|
DILTIAZEM IN DEXTROSE 5 % 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
OP
|
$114.63
|
|
|
Service Code
|
NDC 70092157536
|
| Hospital Charge Code |
117323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$106.60 |
| Rate for Payer: Aetna Commercial |
$96.74
|
| Rate for Payer: Aetna Medicare |
$36.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$65.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$71.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.35
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Centivo All Commercial |
$62.36
|
| Rate for Payer: Cigna All Commercial |
$98.92
|
| Rate for Payer: CORVEL All Commercial |
$106.60
|
| Rate for Payer: Coventry All Commercial |
$100.87
|
| Rate for Payer: Encore All Commercial |
$105.51
|
| Rate for Payer: Frontpath All Commercial |
$105.45
|
| Rate for Payer: Humana ChoiceCare |
$99.00
|
| Rate for Payer: Humana Medicare |
$36.68
|
| Rate for Payer: Lucent All Commercial |
$62.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.16
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$85.97
|
| Rate for Payer: PHP All Commercial |
$86.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$44.70
|
| Rate for Payer: Sagamore Health Network All Products |
$88.49
|
| Rate for Payer: Signature Care EPO |
$95.14
|
| Rate for Payer: Signature Care PPO |
$100.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$97.43
|
| Rate for Payer: United Healthcare Commercial |
$90.32
|
| Rate for Payer: United Healthcare Medicare |
$36.68
|
|
|
DILTIAZEM IN DEXTROSE 5 % 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
IP
|
$114.63
|
|
|
Service Code
|
NDC 70092157536
|
| Hospital Charge Code |
117323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.97 |
| Max. Negotiated Rate |
$106.60 |
| Rate for Payer: Aetna Commercial |
$99.04
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Cigna All Commercial |
$98.92
|
| Rate for Payer: CORVEL All Commercial |
$106.60
|
| Rate for Payer: Coventry All Commercial |
$100.87
|
| Rate for Payer: Encore All Commercial |
$105.51
|
| Rate for Payer: Frontpath All Commercial |
$105.45
|
| Rate for Payer: Humana ChoiceCare |
$99.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.16
|
| Rate for Payer: PHCS All Commercial |
$85.97
|
| Rate for Payer: PHP All Commercial |
$86.93
|
| Rate for Payer: Sagamore Health Network All Products |
$88.49
|
| Rate for Payer: Signature Care EPO |
$95.14
|
| Rate for Payer: Signature Care PPO |
$100.87
|
| Rate for Payer: United Healthcare Commercial |
$90.32
|
|
|
DINOPROSTONE 10 MG VAGL INER
|
Facility
|
OP
|
$2,063.16
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,918.74 |
| Rate for Payer: Aetna Commercial |
$1,741.31
|
| Rate for Payer: Aetna Medicare |
$660.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$639.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,184.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,289.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$759.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$726.23
|
| Rate for Payer: Cash Price |
$1,237.90
|
| Rate for Payer: Cash Price |
$1,237.90
|
| Rate for Payer: Centivo All Commercial |
$1,122.36
|
| Rate for Payer: Cigna All Commercial |
$1,780.51
|
| Rate for Payer: CORVEL All Commercial |
$1,918.74
|
| Rate for Payer: Coventry All Commercial |
$1,815.58
|
| Rate for Payer: Encore All Commercial |
$1,899.14
|
| Rate for Payer: Frontpath All Commercial |
$1,898.11
|
| Rate for Payer: Humana ChoiceCare |
$1,781.95
|
| Rate for Payer: Humana Medicare |
$660.21
|
| Rate for Payer: Lucent All Commercial |
$1,122.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,856.84
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1,547.37
|
| Rate for Payer: PHP All Commercial |
$1,564.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$804.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1,592.76
|
| Rate for Payer: Signature Care EPO |
$1,712.42
|
| Rate for Payer: Signature Care PPO |
$1,815.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,753.69
|
| Rate for Payer: United Healthcare Commercial |
$1,625.77
|
| Rate for Payer: United Healthcare Medicare |
$660.21
|
|
|
DINOPROSTONE 10 MG VAGL INER
|
Facility
|
IP
|
$2,063.16
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,547.37 |
| Max. Negotiated Rate |
$1,918.74 |
| Rate for Payer: Aetna Commercial |
$1,782.57
|
| Rate for Payer: Cash Price |
$1,237.90
|
| Rate for Payer: Cigna All Commercial |
$1,780.51
|
| Rate for Payer: CORVEL All Commercial |
$1,918.74
|
| Rate for Payer: Coventry All Commercial |
$1,815.58
|
| Rate for Payer: Encore All Commercial |
$1,899.14
|
| Rate for Payer: Frontpath All Commercial |
$1,898.11
|
| Rate for Payer: Humana ChoiceCare |
$1,781.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,856.84
|
| Rate for Payer: PHCS All Commercial |
$1,547.37
|
| Rate for Payer: PHP All Commercial |
$1,564.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1,592.76
|
| Rate for Payer: Signature Care EPO |
$1,712.42
|
| Rate for Payer: Signature Care PPO |
$1,815.58
|
| Rate for Payer: United Healthcare Commercial |
$1,625.77
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL ELIX
|
Facility
|
OP
|
$27.86
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna Commercial |
$23.51
|
| Rate for Payer: Aetna Medicare |
$8.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.81
|
| Rate for Payer: Cash Price |
$16.72
|
| Rate for Payer: Centivo All Commercial |
$15.16
|
| Rate for Payer: Cigna All Commercial |
$24.04
|
| Rate for Payer: CORVEL All Commercial |
$25.91
|
| Rate for Payer: Coventry All Commercial |
$24.52
|
| Rate for Payer: Encore All Commercial |
$25.65
|
| Rate for Payer: Frontpath All Commercial |
$25.63
|
| Rate for Payer: Humana ChoiceCare |
$24.06
|
| Rate for Payer: Humana Medicare |
$8.92
|
| Rate for Payer: Lucent All Commercial |
$15.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.07
|
| Rate for Payer: PHCS All Commercial |
$20.89
|
| Rate for Payer: PHP All Commercial |
$21.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.87
|
| Rate for Payer: Sagamore Health Network All Products |
$21.51
|
| Rate for Payer: Signature Care EPO |
$23.12
|
| Rate for Payer: Signature Care PPO |
$24.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.68
|
| Rate for Payer: United Healthcare Commercial |
$21.95
|
| Rate for Payer: United Healthcare Medicare |
$8.92
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL ELIX
|
Facility
|
IP
|
$27.86
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.89 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna Commercial |
$24.07
|
| Rate for Payer: Cash Price |
$16.72
|
| Rate for Payer: Cigna All Commercial |
$24.04
|
| Rate for Payer: CORVEL All Commercial |
$25.91
|
| Rate for Payer: Coventry All Commercial |
$24.52
|
| Rate for Payer: Encore All Commercial |
$25.65
|
| Rate for Payer: Frontpath All Commercial |
$25.63
|
| Rate for Payer: Humana ChoiceCare |
$24.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.07
|
| Rate for Payer: PHCS All Commercial |
$20.89
|
| Rate for Payer: PHP All Commercial |
$21.13
|
| Rate for Payer: Sagamore Health Network All Products |
$21.51
|
| Rate for Payer: Signature Care EPO |
$23.12
|
| Rate for Payer: Signature Care PPO |
$24.52
|
| Rate for Payer: United Healthcare Commercial |
$21.95
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL S.O.
|
Facility
|
OP
|
$8.82
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
140112556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna Medicare |
$2.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$5.29
|
| Rate for Payer: Centivo All Commercial |
$4.80
|
| Rate for Payer: Cigna All Commercial |
$7.61
|
| Rate for Payer: CORVEL All Commercial |
$8.20
|
| Rate for Payer: Coventry All Commercial |
$7.76
|
| Rate for Payer: Encore All Commercial |
$8.12
|
| Rate for Payer: Frontpath All Commercial |
$8.11
|
| Rate for Payer: Humana ChoiceCare |
$7.62
|
| Rate for Payer: Humana Medicare |
$2.82
|
| Rate for Payer: Lucent All Commercial |
$4.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.94
|
| Rate for Payer: PHCS All Commercial |
$6.62
|
| Rate for Payer: PHP All Commercial |
$6.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.44
|
| Rate for Payer: Sagamore Health Network All Products |
$6.81
|
| Rate for Payer: Signature Care EPO |
$7.32
|
| Rate for Payer: Signature Care PPO |
$7.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.50
|
| Rate for Payer: United Healthcare Commercial |
$6.95
|
| Rate for Payer: United Healthcare Medicare |
$2.82
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL S.O.
|
Facility
|
IP
|
$8.82
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
140112556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Aetna Commercial |
$7.62
|
| Rate for Payer: Cash Price |
$5.29
|
| Rate for Payer: Cigna All Commercial |
$7.61
|
| Rate for Payer: CORVEL All Commercial |
$8.20
|
| Rate for Payer: Coventry All Commercial |
$7.76
|
| Rate for Payer: Encore All Commercial |
$8.12
|
| Rate for Payer: Frontpath All Commercial |
$8.11
|
| Rate for Payer: Humana ChoiceCare |
$7.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.94
|
| Rate for Payer: PHCS All Commercial |
$6.62
|
| Rate for Payer: PHP All Commercial |
$6.69
|
| Rate for Payer: Sagamore Health Network All Products |
$6.81
|
| Rate for Payer: Signature Care EPO |
$7.32
|
| Rate for Payer: Signature Care PPO |
$7.76
|
| Rate for Payer: United Healthcare Commercial |
$6.95
|
|
|
DIPHENHYDRAMINE HCL 25 MG ORAL CAP
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$0.26
|
| Rate for Payer: Aetna Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Centivo All Commercial |
$0.17
|
| Rate for Payer: Cigna All Commercial |
$0.27
|
| Rate for Payer: CORVEL All Commercial |
$0.29
|
| Rate for Payer: Coventry All Commercial |
$0.27
|
| Rate for Payer: Encore All Commercial |
$0.28
|
| Rate for Payer: Frontpath All Commercial |
$0.28
|
| Rate for Payer: Humana ChoiceCare |
$0.27
|
| Rate for Payer: Humana Medicare |
$0.10
|
| Rate for Payer: Lucent All Commercial |
$0.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.28
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$0.23
|
| Rate for Payer: PHP All Commercial |
$0.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.12
|
| Rate for Payer: Sagamore Health Network All Products |
$0.24
|
| Rate for Payer: Signature Care EPO |
$0.26
|
| Rate for Payer: Signature Care PPO |
$0.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
|
|
DIPHENHYDRAMINE HCL 25 MG ORAL CAP
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna All Commercial |
$0.27
|
| Rate for Payer: CORVEL All Commercial |
$0.29
|
| Rate for Payer: Coventry All Commercial |
$0.27
|
| Rate for Payer: Encore All Commercial |
$0.28
|
| Rate for Payer: Frontpath All Commercial |
$0.28
|
| Rate for Payer: Humana ChoiceCare |
$0.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.28
|
| Rate for Payer: PHCS All Commercial |
$0.23
|
| Rate for Payer: PHP All Commercial |
$0.23
|
| Rate for Payer: Sagamore Health Network All Products |
$0.24
|
| Rate for Payer: Signature Care EPO |
$0.26
|
| Rate for Payer: Signature Care PPO |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$19.68
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$18.31 |
| Rate for Payer: Aetna Commercial |
$17.01
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna All Commercial |
$16.99
|
| Rate for Payer: CORVEL All Commercial |
$18.31
|
| Rate for Payer: Coventry All Commercial |
$17.32
|
| Rate for Payer: Encore All Commercial |
$18.12
|
| Rate for Payer: Frontpath All Commercial |
$18.11
|
| Rate for Payer: Humana ChoiceCare |
$17.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.72
|
| Rate for Payer: PHCS All Commercial |
$14.76
|
| Rate for Payer: PHP All Commercial |
$14.93
|
| Rate for Payer: Sagamore Health Network All Products |
$15.20
|
| Rate for Payer: Signature Care EPO |
$16.34
|
| Rate for Payer: Signature Care PPO |
$17.32
|
| Rate for Payer: United Healthcare Commercial |
$15.51
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$19.68
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.10 |
| Max. Negotiated Rate |
$18.31 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: Aetna Medicare |
$6.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.93
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Centivo All Commercial |
$10.71
|
| Rate for Payer: Cigna All Commercial |
$16.99
|
| Rate for Payer: CORVEL All Commercial |
$18.31
|
| Rate for Payer: Coventry All Commercial |
$17.32
|
| Rate for Payer: Encore All Commercial |
$18.12
|
| Rate for Payer: Frontpath All Commercial |
$18.11
|
| Rate for Payer: Humana ChoiceCare |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.30
|
| Rate for Payer: Lucent All Commercial |
$10.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.72
|
| Rate for Payer: PHCS All Commercial |
$14.76
|
| Rate for Payer: PHP All Commercial |
$14.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.68
|
| Rate for Payer: Sagamore Health Network All Products |
$15.20
|
| Rate for Payer: Signature Care EPO |
$16.34
|
| Rate for Payer: Signature Care PPO |
$17.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.73
|
| Rate for Payer: United Healthcare Commercial |
$15.51
|
| Rate for Payer: United Healthcare Medicare |
$6.30
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % TOP CREA
|
Facility
|
OP
|
$13.72
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$12.76 |
| Rate for Payer: Aetna Commercial |
$11.58
|
| Rate for Payer: Aetna Medicare |
$4.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.83
|
| Rate for Payer: Cash Price |
$8.23
|
| Rate for Payer: Centivo All Commercial |
$7.46
|
| Rate for Payer: Cigna All Commercial |
$11.84
|
| Rate for Payer: CORVEL All Commercial |
$12.76
|
| Rate for Payer: Coventry All Commercial |
$12.07
|
| Rate for Payer: Encore All Commercial |
$12.63
|
| Rate for Payer: Frontpath All Commercial |
$12.62
|
| Rate for Payer: Humana ChoiceCare |
$11.85
|
| Rate for Payer: Humana Medicare |
$4.39
|
| Rate for Payer: Lucent All Commercial |
$7.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.35
|
| Rate for Payer: PHCS All Commercial |
$10.29
|
| Rate for Payer: PHP All Commercial |
$10.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.35
|
| Rate for Payer: Sagamore Health Network All Products |
$10.59
|
| Rate for Payer: Signature Care EPO |
$11.39
|
| Rate for Payer: Signature Care PPO |
$12.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.66
|
| Rate for Payer: United Healthcare Commercial |
$10.81
|
| Rate for Payer: United Healthcare Medicare |
$4.39
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % TOP CREA
|
Facility
|
IP
|
$13.72
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$12.76 |
| Rate for Payer: Aetna Commercial |
$11.85
|
| Rate for Payer: Cash Price |
$8.23
|
| Rate for Payer: Cigna All Commercial |
$11.84
|
| Rate for Payer: CORVEL All Commercial |
$12.76
|
| Rate for Payer: Coventry All Commercial |
$12.07
|
| Rate for Payer: Encore All Commercial |
$12.63
|
| Rate for Payer: Frontpath All Commercial |
$12.62
|
| Rate for Payer: Humana ChoiceCare |
$11.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.35
|
| Rate for Payer: PHCS All Commercial |
$10.29
|
| Rate for Payer: PHP All Commercial |
$10.41
|
| Rate for Payer: Sagamore Health Network All Products |
$10.59
|
| Rate for Payer: Signature Care EPO |
$11.39
|
| Rate for Payer: Signature Care PPO |
$12.07
|
| Rate for Payer: United Healthcare Commercial |
$10.81
|
|
|
DIPHEN-LIDOCAINE-MAG,AL-SIMETH 25-200-400-40 MG/30ML MM MWSH
|
Facility
|
IP
|
$585.39
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$439.04 |
| Max. Negotiated Rate |
$544.41 |
| Rate for Payer: Aetna Commercial |
$505.78
|
| Rate for Payer: Cash Price |
$351.23
|
| Rate for Payer: Cigna All Commercial |
$505.19
|
| Rate for Payer: CORVEL All Commercial |
$544.41
|
| Rate for Payer: Coventry All Commercial |
$515.14
|
| Rate for Payer: Encore All Commercial |
$538.85
|
| Rate for Payer: Frontpath All Commercial |
$538.56
|
| Rate for Payer: Humana ChoiceCare |
$505.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$526.85
|
| Rate for Payer: PHCS All Commercial |
$439.04
|
| Rate for Payer: PHP All Commercial |
$443.96
|
| Rate for Payer: Sagamore Health Network All Products |
$451.92
|
| Rate for Payer: Signature Care EPO |
$485.87
|
| Rate for Payer: Signature Care PPO |
$515.14
|
| Rate for Payer: United Healthcare Commercial |
$461.29
|
|
|
DIPHEN-LIDOCAINE-MAG,AL-SIMETH 25-200-400-40 MG/30ML MM MWSH
|
Facility
|
OP
|
$585.39
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$544.41 |
| Rate for Payer: Aetna Commercial |
$494.07
|
| Rate for Payer: Aetna Medicare |
$187.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$181.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$336.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$365.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$215.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$206.06
|
| Rate for Payer: Cash Price |
$351.23
|
| Rate for Payer: Cash Price |
$351.23
|
| Rate for Payer: Centivo All Commercial |
$318.45
|
| Rate for Payer: Cigna All Commercial |
$505.19
|
| Rate for Payer: CORVEL All Commercial |
$544.41
|
| Rate for Payer: Coventry All Commercial |
$515.14
|
| Rate for Payer: Encore All Commercial |
$538.85
|
| Rate for Payer: Frontpath All Commercial |
$538.56
|
| Rate for Payer: Humana ChoiceCare |
$505.60
|
| Rate for Payer: Humana Medicare |
$187.32
|
| Rate for Payer: Lucent All Commercial |
$318.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$526.85
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$439.04
|
| Rate for Payer: PHP All Commercial |
$443.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$228.30
|
| Rate for Payer: Sagamore Health Network All Products |
$451.92
|
| Rate for Payer: Signature Care EPO |
$485.87
|
| Rate for Payer: Signature Care PPO |
$515.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$497.58
|
| Rate for Payer: United Healthcare Commercial |
$461.29
|
| Rate for Payer: United Healthcare Medicare |
$187.32
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
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
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$192.93
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
119613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.81 |
| Max. Negotiated Rate |
$179.42 |
| Rate for Payer: Aetna Commercial |
$162.83
|
| Rate for Payer: Aetna Medicare |
$61.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$120.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.91
|
| Rate for Payer: Cash Price |
$115.76
|
| Rate for Payer: Centivo All Commercial |
$104.95
|
| Rate for Payer: Cigna All Commercial |
$166.50
|
| Rate for Payer: CORVEL All Commercial |
$179.42
|
| Rate for Payer: Coventry All Commercial |
$169.78
|
| Rate for Payer: Encore All Commercial |
$177.59
|
| Rate for Payer: Frontpath All Commercial |
$177.49
|
| Rate for Payer: Humana ChoiceCare |
$166.63
|
| Rate for Payer: Humana Medicare |
$61.74
|
| Rate for Payer: Lucent All Commercial |
$104.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.63
|
| Rate for Payer: PHCS All Commercial |
$144.70
|
| Rate for Payer: PHP All Commercial |
$146.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$75.24
|
| Rate for Payer: Sagamore Health Network All Products |
$148.94
|
| Rate for Payer: Signature Care EPO |
$160.13
|
| Rate for Payer: Signature Care PPO |
$169.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$163.99
|
| Rate for Payer: United Healthcare Commercial |
$152.03
|
| Rate for Payer: United Healthcare Medicare |
$61.74
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$192.93
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
119613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.70 |
| Max. Negotiated Rate |
$179.42 |
| Rate for Payer: Aetna Commercial |
$166.69
|
| Rate for Payer: Cash Price |
$115.76
|
| Rate for Payer: Cigna All Commercial |
$166.50
|
| Rate for Payer: CORVEL All Commercial |
$179.42
|
| Rate for Payer: Coventry All Commercial |
$169.78
|
| Rate for Payer: Encore All Commercial |
$177.59
|
| Rate for Payer: Frontpath All Commercial |
$177.49
|
| Rate for Payer: Humana ChoiceCare |
$166.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.63
|
| Rate for Payer: PHCS All Commercial |
$144.70
|
| Rate for Payer: PHP All Commercial |
$146.32
|
| Rate for Payer: Sagamore Health Network All Products |
$148.94
|
| Rate for Payer: Signature Care EPO |
$160.13
|
| Rate for Payer: Signature Care PPO |
$169.78
|
| Rate for Payer: United Healthcare Commercial |
$152.03
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$137.35
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
111041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.58 |
| Max. Negotiated Rate |
$127.74 |
| Rate for Payer: Aetna Commercial |
$115.93
|
| Rate for Payer: Aetna Medicare |
$43.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.35
|
| Rate for Payer: Cash Price |
$82.41
|
| Rate for Payer: Centivo All Commercial |
$74.72
|
| Rate for Payer: Cigna All Commercial |
$118.54
|
| Rate for Payer: CORVEL All Commercial |
$127.74
|
| Rate for Payer: Coventry All Commercial |
$120.87
|
| Rate for Payer: Encore All Commercial |
$126.43
|
| Rate for Payer: Frontpath All Commercial |
$126.37
|
| Rate for Payer: Humana ChoiceCare |
$118.63
|
| Rate for Payer: Humana Medicare |
$43.95
|
| Rate for Payer: Lucent All Commercial |
$74.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.62
|
| Rate for Payer: PHCS All Commercial |
$103.02
|
| Rate for Payer: PHP All Commercial |
$104.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.57
|
| Rate for Payer: Sagamore Health Network All Products |
$106.04
|
| Rate for Payer: Signature Care EPO |
$114.00
|
| Rate for Payer: Signature Care PPO |
$120.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.75
|
| Rate for Payer: United Healthcare Commercial |
$108.23
|
| Rate for Payer: United Healthcare Medicare |
$43.95
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$137.35
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
111041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.02 |
| Max. Negotiated Rate |
$127.74 |
| Rate for Payer: Aetna Commercial |
$118.67
|
| Rate for Payer: Cash Price |
$82.41
|
| Rate for Payer: Cigna All Commercial |
$118.54
|
| Rate for Payer: CORVEL All Commercial |
$127.74
|
| Rate for Payer: Coventry All Commercial |
$120.87
|
| Rate for Payer: Encore All Commercial |
$126.43
|
| Rate for Payer: Frontpath All Commercial |
$126.37
|
| Rate for Payer: Humana ChoiceCare |
$118.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.62
|
| Rate for Payer: PHCS All Commercial |
$103.02
|
| Rate for Payer: PHP All Commercial |
$104.17
|
| Rate for Payer: Sagamore Health Network All Products |
$106.04
|
| Rate for Payer: Signature Care EPO |
$114.00
|
| Rate for Payer: Signature Care PPO |
$120.87
|
| Rate for Payer: United Healthcare Commercial |
$108.23
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
IP
|
$195.17
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.38 |
| Max. Negotiated Rate |
$181.51 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Cash Price |
$117.10
|
| Rate for Payer: Cigna All Commercial |
$168.44
|
| Rate for Payer: CORVEL All Commercial |
$181.51
|
| Rate for Payer: Coventry All Commercial |
$171.75
|
| Rate for Payer: Encore All Commercial |
$179.66
|
| Rate for Payer: Frontpath All Commercial |
$179.56
|
| Rate for Payer: Humana ChoiceCare |
$168.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.66
|
| Rate for Payer: PHCS All Commercial |
$146.38
|
| Rate for Payer: PHP All Commercial |
$148.02
|
| Rate for Payer: Sagamore Health Network All Products |
$150.67
|
| Rate for Payer: Signature Care EPO |
$161.99
|
| Rate for Payer: Signature Care PPO |
$171.75
|
| Rate for Payer: United Healthcare Commercial |
$153.80
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
OP
|
$195.17
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.50 |
| Max. Negotiated Rate |
$181.51 |
| Rate for Payer: Aetna Commercial |
$164.73
|
| Rate for Payer: Aetna Medicare |
$62.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$112.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$122.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.70
|
| Rate for Payer: Cash Price |
$117.10
|
| Rate for Payer: Centivo All Commercial |
$106.17
|
| Rate for Payer: Cigna All Commercial |
$168.44
|
| Rate for Payer: CORVEL All Commercial |
$181.51
|
| Rate for Payer: Coventry All Commercial |
$171.75
|
| Rate for Payer: Encore All Commercial |
$179.66
|
| Rate for Payer: Frontpath All Commercial |
$179.56
|
| Rate for Payer: Humana ChoiceCare |
$168.57
|
| Rate for Payer: Humana Medicare |
$62.46
|
| Rate for Payer: Lucent All Commercial |
$106.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.66
|
| Rate for Payer: PHCS All Commercial |
$146.38
|
| Rate for Payer: PHP All Commercial |
$148.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.12
|
| Rate for Payer: Sagamore Health Network All Products |
$150.67
|
| Rate for Payer: Signature Care EPO |
$161.99
|
| Rate for Payer: Signature Care PPO |
$171.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$165.90
|
| Rate for Payer: United Healthcare Commercial |
$153.80
|
| Rate for Payer: United Healthcare Medicare |
$62.46
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SUSP
|
Facility
|
OP
|
$325.76
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
167647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.98 |
| Max. Negotiated Rate |
$302.95 |
| Rate for Payer: Aetna Commercial |
$274.94
|
| Rate for Payer: Aetna Medicare |
$104.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$187.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$203.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$114.67
|
| Rate for Payer: Cash Price |
$195.45
|
| Rate for Payer: Centivo All Commercial |
$177.21
|
| Rate for Payer: Cigna All Commercial |
$281.13
|
| Rate for Payer: CORVEL All Commercial |
$302.95
|
| Rate for Payer: Coventry All Commercial |
$286.67
|
| Rate for Payer: Encore All Commercial |
$299.86
|
| Rate for Payer: Frontpath All Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$281.36
|
| Rate for Payer: Humana Medicare |
$104.24
|
| Rate for Payer: Lucent All Commercial |
$177.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$293.18
|
| Rate for Payer: PHCS All Commercial |
$244.32
|
| Rate for Payer: PHP All Commercial |
$247.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$127.05
|
| Rate for Payer: Sagamore Health Network All Products |
$251.49
|
| Rate for Payer: Signature Care EPO |
$270.38
|
| Rate for Payer: Signature Care PPO |
$286.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$276.89
|
| Rate for Payer: United Healthcare Commercial |
$256.70
|
| Rate for Payer: United Healthcare Medicare |
$104.24
|
|
