|
DEXTROSE 5% IN WATER (D5W) LINE CARE - 100 ML BAG - CAMERON
|
Facility
|
OP
|
$19.60
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
14010002364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.54
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.11
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Centivo All Commercial |
$10.00
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana Medicare |
$10.00
|
| Rate for Payer: Lucent All Commercial |
$10.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.64
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.66
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Medicare |
$6.47
|
|
|
DEXTROSE 5% IN WATER (D5W) LINE CARE - 100 ML BAG - CAMERON
|
Facility
|
IP
|
$19.60
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
14010002364
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
|
|
DEXTROSE 5 %-LACTATED RINGERS IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
9788
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
DEXTROSE 5 %-LACTATED RINGERS IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
9788
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
DIATRIZOATE AND IODIPAMIDE MEG 52.7-26.8 % INJ SOLN
|
Facility
|
OP
|
$322.74
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9822
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$300.15 |
| Rate for Payer: Aetna Commercial |
$272.39
|
| Rate for Payer: Aetna Medicare |
$106.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$185.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$122.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$117.15
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Centivo All Commercial |
$164.60
|
| Rate for Payer: Cigna All Commercial |
$278.52
|
| Rate for Payer: CORVEL All Commercial |
$300.15
|
| Rate for Payer: Coventry All Commercial |
$284.01
|
| Rate for Payer: Encore All Commercial |
$297.08
|
| Rate for Payer: Frontpath All Commercial |
$296.92
|
| Rate for Payer: Humana ChoiceCare |
$278.75
|
| Rate for Payer: Humana Medicare |
$164.60
|
| Rate for Payer: Lucent All Commercial |
$164.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$290.47
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$242.06
|
| Rate for Payer: PHP All Commercial |
$244.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$125.87
|
| Rate for Payer: Sagamore Health Network All Products |
$249.16
|
| Rate for Payer: Signature Care EPO |
$267.87
|
| Rate for Payer: Signature Care PPO |
$284.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$274.33
|
| Rate for Payer: United Healthcare Commercial |
$254.32
|
| Rate for Payer: United Healthcare Medicare |
$106.50
|
|
|
DIATRIZOATE AND IODIPAMIDE MEG 52.7-26.8 % INJ SOLN
|
Facility
|
IP
|
$322.74
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9822
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.06 |
| Max. Negotiated Rate |
$300.15 |
| Rate for Payer: Aetna Commercial |
$278.85
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna All Commercial |
$278.52
|
| Rate for Payer: CORVEL All Commercial |
$300.15
|
| Rate for Payer: Coventry All Commercial |
$284.01
|
| Rate for Payer: Encore All Commercial |
$297.08
|
| Rate for Payer: Frontpath All Commercial |
$296.92
|
| Rate for Payer: Humana ChoiceCare |
$278.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$290.47
|
| Rate for Payer: PHCS All Commercial |
$242.06
|
| Rate for Payer: PHP All Commercial |
$244.77
|
| Rate for Payer: Sagamore Health Network All Products |
$249.16
|
| Rate for Payer: Signature Care EPO |
$267.87
|
| Rate for Payer: Signature Care PPO |
$284.01
|
| Rate for Payer: United Healthcare Commercial |
$254.32
|
|
|
DIATRIZOATE MEGLUMINE 18 % URTH SOLN 300ML
|
Facility
|
IP
|
$214.20
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$199.21 |
| Rate for Payer: Aetna Commercial |
$185.07
|
| Rate for Payer: Cash Price |
$132.80
|
| Rate for Payer: Cigna All Commercial |
$184.85
|
| Rate for Payer: CORVEL All Commercial |
$199.21
|
| Rate for Payer: Coventry All Commercial |
$188.50
|
| Rate for Payer: Encore All Commercial |
$197.17
|
| Rate for Payer: Frontpath All Commercial |
$197.06
|
| Rate for Payer: Humana ChoiceCare |
$185.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$192.78
|
| Rate for Payer: PHCS All Commercial |
$160.65
|
| Rate for Payer: PHP All Commercial |
$162.45
|
| Rate for Payer: Sagamore Health Network All Products |
$165.36
|
| Rate for Payer: Signature Care EPO |
$177.79
|
| Rate for Payer: Signature Care PPO |
$188.50
|
| Rate for Payer: United Healthcare Commercial |
$168.79
|
|
|
DIATRIZOATE MEGLUMINE 18 % URTH SOLN 300ML
|
Facility
|
OP
|
$214.20
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.69 |
| Max. Negotiated Rate |
$199.21 |
| Rate for Payer: Aetna Commercial |
$180.78
|
| Rate for Payer: Aetna Medicare |
$70.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$70.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$123.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$133.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$81.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$77.75
|
| Rate for Payer: Cash Price |
$132.80
|
| Rate for Payer: Centivo All Commercial |
$109.24
|
| Rate for Payer: Cigna All Commercial |
$184.85
|
| Rate for Payer: CORVEL All Commercial |
$199.21
|
| Rate for Payer: Coventry All Commercial |
$188.50
|
| Rate for Payer: Encore All Commercial |
$197.17
|
| Rate for Payer: Frontpath All Commercial |
$197.06
|
| Rate for Payer: Humana ChoiceCare |
$185.00
|
| Rate for Payer: Humana Medicare |
$109.24
|
| Rate for Payer: Lucent All Commercial |
$109.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$192.78
|
| Rate for Payer: PHCS All Commercial |
$160.65
|
| Rate for Payer: PHP All Commercial |
$162.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$83.54
|
| Rate for Payer: Sagamore Health Network All Products |
$165.36
|
| Rate for Payer: Signature Care EPO |
$177.79
|
| Rate for Payer: Signature Care PPO |
$188.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$182.07
|
| Rate for Payer: United Healthcare Commercial |
$168.79
|
| Rate for Payer: United Healthcare Medicare |
$70.69
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN 120 ML *MULTI-DOSE* BTL
|
Facility
|
OP
|
$105.84
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.93 |
| Max. Negotiated Rate |
$98.43 |
| Rate for Payer: Aetna Commercial |
$89.33
|
| Rate for Payer: Aetna Medicare |
$34.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.42
|
| Rate for Payer: Cash Price |
$65.62
|
| Rate for Payer: Centivo All Commercial |
$53.98
|
| Rate for Payer: Cigna All Commercial |
$91.34
|
| Rate for Payer: CORVEL All Commercial |
$98.43
|
| Rate for Payer: Coventry All Commercial |
$93.14
|
| Rate for Payer: Encore All Commercial |
$97.43
|
| Rate for Payer: Frontpath All Commercial |
$97.37
|
| Rate for Payer: Humana ChoiceCare |
$91.41
|
| Rate for Payer: Humana Medicare |
$53.98
|
| Rate for Payer: Lucent All Commercial |
$53.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.26
|
| Rate for Payer: PHCS All Commercial |
$79.38
|
| Rate for Payer: PHP All Commercial |
$80.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.28
|
| Rate for Payer: Sagamore Health Network All Products |
$81.71
|
| Rate for Payer: Signature Care EPO |
$87.85
|
| Rate for Payer: Signature Care PPO |
$93.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.96
|
| Rate for Payer: United Healthcare Commercial |
$83.40
|
| Rate for Payer: United Healthcare Medicare |
$34.93
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN 120 ML *MULTI-DOSE* BTL
|
Facility
|
IP
|
$105.84
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$79.38 |
| Max. Negotiated Rate |
$98.43 |
| Rate for Payer: Aetna Commercial |
$91.45
|
| Rate for Payer: Cash Price |
$65.62
|
| Rate for Payer: Cigna All Commercial |
$91.34
|
| Rate for Payer: CORVEL All Commercial |
$98.43
|
| Rate for Payer: Coventry All Commercial |
$93.14
|
| Rate for Payer: Encore All Commercial |
$97.43
|
| Rate for Payer: Frontpath All Commercial |
$97.37
|
| Rate for Payer: Humana ChoiceCare |
$91.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.26
|
| Rate for Payer: PHCS All Commercial |
$79.38
|
| Rate for Payer: PHP All Commercial |
$80.27
|
| Rate for Payer: Sagamore Health Network All Products |
$81.71
|
| Rate for Payer: Signature Care EPO |
$87.85
|
| Rate for Payer: Signature Care PPO |
$93.14
|
| Rate for Payer: United Healthcare Commercial |
$83.40
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN PER ML BOTTLE
|
Facility
|
OP
|
$427.68
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
14019828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.13 |
| Max. Negotiated Rate |
$397.74 |
| Rate for Payer: Aetna Commercial |
$360.96
|
| Rate for Payer: Aetna Medicare |
$141.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$141.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$245.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$267.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$162.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$155.25
|
| Rate for Payer: Cash Price |
$265.16
|
| Rate for Payer: Centivo All Commercial |
$218.12
|
| Rate for Payer: Cigna All Commercial |
$369.09
|
| Rate for Payer: CORVEL All Commercial |
$397.74
|
| Rate for Payer: Coventry All Commercial |
$376.36
|
| Rate for Payer: Encore All Commercial |
$393.68
|
| Rate for Payer: Frontpath All Commercial |
$393.47
|
| Rate for Payer: Humana ChoiceCare |
$369.39
|
| Rate for Payer: Humana Medicare |
$218.12
|
| Rate for Payer: Lucent All Commercial |
$218.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$384.91
|
| Rate for Payer: PHCS All Commercial |
$320.76
|
| Rate for Payer: PHP All Commercial |
$324.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$166.80
|
| Rate for Payer: Sagamore Health Network All Products |
$330.17
|
| Rate for Payer: Signature Care EPO |
$354.97
|
| Rate for Payer: Signature Care PPO |
$376.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$363.53
|
| Rate for Payer: United Healthcare Commercial |
$337.01
|
| Rate for Payer: United Healthcare Medicare |
$141.13
|
|
|
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN PER ML BOTTLE
|
Facility
|
IP
|
$427.68
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
14019828
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$320.76 |
| Max. Negotiated Rate |
$397.74 |
| Rate for Payer: Aetna Commercial |
$369.52
|
| Rate for Payer: Cash Price |
$265.16
|
| Rate for Payer: Cigna All Commercial |
$369.09
|
| Rate for Payer: CORVEL All Commercial |
$397.74
|
| Rate for Payer: Coventry All Commercial |
$376.36
|
| Rate for Payer: Encore All Commercial |
$393.68
|
| Rate for Payer: Frontpath All Commercial |
$393.47
|
| Rate for Payer: Humana ChoiceCare |
$369.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$384.91
|
| Rate for Payer: PHCS All Commercial |
$320.76
|
| Rate for Payer: PHP All Commercial |
$324.35
|
| Rate for Payer: Sagamore Health Network All Products |
$330.17
|
| Rate for Payer: Signature Care EPO |
$354.97
|
| Rate for Payer: Signature Care PPO |
$376.36
|
| Rate for Payer: United Healthcare Commercial |
$337.01
|
|
|
DIAZEPAM 5 MG/ML INJ SYRG
|
Facility
|
OP
|
$187.38
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
106278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.83 |
| Max. Negotiated Rate |
$174.26 |
| Rate for Payer: Aetna Commercial |
$158.15
|
| Rate for Payer: Aetna Medicare |
$61.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$61.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$107.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$117.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.02
|
| Rate for Payer: Cash Price |
$116.17
|
| Rate for Payer: Centivo All Commercial |
$95.56
|
| Rate for Payer: Cigna All Commercial |
$161.71
|
| Rate for Payer: CORVEL All Commercial |
$174.26
|
| Rate for Payer: Coventry All Commercial |
$164.89
|
| Rate for Payer: Encore All Commercial |
$172.48
|
| Rate for Payer: Frontpath All Commercial |
$172.39
|
| Rate for Payer: Humana ChoiceCare |
$161.84
|
| Rate for Payer: Humana Medicare |
$95.56
|
| Rate for Payer: Lucent All Commercial |
$95.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.64
|
| Rate for Payer: PHCS All Commercial |
$140.53
|
| Rate for Payer: PHP All Commercial |
$142.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$73.08
|
| Rate for Payer: Sagamore Health Network All Products |
$144.65
|
| Rate for Payer: Signature Care EPO |
$155.52
|
| Rate for Payer: Signature Care PPO |
$164.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$159.27
|
| Rate for Payer: United Healthcare Commercial |
$147.65
|
| Rate for Payer: United Healthcare Medicare |
$61.83
|
|
|
DIAZEPAM 5 MG/ML INJ SYRG
|
Facility
|
IP
|
$187.38
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
106278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.53 |
| Max. Negotiated Rate |
$174.26 |
| Rate for Payer: Aetna Commercial |
$161.89
|
| Rate for Payer: Cash Price |
$116.17
|
| Rate for Payer: Cigna All Commercial |
$161.71
|
| Rate for Payer: CORVEL All Commercial |
$174.26
|
| Rate for Payer: Coventry All Commercial |
$164.89
|
| Rate for Payer: Encore All Commercial |
$172.48
|
| Rate for Payer: Frontpath All Commercial |
$172.39
|
| Rate for Payer: Humana ChoiceCare |
$161.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.64
|
| Rate for Payer: PHCS All Commercial |
$140.53
|
| Rate for Payer: PHP All Commercial |
$142.11
|
| Rate for Payer: Sagamore Health Network All Products |
$144.65
|
| Rate for Payer: Signature Care EPO |
$155.52
|
| Rate for Payer: Signature Care PPO |
$164.89
|
| Rate for Payer: United Healthcare Commercial |
$147.65
|
|
|
DIAZEPAM 5 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
DIAZEPAM 5 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
OP
|
$66.50
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$56.13
|
| Rate for Payer: Aetna Medicare |
$21.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$38.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.14
|
| Rate for Payer: Cash Price |
$41.23
|
| Rate for Payer: Centivo All Commercial |
$33.92
|
| Rate for Payer: Cigna All Commercial |
$57.39
|
| Rate for Payer: CORVEL All Commercial |
$61.84
|
| Rate for Payer: Coventry All Commercial |
$58.52
|
| Rate for Payer: Encore All Commercial |
$61.21
|
| Rate for Payer: Frontpath All Commercial |
$61.18
|
| Rate for Payer: Humana ChoiceCare |
$57.44
|
| Rate for Payer: Humana Medicare |
$33.92
|
| Rate for Payer: Lucent All Commercial |
$33.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.85
|
| Rate for Payer: PHCS All Commercial |
$49.88
|
| Rate for Payer: PHP All Commercial |
$50.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.94
|
| Rate for Payer: Sagamore Health Network All Products |
$51.34
|
| Rate for Payer: Signature Care EPO |
$55.20
|
| Rate for Payer: Signature Care PPO |
$58.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56.52
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
| Rate for Payer: United Healthcare Medicare |
$21.94
|
|
|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
IP
|
$66.50
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.88 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$57.46
|
| Rate for Payer: Cash Price |
$41.23
|
| Rate for Payer: Cigna All Commercial |
$57.39
|
| Rate for Payer: CORVEL All Commercial |
$61.84
|
| Rate for Payer: Coventry All Commercial |
$58.52
|
| Rate for Payer: Encore All Commercial |
$61.21
|
| Rate for Payer: Frontpath All Commercial |
$61.18
|
| Rate for Payer: Humana ChoiceCare |
$57.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.85
|
| Rate for Payer: PHCS All Commercial |
$49.88
|
| Rate for Payer: PHP All Commercial |
$50.43
|
| Rate for Payer: Sagamore Health Network All Products |
$51.34
|
| Rate for Payer: Signature Care EPO |
$55.20
|
| Rate for Payer: Signature Care PPO |
$58.52
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
|
|
DICLOFENAC SODIUM 50 MG ORAL TBEC
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Centivo All Commercial |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$1.13
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.13
|
| Rate for Payer: Humana Medicare |
$0.67
|
| Rate for Payer: Lucent All Commercial |
$0.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
DICLOFENAC SODIUM 50 MG ORAL TBEC
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.13
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
DICLOFENAC SODIUM 75 MG ORAL TBEC
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: Aetna Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Centivo All Commercial |
$1.20
|
| Rate for Payer: Cigna All Commercial |
$2.04
|
| Rate for Payer: CORVEL All Commercial |
$2.19
|
| Rate for Payer: Coventry All Commercial |
$2.08
|
| Rate for Payer: Encore All Commercial |
$2.17
|
| Rate for Payer: Frontpath All Commercial |
$2.17
|
| Rate for Payer: Humana ChoiceCare |
$2.04
|
| Rate for Payer: Humana Medicare |
$1.20
|
| Rate for Payer: Lucent All Commercial |
$1.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.12
|
| Rate for Payer: PHCS All Commercial |
$1.77
|
| Rate for Payer: PHP All Commercial |
$1.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.92
|
| Rate for Payer: Sagamore Health Network All Products |
$1.82
|
| Rate for Payer: Signature Care EPO |
$1.96
|
| Rate for Payer: Signature Care PPO |
$2.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
| Rate for Payer: United Healthcare Medicare |
$0.78
|
|
|
DICLOFENAC SODIUM 75 MG ORAL TBEC
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.04
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna All Commercial |
$2.04
|
| Rate for Payer: CORVEL All Commercial |
$2.19
|
| Rate for Payer: Coventry All Commercial |
$2.08
|
| Rate for Payer: Encore All Commercial |
$2.17
|
| Rate for Payer: Frontpath All Commercial |
$2.17
|
| Rate for Payer: Humana ChoiceCare |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.12
|
| Rate for Payer: PHCS All Commercial |
$1.77
|
| Rate for Payer: PHP All Commercial |
$1.79
|
| Rate for Payer: Sagamore Health Network All Products |
$1.82
|
| Rate for Payer: Signature Care EPO |
$1.96
|
| Rate for Payer: Signature Care PPO |
$2.08
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
IP
|
$63.20
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$58.77 |
| Rate for Payer: Aetna Commercial |
$54.60
|
| Rate for Payer: Cash Price |
$39.18
|
| Rate for Payer: Cigna All Commercial |
$54.54
|
| Rate for Payer: CORVEL All Commercial |
$58.77
|
| Rate for Payer: Coventry All Commercial |
$55.61
|
| Rate for Payer: Encore All Commercial |
$58.17
|
| Rate for Payer: Frontpath All Commercial |
$58.14
|
| Rate for Payer: Humana ChoiceCare |
$54.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.88
|
| Rate for Payer: PHCS All Commercial |
$47.40
|
| Rate for Payer: PHP All Commercial |
$47.93
|
| Rate for Payer: Sagamore Health Network All Products |
$48.79
|
| Rate for Payer: Signature Care EPO |
$52.45
|
| Rate for Payer: Signature Care PPO |
$55.61
|
| Rate for Payer: United Healthcare Commercial |
$49.80
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
OP
|
$63.20
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.85 |
| Max. Negotiated Rate |
$58.77 |
| Rate for Payer: Aetna Commercial |
$53.34
|
| Rate for Payer: Aetna Medicare |
$20.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.94
|
| Rate for Payer: Cash Price |
$39.18
|
| Rate for Payer: Centivo All Commercial |
$32.23
|
| Rate for Payer: Cigna All Commercial |
$54.54
|
| Rate for Payer: CORVEL All Commercial |
$58.77
|
| Rate for Payer: Coventry All Commercial |
$55.61
|
| Rate for Payer: Encore All Commercial |
$58.17
|
| Rate for Payer: Frontpath All Commercial |
$58.14
|
| Rate for Payer: Humana ChoiceCare |
$54.58
|
| Rate for Payer: Humana Medicare |
$32.23
|
| Rate for Payer: Lucent All Commercial |
$32.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.88
|
| Rate for Payer: PHCS All Commercial |
$47.40
|
| Rate for Payer: PHP All Commercial |
$47.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.65
|
| Rate for Payer: Sagamore Health Network All Products |
$48.79
|
| Rate for Payer: Signature Care EPO |
$52.45
|
| Rate for Payer: Signature Care PPO |
$55.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.72
|
| Rate for Payer: United Healthcare Commercial |
$49.80
|
| Rate for Payer: United Healthcare Medicare |
$20.85
|
|
|
DICYCLOMINE 10 MG ORAL CAP
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna All Commercial |
$2.58
|
| Rate for Payer: CORVEL All Commercial |
$2.78
|
| Rate for Payer: Coventry All Commercial |
$2.63
|
| Rate for Payer: Encore All Commercial |
$2.75
|
| Rate for Payer: Frontpath All Commercial |
$2.75
|
| Rate for Payer: Humana ChoiceCare |
$2.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.69
|
| Rate for Payer: PHCS All Commercial |
$2.24
|
| Rate for Payer: PHP All Commercial |
$2.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.31
|
| Rate for Payer: Signature Care EPO |
$2.48
|
| Rate for Payer: Signature Care PPO |
$2.63
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
|
