|
DENOSUMAB 70 MG/ML SUBQ SOLN
|
Facility
|
OP
|
$10,905.86
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$10,142.45 |
| Rate for Payer: Aetna Commercial |
$9,204.55
|
| Rate for Payer: Aetna Medicare |
$3,598.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,598.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,263.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,817.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$26.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,138.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,958.83
|
| Rate for Payer: Cash Price |
$6,761.64
|
| Rate for Payer: Cash Price |
$6,761.64
|
| Rate for Payer: Centivo All Commercial |
$5,561.99
|
| Rate for Payer: Cigna All Commercial |
$9,411.76
|
| Rate for Payer: CORVEL All Commercial |
$10,142.45
|
| Rate for Payer: Coventry All Commercial |
$9,597.16
|
| Rate for Payer: Encore All Commercial |
$10,038.85
|
| Rate for Payer: Frontpath All Commercial |
$10,033.39
|
| Rate for Payer: Humana ChoiceCare |
$9,419.39
|
| Rate for Payer: Humana Medicare |
$5,561.99
|
| Rate for Payer: Lucent All Commercial |
$5,561.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,815.28
|
| Rate for Payer: Managed Health Services Medicaid |
$26.15
|
| Rate for Payer: MDWise Medicaid |
$26.15
|
| Rate for Payer: PHCS All Commercial |
$8,179.40
|
| Rate for Payer: PHP All Commercial |
$8,271.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,253.29
|
| Rate for Payer: Sagamore Health Network All Products |
$8,419.33
|
| Rate for Payer: Signature Care EPO |
$9,051.87
|
| Rate for Payer: Signature Care PPO |
$9,597.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,269.98
|
| Rate for Payer: United Healthcare Commercial |
$8,593.82
|
| Rate for Payer: United Healthcare Medicare |
$3,598.93
|
|
|
DESMOPRESSIN 4 MCG/ML INJ SOLN
|
Facility
|
OP
|
$899.95
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
9748
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$296.98 |
| Max. Negotiated Rate |
$836.95 |
| Rate for Payer: Aetna Commercial |
$759.56
|
| Rate for Payer: Aetna Commercial |
$82.60
|
| Rate for Payer: Aetna Medicare |
$296.98
|
| Rate for Payer: Aetna Medicare |
$32.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$296.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$516.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$56.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$562.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$61.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$341.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$326.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.53
|
| Rate for Payer: Cash Price |
$60.68
|
| Rate for Payer: Cash Price |
$557.97
|
| Rate for Payer: Centivo All Commercial |
$458.97
|
| Rate for Payer: Centivo All Commercial |
$49.91
|
| Rate for Payer: Cigna All Commercial |
$84.46
|
| Rate for Payer: Cigna All Commercial |
$776.66
|
| Rate for Payer: CORVEL All Commercial |
$836.95
|
| Rate for Payer: CORVEL All Commercial |
$91.02
|
| Rate for Payer: Coventry All Commercial |
$791.96
|
| Rate for Payer: Coventry All Commercial |
$86.12
|
| Rate for Payer: Encore All Commercial |
$828.40
|
| Rate for Payer: Encore All Commercial |
$90.09
|
| Rate for Payer: Frontpath All Commercial |
$90.04
|
| Rate for Payer: Frontpath All Commercial |
$827.95
|
| Rate for Payer: Humana ChoiceCare |
$777.29
|
| Rate for Payer: Humana ChoiceCare |
$84.53
|
| Rate for Payer: Humana Medicare |
$49.91
|
| Rate for Payer: Humana Medicare |
$458.97
|
| Rate for Payer: Lucent All Commercial |
$458.97
|
| Rate for Payer: Lucent All Commercial |
$49.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$809.96
|
| Rate for Payer: PHCS All Commercial |
$674.96
|
| Rate for Payer: PHCS All Commercial |
$73.40
|
| Rate for Payer: PHP All Commercial |
$74.22
|
| Rate for Payer: PHP All Commercial |
$682.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$350.98
|
| Rate for Payer: Sagamore Health Network All Products |
$694.76
|
| Rate for Payer: Sagamore Health Network All Products |
$75.55
|
| Rate for Payer: Signature Care EPO |
$81.23
|
| Rate for Payer: Signature Care EPO |
$746.96
|
| Rate for Payer: Signature Care PPO |
$791.96
|
| Rate for Payer: Signature Care PPO |
$86.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$83.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$764.96
|
| Rate for Payer: United Healthcare Commercial |
$709.16
|
| Rate for Payer: United Healthcare Commercial |
$77.12
|
| Rate for Payer: United Healthcare Medicare |
$296.98
|
| Rate for Payer: United Healthcare Medicare |
$32.30
|
|
|
DESMOPRESSIN 4 MCG/ML INJ SOLN
|
Facility
|
IP
|
$899.95
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
9748
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$674.96 |
| Max. Negotiated Rate |
$836.95 |
| Rate for Payer: Aetna Commercial |
$777.56
|
| Rate for Payer: Aetna Commercial |
$84.56
|
| Rate for Payer: Cash Price |
$60.68
|
| Rate for Payer: Cash Price |
$557.97
|
| Rate for Payer: Cigna All Commercial |
$84.46
|
| Rate for Payer: Cigna All Commercial |
$776.66
|
| Rate for Payer: CORVEL All Commercial |
$836.95
|
| Rate for Payer: CORVEL All Commercial |
$91.02
|
| Rate for Payer: Coventry All Commercial |
$791.96
|
| Rate for Payer: Coventry All Commercial |
$86.12
|
| Rate for Payer: Encore All Commercial |
$90.09
|
| Rate for Payer: Encore All Commercial |
$828.40
|
| Rate for Payer: Frontpath All Commercial |
$90.04
|
| Rate for Payer: Frontpath All Commercial |
$827.95
|
| Rate for Payer: Humana ChoiceCare |
$84.53
|
| Rate for Payer: Humana ChoiceCare |
$777.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$809.96
|
| Rate for Payer: PHCS All Commercial |
$73.40
|
| Rate for Payer: PHCS All Commercial |
$674.96
|
| Rate for Payer: PHP All Commercial |
$74.22
|
| Rate for Payer: PHP All Commercial |
$682.52
|
| Rate for Payer: Sagamore Health Network All Products |
$75.55
|
| Rate for Payer: Sagamore Health Network All Products |
$694.76
|
| Rate for Payer: Signature Care EPO |
$81.23
|
| Rate for Payer: Signature Care EPO |
$746.96
|
| Rate for Payer: Signature Care PPO |
$791.96
|
| Rate for Payer: Signature Care PPO |
$86.12
|
| Rate for Payer: United Healthcare Commercial |
$709.16
|
| Rate for Payer: United Healthcare Commercial |
$77.12
|
|
|
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion
|
Facility
|
OP
|
$285.87
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
CPT-17000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.87 |
| Max. Negotiated Rate |
$285.87 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$285.87
|
| Rate for Payer: Managed Health Services Medicaid |
$285.87
|
| Rate for Payer: MDWise Medicaid |
$285.87
|
|
|
DESVENLAFAXINE SUCCINATE 100 MG ORAL TB24
|
Facility
|
IP
|
$3.37
|
|
|
Service Code
|
NDC 70436001304
|
| Hospital Charge Code |
91074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna All Commercial |
$2.91
|
| Rate for Payer: CORVEL All Commercial |
$3.13
|
| Rate for Payer: Coventry All Commercial |
$2.96
|
| Rate for Payer: Encore All Commercial |
$3.10
|
| Rate for Payer: Frontpath All Commercial |
$3.10
|
| Rate for Payer: Humana ChoiceCare |
$2.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.03
|
| Rate for Payer: PHCS All Commercial |
$2.53
|
| Rate for Payer: PHP All Commercial |
$2.55
|
| Rate for Payer: Sagamore Health Network All Products |
$2.60
|
| Rate for Payer: Signature Care EPO |
$2.79
|
| Rate for Payer: Signature Care PPO |
$2.96
|
| Rate for Payer: United Healthcare Commercial |
$2.65
|
|
|
DESVENLAFAXINE SUCCINATE 100 MG ORAL TB24
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
NDC 70436001304
|
| Hospital Charge Code |
91074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.84
|
| Rate for Payer: Aetna Medicare |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.22
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Centivo All Commercial |
$1.72
|
| Rate for Payer: Cigna All Commercial |
$2.91
|
| Rate for Payer: CORVEL All Commercial |
$3.13
|
| Rate for Payer: Coventry All Commercial |
$2.96
|
| Rate for Payer: Encore All Commercial |
$3.10
|
| Rate for Payer: Frontpath All Commercial |
$3.10
|
| Rate for Payer: Humana ChoiceCare |
$2.91
|
| Rate for Payer: Humana Medicare |
$1.72
|
| Rate for Payer: Lucent All Commercial |
$1.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.03
|
| Rate for Payer: PHCS All Commercial |
$2.53
|
| Rate for Payer: PHP All Commercial |
$2.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.31
|
| Rate for Payer: Sagamore Health Network All Products |
$2.60
|
| Rate for Payer: Signature Care EPO |
$2.79
|
| Rate for Payer: Signature Care PPO |
$2.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.86
|
| Rate for Payer: United Healthcare Commercial |
$2.65
|
| Rate for Payer: United Healthcare Medicare |
$1.11
|
|
|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
OP
|
$89.95
|
|
|
Service Code
|
NDC 00008121150
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$83.65 |
| Rate for Payer: Aetna Commercial |
$75.92
|
| Rate for Payer: Aetna Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$51.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$34.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$32.65
|
| Rate for Payer: Cash Price |
$55.77
|
| Rate for Payer: Centivo All Commercial |
$45.87
|
| Rate for Payer: Cigna All Commercial |
$77.63
|
| Rate for Payer: CORVEL All Commercial |
$83.65
|
| Rate for Payer: Coventry All Commercial |
$79.16
|
| Rate for Payer: Encore All Commercial |
$82.80
|
| Rate for Payer: Frontpath All Commercial |
$82.75
|
| Rate for Payer: Humana ChoiceCare |
$77.69
|
| Rate for Payer: Humana Medicare |
$45.87
|
| Rate for Payer: Lucent All Commercial |
$45.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.96
|
| Rate for Payer: PHCS All Commercial |
$67.46
|
| Rate for Payer: PHP All Commercial |
$68.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.08
|
| Rate for Payer: Sagamore Health Network All Products |
$69.44
|
| Rate for Payer: Signature Care EPO |
$74.66
|
| Rate for Payer: Signature Care PPO |
$79.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$76.46
|
| Rate for Payer: United Healthcare Commercial |
$70.88
|
| Rate for Payer: United Healthcare Medicare |
$29.68
|
|
|
DESVENLAFAXINE SUCCINATE 50 MG ORAL TB24
|
Facility
|
IP
|
$89.95
|
|
|
Service Code
|
NDC 00008121150
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.46 |
| Max. Negotiated Rate |
$83.65 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: Cash Price |
$55.77
|
| Rate for Payer: Cigna All Commercial |
$77.63
|
| Rate for Payer: CORVEL All Commercial |
$83.65
|
| Rate for Payer: Coventry All Commercial |
$79.16
|
| Rate for Payer: Encore All Commercial |
$82.80
|
| Rate for Payer: Frontpath All Commercial |
$82.75
|
| Rate for Payer: Humana ChoiceCare |
$77.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.96
|
| Rate for Payer: PHCS All Commercial |
$67.46
|
| Rate for Payer: PHP All Commercial |
$68.22
|
| Rate for Payer: Sagamore Health Network All Products |
$69.44
|
| Rate for Payer: Signature Care EPO |
$74.66
|
| Rate for Payer: Signature Care PPO |
$79.16
|
| Rate for Payer: United Healthcare Commercial |
$70.88
|
|
|
DEXAMETHASONE 24 MG/ML OTIC SOLUTION - CLINIC ADMINISTRATION
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
13060023212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$295.40
|
| Rate for Payer: Aetna Medicare |
$115.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$115.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$201.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$127.05
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Centivo All Commercial |
$178.50
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Humana Medicare |
$178.50
|
| Rate for Payer: Lucent All Commercial |
$178.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.50
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$297.50
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
| Rate for Payer: United Healthcare Medicare |
$115.50
|
|
|
DEXAMETHASONE 24 MG/ML OTIC SOLUTION - CLINIC ADMINISTRATION
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
13060023212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$302.40
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
|
|
DEXAMETHASONE 4 MG/ML INJ *FOR ORAL USE ONLY*
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4082332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
DEXAMETHASONE 4 MG/ML INJ *FOR ORAL USE ONLY*
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
4082332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXAMETHASONE 4 MG ORAL TAB
|
Facility
|
OP
|
$6.96
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna Commercial |
$5.87
|
| Rate for Payer: Aetna Medicare |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.53
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Centivo All Commercial |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$6.00
|
| Rate for Payer: CORVEL All Commercial |
$6.47
|
| Rate for Payer: Coventry All Commercial |
$6.12
|
| Rate for Payer: Encore All Commercial |
$6.40
|
| Rate for Payer: Frontpath All Commercial |
$6.40
|
| Rate for Payer: Humana ChoiceCare |
$6.01
|
| Rate for Payer: Humana Medicare |
$3.55
|
| Rate for Payer: Lucent All Commercial |
$3.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.26
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.71
|
| Rate for Payer: Sagamore Health Network All Products |
$5.37
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.91
|
| Rate for Payer: United Healthcare Commercial |
$5.48
|
| Rate for Payer: United Healthcare Medicare |
$2.30
|
|
|
DEXAMETHASONE 4 MG ORAL TAB
|
Facility
|
IP
|
$6.96
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna Commercial |
$6.01
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cigna All Commercial |
$6.00
|
| Rate for Payer: CORVEL All Commercial |
$6.47
|
| Rate for Payer: Coventry All Commercial |
$6.12
|
| Rate for Payer: Encore All Commercial |
$6.40
|
| Rate for Payer: Frontpath All Commercial |
$6.40
|
| Rate for Payer: Humana ChoiceCare |
$6.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.26
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Sagamore Health Network All Products |
$5.37
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.12
|
| Rate for Payer: United Healthcare Commercial |
$5.48
|
|
|
DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
118427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
118427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 71288050503
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 71288050502
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 71288050503
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
DEXMEDETOMIDINE 100 MCG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 71288050502
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML BOLUS INJECTION
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4080171613
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML BOLUS INJECTION
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4080171613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$196.70
|
|
|
Service Code
|
NDC 00338955712
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$182.93 |
| Rate for Payer: Aetna Commercial |
$166.01
|
| Rate for Payer: Aetna Medicare |
$64.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$112.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$122.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$74.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$121.95
|
| Rate for Payer: Cash Price |
$121.95
|
| Rate for Payer: Centivo All Commercial |
$100.32
|
| Rate for Payer: Cigna All Commercial |
$169.75
|
| Rate for Payer: CORVEL All Commercial |
$182.93
|
| Rate for Payer: Coventry All Commercial |
$173.10
|
| Rate for Payer: Encore All Commercial |
$181.06
|
| Rate for Payer: Frontpath All Commercial |
$180.96
|
| Rate for Payer: Humana ChoiceCare |
$169.89
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Lucent All Commercial |
$100.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.03
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$147.52
|
| Rate for Payer: PHP All Commercial |
$149.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.71
|
| Rate for Payer: Sagamore Health Network All Products |
$151.85
|
| Rate for Payer: Signature Care EPO |
$163.26
|
| Rate for Payer: Signature Care PPO |
$173.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$167.20
|
| Rate for Payer: United Healthcare Commercial |
$155.00
|
| Rate for Payer: United Healthcare Medicare |
$64.91
|
|
