|
DISORDERS OF PERSONALITY & IMPULSE CONTROL
|
Facility
|
IP
|
$1,685.88
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$1,685.88 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
DISORDERS OF PERSONALITY & IMPULSE CONTROL
|
Facility
|
IP
|
$11,714.73
|
|
|
Service Code
|
APR-DRG 7524
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$11,714.73 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
DIVALPROEX 125 MG ORAL CDRS
|
Facility
|
OP
|
$6.77
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna Commercial |
$5.71
|
| Rate for Payer: Aetna Medicare |
$2.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$4.06
|
| Rate for Payer: Centivo All Commercial |
$3.68
|
| Rate for Payer: Cigna All Commercial |
$5.84
|
| Rate for Payer: CORVEL All Commercial |
$6.30
|
| Rate for Payer: Coventry All Commercial |
$5.96
|
| Rate for Payer: Encore All Commercial |
$6.23
|
| Rate for Payer: Frontpath All Commercial |
$6.23
|
| Rate for Payer: Humana ChoiceCare |
$5.85
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Lucent All Commercial |
$3.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.09
|
| Rate for Payer: PHCS All Commercial |
$5.08
|
| Rate for Payer: PHP All Commercial |
$5.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.64
|
| Rate for Payer: Sagamore Health Network All Products |
$5.23
|
| Rate for Payer: Signature Care EPO |
$5.62
|
| Rate for Payer: Signature Care PPO |
$5.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.75
|
| Rate for Payer: United Healthcare Commercial |
$5.33
|
| Rate for Payer: United Healthcare Medicare |
$2.17
|
|
|
DIVALPROEX 125 MG ORAL CDRS
|
Facility
|
IP
|
$6.77
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: Cash Price |
$4.06
|
| Rate for Payer: Cigna All Commercial |
$5.84
|
| Rate for Payer: CORVEL All Commercial |
$6.30
|
| Rate for Payer: Coventry All Commercial |
$5.96
|
| Rate for Payer: Encore All Commercial |
$6.23
|
| Rate for Payer: Frontpath All Commercial |
$6.23
|
| Rate for Payer: Humana ChoiceCare |
$5.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.09
|
| Rate for Payer: PHCS All Commercial |
$5.08
|
| Rate for Payer: PHP All Commercial |
$5.13
|
| Rate for Payer: Sagamore Health Network All Products |
$5.23
|
| Rate for Payer: Signature Care EPO |
$5.62
|
| Rate for Payer: Signature Care PPO |
$5.96
|
| Rate for Payer: United Healthcare Commercial |
$5.33
|
|
|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
OP
|
$5.73
|
|
|
Service Code
|
NDC 60687085721
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Centivo All Commercial |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Humana Medicare |
$1.83
|
| Rate for Payer: Lucent All Commercial |
$3.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.87
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.83
|
|
|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
OP
|
$5.73
|
|
|
Service Code
|
NDC 60687085711
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Centivo All Commercial |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Humana Medicare |
$1.83
|
| Rate for Payer: Lucent All Commercial |
$3.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.87
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.83
|
|
|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
IP
|
$5.73
|
|
|
Service Code
|
NDC 60687085721
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
IP
|
$5.73
|
|
|
Service Code
|
NDC 60687085711
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
OP
|
$6.64
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna Commercial |
$5.61
|
| Rate for Payer: Aetna Medicare |
$2.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Centivo All Commercial |
$3.61
|
| Rate for Payer: Cigna All Commercial |
$5.73
|
| Rate for Payer: CORVEL All Commercial |
$6.18
|
| Rate for Payer: Coventry All Commercial |
$5.85
|
| Rate for Payer: Encore All Commercial |
$6.11
|
| Rate for Payer: Frontpath All Commercial |
$6.11
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare |
$2.13
|
| Rate for Payer: Lucent All Commercial |
$3.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.98
|
| Rate for Payer: PHCS All Commercial |
$4.98
|
| Rate for Payer: PHP All Commercial |
$5.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$5.13
|
| Rate for Payer: Signature Care EPO |
$5.51
|
| Rate for Payer: Signature Care PPO |
$5.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.65
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
OP
|
$6.64
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna Commercial |
$5.61
|
| Rate for Payer: Aetna Medicare |
$2.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Centivo All Commercial |
$3.61
|
| Rate for Payer: Cigna All Commercial |
$5.73
|
| Rate for Payer: CORVEL All Commercial |
$6.18
|
| Rate for Payer: Coventry All Commercial |
$5.85
|
| Rate for Payer: Encore All Commercial |
$6.11
|
| Rate for Payer: Frontpath All Commercial |
$6.11
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare |
$2.13
|
| Rate for Payer: Lucent All Commercial |
$3.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.98
|
| Rate for Payer: PHCS All Commercial |
$4.98
|
| Rate for Payer: PHP All Commercial |
$5.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$5.13
|
| Rate for Payer: Signature Care EPO |
$5.51
|
| Rate for Payer: Signature Care PPO |
$5.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.65
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
IP
|
$6.64
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna Commercial |
$5.74
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna All Commercial |
$5.73
|
| Rate for Payer: CORVEL All Commercial |
$6.18
|
| Rate for Payer: Coventry All Commercial |
$5.85
|
| Rate for Payer: Encore All Commercial |
$6.11
|
| Rate for Payer: Frontpath All Commercial |
$6.11
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.98
|
| Rate for Payer: PHCS All Commercial |
$4.98
|
| Rate for Payer: PHP All Commercial |
$5.04
|
| Rate for Payer: Sagamore Health Network All Products |
$5.13
|
| Rate for Payer: Signature Care EPO |
$5.51
|
| Rate for Payer: Signature Care PPO |
$5.85
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
IP
|
$6.64
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna Commercial |
$5.74
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna All Commercial |
$5.73
|
| Rate for Payer: CORVEL All Commercial |
$6.18
|
| Rate for Payer: Coventry All Commercial |
$5.85
|
| Rate for Payer: Encore All Commercial |
$6.11
|
| Rate for Payer: Frontpath All Commercial |
$6.11
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.98
|
| Rate for Payer: PHCS All Commercial |
$4.98
|
| Rate for Payer: PHP All Commercial |
$5.04
|
| Rate for Payer: Sagamore Health Network All Products |
$5.13
|
| Rate for Payer: Signature Care EPO |
$5.51
|
| Rate for Payer: Signature Care PPO |
$5.85
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
|
|
DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP
|
Facility
|
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
15981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.12 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$136.08
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
|
|
DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP
|
Facility
|
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
15981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.83 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$132.93
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$90.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.44
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Centivo All Commercial |
$85.68
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Humana Medicare |
$50.40
|
| Rate for Payer: Lucent All Commercial |
$85.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.42
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.88
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
| Rate for Payer: United Healthcare Medicare |
$50.40
|
|
|
DOCUSATE SODIUM 100 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 63739047802
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
DOCUSATE SODIUM 100 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 63739047802
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
DOCUSATE SODIUM 283 MG/5 ML RECT ENEM
|
Facility
|
OP
|
$13.16
|
|
|
Service Code
|
NDC 17433987603
|
| Hospital Charge Code |
153577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Aetna Commercial |
$11.11
|
| Rate for Payer: Aetna Medicare |
$4.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.23
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.63
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Centivo All Commercial |
$7.16
|
| Rate for Payer: Cigna All Commercial |
$11.36
|
| Rate for Payer: CORVEL All Commercial |
$12.24
|
| Rate for Payer: Coventry All Commercial |
$11.58
|
| Rate for Payer: Encore All Commercial |
$12.11
|
| Rate for Payer: Frontpath All Commercial |
$12.11
|
| Rate for Payer: Humana ChoiceCare |
$11.37
|
| Rate for Payer: Humana Medicare |
$4.21
|
| Rate for Payer: Lucent All Commercial |
$7.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.84
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$9.87
|
| Rate for Payer: PHP All Commercial |
$9.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.13
|
| Rate for Payer: Sagamore Health Network All Products |
$10.16
|
| Rate for Payer: Signature Care EPO |
$10.92
|
| Rate for Payer: Signature Care PPO |
$11.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.19
|
| Rate for Payer: United Healthcare Commercial |
$10.37
|
| Rate for Payer: United Healthcare Medicare |
$4.21
|
|
|
DOCUSATE SODIUM 283 MG/5 ML RECT ENEM
|
Facility
|
IP
|
$13.16
|
|
|
Service Code
|
NDC 17433987603
|
| Hospital Charge Code |
153577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Aetna Commercial |
$11.37
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna All Commercial |
$11.36
|
| Rate for Payer: CORVEL All Commercial |
$12.24
|
| Rate for Payer: Coventry All Commercial |
$11.58
|
| Rate for Payer: Encore All Commercial |
$12.11
|
| Rate for Payer: Frontpath All Commercial |
$12.11
|
| Rate for Payer: Humana ChoiceCare |
$11.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.84
|
| Rate for Payer: PHCS All Commercial |
$9.87
|
| Rate for Payer: PHP All Commercial |
$9.98
|
| Rate for Payer: Sagamore Health Network All Products |
$10.16
|
| Rate for Payer: Signature Care EPO |
$10.92
|
| Rate for Payer: Signature Care PPO |
$11.58
|
| Rate for Payer: United Healthcare Commercial |
$10.37
|
|
|
DOFETILIDE 125 MCG ORAL CAP
|
Facility
|
OP
|
$26.85
|
|
|
Service Code
|
NDC 00904752208
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$24.97 |
| Rate for Payer: Aetna Commercial |
$22.66
|
| Rate for Payer: Aetna Medicare |
$8.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.45
|
| Rate for Payer: Cash Price |
$16.11
|
| Rate for Payer: Centivo All Commercial |
$14.60
|
| Rate for Payer: Cigna All Commercial |
$23.17
|
| Rate for Payer: CORVEL All Commercial |
$24.97
|
| Rate for Payer: Coventry All Commercial |
$23.62
|
| Rate for Payer: Encore All Commercial |
$24.71
|
| Rate for Payer: Frontpath All Commercial |
$24.70
|
| Rate for Payer: Humana ChoiceCare |
$23.19
|
| Rate for Payer: Humana Medicare |
$8.59
|
| Rate for Payer: Lucent All Commercial |
$14.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.16
|
| Rate for Payer: PHCS All Commercial |
$20.13
|
| Rate for Payer: PHP All Commercial |
$20.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.47
|
| Rate for Payer: Sagamore Health Network All Products |
$20.72
|
| Rate for Payer: Signature Care EPO |
$22.28
|
| Rate for Payer: Signature Care PPO |
$23.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.82
|
| Rate for Payer: United Healthcare Commercial |
$21.15
|
| Rate for Payer: United Healthcare Medicare |
$8.59
|
|
|
DOFETILIDE 125 MCG ORAL CAP
|
Facility
|
IP
|
$26.85
|
|
|
Service Code
|
NDC 00904752208
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.13 |
| Max. Negotiated Rate |
$24.97 |
| Rate for Payer: Aetna Commercial |
$23.19
|
| Rate for Payer: Cash Price |
$16.11
|
| Rate for Payer: Cigna All Commercial |
$23.17
|
| Rate for Payer: CORVEL All Commercial |
$24.97
|
| Rate for Payer: Coventry All Commercial |
$23.62
|
| Rate for Payer: Encore All Commercial |
$24.71
|
| Rate for Payer: Frontpath All Commercial |
$24.70
|
| Rate for Payer: Humana ChoiceCare |
$23.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.16
|
| Rate for Payer: PHCS All Commercial |
$20.13
|
| Rate for Payer: PHP All Commercial |
$20.36
|
| Rate for Payer: Sagamore Health Network All Products |
$20.72
|
| Rate for Payer: Signature Care EPO |
$22.28
|
| Rate for Payer: Signature Care PPO |
$23.62
|
| Rate for Payer: United Healthcare Commercial |
$21.15
|
|
|
DONEPEZIL 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
DONEPEZIL 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN
|
Facility
|
OP
|
$110.25
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$102.53 |
| Rate for Payer: Aetna Commercial |
$93.05
|
| Rate for Payer: Aetna Medicare |
$35.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$63.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$68.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.81
|
| Rate for Payer: Cash Price |
$66.15
|
| Rate for Payer: Centivo All Commercial |
$59.98
|
| Rate for Payer: Cigna All Commercial |
$95.15
|
| Rate for Payer: CORVEL All Commercial |
$102.53
|
| Rate for Payer: Coventry All Commercial |
$97.02
|
| Rate for Payer: Encore All Commercial |
$101.49
|
| Rate for Payer: Frontpath All Commercial |
$101.43
|
| Rate for Payer: Humana ChoiceCare |
$95.22
|
| Rate for Payer: Humana Medicare |
$35.28
|
| Rate for Payer: Lucent All Commercial |
$59.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.22
|
| Rate for Payer: PHCS All Commercial |
$82.69
|
| Rate for Payer: PHP All Commercial |
$83.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.00
|
| Rate for Payer: Sagamore Health Network All Products |
$85.11
|
| Rate for Payer: Signature Care EPO |
$91.51
|
| Rate for Payer: Signature Care PPO |
$97.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$93.71
|
| Rate for Payer: United Healthcare Commercial |
$86.88
|
| Rate for Payer: United Healthcare Medicare |
$35.28
|
|
|
DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN
|
Facility
|
IP
|
$110.25
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$82.69 |
| Max. Negotiated Rate |
$102.53 |
| Rate for Payer: Aetna Commercial |
$95.26
|
| Rate for Payer: Cash Price |
$66.15
|
| Rate for Payer: Cigna All Commercial |
$95.15
|
| Rate for Payer: CORVEL All Commercial |
$102.53
|
| Rate for Payer: Coventry All Commercial |
$97.02
|
| Rate for Payer: Encore All Commercial |
$101.49
|
| Rate for Payer: Frontpath All Commercial |
$101.43
|
| Rate for Payer: Humana ChoiceCare |
$95.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.22
|
| Rate for Payer: PHCS All Commercial |
$82.69
|
| Rate for Payer: PHP All Commercial |
$83.61
|
| Rate for Payer: Sagamore Health Network All Products |
$85.11
|
| Rate for Payer: Signature Care EPO |
$91.51
|
| Rate for Payer: Signature Care PPO |
$97.02
|
| Rate for Payer: United Healthcare Commercial |
$86.88
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DPET
|
Facility
|
OP
|
$10.80
|
|
|
Service Code
|
NDC 42571038273
|
| Hospital Charge Code |
154152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Aetna Commercial |
$9.12
|
| Rate for Payer: Aetna Medicare |
$3.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Centivo All Commercial |
$5.88
|
| Rate for Payer: Cigna All Commercial |
$9.32
|
| Rate for Payer: CORVEL All Commercial |
$10.04
|
| Rate for Payer: Coventry All Commercial |
$9.50
|
| Rate for Payer: Encore All Commercial |
$9.94
|
| Rate for Payer: Frontpath All Commercial |
$9.94
|
| Rate for Payer: Humana ChoiceCare |
$9.33
|
| Rate for Payer: Humana Medicare |
$3.46
|
| Rate for Payer: Lucent All Commercial |
$5.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.72
|
| Rate for Payer: PHCS All Commercial |
$8.10
|
| Rate for Payer: PHP All Commercial |
$8.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.21
|
| Rate for Payer: Sagamore Health Network All Products |
$8.34
|
| Rate for Payer: Signature Care EPO |
$8.96
|
| Rate for Payer: Signature Care PPO |
$9.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.18
|
| Rate for Payer: United Healthcare Commercial |
$8.51
|
| Rate for Payer: United Healthcare Medicare |
$3.46
|
|
