|
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
|
|
|
DOXAZOSIN 1 MG ORAL TAB
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
NDC 00904552261
|
| Hospital Charge Code |
9894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Centivo All Commercial |
$1.45
|
| Rate for Payer: Cigna All Commercial |
$2.45
|
| Rate for Payer: CORVEL All Commercial |
$2.64
|
| Rate for Payer: Coventry All Commercial |
$2.50
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.61
|
| Rate for Payer: Humana ChoiceCare |
$2.45
|
| Rate for Payer: Humana Medicare |
$1.45
|
| Rate for Payer: Lucent All Commercial |
$1.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.13
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$2.19
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
|
|
DOXAZOSIN 1 MG ORAL TAB
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
NDC 00904552261
|
| Hospital Charge Code |
9894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna All Commercial |
$2.45
|
| Rate for Payer: CORVEL All Commercial |
$2.64
|
| Rate for Payer: Coventry All Commercial |
$2.50
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.61
|
| Rate for Payer: Humana ChoiceCare |
$2.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.13
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Sagamore Health Network All Products |
$2.19
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.50
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
|
|
DOXAZOSIN 4 MG ORAL TAB
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 68084086225
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$4.94
|
| Rate for Payer: CORVEL All Commercial |
$5.32
|
| Rate for Payer: Coventry All Commercial |
$5.03
|
| Rate for Payer: Encore All Commercial |
$5.26
|
| Rate for Payer: Frontpath All Commercial |
$5.26
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.15
|
| Rate for Payer: PHCS All Commercial |
$4.29
|
| Rate for Payer: PHP All Commercial |
$4.34
|
| Rate for Payer: Sagamore Health Network All Products |
$4.42
|
| Rate for Payer: Signature Care EPO |
$4.75
|
| Rate for Payer: Signature Care PPO |
$5.03
|
| Rate for Payer: United Healthcare Commercial |
$4.51
|
|
|
DOXAZOSIN 4 MG ORAL TAB
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 68084086225
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$4.83
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Centivo All Commercial |
$2.92
|
| Rate for Payer: Cigna All Commercial |
$4.94
|
| Rate for Payer: CORVEL All Commercial |
$5.32
|
| Rate for Payer: Coventry All Commercial |
$5.03
|
| Rate for Payer: Encore All Commercial |
$5.26
|
| Rate for Payer: Frontpath All Commercial |
$5.26
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Humana Medicare |
$2.92
|
| Rate for Payer: Lucent All Commercial |
$2.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.15
|
| Rate for Payer: PHCS All Commercial |
$4.29
|
| Rate for Payer: PHP All Commercial |
$4.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.23
|
| Rate for Payer: Sagamore Health Network All Products |
$4.42
|
| Rate for Payer: Signature Care EPO |
$4.75
|
| Rate for Payer: Signature Care PPO |
$5.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.86
|
| Rate for Payer: United Healthcare Commercial |
$4.51
|
| Rate for Payer: United Healthcare Medicare |
$1.89
|
|
|
DOXEPIN 10 MG ORAL CAP
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Centivo All Commercial |
$1.96
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.57
|
| Rate for Payer: Coventry All Commercial |
$3.38
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.32
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Lucent All Commercial |
$1.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.88
|
| Rate for Payer: PHP All Commercial |
$2.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.50
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.19
|
| Rate for Payer: Signature Care PPO |
$3.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.27
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
DOXEPIN 10 MG ORAL CAP
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.57
|
| Rate for Payer: Coventry All Commercial |
$3.38
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.88
|
| Rate for Payer: PHP All Commercial |
$2.91
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.19
|
| Rate for Payer: Signature Care PPO |
$3.38
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
|
|
DOXYCYCLINE HYCLATE 100 MG IV SOLR
|
Facility
|
OP
|
$80.34
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.51 |
| Max. Negotiated Rate |
$74.72 |
| Rate for Payer: Aetna Commercial |
$67.81
|
| Rate for Payer: Aetna Medicare |
$26.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$46.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.16
|
| Rate for Payer: Cash Price |
$49.81
|
| Rate for Payer: Centivo All Commercial |
$40.97
|
| Rate for Payer: Cigna All Commercial |
$69.33
|
| Rate for Payer: CORVEL All Commercial |
$74.72
|
| Rate for Payer: Coventry All Commercial |
$70.70
|
| Rate for Payer: Encore All Commercial |
$73.95
|
| Rate for Payer: Frontpath All Commercial |
$73.91
|
| Rate for Payer: Humana ChoiceCare |
$69.39
|
| Rate for Payer: Humana Medicare |
$40.97
|
| Rate for Payer: Lucent All Commercial |
$40.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.31
|
| Rate for Payer: PHCS All Commercial |
$60.25
|
| Rate for Payer: PHP All Commercial |
$60.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.33
|
| Rate for Payer: Sagamore Health Network All Products |
$62.02
|
| Rate for Payer: Signature Care EPO |
$66.68
|
| Rate for Payer: Signature Care PPO |
$70.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$68.29
|
| Rate for Payer: United Healthcare Commercial |
$63.31
|
| Rate for Payer: United Healthcare Medicare |
$26.51
|
|
|
DOXYCYCLINE HYCLATE 100 MG IV SOLR
|
Facility
|
IP
|
$80.34
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.25 |
| Max. Negotiated Rate |
$74.72 |
| Rate for Payer: Aetna Commercial |
$69.41
|
| Rate for Payer: Cash Price |
$49.81
|
| Rate for Payer: Cigna All Commercial |
$69.33
|
| Rate for Payer: CORVEL All Commercial |
$74.72
|
| Rate for Payer: Coventry All Commercial |
$70.70
|
| Rate for Payer: Encore All Commercial |
$73.95
|
| Rate for Payer: Frontpath All Commercial |
$73.91
|
| Rate for Payer: Humana ChoiceCare |
$69.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.31
|
| Rate for Payer: PHCS All Commercial |
$60.25
|
| Rate for Payer: PHP All Commercial |
$60.93
|
| Rate for Payer: Sagamore Health Network All Products |
$62.02
|
| Rate for Payer: Signature Care EPO |
$66.68
|
| Rate for Payer: Signature Care PPO |
$70.70
|
| Rate for Payer: United Healthcare Commercial |
$63.31
|
|
|
DOXYCYCLINE HYCLATE 100 MG ORAL TAB
|
Facility
|
OP
|
$8.95
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: Aetna Commercial |
$7.56
|
| Rate for Payer: Aetna Medicare |
$2.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.25
|
| Rate for Payer: Cash Price |
$5.55
|
| Rate for Payer: Centivo All Commercial |
$4.57
|
| Rate for Payer: Cigna All Commercial |
$7.73
|
| Rate for Payer: CORVEL All Commercial |
$8.33
|
| Rate for Payer: Coventry All Commercial |
$7.88
|
| Rate for Payer: Encore All Commercial |
$8.24
|
| Rate for Payer: Frontpath All Commercial |
$8.24
|
| Rate for Payer: Humana ChoiceCare |
$7.73
|
| Rate for Payer: Humana Medicare |
$4.57
|
| Rate for Payer: Lucent All Commercial |
$4.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.06
|
| Rate for Payer: PHCS All Commercial |
$6.71
|
| Rate for Payer: PHP All Commercial |
$6.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.49
|
| Rate for Payer: Sagamore Health Network All Products |
$6.91
|
| Rate for Payer: Signature Care EPO |
$7.43
|
| Rate for Payer: Signature Care PPO |
$7.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.61
|
| Rate for Payer: United Healthcare Commercial |
$7.05
|
| Rate for Payer: United Healthcare Medicare |
$2.95
|
|
|
DOXYCYCLINE HYCLATE 100 MG ORAL TAB
|
Facility
|
IP
|
$8.95
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: Aetna Commercial |
$7.74
|
| Rate for Payer: Cash Price |
$5.55
|
| Rate for Payer: Cigna All Commercial |
$7.73
|
| Rate for Payer: CORVEL All Commercial |
$8.33
|
| Rate for Payer: Coventry All Commercial |
$7.88
|
| Rate for Payer: Encore All Commercial |
$8.24
|
| Rate for Payer: Frontpath All Commercial |
$8.24
|
| Rate for Payer: Humana ChoiceCare |
$7.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.06
|
| Rate for Payer: PHCS All Commercial |
$6.71
|
| Rate for Payer: PHP All Commercial |
$6.79
|
| Rate for Payer: Sagamore Health Network All Products |
$6.91
|
| Rate for Payer: Signature Care EPO |
$7.43
|
| Rate for Payer: Signature Care PPO |
$7.88
|
| Rate for Payer: United Healthcare Commercial |
$7.05
|
|
|
Drainage of finger abscess; complicated (eg, felon)
|
Facility
|
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 26011
|
| Hospital Charge Code |
CPT-26011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Drainage of tendon sheath, digit and/or palm, each
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 26020
|
| Hospital Charge Code |
CPT-26020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
Dressing change (for other than burns) under anesthesia (other than local)
|
Facility
|
OP
|
$190.59
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
CPT-15852
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$190.59 |
| Max. Negotiated Rate |
$190.59 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$190.59
|
| Rate for Payer: Managed Health Services Medicaid |
$190.59
|
| Rate for Payer: MDWise Medicaid |
$190.59
|
|
|
DROPERIDOL 2.5 MG/ML INJ SOLN
|
Facility
|
OP
|
$64.13
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.16 |
| Max. Negotiated Rate |
$59.64 |
| Rate for Payer: Aetna Commercial |
$54.13
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.28
|
| Rate for Payer: Cash Price |
$39.76
|
| Rate for Payer: Centivo All Commercial |
$32.71
|
| Rate for Payer: Cigna All Commercial |
$55.35
|
| Rate for Payer: CORVEL All Commercial |
$59.64
|
| Rate for Payer: Coventry All Commercial |
$56.44
|
| Rate for Payer: Encore All Commercial |
$59.04
|
| Rate for Payer: Frontpath All Commercial |
$59.00
|
| Rate for Payer: Humana ChoiceCare |
$55.39
|
| Rate for Payer: Humana Medicare |
$32.71
|
| Rate for Payer: Lucent All Commercial |
$32.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.72
|
| Rate for Payer: PHCS All Commercial |
$48.10
|
| Rate for Payer: PHP All Commercial |
$48.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.01
|
| Rate for Payer: Sagamore Health Network All Products |
$49.51
|
| Rate for Payer: Signature Care EPO |
$53.23
|
| Rate for Payer: Signature Care PPO |
$56.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$54.51
|
| Rate for Payer: United Healthcare Commercial |
$50.54
|
| Rate for Payer: United Healthcare Medicare |
$21.16
|
|
|
DROPERIDOL 2.5 MG/ML INJ SOLN
|
Facility
|
IP
|
$64.13
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.10 |
| Max. Negotiated Rate |
$59.64 |
| Rate for Payer: Aetna Commercial |
$55.41
|
| Rate for Payer: Cash Price |
$39.76
|
| Rate for Payer: Cigna All Commercial |
$55.35
|
| Rate for Payer: CORVEL All Commercial |
$59.64
|
| Rate for Payer: Coventry All Commercial |
$56.44
|
| Rate for Payer: Encore All Commercial |
$59.04
|
| Rate for Payer: Frontpath All Commercial |
$59.00
|
| Rate for Payer: Humana ChoiceCare |
$55.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.72
|
| Rate for Payer: PHCS All Commercial |
$48.10
|
| Rate for Payer: PHP All Commercial |
$48.64
|
| Rate for Payer: Sagamore Health Network All Products |
$49.51
|
| Rate for Payer: Signature Care EPO |
$53.23
|
| Rate for Payer: Signature Care PPO |
$56.44
|
| Rate for Payer: United Healthcare Commercial |
$50.54
|
|
|
DULOXETINE 30 MG ORAL CPDR
|
Facility
|
OP
|
$6.55
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Aetna Commercial |
$5.52
|
| Rate for Payer: Aetna Medicare |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$4.06
|
| Rate for Payer: Centivo All Commercial |
$3.34
|
| Rate for Payer: Cigna All Commercial |
$5.65
|
| Rate for Payer: CORVEL All Commercial |
$6.09
|
| Rate for Payer: Coventry All Commercial |
$5.76
|
| Rate for Payer: Encore All Commercial |
$6.02
|
| Rate for Payer: Frontpath All Commercial |
$6.02
|
| Rate for Payer: Humana ChoiceCare |
$5.65
|
| Rate for Payer: Humana Medicare |
$3.34
|
| Rate for Payer: Lucent All Commercial |
$3.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.89
|
| Rate for Payer: PHCS All Commercial |
$4.91
|
| Rate for Payer: PHP All Commercial |
$4.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.55
|
| Rate for Payer: Sagamore Health Network All Products |
$5.05
|
| Rate for Payer: Signature Care EPO |
$5.43
|
| Rate for Payer: Signature Care PPO |
$5.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.56
|
| Rate for Payer: United Healthcare Commercial |
$5.16
|
| Rate for Payer: United Healthcare Medicare |
$2.16
|
|
|
DULOXETINE 30 MG ORAL CPDR
|
Facility
|
IP
|
$6.55
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: Cash Price |
$4.06
|
| Rate for Payer: Cigna All Commercial |
$5.65
|
| Rate for Payer: CORVEL All Commercial |
$6.09
|
| Rate for Payer: Coventry All Commercial |
$5.76
|
| Rate for Payer: Encore All Commercial |
$6.02
|
| Rate for Payer: Frontpath All Commercial |
$6.02
|
| Rate for Payer: Humana ChoiceCare |
$5.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.89
|
| Rate for Payer: PHCS All Commercial |
$4.91
|
| Rate for Payer: PHP All Commercial |
$4.96
|
| Rate for Payer: Sagamore Health Network All Products |
$5.05
|
| Rate for Payer: Signature Care EPO |
$5.43
|
| Rate for Payer: Signature Care PPO |
$5.76
|
| Rate for Payer: United Healthcare Commercial |
$5.16
|
|
|
DUTASTERIDE 0.5 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 31722013130
|
| Hospital Charge Code |
34089
|
|
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
|
|
|
DUTASTERIDE 0.5 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 31722013130
|
| Hospital Charge Code |
34089
|
|
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
|
|
|
EMPAGLIFLOZIN 10 MG ORAL TAB
|
Facility
|
OP
|
$107.52
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
169570
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$99.99 |
| Rate for Payer: Aetna Commercial |
$90.75
|
| Rate for Payer: Aetna Medicare |
$35.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.03
|
| Rate for Payer: Cash Price |
$66.66
|
| Rate for Payer: Centivo All Commercial |
$54.84
|
| Rate for Payer: Cigna All Commercial |
$92.79
|
| Rate for Payer: CORVEL All Commercial |
$99.99
|
| Rate for Payer: Coventry All Commercial |
$94.62
|
| Rate for Payer: Encore All Commercial |
$98.97
|
| Rate for Payer: Frontpath All Commercial |
$98.92
|
| Rate for Payer: Humana ChoiceCare |
$92.87
|
| Rate for Payer: Humana Medicare |
$54.84
|
| Rate for Payer: Lucent All Commercial |
$54.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.77
|
| Rate for Payer: PHCS All Commercial |
$80.64
|
| Rate for Payer: PHP All Commercial |
$81.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.93
|
| Rate for Payer: Sagamore Health Network All Products |
$83.01
|
| Rate for Payer: Signature Care EPO |
$89.24
|
| Rate for Payer: Signature Care PPO |
$94.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.39
|
| Rate for Payer: United Healthcare Commercial |
$84.73
|
| Rate for Payer: United Healthcare Medicare |
$35.48
|
|
|
EMPAGLIFLOZIN 10 MG ORAL TAB
|
Facility
|
IP
|
$107.52
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
169570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$99.99 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: Cash Price |
$66.66
|
| Rate for Payer: Cigna All Commercial |
$92.79
|
| Rate for Payer: CORVEL All Commercial |
$99.99
|
| Rate for Payer: Coventry All Commercial |
$94.62
|
| Rate for Payer: Encore All Commercial |
$98.97
|
| Rate for Payer: Frontpath All Commercial |
$98.92
|
| Rate for Payer: Humana ChoiceCare |
$92.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.77
|
| Rate for Payer: PHCS All Commercial |
$80.64
|
| Rate for Payer: PHP All Commercial |
$81.54
|
| Rate for Payer: Sagamore Health Network All Products |
$83.01
|
| Rate for Payer: Signature Care EPO |
$89.24
|
| Rate for Payer: Signature Care PPO |
$94.62
|
| Rate for Payer: United Healthcare Commercial |
$84.73
|
|
|
EMPAGLIFLOZIN 25 MG ORAL TAB
|
Facility
|
OP
|
$107.52
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
169569
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$99.99 |
| Rate for Payer: Aetna Commercial |
$90.75
|
| Rate for Payer: Aetna Medicare |
$35.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.03
|
| Rate for Payer: Cash Price |
$66.66
|
| Rate for Payer: Centivo All Commercial |
$54.84
|
| Rate for Payer: Cigna All Commercial |
$92.79
|
| Rate for Payer: CORVEL All Commercial |
$99.99
|
| Rate for Payer: Coventry All Commercial |
$94.62
|
| Rate for Payer: Encore All Commercial |
$98.97
|
| Rate for Payer: Frontpath All Commercial |
$98.92
|
| Rate for Payer: Humana ChoiceCare |
$92.87
|
| Rate for Payer: Humana Medicare |
$54.84
|
| Rate for Payer: Lucent All Commercial |
$54.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.77
|
| Rate for Payer: PHCS All Commercial |
$80.64
|
| Rate for Payer: PHP All Commercial |
$81.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.93
|
| Rate for Payer: Sagamore Health Network All Products |
$83.01
|
| Rate for Payer: Signature Care EPO |
$89.24
|
| Rate for Payer: Signature Care PPO |
$94.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.39
|
| Rate for Payer: United Healthcare Commercial |
$84.73
|
| Rate for Payer: United Healthcare Medicare |
$35.48
|
|
|
EMPAGLIFLOZIN 25 MG ORAL TAB
|
Facility
|
IP
|
$107.52
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
169569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$99.99 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: Cash Price |
$66.66
|
| Rate for Payer: Cigna All Commercial |
$92.79
|
| Rate for Payer: CORVEL All Commercial |
$99.99
|
| Rate for Payer: Coventry All Commercial |
$94.62
|
| Rate for Payer: Encore All Commercial |
$98.97
|
| Rate for Payer: Frontpath All Commercial |
$98.92
|
| Rate for Payer: Humana ChoiceCare |
$92.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.77
|
| Rate for Payer: PHCS All Commercial |
$80.64
|
| Rate for Payer: PHP All Commercial |
$81.54
|
| Rate for Payer: Sagamore Health Network All Products |
$83.01
|
| Rate for Payer: Signature Care EPO |
$89.24
|
| Rate for Payer: Signature Care PPO |
$94.62
|
| Rate for Payer: United Healthcare Commercial |
$84.73
|
|
|
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB
|
Facility
|
OP
|
$359.24
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.55 |
| Max. Negotiated Rate |
$334.10 |
| Rate for Payer: Aetna Commercial |
$303.20
|
| Rate for Payer: Aetna Medicare |
$118.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$118.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$206.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$224.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$136.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$130.41
|
| Rate for Payer: Cash Price |
$222.73
|
| Rate for Payer: Centivo All Commercial |
$183.21
|
| Rate for Payer: Cigna All Commercial |
$310.03
|
| Rate for Payer: CORVEL All Commercial |
$334.10
|
| Rate for Payer: Coventry All Commercial |
$316.13
|
| Rate for Payer: Encore All Commercial |
$330.68
|
| Rate for Payer: Frontpath All Commercial |
$330.50
|
| Rate for Payer: Humana ChoiceCare |
$310.28
|
| Rate for Payer: Humana Medicare |
$183.21
|
| Rate for Payer: Lucent All Commercial |
$183.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.32
|
| Rate for Payer: PHCS All Commercial |
$269.43
|
| Rate for Payer: PHP All Commercial |
$272.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$140.11
|
| Rate for Payer: Sagamore Health Network All Products |
$277.34
|
| Rate for Payer: Signature Care EPO |
$298.17
|
| Rate for Payer: Signature Care PPO |
$316.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.36
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
| Rate for Payer: United Healthcare Medicare |
$118.55
|
|
