|
DICYCLOMINE 10 MG ORAL CAP
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.09
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Centivo All Commercial |
$1.52
|
| 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: Humana Medicare |
$1.52
|
| Rate for Payer: Lucent All Commercial |
$1.52
|
| 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: Plain Church Group Ministry All Commercial |
$1.17
|
| 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: Three Rivers Preferred All Commercial |
$2.54
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
| Rate for Payer: United Healthcare Medicare |
$0.99
|
|
|
DIGOXIN 125 MCG (0.125 MG) ORAL TAB
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cigna All Commercial |
$4.43
|
| Rate for Payer: CORVEL All Commercial |
$4.77
|
| Rate for Payer: Coventry All Commercial |
$4.52
|
| Rate for Payer: Encore All Commercial |
$4.72
|
| Rate for Payer: Frontpath All Commercial |
$4.72
|
| Rate for Payer: Humana ChoiceCare |
$4.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.62
|
| Rate for Payer: PHCS All Commercial |
$3.85
|
| Rate for Payer: PHP All Commercial |
$3.89
|
| Rate for Payer: Sagamore Health Network All Products |
$3.96
|
| Rate for Payer: Signature Care EPO |
$4.26
|
| Rate for Payer: Signature Care PPO |
$4.52
|
| Rate for Payer: United Healthcare Commercial |
$4.04
|
|
|
DIGOXIN 125 MCG (0.125 MG) ORAL TAB
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$4.33
|
| Rate for Payer: Aetna Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Centivo All Commercial |
$2.62
|
| Rate for Payer: Cigna All Commercial |
$4.43
|
| Rate for Payer: CORVEL All Commercial |
$4.77
|
| Rate for Payer: Coventry All Commercial |
$4.52
|
| Rate for Payer: Encore All Commercial |
$4.72
|
| Rate for Payer: Frontpath All Commercial |
$4.72
|
| Rate for Payer: Humana ChoiceCare |
$4.43
|
| Rate for Payer: Humana Medicare |
$2.62
|
| Rate for Payer: Lucent All Commercial |
$2.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.62
|
| Rate for Payer: PHCS All Commercial |
$3.85
|
| Rate for Payer: PHP All Commercial |
$3.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.00
|
| Rate for Payer: Sagamore Health Network All Products |
$3.96
|
| Rate for Payer: Signature Care EPO |
$4.26
|
| Rate for Payer: Signature Care PPO |
$4.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.36
|
| Rate for Payer: United Healthcare Commercial |
$4.04
|
| Rate for Payer: United Healthcare Medicare |
$1.69
|
|
|
DIGOXIN 250 MCG (0.25 MG) ORAL TAB
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
NDC 00904592261
|
| Hospital Charge Code |
2445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$6.11 |
| Rate for Payer: Aetna Commercial |
$5.54
|
| Rate for Payer: Aetna Medicare |
$2.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$4.07
|
| Rate for Payer: Centivo All Commercial |
$3.35
|
| Rate for Payer: Cigna All Commercial |
$5.67
|
| Rate for Payer: CORVEL All Commercial |
$6.11
|
| Rate for Payer: Coventry All Commercial |
$5.78
|
| Rate for Payer: Encore All Commercial |
$6.04
|
| Rate for Payer: Frontpath All Commercial |
$6.04
|
| Rate for Payer: Humana ChoiceCare |
$5.67
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: Lucent All Commercial |
$3.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.91
|
| Rate for Payer: PHCS All Commercial |
$4.92
|
| Rate for Payer: PHP All Commercial |
$4.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.56
|
| Rate for Payer: Sagamore Health Network All Products |
$5.07
|
| Rate for Payer: Signature Care EPO |
$5.45
|
| Rate for Payer: Signature Care PPO |
$5.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.58
|
| Rate for Payer: United Healthcare Commercial |
$5.17
|
| Rate for Payer: United Healthcare Medicare |
$2.17
|
|
|
DIGOXIN 250 MCG (0.25 MG) ORAL TAB
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
NDC 00904592261
|
| Hospital Charge Code |
2445
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$6.11 |
| Rate for Payer: Aetna Commercial |
$5.67
|
| Rate for Payer: Cash Price |
$4.07
|
| Rate for Payer: Cigna All Commercial |
$5.67
|
| Rate for Payer: CORVEL All Commercial |
$6.11
|
| Rate for Payer: Coventry All Commercial |
$5.78
|
| Rate for Payer: Encore All Commercial |
$6.04
|
| Rate for Payer: Frontpath All Commercial |
$6.04
|
| Rate for Payer: Humana ChoiceCare |
$5.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.91
|
| Rate for Payer: PHCS All Commercial |
$4.92
|
| Rate for Payer: PHP All Commercial |
$4.98
|
| Rate for Payer: Sagamore Health Network All Products |
$5.07
|
| Rate for Payer: Signature Care EPO |
$5.45
|
| Rate for Payer: Signature Care PPO |
$5.78
|
| Rate for Payer: United Healthcare Commercial |
$5.17
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN
|
Facility
|
IP
|
$41.85
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
110919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.38 |
| Max. Negotiated Rate |
$38.92 |
| Rate for Payer: Aetna Commercial |
$36.15
|
| Rate for Payer: Cash Price |
$25.94
|
| Rate for Payer: Cigna All Commercial |
$36.11
|
| Rate for Payer: CORVEL All Commercial |
$38.92
|
| Rate for Payer: Coventry All Commercial |
$36.82
|
| Rate for Payer: Encore All Commercial |
$38.52
|
| Rate for Payer: Frontpath All Commercial |
$38.50
|
| Rate for Payer: Humana ChoiceCare |
$36.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.66
|
| Rate for Payer: PHCS All Commercial |
$31.38
|
| Rate for Payer: PHP All Commercial |
$31.74
|
| Rate for Payer: Sagamore Health Network All Products |
$32.31
|
| Rate for Payer: Signature Care EPO |
$34.73
|
| Rate for Payer: Signature Care PPO |
$36.82
|
| Rate for Payer: United Healthcare Commercial |
$32.97
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN
|
Facility
|
OP
|
$41.85
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
110919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$38.92 |
| Rate for Payer: Aetna Commercial |
$35.32
|
| Rate for Payer: Aetna Medicare |
$13.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.19
|
| Rate for Payer: Cash Price |
$25.94
|
| Rate for Payer: Centivo All Commercial |
$21.34
|
| Rate for Payer: Cigna All Commercial |
$36.11
|
| Rate for Payer: CORVEL All Commercial |
$38.92
|
| Rate for Payer: Coventry All Commercial |
$36.82
|
| Rate for Payer: Encore All Commercial |
$38.52
|
| Rate for Payer: Frontpath All Commercial |
$38.50
|
| Rate for Payer: Humana ChoiceCare |
$36.14
|
| Rate for Payer: Humana Medicare |
$21.34
|
| Rate for Payer: Lucent All Commercial |
$21.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.66
|
| Rate for Payer: PHCS All Commercial |
$31.38
|
| Rate for Payer: PHP All Commercial |
$31.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.32
|
| Rate for Payer: Sagamore Health Network All Products |
$32.31
|
| Rate for Payer: Signature Care EPO |
$34.73
|
| Rate for Payer: Signature Care PPO |
$36.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.57
|
| Rate for Payer: United Healthcare Commercial |
$32.97
|
| Rate for Payer: United Healthcare Medicare |
$13.81
|
|
|
DIGOXIN IMMUNE FAB 40 MG IV SOLR
|
Facility
|
IP
|
$15,878.38
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
31432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,908.78 |
| Max. Negotiated Rate |
$14,766.89 |
| Rate for Payer: Aetna Commercial |
$13,718.92
|
| Rate for Payer: Cash Price |
$9,844.60
|
| Rate for Payer: Cigna All Commercial |
$13,703.04
|
| Rate for Payer: CORVEL All Commercial |
$14,766.89
|
| Rate for Payer: Coventry All Commercial |
$13,972.97
|
| Rate for Payer: Encore All Commercial |
$14,616.05
|
| Rate for Payer: Frontpath All Commercial |
$14,608.11
|
| Rate for Payer: Humana ChoiceCare |
$13,714.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,290.54
|
| Rate for Payer: PHCS All Commercial |
$11,908.78
|
| Rate for Payer: PHP All Commercial |
$12,042.16
|
| Rate for Payer: Sagamore Health Network All Products |
$12,258.11
|
| Rate for Payer: Signature Care EPO |
$13,179.06
|
| Rate for Payer: Signature Care PPO |
$13,972.97
|
| Rate for Payer: United Healthcare Commercial |
$12,512.16
|
|
|
DIGOXIN IMMUNE FAB 40 MG IV SOLR
|
Facility
|
OP
|
$15,878.38
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
31432
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,239.87 |
| Max. Negotiated Rate |
$14,766.89 |
| Rate for Payer: Aetna Commercial |
$13,401.35
|
| Rate for Payer: Aetna Medicare |
$5,239.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,239.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,118.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,925.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,025.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,763.85
|
| Rate for Payer: Cash Price |
$9,844.60
|
| Rate for Payer: Centivo All Commercial |
$8,097.97
|
| Rate for Payer: Cigna All Commercial |
$13,703.04
|
| Rate for Payer: CORVEL All Commercial |
$14,766.89
|
| Rate for Payer: Coventry All Commercial |
$13,972.97
|
| Rate for Payer: Encore All Commercial |
$14,616.05
|
| Rate for Payer: Frontpath All Commercial |
$14,608.11
|
| Rate for Payer: Humana ChoiceCare |
$13,714.16
|
| Rate for Payer: Humana Medicare |
$8,097.97
|
| Rate for Payer: Lucent All Commercial |
$8,097.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,290.54
|
| Rate for Payer: PHCS All Commercial |
$11,908.78
|
| Rate for Payer: PHP All Commercial |
$12,042.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,192.57
|
| Rate for Payer: Sagamore Health Network All Products |
$12,258.11
|
| Rate for Payer: Signature Care EPO |
$13,179.06
|
| Rate for Payer: Signature Care PPO |
$13,972.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,496.62
|
| Rate for Payer: United Healthcare Commercial |
$12,512.16
|
| Rate for Payer: United Healthcare Medicare |
$5,239.87
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$788.10
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
9859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$591.08 |
| Max. Negotiated Rate |
$732.93 |
| Rate for Payer: Aetna Commercial |
$680.92
|
| Rate for Payer: Cash Price |
$488.62
|
| Rate for Payer: Cigna All Commercial |
$680.13
|
| Rate for Payer: CORVEL All Commercial |
$732.93
|
| Rate for Payer: Coventry All Commercial |
$693.53
|
| Rate for Payer: Encore All Commercial |
$725.45
|
| Rate for Payer: Frontpath All Commercial |
$725.05
|
| Rate for Payer: Humana ChoiceCare |
$680.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$709.29
|
| Rate for Payer: PHCS All Commercial |
$591.08
|
| Rate for Payer: PHP All Commercial |
$597.70
|
| Rate for Payer: Sagamore Health Network All Products |
$608.41
|
| Rate for Payer: Signature Care EPO |
$654.12
|
| Rate for Payer: Signature Care PPO |
$693.53
|
| Rate for Payer: United Healthcare Commercial |
$621.02
|
|
|
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN
|
Facility
|
OP
|
$788.10
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
9859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.62 |
| Max. Negotiated Rate |
$732.93 |
| Rate for Payer: Aetna Commercial |
$665.16
|
| Rate for Payer: Aetna Medicare |
$260.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$260.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$452.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$492.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$69.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$299.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$286.08
|
| Rate for Payer: Cash Price |
$488.62
|
| Rate for Payer: Cash Price |
$488.62
|
| Rate for Payer: Centivo All Commercial |
$401.93
|
| Rate for Payer: Cigna All Commercial |
$680.13
|
| Rate for Payer: CORVEL All Commercial |
$732.93
|
| Rate for Payer: Coventry All Commercial |
$693.53
|
| Rate for Payer: Encore All Commercial |
$725.45
|
| Rate for Payer: Frontpath All Commercial |
$725.05
|
| Rate for Payer: Humana ChoiceCare |
$680.68
|
| Rate for Payer: Humana Medicare |
$401.93
|
| Rate for Payer: Lucent All Commercial |
$401.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$709.29
|
| Rate for Payer: Managed Health Services Medicaid |
$69.62
|
| Rate for Payer: MDWise Medicaid |
$69.62
|
| Rate for Payer: PHCS All Commercial |
$591.08
|
| Rate for Payer: PHP All Commercial |
$597.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$307.36
|
| Rate for Payer: Sagamore Health Network All Products |
$608.41
|
| Rate for Payer: Signature Care EPO |
$654.12
|
| Rate for Payer: Signature Care PPO |
$693.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$669.88
|
| Rate for Payer: United Healthcare Commercial |
$621.02
|
| Rate for Payer: United Healthcare Medicare |
$260.07
|
|
|
DILTIAZEM HCL 120 MG ORAL CP24
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna All Commercial |
$2.41
|
| Rate for Payer: CORVEL All Commercial |
$2.60
|
| Rate for Payer: Coventry All Commercial |
$2.46
|
| Rate for Payer: Encore All Commercial |
$2.57
|
| Rate for Payer: Frontpath All Commercial |
$2.57
|
| Rate for Payer: Humana ChoiceCare |
$2.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.51
|
| Rate for Payer: PHCS All Commercial |
$2.09
|
| Rate for Payer: PHP All Commercial |
$2.12
|
| Rate for Payer: Sagamore Health Network All Products |
$2.16
|
| Rate for Payer: Signature Care EPO |
$2.32
|
| Rate for Payer: Signature Care PPO |
$2.46
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
|
|
DILTIAZEM HCL 120 MG ORAL CP24
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
NDC 60687019511
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna All Commercial |
$2.41
|
| Rate for Payer: CORVEL All Commercial |
$2.60
|
| Rate for Payer: Coventry All Commercial |
$2.46
|
| Rate for Payer: Encore All Commercial |
$2.57
|
| Rate for Payer: Frontpath All Commercial |
$2.57
|
| Rate for Payer: Humana ChoiceCare |
$2.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.51
|
| Rate for Payer: PHCS All Commercial |
$2.09
|
| Rate for Payer: PHP All Commercial |
$2.12
|
| Rate for Payer: Sagamore Health Network All Products |
$2.16
|
| Rate for Payer: Signature Care EPO |
$2.32
|
| Rate for Payer: Signature Care PPO |
$2.46
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
|
|
DILTIAZEM HCL 120 MG ORAL CP24
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
NDC 60687019511
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Centivo All Commercial |
$1.42
|
| Rate for Payer: Cigna All Commercial |
$2.41
|
| Rate for Payer: CORVEL All Commercial |
$2.60
|
| Rate for Payer: Coventry All Commercial |
$2.46
|
| Rate for Payer: Encore All Commercial |
$2.57
|
| Rate for Payer: Frontpath All Commercial |
$2.57
|
| Rate for Payer: Humana ChoiceCare |
$2.41
|
| Rate for Payer: Humana Medicare |
$1.42
|
| Rate for Payer: Lucent All Commercial |
$1.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.51
|
| Rate for Payer: PHCS All Commercial |
$2.09
|
| Rate for Payer: PHP All Commercial |
$2.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.09
|
| Rate for Payer: Sagamore Health Network All Products |
$2.16
|
| Rate for Payer: Signature Care EPO |
$2.32
|
| Rate for Payer: Signature Care PPO |
$2.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.37
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
| Rate for Payer: United Healthcare Medicare |
$0.92
|
|
|
DILTIAZEM HCL 120 MG ORAL CP24
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
27480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Centivo All Commercial |
$1.42
|
| Rate for Payer: Cigna All Commercial |
$2.41
|
| Rate for Payer: CORVEL All Commercial |
$2.60
|
| Rate for Payer: Coventry All Commercial |
$2.46
|
| Rate for Payer: Encore All Commercial |
$2.57
|
| Rate for Payer: Frontpath All Commercial |
$2.57
|
| Rate for Payer: Humana ChoiceCare |
$2.41
|
| Rate for Payer: Humana Medicare |
$1.42
|
| Rate for Payer: Lucent All Commercial |
$1.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.51
|
| Rate for Payer: PHCS All Commercial |
$2.09
|
| Rate for Payer: PHP All Commercial |
$2.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.09
|
| Rate for Payer: Sagamore Health Network All Products |
$2.16
|
| Rate for Payer: Signature Care EPO |
$2.32
|
| Rate for Payer: Signature Care PPO |
$2.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.37
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
| Rate for Payer: United Healthcare Medicare |
$0.92
|
|
|
DILTIAZEM HCL 180 MG ORAL CP24
|
Facility
|
IP
|
$2.29
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna All Commercial |
$1.98
|
| Rate for Payer: CORVEL All Commercial |
$2.13
|
| Rate for Payer: Coventry All Commercial |
$2.01
|
| Rate for Payer: Encore All Commercial |
$2.11
|
| Rate for Payer: Frontpath All Commercial |
$2.11
|
| Rate for Payer: Humana ChoiceCare |
$1.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.06
|
| Rate for Payer: PHCS All Commercial |
$1.72
|
| Rate for Payer: PHP All Commercial |
$1.74
|
| Rate for Payer: Sagamore Health Network All Products |
$1.77
|
| Rate for Payer: Signature Care EPO |
$1.90
|
| Rate for Payer: Signature Care PPO |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
|
|
DILTIAZEM HCL 180 MG ORAL CP24
|
Facility
|
OP
|
$2.29
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
29272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna Commercial |
$1.93
|
| Rate for Payer: Aetna Medicare |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.83
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Centivo All Commercial |
$1.17
|
| Rate for Payer: Cigna All Commercial |
$1.98
|
| Rate for Payer: CORVEL All Commercial |
$2.13
|
| Rate for Payer: Coventry All Commercial |
$2.01
|
| Rate for Payer: Encore All Commercial |
$2.11
|
| Rate for Payer: Frontpath All Commercial |
$2.11
|
| Rate for Payer: Humana ChoiceCare |
$1.98
|
| Rate for Payer: Humana Medicare |
$1.17
|
| Rate for Payer: Lucent All Commercial |
$1.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.06
|
| Rate for Payer: PHCS All Commercial |
$1.72
|
| Rate for Payer: PHP All Commercial |
$1.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.89
|
| Rate for Payer: Sagamore Health Network All Products |
$1.77
|
| Rate for Payer: Signature Care EPO |
$1.90
|
| Rate for Payer: Signature Care PPO |
$2.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.95
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
| Rate for Payer: United Healthcare Medicare |
$0.76
|
|
|
DILTIAZEM HCL 30 MG ORAL TAB
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.56
|
| Rate for Payer: Coventry All Commercial |
$2.42
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.53
|
| Rate for Payer: Humana ChoiceCare |
$2.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.48
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.09
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
|
|
DILTIAZEM HCL 30 MG ORAL TAB
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Centivo All Commercial |
$1.40
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.56
|
| Rate for Payer: Coventry All Commercial |
$2.42
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.53
|
| Rate for Payer: Humana ChoiceCare |
$2.38
|
| Rate for Payer: Humana Medicare |
$1.40
|
| Rate for Payer: Lucent All Commercial |
$1.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.48
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.34
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
| Rate for Payer: United Healthcare Medicare |
$0.91
|
|
|
DILTIAZEM HCL 30 MG ORAL TAB
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687071711
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Centivo All Commercial |
$1.40
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.56
|
| Rate for Payer: Coventry All Commercial |
$2.42
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.53
|
| Rate for Payer: Humana ChoiceCare |
$2.38
|
| Rate for Payer: Humana Medicare |
$1.40
|
| Rate for Payer: Lucent All Commercial |
$1.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.48
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.34
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
| Rate for Payer: United Healthcare Medicare |
$0.91
|
|
|
DILTIAZEM HCL 30 MG ORAL TAB
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687071711
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.56
|
| Rate for Payer: Coventry All Commercial |
$2.42
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.53
|
| Rate for Payer: Humana ChoiceCare |
$2.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.48
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.09
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
|
|
DILTIAZEM HCL 5 MG/ML IV SOLN
|
Facility
|
IP
|
$24.57
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
97253
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$22.85 |
| Rate for Payer: Aetna Commercial |
$21.23
|
| Rate for Payer: Aetna Commercial |
$49.59
|
| Rate for Payer: Cash Price |
$15.23
|
| Rate for Payer: Cash Price |
$35.59
|
| Rate for Payer: Cigna All Commercial |
$49.54
|
| Rate for Payer: Cigna All Commercial |
$21.20
|
| Rate for Payer: CORVEL All Commercial |
$22.85
|
| Rate for Payer: CORVEL All Commercial |
$53.38
|
| Rate for Payer: Coventry All Commercial |
$21.62
|
| Rate for Payer: Coventry All Commercial |
$50.51
|
| Rate for Payer: Encore All Commercial |
$52.84
|
| Rate for Payer: Encore All Commercial |
$22.62
|
| Rate for Payer: Frontpath All Commercial |
$52.81
|
| Rate for Payer: Frontpath All Commercial |
$22.60
|
| Rate for Payer: Humana ChoiceCare |
$21.22
|
| Rate for Payer: Humana ChoiceCare |
$49.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.11
|
| Rate for Payer: PHCS All Commercial |
$18.43
|
| Rate for Payer: PHCS All Commercial |
$43.05
|
| Rate for Payer: PHP All Commercial |
$43.53
|
| Rate for Payer: PHP All Commercial |
$18.63
|
| Rate for Payer: Sagamore Health Network All Products |
$44.31
|
| Rate for Payer: Sagamore Health Network All Products |
$18.97
|
| Rate for Payer: Signature Care EPO |
$20.39
|
| Rate for Payer: Signature Care EPO |
$47.64
|
| Rate for Payer: Signature Care PPO |
$50.51
|
| Rate for Payer: Signature Care PPO |
$21.62
|
| Rate for Payer: United Healthcare Commercial |
$19.36
|
| Rate for Payer: United Healthcare Commercial |
$45.23
|
|
|
DILTIAZEM HCL 5 MG/ML IV SOLN
|
Facility
|
OP
|
$24.57
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
97253
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$22.85 |
| Rate for Payer: Aetna Commercial |
$20.74
|
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$18.94
|
| Rate for Payer: Aetna Medicare |
$8.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$32.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.84
|
| Rate for Payer: Cash Price |
$15.23
|
| Rate for Payer: Cash Price |
$35.59
|
| Rate for Payer: Centivo All Commercial |
$29.27
|
| Rate for Payer: Centivo All Commercial |
$12.53
|
| Rate for Payer: Cigna All Commercial |
$49.54
|
| Rate for Payer: Cigna All Commercial |
$21.20
|
| Rate for Payer: CORVEL All Commercial |
$22.85
|
| Rate for Payer: CORVEL All Commercial |
$53.38
|
| Rate for Payer: Coventry All Commercial |
$50.51
|
| Rate for Payer: Coventry All Commercial |
$21.62
|
| Rate for Payer: Encore All Commercial |
$22.62
|
| Rate for Payer: Encore All Commercial |
$52.84
|
| Rate for Payer: Frontpath All Commercial |
$22.60
|
| Rate for Payer: Frontpath All Commercial |
$52.81
|
| Rate for Payer: Humana ChoiceCare |
$49.58
|
| Rate for Payer: Humana ChoiceCare |
$21.22
|
| Rate for Payer: Humana Medicare |
$29.27
|
| Rate for Payer: Humana Medicare |
$12.53
|
| Rate for Payer: Lucent All Commercial |
$29.27
|
| Rate for Payer: Lucent All Commercial |
$12.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.66
|
| Rate for Payer: PHCS All Commercial |
$18.43
|
| Rate for Payer: PHCS All Commercial |
$43.05
|
| Rate for Payer: PHP All Commercial |
$18.63
|
| Rate for Payer: PHP All Commercial |
$43.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.58
|
| Rate for Payer: Sagamore Health Network All Products |
$44.31
|
| Rate for Payer: Sagamore Health Network All Products |
$18.97
|
| Rate for Payer: Signature Care EPO |
$47.64
|
| Rate for Payer: Signature Care EPO |
$20.39
|
| Rate for Payer: Signature Care PPO |
$21.62
|
| Rate for Payer: Signature Care PPO |
$50.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.79
|
| Rate for Payer: United Healthcare Commercial |
$45.23
|
| Rate for Payer: United Healthcare Commercial |
$19.36
|
| Rate for Payer: United Healthcare Medicare |
$8.11
|
| Rate for Payer: United Healthcare Medicare |
$18.94
|
|
|
DILTIAZEM HCL 60 MG ORAL TAB
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 00093031901
|
| Hospital Charge Code |
2476
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.35
|
| Rate for Payer: Encore All Commercial |
$1.41
|
| Rate for Payer: Frontpath All Commercial |
$1.41
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.38
|
| Rate for Payer: PHCS All Commercial |
$1.15
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
DILTIAZEM HCL 60 MG ORAL TAB
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 00093031901
|
| Hospital Charge Code |
2476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Aetna Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.96
|
| 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 |
$0.78
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.35
|
| Rate for Payer: Encore All Commercial |
$1.41
|
| Rate for Payer: Frontpath All Commercial |
$1.41
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Humana Medicare |
$0.78
|
| Rate for Payer: Lucent All Commercial |
$0.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.38
|
| Rate for Payer: PHCS All Commercial |
$1.15
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
|
