|
DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DPET
|
Facility
|
IP
|
$10.80
|
|
|
Service Code
|
NDC 42571038273
|
| Hospital Charge Code |
154152
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Aetna Commercial |
$9.33
|
| Rate for Payer: Cash Price |
$6.48
|
| 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: 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: 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: United Healthcare Commercial |
$8.51
|
|
|
DOXAPRAM 20 MG/ML IV SOLN
|
Facility
|
IP
|
$347.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.71 |
| Max. Negotiated Rate |
$323.29 |
| Rate for Payer: Aetna Commercial |
$300.34
|
| Rate for Payer: Cash Price |
$208.57
|
| Rate for Payer: Cigna All Commercial |
$300.00
|
| Rate for Payer: CORVEL All Commercial |
$323.29
|
| Rate for Payer: Coventry All Commercial |
$305.91
|
| Rate for Payer: Encore All Commercial |
$319.98
|
| Rate for Payer: Frontpath All Commercial |
$319.81
|
| Rate for Payer: Humana ChoiceCare |
$300.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.86
|
| Rate for Payer: PHCS All Commercial |
$260.71
|
| Rate for Payer: PHP All Commercial |
$263.64
|
| Rate for Payer: Sagamore Health Network All Products |
$268.36
|
| Rate for Payer: Signature Care EPO |
$288.52
|
| Rate for Payer: Signature Care PPO |
$305.91
|
| Rate for Payer: United Healthcare Commercial |
$273.92
|
|
|
DOXAPRAM 20 MG/ML IV SOLN
|
Facility
|
OP
|
$347.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$323.29 |
| Rate for Payer: Aetna Commercial |
$293.39
|
| Rate for Payer: Aetna Medicare |
$111.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$107.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$199.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$217.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$127.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$122.36
|
| Rate for Payer: Cash Price |
$208.57
|
| Rate for Payer: Centivo All Commercial |
$189.11
|
| Rate for Payer: Cigna All Commercial |
$300.00
|
| Rate for Payer: CORVEL All Commercial |
$323.29
|
| Rate for Payer: Coventry All Commercial |
$305.91
|
| Rate for Payer: Encore All Commercial |
$319.98
|
| Rate for Payer: Frontpath All Commercial |
$319.81
|
| Rate for Payer: Humana ChoiceCare |
$300.24
|
| Rate for Payer: Humana Medicare |
$111.24
|
| Rate for Payer: Lucent All Commercial |
$189.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.86
|
| Rate for Payer: PHCS All Commercial |
$260.71
|
| Rate for Payer: PHP All Commercial |
$263.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$135.57
|
| Rate for Payer: Sagamore Health Network All Products |
$268.36
|
| Rate for Payer: Signature Care EPO |
$288.52
|
| Rate for Payer: Signature Care PPO |
$305.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$295.48
|
| Rate for Payer: United Healthcare Commercial |
$273.92
|
| Rate for Payer: United Healthcare Medicare |
$111.24
|
|
|
DOXAZOSIN 1 MG ORAL TAB
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 00904552261
|
| Hospital Charge Code |
9894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Centivo All Commercial |
$1.57
|
| Rate for Payer: Cigna All Commercial |
$2.49
|
| Rate for Payer: CORVEL All Commercial |
$2.68
|
| Rate for Payer: Coventry All Commercial |
$2.54
|
| Rate for Payer: Encore All Commercial |
$2.65
|
| Rate for Payer: Frontpath All Commercial |
$2.65
|
| Rate for Payer: Humana ChoiceCare |
$2.49
|
| Rate for Payer: Humana Medicare |
$0.92
|
| Rate for Payer: Lucent All Commercial |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.60
|
| Rate for Payer: PHCS All Commercial |
$2.16
|
| Rate for Payer: PHP All Commercial |
$2.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.12
|
| Rate for Payer: Sagamore Health Network All Products |
$2.23
|
| Rate for Payer: Signature Care EPO |
$2.39
|
| Rate for Payer: Signature Care PPO |
$2.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.45
|
| Rate for Payer: United Healthcare Commercial |
$2.27
|
| Rate for Payer: United Healthcare Medicare |
$0.92
|
|
|
DOXAZOSIN 1 MG ORAL TAB
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 00904552261
|
| Hospital Charge Code |
9894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna All Commercial |
$2.49
|
| Rate for Payer: CORVEL All Commercial |
$2.68
|
| Rate for Payer: Coventry All Commercial |
$2.54
|
| Rate for Payer: Encore All Commercial |
$2.65
|
| Rate for Payer: Frontpath All Commercial |
$2.65
|
| Rate for Payer: Humana ChoiceCare |
$2.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.60
|
| Rate for Payer: PHCS All Commercial |
$2.16
|
| Rate for Payer: PHP All Commercial |
$2.19
|
| Rate for Payer: Sagamore Health Network All Products |
$2.23
|
| Rate for Payer: Signature Care EPO |
$2.39
|
| Rate for Payer: Signature Care PPO |
$2.54
|
| Rate for Payer: United Healthcare Commercial |
$2.27
|
|
|
DOXAZOSIN 4 MG ORAL TAB
|
Facility
|
IP
|
$5.71
|
|
|
Service Code
|
NDC 68084086225
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$5.31 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cigna All Commercial |
$4.93
|
| Rate for Payer: CORVEL All Commercial |
$5.31
|
| Rate for Payer: Coventry All Commercial |
$5.03
|
| Rate for Payer: Encore All Commercial |
$5.26
|
| Rate for Payer: Frontpath All Commercial |
$5.26
|
| Rate for Payer: Humana ChoiceCare |
$4.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.14
|
| Rate for Payer: PHCS All Commercial |
$4.28
|
| Rate for Payer: PHP All Commercial |
$4.33
|
| Rate for Payer: Sagamore Health Network All Products |
$4.41
|
| Rate for Payer: Signature Care EPO |
$4.74
|
| Rate for Payer: Signature Care PPO |
$5.03
|
| Rate for Payer: United Healthcare Commercial |
$4.50
|
|
|
DOXAZOSIN 4 MG ORAL TAB
|
Facility
|
OP
|
$5.71
|
|
|
Service Code
|
NDC 68084086225
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$5.31 |
| Rate for Payer: Aetna Commercial |
$4.82
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.01
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Centivo All Commercial |
$3.11
|
| Rate for Payer: Cigna All Commercial |
$4.93
|
| Rate for Payer: CORVEL All Commercial |
$5.31
|
| Rate for Payer: Coventry All Commercial |
$5.03
|
| Rate for Payer: Encore All Commercial |
$5.26
|
| Rate for Payer: Frontpath All Commercial |
$5.26
|
| Rate for Payer: Humana ChoiceCare |
$4.93
|
| Rate for Payer: Humana Medicare |
$1.83
|
| Rate for Payer: Lucent All Commercial |
$3.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.14
|
| Rate for Payer: PHCS All Commercial |
$4.28
|
| Rate for Payer: PHP All Commercial |
$4.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.23
|
| Rate for Payer: Sagamore Health Network All Products |
$4.41
|
| Rate for Payer: Signature Care EPO |
$4.74
|
| Rate for Payer: Signature Care PPO |
$5.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.86
|
| Rate for Payer: United Healthcare Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$1.83
|
|
|
DOXEPIN 10 MG ORAL CAP
|
Facility
|
OP
|
$3.81
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: Aetna Medicare |
$1.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.34
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Centivo All Commercial |
$2.07
|
| Rate for Payer: Cigna All Commercial |
$3.29
|
| Rate for Payer: CORVEL All Commercial |
$3.54
|
| Rate for Payer: Coventry All Commercial |
$3.35
|
| Rate for Payer: Encore All Commercial |
$3.51
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.29
|
| Rate for Payer: Humana Medicare |
$1.22
|
| Rate for Payer: Lucent All Commercial |
$2.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.43
|
| Rate for Payer: PHCS All Commercial |
$2.86
|
| Rate for Payer: PHP All Commercial |
$2.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.49
|
| Rate for Payer: Sagamore Health Network All Products |
$2.94
|
| Rate for Payer: Signature Care EPO |
$3.16
|
| Rate for Payer: Signature Care PPO |
$3.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.24
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
| Rate for Payer: United Healthcare Medicare |
$1.22
|
|
|
DOXEPIN 10 MG ORAL CAP
|
Facility
|
IP
|
$3.81
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna All Commercial |
$3.29
|
| Rate for Payer: CORVEL All Commercial |
$3.54
|
| Rate for Payer: Coventry All Commercial |
$3.35
|
| Rate for Payer: Encore All Commercial |
$3.51
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.43
|
| Rate for Payer: PHCS All Commercial |
$2.86
|
| Rate for Payer: PHP All Commercial |
$2.89
|
| Rate for Payer: Sagamore Health Network All Products |
$2.94
|
| Rate for Payer: Signature Care EPO |
$3.16
|
| Rate for Payer: Signature Care PPO |
$3.35
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
|
|
DOXYCYCLINE HYCLATE 100 MG IV SOLR
|
Facility
|
OP
|
$79.41
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.62 |
| Max. Negotiated Rate |
$73.85 |
| Rate for Payer: Aetna Commercial |
$67.02
|
| Rate for Payer: Aetna Medicare |
$25.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.95
|
| Rate for Payer: Cash Price |
$47.64
|
| Rate for Payer: Centivo All Commercial |
$43.20
|
| Rate for Payer: Cigna All Commercial |
$68.53
|
| Rate for Payer: CORVEL All Commercial |
$73.85
|
| Rate for Payer: Coventry All Commercial |
$69.88
|
| Rate for Payer: Encore All Commercial |
$73.10
|
| Rate for Payer: Frontpath All Commercial |
$73.06
|
| Rate for Payer: Humana ChoiceCare |
$68.58
|
| Rate for Payer: Humana Medicare |
$25.41
|
| Rate for Payer: Lucent All Commercial |
$43.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.47
|
| Rate for Payer: PHCS All Commercial |
$59.56
|
| Rate for Payer: PHP All Commercial |
$60.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.97
|
| Rate for Payer: Sagamore Health Network All Products |
$61.30
|
| Rate for Payer: Signature Care EPO |
$65.91
|
| Rate for Payer: Signature Care PPO |
$69.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.50
|
| Rate for Payer: United Healthcare Commercial |
$62.57
|
| Rate for Payer: United Healthcare Medicare |
$25.41
|
|
|
DOXYCYCLINE HYCLATE 100 MG IV SOLR
|
Facility
|
IP
|
$79.41
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$73.85 |
| Rate for Payer: Aetna Commercial |
$68.61
|
| Rate for Payer: Cash Price |
$47.64
|
| Rate for Payer: Cigna All Commercial |
$68.53
|
| Rate for Payer: CORVEL All Commercial |
$73.85
|
| Rate for Payer: Coventry All Commercial |
$69.88
|
| Rate for Payer: Encore All Commercial |
$73.10
|
| Rate for Payer: Frontpath All Commercial |
$73.06
|
| Rate for Payer: Humana ChoiceCare |
$68.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.47
|
| Rate for Payer: PHCS All Commercial |
$59.56
|
| Rate for Payer: PHP All Commercial |
$60.22
|
| Rate for Payer: Sagamore Health Network All Products |
$61.30
|
| Rate for Payer: Signature Care EPO |
$65.91
|
| Rate for Payer: Signature Care PPO |
$69.88
|
| Rate for Payer: United Healthcare Commercial |
$62.57
|
|
|
DOXYCYCLINE HYCLATE 100 MG ORAL TAB
|
Facility
|
IP
|
$9.48
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cigna All Commercial |
$8.18
|
| Rate for Payer: CORVEL All Commercial |
$8.81
|
| Rate for Payer: Coventry All Commercial |
$8.34
|
| Rate for Payer: Encore All Commercial |
$8.72
|
| Rate for Payer: Frontpath All Commercial |
$8.72
|
| Rate for Payer: Humana ChoiceCare |
$8.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.53
|
| Rate for Payer: PHCS All Commercial |
$7.11
|
| Rate for Payer: PHP All Commercial |
$7.19
|
| Rate for Payer: Sagamore Health Network All Products |
$7.32
|
| Rate for Payer: Signature Care EPO |
$7.87
|
| Rate for Payer: Signature Care PPO |
$8.34
|
| Rate for Payer: United Healthcare Commercial |
$7.47
|
|
|
DOXYCYCLINE HYCLATE 100 MG ORAL TAB
|
Facility
|
OP
|
$9.48
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$8.00
|
| Rate for Payer: Aetna Medicare |
$3.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.34
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Centivo All Commercial |
$5.16
|
| Rate for Payer: Cigna All Commercial |
$8.18
|
| Rate for Payer: CORVEL All Commercial |
$8.81
|
| Rate for Payer: Coventry All Commercial |
$8.34
|
| Rate for Payer: Encore All Commercial |
$8.72
|
| Rate for Payer: Frontpath All Commercial |
$8.72
|
| Rate for Payer: Humana ChoiceCare |
$8.19
|
| Rate for Payer: Humana Medicare |
$3.03
|
| Rate for Payer: Lucent All Commercial |
$5.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.53
|
| Rate for Payer: PHCS All Commercial |
$7.11
|
| Rate for Payer: PHP All Commercial |
$7.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.70
|
| Rate for Payer: Sagamore Health Network All Products |
$7.32
|
| Rate for Payer: Signature Care EPO |
$7.87
|
| Rate for Payer: Signature Care PPO |
$8.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.06
|
| Rate for Payer: United Healthcare Commercial |
$7.47
|
| Rate for Payer: United Healthcare Medicare |
$3.03
|
|
|
DROPERIDOL 2.5 MG/ML INJ SOLN
|
Facility
|
OP
|
$62.68
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.43 |
| Max. Negotiated Rate |
$58.29 |
| Rate for Payer: Aetna Commercial |
$52.90
|
| Rate for Payer: Aetna Commercial |
$26.00
|
| Rate for Payer: Aetna Medicare |
$9.86
|
| Rate for Payer: Aetna Medicare |
$20.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.06
|
| Rate for Payer: Cash Price |
$37.61
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Centivo All Commercial |
$34.10
|
| Rate for Payer: Centivo All Commercial |
$16.76
|
| Rate for Payer: Cigna All Commercial |
$26.59
|
| Rate for Payer: Cigna All Commercial |
$54.09
|
| Rate for Payer: CORVEL All Commercial |
$28.65
|
| Rate for Payer: CORVEL All Commercial |
$58.29
|
| Rate for Payer: Coventry All Commercial |
$27.11
|
| Rate for Payer: Coventry All Commercial |
$55.16
|
| Rate for Payer: Encore All Commercial |
$28.36
|
| Rate for Payer: Encore All Commercial |
$57.70
|
| Rate for Payer: Frontpath All Commercial |
$57.66
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Humana ChoiceCare |
$54.13
|
| Rate for Payer: Humana ChoiceCare |
$26.61
|
| Rate for Payer: Humana Medicare |
$20.06
|
| Rate for Payer: Humana Medicare |
$9.86
|
| Rate for Payer: Lucent All Commercial |
$16.76
|
| Rate for Payer: Lucent All Commercial |
$34.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.73
|
| Rate for Payer: PHCS All Commercial |
$47.01
|
| Rate for Payer: PHCS All Commercial |
$23.11
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: PHP All Commercial |
$47.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.44
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Sagamore Health Network All Products |
$48.39
|
| Rate for Payer: Signature Care EPO |
$52.02
|
| Rate for Payer: Signature Care EPO |
$25.57
|
| Rate for Payer: Signature Care PPO |
$27.11
|
| Rate for Payer: Signature Care PPO |
$55.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.19
|
| Rate for Payer: United Healthcare Commercial |
$24.28
|
| Rate for Payer: United Healthcare Commercial |
$49.39
|
| Rate for Payer: United Healthcare Medicare |
$9.86
|
| Rate for Payer: United Healthcare Medicare |
$20.06
|
|
|
DROPERIDOL 2.5 MG/ML INJ SOLN
|
Facility
|
IP
|
$62.68
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.01 |
| Max. Negotiated Rate |
$58.29 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Commercial |
$26.62
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$37.61
|
| Rate for Payer: Cigna All Commercial |
$26.59
|
| Rate for Payer: Cigna All Commercial |
$54.09
|
| Rate for Payer: CORVEL All Commercial |
$28.65
|
| Rate for Payer: CORVEL All Commercial |
$58.29
|
| Rate for Payer: Coventry All Commercial |
$55.16
|
| Rate for Payer: Coventry All Commercial |
$27.11
|
| Rate for Payer: Encore All Commercial |
$57.70
|
| Rate for Payer: Encore All Commercial |
$28.36
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Frontpath All Commercial |
$57.66
|
| Rate for Payer: Humana ChoiceCare |
$26.61
|
| Rate for Payer: Humana ChoiceCare |
$54.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.41
|
| Rate for Payer: PHCS All Commercial |
$47.01
|
| Rate for Payer: PHCS All Commercial |
$23.11
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: PHP All Commercial |
$47.53
|
| Rate for Payer: Sagamore Health Network All Products |
$48.39
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Signature Care EPO |
$52.02
|
| Rate for Payer: Signature Care EPO |
$25.57
|
| Rate for Payer: Signature Care PPO |
$27.11
|
| Rate for Payer: Signature Care PPO |
$55.16
|
| Rate for Payer: United Healthcare Commercial |
$24.28
|
| Rate for Payer: United Healthcare Commercial |
$49.39
|
|
|
DULOXETINE 30 MG ORAL CPDR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68180029506
|
| Hospital Charge Code |
39276
|
|
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
|
|
|
DULOXETINE 30 MG ORAL CPDR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68180029506
|
| Hospital Charge Code |
39276
|
|
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
|
|
|
DUTASTERIDE 0.5 MG ORAL CAP
|
Facility
|
OP
|
$1.58
|
|
|
Service Code
|
NDC 31722013130
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Aetna Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Centivo All Commercial |
$0.86
|
| Rate for Payer: Cigna All Commercial |
$1.37
|
| Rate for Payer: CORVEL All Commercial |
$1.47
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.46
|
| Rate for Payer: Frontpath All Commercial |
$1.46
|
| Rate for Payer: Humana ChoiceCare |
$1.37
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: PHCS All Commercial |
$1.19
|
| Rate for Payer: PHP All Commercial |
$1.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.62
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.25
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
|
|
DUTASTERIDE 0.5 MG ORAL CAP
|
Facility
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 31722013130
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna Commercial |
$1.37
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.37
|
| Rate for Payer: CORVEL All Commercial |
$1.47
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.46
|
| Rate for Payer: Frontpath All Commercial |
$1.46
|
| Rate for Payer: Humana ChoiceCare |
$1.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: PHCS All Commercial |
$1.19
|
| Rate for Payer: PHP All Commercial |
$1.20
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$1.25
|
|
|
EAPG 3.18: ABDOMINAL HERNIA REPAIR
|
Facility
|
OP
|
$1,089.43
|
|
|
Service Code
|
EAPG 03035
|
| Min. Negotiated Rate |
$1,089.43 |
| Max. Negotiated Rate |
$1,089.43 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,089.43
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$1,089.43
|
|
|
EAPG 3.18: ABDOMINAL PAIN
|
Facility
|
OP
|
$70.67
|
|
|
Service Code
|
EAPG 00628
|
| Min. Negotiated Rate |
$70.67 |
| Max. Negotiated Rate |
$70.67 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$70.67
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$70.67
|
|
|
EAPG 3.18: ABDOMINAL PARACENTESIS AND RELATED PERITONEAL DRAINAGE PROCEDURES
|
Facility
|
OP
|
$301.96
|
|
|
Service Code
|
EAPG 00150
|
| Min. Negotiated Rate |
$301.96 |
| Max. Negotiated Rate |
$301.96 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$301.96
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$301.96
|
|
|
EAPG 3.18: ABORTION AND MISCARRIAGE TREATMENT AND PROCEDURES
|
Facility
|
OP
|
$380.89
|
|
|
Service Code
|
EAPG 00194
|
| Min. Negotiated Rate |
$380.89 |
| Max. Negotiated Rate |
$380.89 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$380.89
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$380.89
|
|
|
EAPG 3.18: ABORTION RELATED DIAGNOSES
|
Facility
|
OP
|
$67.92
|
|
|
Service Code
|
EAPG 00763
|
| Min. Negotiated Rate |
$67.92 |
| Max. Negotiated Rate |
$67.92 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$67.92
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$67.92
|
|
|
EAPG 3.18: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
OP
|
$65.16
|
|
|
Service Code
|
EAPG 00608
|
| Min. Negotiated Rate |
$65.16 |
| Max. Negotiated Rate |
$65.16 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$65.16
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$65.16
|
|
