|
|
DIAZEPAM 5 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
DIAZEPAM 5 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
OP
|
$79.45
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.63 |
| Max. Negotiated Rate |
$73.89 |
| Rate for Payer: Aetna Commercial |
$67.06
|
| Rate for Payer: Aetna Medicare |
$25.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.97
|
| Rate for Payer: Cash Price |
$47.67
|
| Rate for Payer: Centivo All Commercial |
$43.22
|
| Rate for Payer: Cigna All Commercial |
$68.57
|
| Rate for Payer: CORVEL All Commercial |
$73.89
|
| Rate for Payer: Coventry All Commercial |
$69.92
|
| Rate for Payer: Encore All Commercial |
$73.13
|
| Rate for Payer: Frontpath All Commercial |
$73.09
|
| Rate for Payer: Humana ChoiceCare |
$68.62
|
| Rate for Payer: Humana Medicare |
$25.42
|
| Rate for Payer: Lucent All Commercial |
$43.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.50
|
| Rate for Payer: PHCS All Commercial |
$59.59
|
| Rate for Payer: PHP All Commercial |
$60.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.99
|
| Rate for Payer: Sagamore Health Network All Products |
$61.34
|
| Rate for Payer: Signature Care EPO |
$65.94
|
| Rate for Payer: Signature Care PPO |
$69.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.53
|
| Rate for Payer: United Healthcare Commercial |
$62.61
|
| Rate for Payer: United Healthcare Medicare |
$25.42
|
|
|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
IP
|
$79.45
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.59 |
| Max. Negotiated Rate |
$73.89 |
| Rate for Payer: Aetna Commercial |
$68.64
|
| Rate for Payer: Cash Price |
$47.67
|
| Rate for Payer: Cigna All Commercial |
$68.57
|
| Rate for Payer: CORVEL All Commercial |
$73.89
|
| Rate for Payer: Coventry All Commercial |
$69.92
|
| Rate for Payer: Encore All Commercial |
$73.13
|
| Rate for Payer: Frontpath All Commercial |
$73.09
|
| Rate for Payer: Humana ChoiceCare |
$68.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.50
|
| Rate for Payer: PHCS All Commercial |
$59.59
|
| Rate for Payer: PHP All Commercial |
$60.25
|
| Rate for Payer: Sagamore Health Network All Products |
$61.34
|
| Rate for Payer: Signature Care EPO |
$65.94
|
| Rate for Payer: Signature Care PPO |
$69.92
|
| Rate for Payer: United Healthcare Commercial |
$62.61
|
|
|
DICLOFENAC SODIUM 50 MG ORAL TBEC
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.09
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Centivo All Commercial |
$0.70
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.41
|
| Rate for Payer: Lucent All Commercial |
$0.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
|
|
DICLOFENAC SODIUM 50 MG ORAL TBEC
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
DICLOFENAC SODIUM 75 MG ORAL TBEC
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.83
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Centivo All Commercial |
$1.28
|
| Rate for Payer: Cigna All Commercial |
$2.04
|
| Rate for Payer: CORVEL All Commercial |
$2.19
|
| Rate for Payer: Coventry All Commercial |
$2.08
|
| Rate for Payer: Encore All Commercial |
$2.17
|
| Rate for Payer: Frontpath All Commercial |
$2.17
|
| Rate for Payer: Humana ChoiceCare |
$2.04
|
| Rate for Payer: Humana Medicare |
$0.75
|
| Rate for Payer: Lucent All Commercial |
$1.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.12
|
| Rate for Payer: PHCS All Commercial |
$1.77
|
| Rate for Payer: PHP All Commercial |
$1.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.92
|
| Rate for Payer: Sagamore Health Network All Products |
$1.82
|
| Rate for Payer: Signature Care EPO |
$1.96
|
| Rate for Payer: Signature Care PPO |
$2.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
| Rate for Payer: United Healthcare Medicare |
$0.75
|
|
|
DICLOFENAC SODIUM 75 MG ORAL TBEC
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.04
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna All Commercial |
$2.04
|
| Rate for Payer: CORVEL All Commercial |
$2.19
|
| Rate for Payer: Coventry All Commercial |
$2.08
|
| Rate for Payer: Encore All Commercial |
$2.17
|
| Rate for Payer: Frontpath All Commercial |
$2.17
|
| Rate for Payer: Humana ChoiceCare |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.12
|
| Rate for Payer: PHCS All Commercial |
$1.77
|
| Rate for Payer: PHP All Commercial |
$1.79
|
| Rate for Payer: Sagamore Health Network All Products |
$1.82
|
| Rate for Payer: Signature Care EPO |
$1.96
|
| Rate for Payer: Signature Care PPO |
$2.08
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
OP
|
$57.18
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$53.17 |
| Rate for Payer: Aetna Commercial |
$48.26
|
| Rate for Payer: Aetna Medicare |
$18.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$32.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.13
|
| Rate for Payer: Cash Price |
$34.31
|
| Rate for Payer: Centivo All Commercial |
$31.10
|
| Rate for Payer: Cigna All Commercial |
$49.34
|
| Rate for Payer: CORVEL All Commercial |
$53.17
|
| Rate for Payer: Coventry All Commercial |
$50.31
|
| Rate for Payer: Encore All Commercial |
$52.63
|
| Rate for Payer: Frontpath All Commercial |
$52.60
|
| Rate for Payer: Humana ChoiceCare |
$49.38
|
| Rate for Payer: Humana Medicare |
$18.30
|
| Rate for Payer: Lucent All Commercial |
$31.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.46
|
| Rate for Payer: PHCS All Commercial |
$42.88
|
| Rate for Payer: PHP All Commercial |
$43.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.30
|
| Rate for Payer: Sagamore Health Network All Products |
$44.14
|
| Rate for Payer: Signature Care EPO |
$47.46
|
| Rate for Payer: Signature Care PPO |
$50.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.60
|
| Rate for Payer: United Healthcare Commercial |
$45.05
|
| Rate for Payer: United Healthcare Medicare |
$18.30
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
IP
|
$57.18
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.88 |
| Max. Negotiated Rate |
$53.17 |
| Rate for Payer: Aetna Commercial |
$49.40
|
| Rate for Payer: Cash Price |
$34.31
|
| Rate for Payer: Cigna All Commercial |
$49.34
|
| Rate for Payer: CORVEL All Commercial |
$53.17
|
| Rate for Payer: Coventry All Commercial |
$50.31
|
| Rate for Payer: Encore All Commercial |
$52.63
|
| Rate for Payer: Frontpath All Commercial |
$52.60
|
| Rate for Payer: Humana ChoiceCare |
$49.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.46
|
| Rate for Payer: PHCS All Commercial |
$42.88
|
| Rate for Payer: PHP All Commercial |
$43.36
|
| Rate for Payer: Sagamore Health Network All Products |
$44.14
|
| Rate for Payer: Signature Care EPO |
$47.46
|
| Rate for Payer: Signature Care PPO |
$50.31
|
| Rate for Payer: United Healthcare Commercial |
$45.05
|
|
|
DICYCLOMINE 10 MG ORAL CAP
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna Medicare |
$0.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Centivo All Commercial |
$1.61
|
| Rate for Payer: Cigna All Commercial |
$2.55
|
| Rate for Payer: CORVEL All Commercial |
$2.75
|
| Rate for Payer: Coventry All Commercial |
$2.60
|
| Rate for Payer: Encore All Commercial |
$2.72
|
| Rate for Payer: Frontpath All Commercial |
$2.72
|
| Rate for Payer: Humana ChoiceCare |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.95
|
| Rate for Payer: Lucent All Commercial |
$1.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.66
|
| Rate for Payer: PHCS All Commercial |
$2.22
|
| Rate for Payer: PHP All Commercial |
$2.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2.28
|
| Rate for Payer: Signature Care EPO |
$2.45
|
| Rate for Payer: Signature Care PPO |
$2.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$0.95
|
|
|
DICYCLOMINE 10 MG ORAL CAP
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.55
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna All Commercial |
$2.55
|
| Rate for Payer: CORVEL All Commercial |
$2.75
|
| Rate for Payer: Coventry All Commercial |
$2.60
|
| Rate for Payer: Encore All Commercial |
$2.72
|
| Rate for Payer: Frontpath All Commercial |
$2.72
|
| Rate for Payer: Humana ChoiceCare |
$2.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.66
|
| Rate for Payer: PHCS All Commercial |
$2.22
|
| Rate for Payer: PHP All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2.28
|
| Rate for Payer: Signature Care EPO |
$2.45
|
| Rate for Payer: Signature Care PPO |
$2.60
|
| Rate for Payer: United Healthcare Commercial |
$2.33
|
|
|
DIGOXIN 125 MCG (0.125 MG) ORAL TAB
|
Facility
|
OP
|
$5.22
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$4.41
|
| Rate for Payer: Aetna Medicare |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.84
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Centivo All Commercial |
$2.84
|
| Rate for Payer: Cigna All Commercial |
$4.51
|
| Rate for Payer: CORVEL All Commercial |
$4.86
|
| Rate for Payer: Coventry All Commercial |
$4.60
|
| Rate for Payer: Encore All Commercial |
$4.81
|
| Rate for Payer: Frontpath All Commercial |
$4.80
|
| Rate for Payer: Humana ChoiceCare |
$4.51
|
| Rate for Payer: Humana Medicare |
$1.67
|
| Rate for Payer: Lucent All Commercial |
$2.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.70
|
| Rate for Payer: PHCS All Commercial |
$3.92
|
| Rate for Payer: PHP All Commercial |
$3.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.04
|
| Rate for Payer: Sagamore Health Network All Products |
$4.03
|
| Rate for Payer: Signature Care EPO |
$4.33
|
| Rate for Payer: Signature Care PPO |
$4.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.44
|
| Rate for Payer: United Healthcare Commercial |
$4.11
|
| Rate for Payer: United Healthcare Medicare |
$1.67
|
|
