|
DILTIAZEM HCL IN 0.9% NACL 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
121619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
|
|
DILTIAZEM HCL IN 0.9% NACL 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
121619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$88.62
|
| Rate for Payer: Aetna Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.12
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Centivo All Commercial |
$53.55
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Humana Medicare |
$53.55
|
| Rate for Payer: Lucent All Commercial |
$53.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.95
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
| Rate for Payer: United Healthcare Medicare |
$34.65
|
|
|
DILTIAZEM IN DEXTROSE 5 % 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
OP
|
$143.50
|
|
|
Service Code
|
NDC 70092157536
|
| Hospital Charge Code |
117323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$121.11
|
| Rate for Payer: Aetna Medicare |
$47.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$82.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.09
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centivo All Commercial |
$73.18
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Humana Medicare |
$73.18
|
| Rate for Payer: Lucent All Commercial |
$73.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.96
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.10
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.98
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
| Rate for Payer: United Healthcare Medicare |
$47.36
|
|
|
DILTIAZEM IN DEXTROSE 5 % 125 MG/125 ML (1 MG/ML) IV SOLN
|
Facility
|
IP
|
$143.50
|
|
|
Service Code
|
NDC 70092157536
|
| Hospital Charge Code |
117323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.62 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$123.98
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.10
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
|
|
DINOPROSTONE 10 MG VAGL INER
|
Facility
|
IP
|
$1,988.00
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,491.00 |
| Max. Negotiated Rate |
$1,848.84 |
| Rate for Payer: Aetna Commercial |
$1,717.63
|
| Rate for Payer: Cash Price |
$1,232.56
|
| Rate for Payer: Cigna All Commercial |
$1,715.64
|
| Rate for Payer: CORVEL All Commercial |
$1,848.84
|
| Rate for Payer: Coventry All Commercial |
$1,749.44
|
| Rate for Payer: Encore All Commercial |
$1,829.95
|
| Rate for Payer: Frontpath All Commercial |
$1,828.96
|
| Rate for Payer: Humana ChoiceCare |
$1,717.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,789.20
|
| Rate for Payer: PHCS All Commercial |
$1,491.00
|
| Rate for Payer: PHP All Commercial |
$1,507.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.74
|
| Rate for Payer: Signature Care EPO |
$1,650.04
|
| Rate for Payer: Signature Care PPO |
$1,749.44
|
| Rate for Payer: United Healthcare Commercial |
$1,566.54
|
|
|
DINOPROSTONE 10 MG VAGL INER
|
Facility
|
OP
|
$1,988.00
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,848.84 |
| Rate for Payer: Aetna Commercial |
$1,677.87
|
| Rate for Payer: Aetna Medicare |
$656.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$656.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,141.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,242.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$754.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$721.64
|
| Rate for Payer: Cash Price |
$1,232.56
|
| Rate for Payer: Cash Price |
$1,232.56
|
| Rate for Payer: Centivo All Commercial |
$1,013.88
|
| Rate for Payer: Cigna All Commercial |
$1,715.64
|
| Rate for Payer: CORVEL All Commercial |
$1,848.84
|
| Rate for Payer: Coventry All Commercial |
$1,749.44
|
| Rate for Payer: Encore All Commercial |
$1,829.95
|
| Rate for Payer: Frontpath All Commercial |
$1,828.96
|
| Rate for Payer: Humana ChoiceCare |
$1,717.04
|
| Rate for Payer: Humana Medicare |
$1,013.88
|
| Rate for Payer: Lucent All Commercial |
$1,013.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,789.20
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1,491.00
|
| Rate for Payer: PHP All Commercial |
$1,507.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$775.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.74
|
| Rate for Payer: Signature Care EPO |
$1,650.04
|
| Rate for Payer: Signature Care PPO |
$1,749.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,689.80
|
| Rate for Payer: United Healthcare Commercial |
$1,566.54
|
| Rate for Payer: United Healthcare Medicare |
$656.04
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL ELIX
|
Facility
|
IP
|
$26.46
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.84 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cigna All Commercial |
$22.83
|
| Rate for Payer: CORVEL All Commercial |
$24.61
|
| Rate for Payer: Coventry All Commercial |
$23.28
|
| Rate for Payer: Encore All Commercial |
$24.36
|
| Rate for Payer: Frontpath All Commercial |
$24.34
|
| Rate for Payer: Humana ChoiceCare |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.81
|
| Rate for Payer: PHCS All Commercial |
$19.84
|
| Rate for Payer: PHP All Commercial |
$20.07
|
| Rate for Payer: Sagamore Health Network All Products |
$20.43
|
| Rate for Payer: Signature Care EPO |
$21.96
|
| Rate for Payer: Signature Care PPO |
$23.28
|
| Rate for Payer: United Healthcare Commercial |
$20.85
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL ELIX
|
Facility
|
OP
|
$26.46
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.73 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Aetna Medicare |
$8.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.60
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Centivo All Commercial |
$13.49
|
| Rate for Payer: Cigna All Commercial |
$22.83
|
| Rate for Payer: CORVEL All Commercial |
$24.61
|
| Rate for Payer: Coventry All Commercial |
$23.28
|
| Rate for Payer: Encore All Commercial |
$24.36
|
| Rate for Payer: Frontpath All Commercial |
$24.34
|
| Rate for Payer: Humana ChoiceCare |
$22.85
|
| Rate for Payer: Humana Medicare |
$13.49
|
| Rate for Payer: Lucent All Commercial |
$13.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.81
|
| Rate for Payer: PHCS All Commercial |
$19.84
|
| Rate for Payer: PHP All Commercial |
$20.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.32
|
| Rate for Payer: Sagamore Health Network All Products |
$20.43
|
| Rate for Payer: Signature Care EPO |
$21.96
|
| Rate for Payer: Signature Care PPO |
$23.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.49
|
| Rate for Payer: United Healthcare Commercial |
$20.85
|
| Rate for Payer: United Healthcare Medicare |
$8.73
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL S.O.
|
Facility
|
IP
|
$8.82
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
140112556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Aetna Commercial |
$7.62
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cigna All Commercial |
$7.61
|
| Rate for Payer: CORVEL All Commercial |
$8.20
|
| Rate for Payer: Coventry All Commercial |
$7.76
|
| Rate for Payer: Encore All Commercial |
$8.12
|
| Rate for Payer: Frontpath All Commercial |
$8.11
|
| Rate for Payer: Humana ChoiceCare |
$7.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.94
|
| Rate for Payer: PHCS All Commercial |
$6.62
|
| Rate for Payer: PHP All Commercial |
$6.69
|
| Rate for Payer: Sagamore Health Network All Products |
$6.81
|
| Rate for Payer: Signature Care EPO |
$7.32
|
| Rate for Payer: Signature Care PPO |
$7.76
|
| Rate for Payer: United Healthcare Commercial |
$6.95
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML ORAL S.O.
|
Facility
|
OP
|
$8.82
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
140112556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Centivo All Commercial |
$4.50
|
| Rate for Payer: Cigna All Commercial |
$7.61
|
| Rate for Payer: CORVEL All Commercial |
$8.20
|
| Rate for Payer: Coventry All Commercial |
$7.76
|
| Rate for Payer: Encore All Commercial |
$8.12
|
| Rate for Payer: Frontpath All Commercial |
$8.11
|
| Rate for Payer: Humana ChoiceCare |
$7.62
|
| Rate for Payer: Humana Medicare |
$4.50
|
| Rate for Payer: Lucent All Commercial |
$4.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.94
|
| Rate for Payer: PHCS All Commercial |
$6.62
|
| Rate for Payer: PHP All Commercial |
$6.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.44
|
| Rate for Payer: Sagamore Health Network All Products |
$6.81
|
| Rate for Payer: Signature Care EPO |
$7.32
|
| Rate for Payer: Signature Care PPO |
$7.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.50
|
| Rate for Payer: United Healthcare Commercial |
$6.95
|
| Rate for Payer: United Healthcare Medicare |
$2.91
|
|
|
DIPHENHYDRAMINE HCL 25 MG ORAL CAP
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna All Commercial |
$0.26
|
| Rate for Payer: CORVEL All Commercial |
$0.28
|
| Rate for Payer: Coventry All Commercial |
$0.26
|
| Rate for Payer: Encore All Commercial |
$0.28
|
| Rate for Payer: Frontpath All Commercial |
$0.28
|
| Rate for Payer: Humana ChoiceCare |
$0.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.27
|
| Rate for Payer: PHCS All Commercial |
$0.23
|
| Rate for Payer: PHP All Commercial |
$0.23
|
| Rate for Payer: Sagamore Health Network All Products |
$0.23
|
| Rate for Payer: Signature Care EPO |
$0.25
|
| Rate for Payer: Signature Care PPO |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
|
|
DIPHENHYDRAMINE HCL 25 MG ORAL CAP
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$0.25
|
| Rate for Payer: Aetna Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Centivo All Commercial |
$0.15
|
| Rate for Payer: Cigna All Commercial |
$0.26
|
| Rate for Payer: CORVEL All Commercial |
$0.28
|
| Rate for Payer: Coventry All Commercial |
$0.26
|
| Rate for Payer: Encore All Commercial |
$0.28
|
| Rate for Payer: Frontpath All Commercial |
$0.28
|
| Rate for Payer: Humana ChoiceCare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.15
|
| Rate for Payer: Lucent All Commercial |
$0.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.27
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$0.23
|
| Rate for Payer: PHP All Commercial |
$0.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.12
|
| Rate for Payer: Sagamore Health Network All Products |
$0.23
|
| Rate for Payer: Signature Care EPO |
$0.25
|
| Rate for Payer: Signature Care PPO |
$0.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$19.92
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$18.53 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Aetna Medicare |
$6.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.23
|
| Rate for Payer: Cash Price |
$12.35
|
| Rate for Payer: Centivo All Commercial |
$10.16
|
| Rate for Payer: Cigna All Commercial |
$17.19
|
| Rate for Payer: CORVEL All Commercial |
$18.53
|
| Rate for Payer: Coventry All Commercial |
$17.53
|
| Rate for Payer: Encore All Commercial |
$18.34
|
| Rate for Payer: Frontpath All Commercial |
$18.33
|
| Rate for Payer: Humana ChoiceCare |
$17.21
|
| Rate for Payer: Humana Medicare |
$10.16
|
| Rate for Payer: Lucent All Commercial |
$10.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.93
|
| Rate for Payer: PHCS All Commercial |
$14.94
|
| Rate for Payer: PHP All Commercial |
$15.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.77
|
| Rate for Payer: Sagamore Health Network All Products |
$15.38
|
| Rate for Payer: Signature Care EPO |
$16.54
|
| Rate for Payer: Signature Care PPO |
$17.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.93
|
| Rate for Payer: United Healthcare Commercial |
$15.70
|
| Rate for Payer: United Healthcare Medicare |
$6.57
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$19.92
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$18.53 |
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$12.35
|
| Rate for Payer: Cigna All Commercial |
$17.19
|
| Rate for Payer: CORVEL All Commercial |
$18.53
|
| Rate for Payer: Coventry All Commercial |
$17.53
|
| Rate for Payer: Encore All Commercial |
$18.34
|
| Rate for Payer: Frontpath All Commercial |
$18.33
|
| Rate for Payer: Humana ChoiceCare |
$17.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.93
|
| Rate for Payer: PHCS All Commercial |
$14.94
|
| Rate for Payer: PHP All Commercial |
$15.11
|
| Rate for Payer: Sagamore Health Network All Products |
$15.38
|
| Rate for Payer: Signature Care EPO |
$16.54
|
| Rate for Payer: Signature Care PPO |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$15.70
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % TOP CREA
|
Facility
|
OP
|
$12.94
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$12.03 |
| Rate for Payer: Aetna Commercial |
$10.92
|
| Rate for Payer: Aetna Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.70
|
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Centivo All Commercial |
$6.60
|
| Rate for Payer: Cigna All Commercial |
$11.16
|
| Rate for Payer: CORVEL All Commercial |
$12.03
|
| Rate for Payer: Coventry All Commercial |
$11.38
|
| Rate for Payer: Encore All Commercial |
$11.91
|
| Rate for Payer: Frontpath All Commercial |
$11.90
|
| Rate for Payer: Humana ChoiceCare |
$11.17
|
| Rate for Payer: Humana Medicare |
$6.60
|
| Rate for Payer: Lucent All Commercial |
$6.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.64
|
| Rate for Payer: PHCS All Commercial |
$9.70
|
| Rate for Payer: PHP All Commercial |
$9.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.05
|
| Rate for Payer: Sagamore Health Network All Products |
$9.99
|
| Rate for Payer: Signature Care EPO |
$10.74
|
| Rate for Payer: Signature Care PPO |
$11.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.00
|
| Rate for Payer: United Healthcare Commercial |
$10.19
|
| Rate for Payer: United Healthcare Medicare |
$4.27
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % TOP CREA
|
Facility
|
IP
|
$12.94
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$12.03 |
| Rate for Payer: Aetna Commercial |
$11.18
|
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Cigna All Commercial |
$11.16
|
| Rate for Payer: CORVEL All Commercial |
$12.03
|
| Rate for Payer: Coventry All Commercial |
$11.38
|
| Rate for Payer: Encore All Commercial |
$11.91
|
| Rate for Payer: Frontpath All Commercial |
$11.90
|
| Rate for Payer: Humana ChoiceCare |
$11.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.64
|
| Rate for Payer: PHCS All Commercial |
$9.70
|
| Rate for Payer: PHP All Commercial |
$9.81
|
| Rate for Payer: Sagamore Health Network All Products |
$9.99
|
| Rate for Payer: Signature Care EPO |
$10.74
|
| Rate for Payer: Signature Care PPO |
$11.38
|
| Rate for Payer: United Healthcare Commercial |
$10.19
|
|
|
DIPHEN-LIDOCAINE-MAG,AL-SIMETH 25-200-400-40 MG/30ML MM MWSH
|
Facility
|
IP
|
$592.50
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$444.38 |
| Max. Negotiated Rate |
$551.02 |
| Rate for Payer: Aetna Commercial |
$511.92
|
| Rate for Payer: Cash Price |
$367.35
|
| Rate for Payer: Cigna All Commercial |
$511.33
|
| Rate for Payer: CORVEL All Commercial |
$551.02
|
| Rate for Payer: Coventry All Commercial |
$521.40
|
| Rate for Payer: Encore All Commercial |
$545.40
|
| Rate for Payer: Frontpath All Commercial |
$545.10
|
| Rate for Payer: Humana ChoiceCare |
$511.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$533.25
|
| Rate for Payer: PHCS All Commercial |
$444.38
|
| Rate for Payer: PHP All Commercial |
$449.35
|
| Rate for Payer: Sagamore Health Network All Products |
$457.41
|
| Rate for Payer: Signature Care EPO |
$491.78
|
| Rate for Payer: Signature Care PPO |
$521.40
|
| Rate for Payer: United Healthcare Commercial |
$466.89
|
|
|
DIPHEN-LIDOCAINE-MAG,AL-SIMETH 25-200-400-40 MG/30ML MM MWSH
|
Facility
|
OP
|
$592.50
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$551.02 |
| Rate for Payer: Aetna Commercial |
$500.07
|
| Rate for Payer: Aetna Medicare |
$195.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$195.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$340.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$370.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$224.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$215.08
|
| Rate for Payer: Cash Price |
$367.35
|
| Rate for Payer: Cash Price |
$367.35
|
| Rate for Payer: Centivo All Commercial |
$302.18
|
| Rate for Payer: Cigna All Commercial |
$511.33
|
| Rate for Payer: CORVEL All Commercial |
$551.02
|
| Rate for Payer: Coventry All Commercial |
$521.40
|
| Rate for Payer: Encore All Commercial |
$545.40
|
| Rate for Payer: Frontpath All Commercial |
$545.10
|
| Rate for Payer: Humana ChoiceCare |
$511.74
|
| Rate for Payer: Humana Medicare |
$302.18
|
| Rate for Payer: Lucent All Commercial |
$302.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$533.25
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$444.38
|
| Rate for Payer: PHP All Commercial |
$449.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$231.08
|
| Rate for Payer: Sagamore Health Network All Products |
$457.41
|
| Rate for Payer: Signature Care EPO |
$491.78
|
| Rate for Payer: Signature Care PPO |
$521.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$503.62
|
| Rate for Payer: United Healthcare Commercial |
$466.89
|
| Rate for Payer: United Healthcare Medicare |
$195.52
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687056901
|
| Hospital Charge Code |
2516
|
|
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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687056901
|
| Hospital Charge Code |
2516
|
|
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
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$137.35
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
111041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.02 |
| Max. Negotiated Rate |
$127.74 |
| Rate for Payer: Aetna Commercial |
$118.67
|
| Rate for Payer: Cash Price |
$85.16
|
| Rate for Payer: Cigna All Commercial |
$118.54
|
| Rate for Payer: CORVEL All Commercial |
$127.74
|
| Rate for Payer: Coventry All Commercial |
$120.87
|
| Rate for Payer: Encore All Commercial |
$126.43
|
| Rate for Payer: Frontpath All Commercial |
$126.37
|
| Rate for Payer: Humana ChoiceCare |
$118.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.62
|
| Rate for Payer: PHCS All Commercial |
$103.02
|
| Rate for Payer: PHP All Commercial |
$104.17
|
| Rate for Payer: Sagamore Health Network All Products |
$106.04
|
| Rate for Payer: Signature Care EPO |
$114.00
|
| Rate for Payer: Signature Care PPO |
$120.87
|
| Rate for Payer: United Healthcare Commercial |
$108.23
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$137.35
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
111041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.33 |
| Max. Negotiated Rate |
$127.74 |
| Rate for Payer: Aetna Commercial |
$115.93
|
| Rate for Payer: Aetna Medicare |
$45.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$78.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$49.86
|
| Rate for Payer: Cash Price |
$85.16
|
| Rate for Payer: Centivo All Commercial |
$70.05
|
| Rate for Payer: Cigna All Commercial |
$118.54
|
| Rate for Payer: CORVEL All Commercial |
$127.74
|
| Rate for Payer: Coventry All Commercial |
$120.87
|
| Rate for Payer: Encore All Commercial |
$126.43
|
| Rate for Payer: Frontpath All Commercial |
$126.37
|
| Rate for Payer: Humana ChoiceCare |
$118.63
|
| Rate for Payer: Humana Medicare |
$70.05
|
| Rate for Payer: Lucent All Commercial |
$70.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.62
|
| Rate for Payer: PHCS All Commercial |
$103.02
|
| Rate for Payer: PHP All Commercial |
$104.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.57
|
| Rate for Payer: Sagamore Health Network All Products |
$106.04
|
| Rate for Payer: Signature Care EPO |
$114.00
|
| Rate for Payer: Signature Care PPO |
$120.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.75
|
| Rate for Payer: United Healthcare Commercial |
$108.23
|
| Rate for Payer: United Healthcare Medicare |
$45.33
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.36 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$162.04
|
| Rate for Payer: Aetna Medicare |
$63.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$63.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$110.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$120.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$72.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$69.69
|
| Rate for Payer: Cash Price |
$119.04
|
| Rate for Payer: Centivo All Commercial |
$97.92
|
| Rate for Payer: Cigna All Commercial |
$165.69
|
| Rate for Payer: CORVEL All Commercial |
$178.56
|
| Rate for Payer: Coventry All Commercial |
$168.96
|
| Rate for Payer: Encore All Commercial |
$176.73
|
| Rate for Payer: Frontpath All Commercial |
$176.64
|
| Rate for Payer: Humana ChoiceCare |
$165.83
|
| Rate for Payer: Humana Medicare |
$97.92
|
| Rate for Payer: Lucent All Commercial |
$97.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.80
|
| Rate for Payer: PHCS All Commercial |
$144.00
|
| Rate for Payer: PHP All Commercial |
$145.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$74.88
|
| Rate for Payer: Sagamore Health Network All Products |
$148.22
|
| Rate for Payer: Signature Care EPO |
$159.36
|
| Rate for Payer: Signature Care PPO |
$168.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$163.20
|
| Rate for Payer: United Healthcare Commercial |
$151.29
|
| Rate for Payer: United Healthcare Medicare |
$63.36
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$165.88
|
| Rate for Payer: Cash Price |
$119.04
|
| Rate for Payer: Cigna All Commercial |
$165.69
|
| Rate for Payer: CORVEL All Commercial |
$178.56
|
| Rate for Payer: Coventry All Commercial |
$168.96
|
| Rate for Payer: Encore All Commercial |
$176.73
|
| Rate for Payer: Frontpath All Commercial |
$176.64
|
| Rate for Payer: Humana ChoiceCare |
$165.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.80
|
| Rate for Payer: PHCS All Commercial |
$144.00
|
| Rate for Payer: PHP All Commercial |
$145.61
|
| Rate for Payer: Sagamore Health Network All Products |
$148.22
|
| Rate for Payer: Signature Care EPO |
$159.36
|
| Rate for Payer: Signature Care PPO |
$168.96
|
| Rate for Payer: United Healthcare Commercial |
$151.29
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SUSP
|
Facility
|
OP
|
$325.76
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
167647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.50 |
| Max. Negotiated Rate |
$302.95 |
| Rate for Payer: Aetna Commercial |
$274.94
|
| Rate for Payer: Aetna Medicare |
$107.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$107.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$187.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$203.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$123.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$118.25
|
| Rate for Payer: Cash Price |
$201.97
|
| Rate for Payer: Centivo All Commercial |
$166.14
|
| Rate for Payer: Cigna All Commercial |
$281.13
|
| Rate for Payer: CORVEL All Commercial |
$302.95
|
| Rate for Payer: Coventry All Commercial |
$286.67
|
| Rate for Payer: Encore All Commercial |
$299.86
|
| Rate for Payer: Frontpath All Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$281.36
|
| Rate for Payer: Humana Medicare |
$166.14
|
| Rate for Payer: Lucent All Commercial |
$166.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$293.18
|
| Rate for Payer: PHCS All Commercial |
$244.32
|
| Rate for Payer: PHP All Commercial |
$247.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$127.05
|
| Rate for Payer: Sagamore Health Network All Products |
$251.49
|
| Rate for Payer: Signature Care EPO |
$270.38
|
| Rate for Payer: Signature Care PPO |
$286.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$276.89
|
| Rate for Payer: United Healthcare Commercial |
$256.70
|
| Rate for Payer: United Healthcare Medicare |
$107.50
|
|
