|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Centivo All Commercial |
$2.12
|
| Rate for Payer: Cigna All Commercial |
$3.59
|
| Rate for Payer: CORVEL All Commercial |
$3.87
|
| Rate for Payer: Coventry All Commercial |
$3.66
|
| Rate for Payer: Encore All Commercial |
$3.83
|
| Rate for Payer: Frontpath All Commercial |
$3.83
|
| Rate for Payer: Humana ChoiceCare |
$3.59
|
| Rate for Payer: Humana Medicare |
$2.12
|
| Rate for Payer: Lucent All Commercial |
$2.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.74
|
| Rate for Payer: PHCS All Commercial |
$3.12
|
| Rate for Payer: PHP All Commercial |
$3.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.62
|
| Rate for Payer: Sagamore Health Network All Products |
$3.21
|
| Rate for Payer: Signature Care EPO |
$3.45
|
| Rate for Payer: Signature Care PPO |
$3.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.53
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
| Rate for Payer: United Healthcare Medicare |
$1.37
|
|
|
DIVALPROEX 125 MG ORAL TBEC
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna All Commercial |
$3.59
|
| Rate for Payer: CORVEL All Commercial |
$3.87
|
| Rate for Payer: Coventry All Commercial |
$3.66
|
| Rate for Payer: Encore All Commercial |
$3.83
|
| Rate for Payer: Frontpath All Commercial |
$3.83
|
| Rate for Payer: Humana ChoiceCare |
$3.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.74
|
| Rate for Payer: PHCS All Commercial |
$3.12
|
| Rate for Payer: PHP All Commercial |
$3.15
|
| Rate for Payer: Sagamore Health Network All Products |
$3.21
|
| Rate for Payer: Signature Care EPO |
$3.45
|
| Rate for Payer: Signature Care PPO |
$3.66
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
OP
|
$6.50
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$5.48
|
| Rate for Payer: Aetna Medicare |
$2.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.36
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Centivo All Commercial |
$3.31
|
| Rate for Payer: Cigna All Commercial |
$5.61
|
| Rate for Payer: CORVEL All Commercial |
$6.04
|
| Rate for Payer: Coventry All Commercial |
$5.72
|
| Rate for Payer: Encore All Commercial |
$5.98
|
| Rate for Payer: Frontpath All Commercial |
$5.98
|
| Rate for Payer: Humana ChoiceCare |
$5.61
|
| Rate for Payer: Humana Medicare |
$3.31
|
| Rate for Payer: Lucent All Commercial |
$3.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.85
|
| Rate for Payer: PHCS All Commercial |
$4.87
|
| Rate for Payer: PHP All Commercial |
$4.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.53
|
| Rate for Payer: Sagamore Health Network All Products |
$5.01
|
| Rate for Payer: Signature Care EPO |
$5.39
|
| Rate for Payer: Signature Care PPO |
$5.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.52
|
| Rate for Payer: United Healthcare Commercial |
$5.12
|
| Rate for Payer: United Healthcare Medicare |
$2.14
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
IP
|
$6.50
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$5.61
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Cigna All Commercial |
$5.61
|
| Rate for Payer: CORVEL All Commercial |
$6.04
|
| Rate for Payer: Coventry All Commercial |
$5.72
|
| Rate for Payer: Encore All Commercial |
$5.98
|
| Rate for Payer: Frontpath All Commercial |
$5.98
|
| Rate for Payer: Humana ChoiceCare |
$5.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.85
|
| Rate for Payer: PHCS All Commercial |
$4.87
|
| Rate for Payer: PHP All Commercial |
$4.93
|
| Rate for Payer: Sagamore Health Network All Products |
$5.01
|
| Rate for Payer: Signature Care EPO |
$5.39
|
| Rate for Payer: Signature Care PPO |
$5.72
|
| Rate for Payer: United Healthcare Commercial |
$5.12
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
IP
|
$6.50
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$5.61
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Cigna All Commercial |
$5.61
|
| Rate for Payer: CORVEL All Commercial |
$6.04
|
| Rate for Payer: Coventry All Commercial |
$5.72
|
| Rate for Payer: Encore All Commercial |
$5.98
|
| Rate for Payer: Frontpath All Commercial |
$5.98
|
| Rate for Payer: Humana ChoiceCare |
$5.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.85
|
| Rate for Payer: PHCS All Commercial |
$4.87
|
| Rate for Payer: PHP All Commercial |
$4.93
|
| Rate for Payer: Sagamore Health Network All Products |
$5.01
|
| Rate for Payer: Signature Care EPO |
$5.39
|
| Rate for Payer: Signature Care PPO |
$5.72
|
| Rate for Payer: United Healthcare Commercial |
$5.12
|
|
|
DIVALPROEX 250 MG ORAL TB24
|
Facility
|
OP
|
$6.50
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$5.48
|
| Rate for Payer: Aetna Medicare |
$2.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.36
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Centivo All Commercial |
$3.31
|
| Rate for Payer: Cigna All Commercial |
$5.61
|
| Rate for Payer: CORVEL All Commercial |
$6.04
|
| Rate for Payer: Coventry All Commercial |
$5.72
|
| Rate for Payer: Encore All Commercial |
$5.98
|
| Rate for Payer: Frontpath All Commercial |
$5.98
|
| Rate for Payer: Humana ChoiceCare |
$5.61
|
| Rate for Payer: Humana Medicare |
$3.31
|
| Rate for Payer: Lucent All Commercial |
$3.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.85
|
| Rate for Payer: PHCS All Commercial |
$4.87
|
| Rate for Payer: PHP All Commercial |
$4.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.53
|
| Rate for Payer: Sagamore Health Network All Products |
$5.01
|
| Rate for Payer: Signature Care EPO |
$5.39
|
| Rate for Payer: Signature Care PPO |
$5.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.52
|
| Rate for Payer: United Healthcare Commercial |
$5.12
|
| Rate for Payer: United Healthcare Medicare |
$2.14
|
|
|
DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP
|
Facility
|
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
15981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.12 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna Commercial |
$136.08
|
| Rate for Payer: Cash Price |
$97.65
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.48
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
|
|
DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP
|
Facility
|
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
15981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna Commercial |
$132.93
|
| Rate for Payer: Aetna Medicare |
$51.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$90.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.17
|
| Rate for Payer: Cash Price |
$97.65
|
| Rate for Payer: Centivo All Commercial |
$80.32
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.48
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Humana Medicare |
$80.32
|
| Rate for Payer: Lucent All Commercial |
$80.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.42
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.88
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
| Rate for Payer: United Healthcare Medicare |
$51.98
|
|
|
DOCUSATE SODIUM 100 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 63739047802
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
DOCUSATE SODIUM 100 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 63739047802
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
DOCUSATE SODIUM 283 MG/5 ML RECT ENEM
|
Facility
|
OP
|
$13.16
|
|
|
Service Code
|
NDC 17433987603
|
| Hospital Charge Code |
153577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$11.11
|
| Rate for Payer: Aetna Medicare |
$4.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.23
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.78
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Centivo All Commercial |
$6.71
|
| Rate for Payer: Cigna All Commercial |
$11.36
|
| Rate for Payer: CORVEL All Commercial |
$12.24
|
| Rate for Payer: Coventry All Commercial |
$11.58
|
| Rate for Payer: Encore All Commercial |
$12.11
|
| Rate for Payer: Frontpath All Commercial |
$12.11
|
| Rate for Payer: Humana ChoiceCare |
$11.37
|
| Rate for Payer: Humana Medicare |
$6.71
|
| Rate for Payer: Lucent All Commercial |
$6.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.84
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$9.87
|
| Rate for Payer: PHP All Commercial |
$9.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.13
|
| Rate for Payer: Sagamore Health Network All Products |
$10.16
|
| Rate for Payer: Signature Care EPO |
$10.92
|
| Rate for Payer: Signature Care PPO |
$11.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.19
|
| Rate for Payer: United Healthcare Commercial |
$10.37
|
| Rate for Payer: United Healthcare Medicare |
$4.34
|
|
|
DOCUSATE SODIUM 283 MG/5 ML RECT ENEM
|
Facility
|
IP
|
$13.16
|
|
|
Service Code
|
NDC 17433987603
|
| Hospital Charge Code |
153577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Aetna Commercial |
$11.37
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cigna All Commercial |
$11.36
|
| Rate for Payer: CORVEL All Commercial |
$12.24
|
| Rate for Payer: Coventry All Commercial |
$11.58
|
| Rate for Payer: Encore All Commercial |
$12.11
|
| Rate for Payer: Frontpath All Commercial |
$12.11
|
| Rate for Payer: Humana ChoiceCare |
$11.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.84
|
| Rate for Payer: PHCS All Commercial |
$9.87
|
| Rate for Payer: PHP All Commercial |
$9.98
|
| Rate for Payer: Sagamore Health Network All Products |
$10.16
|
| Rate for Payer: Signature Care EPO |
$10.92
|
| Rate for Payer: Signature Care PPO |
$11.58
|
| Rate for Payer: United Healthcare Commercial |
$10.37
|
|
|
DOCUSATE SODIUM 60 MG/15 ML ORAL SYRP
|
Facility
|
IP
|
$102.64
|
|
|
Service Code
|
NDC 54838010780
|
| Hospital Charge Code |
2571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.98 |
| Max. Negotiated Rate |
$95.46 |
| Rate for Payer: Aetna Commercial |
$88.68
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cigna All Commercial |
$88.58
|
| Rate for Payer: CORVEL All Commercial |
$95.46
|
| Rate for Payer: Coventry All Commercial |
$90.32
|
| Rate for Payer: Encore All Commercial |
$94.48
|
| Rate for Payer: Frontpath All Commercial |
$94.43
|
| Rate for Payer: Humana ChoiceCare |
$88.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.38
|
| Rate for Payer: PHCS All Commercial |
$76.98
|
| Rate for Payer: PHP All Commercial |
$77.84
|
| Rate for Payer: Sagamore Health Network All Products |
$79.24
|
| Rate for Payer: Signature Care EPO |
$85.19
|
| Rate for Payer: Signature Care PPO |
$90.32
|
| Rate for Payer: United Healthcare Commercial |
$80.88
|
|
|
DOCUSATE SODIUM 60 MG/15 ML ORAL SYRP
|
Facility
|
OP
|
$3.26
|
|
|
Service Code
|
NDC 54838107CMC
|
| Hospital Charge Code |
2571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Aetna Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Centivo All Commercial |
$1.66
|
| Rate for Payer: Cigna All Commercial |
$2.81
|
| Rate for Payer: CORVEL All Commercial |
$3.03
|
| Rate for Payer: Coventry All Commercial |
$2.86
|
| Rate for Payer: Encore All Commercial |
$3.00
|
| Rate for Payer: Frontpath All Commercial |
$2.99
|
| Rate for Payer: Humana ChoiceCare |
$2.81
|
| Rate for Payer: Humana Medicare |
$1.66
|
| Rate for Payer: Lucent All Commercial |
$1.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.93
|
| Rate for Payer: PHCS All Commercial |
$2.44
|
| Rate for Payer: PHP All Commercial |
$2.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.51
|
| Rate for Payer: Signature Care EPO |
$2.70
|
| Rate for Payer: Signature Care PPO |
$2.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.77
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Medicare |
$1.07
|
|
|
DOCUSATE SODIUM 60 MG/15 ML ORAL SYRP
|
Facility
|
OP
|
$102.64
|
|
|
Service Code
|
NDC 54838010780
|
| Hospital Charge Code |
2571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.87 |
| Max. Negotiated Rate |
$95.46 |
| Rate for Payer: Aetna Commercial |
$86.63
|
| Rate for Payer: Aetna Medicare |
$33.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$58.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$64.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.26
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Centivo All Commercial |
$52.35
|
| Rate for Payer: Cigna All Commercial |
$88.58
|
| Rate for Payer: CORVEL All Commercial |
$95.46
|
| Rate for Payer: Coventry All Commercial |
$90.32
|
| Rate for Payer: Encore All Commercial |
$94.48
|
| Rate for Payer: Frontpath All Commercial |
$94.43
|
| Rate for Payer: Humana ChoiceCare |
$88.65
|
| Rate for Payer: Humana Medicare |
$52.35
|
| Rate for Payer: Lucent All Commercial |
$52.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.38
|
| Rate for Payer: PHCS All Commercial |
$76.98
|
| Rate for Payer: PHP All Commercial |
$77.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.03
|
| Rate for Payer: Sagamore Health Network All Products |
$79.24
|
| Rate for Payer: Signature Care EPO |
$85.19
|
| Rate for Payer: Signature Care PPO |
$90.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$87.24
|
| Rate for Payer: United Healthcare Commercial |
$80.88
|
| Rate for Payer: United Healthcare Medicare |
$33.87
|
|
|
DOCUSATE SODIUM 60 MG/15 ML ORAL SYRP
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 54838107CMC
|
| Hospital Charge Code |
2571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cigna All Commercial |
$2.81
|
| Rate for Payer: CORVEL All Commercial |
$3.03
|
| Rate for Payer: Coventry All Commercial |
$2.86
|
| Rate for Payer: Encore All Commercial |
$3.00
|
| Rate for Payer: Frontpath All Commercial |
$2.99
|
| Rate for Payer: Humana ChoiceCare |
$2.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.93
|
| Rate for Payer: PHCS All Commercial |
$2.44
|
| Rate for Payer: PHP All Commercial |
$2.47
|
| Rate for Payer: Sagamore Health Network All Products |
$2.51
|
| Rate for Payer: Signature Care EPO |
$2.70
|
| Rate for Payer: Signature Care PPO |
$2.86
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
|
|
DOFETILIDE 125 MCG ORAL CAP
|
Facility
|
IP
|
$20.34
|
|
|
Service Code
|
NDC 00904668108
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.26 |
| Max. Negotiated Rate |
$18.92 |
| Rate for Payer: Aetna Commercial |
$17.58
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna All Commercial |
$17.56
|
| Rate for Payer: CORVEL All Commercial |
$18.92
|
| Rate for Payer: Coventry All Commercial |
$17.90
|
| Rate for Payer: Encore All Commercial |
$18.72
|
| Rate for Payer: Frontpath All Commercial |
$18.71
|
| Rate for Payer: Humana ChoiceCare |
$17.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.31
|
| Rate for Payer: PHCS All Commercial |
$15.26
|
| Rate for Payer: PHP All Commercial |
$15.43
|
| Rate for Payer: Sagamore Health Network All Products |
$15.70
|
| Rate for Payer: Signature Care EPO |
$16.88
|
| Rate for Payer: Signature Care PPO |
$17.90
|
| Rate for Payer: United Healthcare Commercial |
$16.03
|
|
|
DOFETILIDE 125 MCG ORAL CAP
|
Facility
|
OP
|
$20.34
|
|
|
Service Code
|
NDC 00904668108
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$18.92 |
| Rate for Payer: Aetna Commercial |
$17.17
|
| Rate for Payer: Aetna Medicare |
$6.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Centivo All Commercial |
$10.37
|
| Rate for Payer: Cigna All Commercial |
$17.56
|
| Rate for Payer: CORVEL All Commercial |
$18.92
|
| Rate for Payer: Coventry All Commercial |
$17.90
|
| Rate for Payer: Encore All Commercial |
$18.72
|
| Rate for Payer: Frontpath All Commercial |
$18.71
|
| Rate for Payer: Humana ChoiceCare |
$17.57
|
| Rate for Payer: Humana Medicare |
$10.37
|
| Rate for Payer: Lucent All Commercial |
$10.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.31
|
| Rate for Payer: PHCS All Commercial |
$15.26
|
| Rate for Payer: PHP All Commercial |
$15.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.93
|
| Rate for Payer: Sagamore Health Network All Products |
$15.70
|
| Rate for Payer: Signature Care EPO |
$16.88
|
| Rate for Payer: Signature Care PPO |
$17.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.29
|
| Rate for Payer: United Healthcare Commercial |
$16.03
|
| Rate for Payer: United Healthcare Medicare |
$6.71
|
|
|
DONEPEZIL 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
DONEPEZIL 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN
|
Facility
|
OP
|
$96.25
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.76 |
| Max. Negotiated Rate |
$89.51 |
| Rate for Payer: Aetna Commercial |
$81.24
|
| Rate for Payer: Aetna Medicare |
$31.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$55.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$60.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.94
|
| Rate for Payer: Cash Price |
$59.68
|
| Rate for Payer: Centivo All Commercial |
$49.09
|
| Rate for Payer: Cigna All Commercial |
$83.06
|
| Rate for Payer: CORVEL All Commercial |
$89.51
|
| Rate for Payer: Coventry All Commercial |
$84.70
|
| Rate for Payer: Encore All Commercial |
$88.60
|
| Rate for Payer: Frontpath All Commercial |
$88.55
|
| Rate for Payer: Humana ChoiceCare |
$83.13
|
| Rate for Payer: Humana Medicare |
$49.09
|
| Rate for Payer: Lucent All Commercial |
$49.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.62
|
| Rate for Payer: PHCS All Commercial |
$72.19
|
| Rate for Payer: PHP All Commercial |
$73.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.54
|
| Rate for Payer: Sagamore Health Network All Products |
$74.30
|
| Rate for Payer: Signature Care EPO |
$79.89
|
| Rate for Payer: Signature Care PPO |
$84.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$81.81
|
| Rate for Payer: United Healthcare Commercial |
$75.84
|
| Rate for Payer: United Healthcare Medicare |
$31.76
|
|
|
DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN
|
Facility
|
IP
|
$96.25
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$72.19 |
| Max. Negotiated Rate |
$89.51 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Cash Price |
$59.68
|
| Rate for Payer: Cigna All Commercial |
$83.06
|
| Rate for Payer: CORVEL All Commercial |
$89.51
|
| Rate for Payer: Coventry All Commercial |
$84.70
|
| Rate for Payer: Encore All Commercial |
$88.60
|
| Rate for Payer: Frontpath All Commercial |
$88.55
|
| Rate for Payer: Humana ChoiceCare |
$83.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.62
|
| Rate for Payer: PHCS All Commercial |
$72.19
|
| Rate for Payer: PHP All Commercial |
$73.00
|
| Rate for Payer: Sagamore Health Network All Products |
$74.30
|
| Rate for Payer: Signature Care EPO |
$79.89
|
| Rate for Payer: Signature Care PPO |
$84.70
|
| Rate for Payer: United Healthcare Commercial |
$75.84
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DPET
|
Facility
|
IP
|
$10.63
|
|
|
Service Code
|
NDC 42571038273
|
| Hospital Charge Code |
154152
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.18
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % OPHT DPET
|
Facility
|
OP
|
$10.63
|
|
|
Service Code
|
NDC 42571038273
|
| Hospital Charge Code |
154152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$8.97
|
| Rate for Payer: Aetna Medicare |
$3.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.86
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Centivo All Commercial |
$5.42
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Humana Medicare |
$5.42
|
| Rate for Payer: Lucent All Commercial |
$5.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.14
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.03
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
| Rate for Payer: United Healthcare Medicare |
$3.51
|
|
|
DOXAPRAM 20 MG/ML IV SOLN
|
Facility
|
IP
|
$301.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$226.08 |
| Max. Negotiated Rate |
$280.34 |
| Rate for Payer: Aetna Commercial |
$260.44
|
| Rate for Payer: Cash Price |
$186.89
|
| Rate for Payer: Cigna All Commercial |
$260.14
|
| Rate for Payer: CORVEL All Commercial |
$280.34
|
| Rate for Payer: Coventry All Commercial |
$265.27
|
| Rate for Payer: Encore All Commercial |
$277.48
|
| Rate for Payer: Frontpath All Commercial |
$277.32
|
| Rate for Payer: Humana ChoiceCare |
$260.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$271.30
|
| Rate for Payer: PHCS All Commercial |
$226.08
|
| Rate for Payer: PHP All Commercial |
$228.61
|
| Rate for Payer: Sagamore Health Network All Products |
$232.71
|
| Rate for Payer: Signature Care EPO |
$250.20
|
| Rate for Payer: Signature Care PPO |
$265.27
|
| Rate for Payer: United Healthcare Commercial |
$237.53
|
|
