|
RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR
|
Facility
OP
|
$1,074.46
|
|
|
Service Code
|
HCPCS 90678
|
| Hospital Charge Code |
202248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$354.57 |
| Max. Negotiated Rate |
$999.25 |
| Rate for Payer: Aetna Commercial |
$906.85
|
| Rate for Payer: Aetna Medicare |
$354.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$354.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$617.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$671.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$407.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$390.03
|
| Rate for Payer: Cash Price |
$666.17
|
| Rate for Payer: Centivo All Commercial |
$547.98
|
| Rate for Payer: Cigna All Commercial |
$927.26
|
| Rate for Payer: CORVEL All Commercial |
$999.25
|
| Rate for Payer: Coventry All Commercial |
$945.53
|
| Rate for Payer: Encore All Commercial |
$989.04
|
| Rate for Payer: Frontpath All Commercial |
$988.51
|
| Rate for Payer: Humana ChoiceCare |
$928.01
|
| Rate for Payer: Humana Medicare |
$547.98
|
| Rate for Payer: Lucent All Commercial |
$547.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$967.02
|
| Rate for Payer: PHCS All Commercial |
$805.85
|
| Rate for Payer: PHP All Commercial |
$814.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$419.04
|
| Rate for Payer: Sagamore Health Network All Products |
$829.49
|
| Rate for Payer: Signature Care EPO |
$891.81
|
| Rate for Payer: Signature Care PPO |
$945.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$913.29
|
| Rate for Payer: United Healthcare Commercial |
$846.68
|
| Rate for Payer: United Healthcare Medicare |
$354.57
|
|
|
RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR
|
Facility
IP
|
$1,074.46
|
|
|
Service Code
|
HCPCS 90678
|
| Hospital Charge Code |
202248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$805.85 |
| Max. Negotiated Rate |
$999.25 |
| Rate for Payer: Aetna Commercial |
$928.34
|
| Rate for Payer: Cash Price |
$666.17
|
| Rate for Payer: Cigna All Commercial |
$927.26
|
| Rate for Payer: CORVEL All Commercial |
$999.25
|
| Rate for Payer: Coventry All Commercial |
$945.53
|
| Rate for Payer: Encore All Commercial |
$989.04
|
| Rate for Payer: Frontpath All Commercial |
$988.51
|
| Rate for Payer: Humana ChoiceCare |
$928.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$967.02
|
| Rate for Payer: PHCS All Commercial |
$805.85
|
| Rate for Payer: PHP All Commercial |
$814.87
|
| Rate for Payer: Sagamore Health Network All Products |
$829.49
|
| Rate for Payer: Signature Care EPO |
$891.81
|
| Rate for Payer: Signature Care PPO |
$945.53
|
| Rate for Payer: United Healthcare Commercial |
$846.68
|
|
|
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB
|
Facility
IP
|
$75.38
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
173291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.53 |
| Max. Negotiated Rate |
$70.10 |
| Rate for Payer: Aetna Commercial |
$65.12
|
| Rate for Payer: Cash Price |
$46.73
|
| Rate for Payer: Cigna All Commercial |
$65.05
|
| Rate for Payer: CORVEL All Commercial |
$70.10
|
| Rate for Payer: Coventry All Commercial |
$66.33
|
| Rate for Payer: Encore All Commercial |
$69.38
|
| Rate for Payer: Frontpath All Commercial |
$69.35
|
| Rate for Payer: Humana ChoiceCare |
$65.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.84
|
| Rate for Payer: PHCS All Commercial |
$56.53
|
| Rate for Payer: PHP All Commercial |
$57.17
|
| Rate for Payer: Sagamore Health Network All Products |
$58.19
|
| Rate for Payer: Signature Care EPO |
$62.56
|
| Rate for Payer: Signature Care PPO |
$66.33
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
|
|
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB
|
Facility
OP
|
$75.38
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
173291
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.87 |
| Max. Negotiated Rate |
$70.10 |
| Rate for Payer: Aetna Commercial |
$63.62
|
| Rate for Payer: Aetna Medicare |
$24.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.36
|
| Rate for Payer: Cash Price |
$46.73
|
| Rate for Payer: Centivo All Commercial |
$38.44
|
| Rate for Payer: Cigna All Commercial |
$65.05
|
| Rate for Payer: CORVEL All Commercial |
$70.10
|
| Rate for Payer: Coventry All Commercial |
$66.33
|
| Rate for Payer: Encore All Commercial |
$69.38
|
| Rate for Payer: Frontpath All Commercial |
$69.35
|
| Rate for Payer: Humana ChoiceCare |
$65.10
|
| Rate for Payer: Humana Medicare |
$38.44
|
| Rate for Payer: Lucent All Commercial |
$38.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.84
|
| Rate for Payer: PHCS All Commercial |
$56.53
|
| Rate for Payer: PHP All Commercial |
$57.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.40
|
| Rate for Payer: Sagamore Health Network All Products |
$58.19
|
| Rate for Payer: Signature Care EPO |
$62.56
|
| Rate for Payer: Signature Care PPO |
$66.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$64.07
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Medicare |
$24.87
|
|
|
SALINE SYRINGE FOR PLEURODESIS
|
Facility
IP
|
$14.49
|
|
|
Service Code
|
NDC 00409488812
|
| Hospital Charge Code |
800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Cigna All Commercial |
$12.50
|
| Rate for Payer: CORVEL All Commercial |
$13.48
|
| Rate for Payer: Coventry All Commercial |
$12.75
|
| Rate for Payer: Encore All Commercial |
$13.34
|
| Rate for Payer: Frontpath All Commercial |
$13.33
|
| Rate for Payer: Humana ChoiceCare |
$12.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.04
|
| Rate for Payer: PHCS All Commercial |
$10.87
|
| Rate for Payer: PHP All Commercial |
$10.99
|
| Rate for Payer: Sagamore Health Network All Products |
$11.19
|
| Rate for Payer: Signature Care EPO |
$12.03
|
| Rate for Payer: Signature Care PPO |
$12.75
|
| Rate for Payer: United Healthcare Commercial |
$11.42
|
|
|
SALINE SYRINGE FOR PLEURODESIS
|
Facility
OP
|
$14.49
|
|
|
Service Code
|
NDC 00409488812
|
| Hospital Charge Code |
800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$12.23
|
| Rate for Payer: Aetna Medicare |
$4.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.26
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Centivo All Commercial |
$7.39
|
| Rate for Payer: Cigna All Commercial |
$12.50
|
| Rate for Payer: CORVEL All Commercial |
$13.48
|
| Rate for Payer: Coventry All Commercial |
$12.75
|
| Rate for Payer: Encore All Commercial |
$13.34
|
| Rate for Payer: Frontpath All Commercial |
$13.33
|
| Rate for Payer: Humana ChoiceCare |
$12.52
|
| Rate for Payer: Humana Medicare |
$7.39
|
| Rate for Payer: Lucent All Commercial |
$7.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.04
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$10.87
|
| Rate for Payer: PHP All Commercial |
$10.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.65
|
| Rate for Payer: Sagamore Health Network All Products |
$11.19
|
| Rate for Payer: Signature Care EPO |
$12.03
|
| Rate for Payer: Signature Care PPO |
$12.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.32
|
| Rate for Payer: United Healthcare Commercial |
$11.42
|
| Rate for Payer: United Healthcare Medicare |
$4.78
|
|
|
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D
|
Facility
OP
|
$46.05
|
|
|
Service Code
|
NDC 50742050504
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$42.82 |
| Rate for Payer: Aetna Commercial |
$38.86
|
| Rate for Payer: Aetna Medicare |
$15.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$26.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.71
|
| Rate for Payer: Cash Price |
$28.55
|
| Rate for Payer: Centivo All Commercial |
$23.48
|
| Rate for Payer: Cigna All Commercial |
$39.74
|
| Rate for Payer: CORVEL All Commercial |
$42.82
|
| Rate for Payer: Coventry All Commercial |
$40.52
|
| Rate for Payer: Encore All Commercial |
$42.39
|
| Rate for Payer: Frontpath All Commercial |
$42.36
|
| Rate for Payer: Humana ChoiceCare |
$39.77
|
| Rate for Payer: Humana Medicare |
$23.48
|
| Rate for Payer: Lucent All Commercial |
$23.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.44
|
| Rate for Payer: PHCS All Commercial |
$34.53
|
| Rate for Payer: PHP All Commercial |
$34.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.96
|
| Rate for Payer: Sagamore Health Network All Products |
$35.55
|
| Rate for Payer: Signature Care EPO |
$38.22
|
| Rate for Payer: Signature Care PPO |
$40.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39.14
|
| Rate for Payer: United Healthcare Commercial |
$36.28
|
| Rate for Payer: United Healthcare Medicare |
$15.20
|
|
|
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D
|
Facility
IP
|
$46.05
|
|
|
Service Code
|
NDC 50742050504
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.53 |
| Max. Negotiated Rate |
$42.82 |
| Rate for Payer: Aetna Commercial |
$39.78
|
| Rate for Payer: Cash Price |
$28.55
|
| Rate for Payer: Cigna All Commercial |
$39.74
|
| Rate for Payer: CORVEL All Commercial |
$42.82
|
| Rate for Payer: Coventry All Commercial |
$40.52
|
| Rate for Payer: Encore All Commercial |
$42.39
|
| Rate for Payer: Frontpath All Commercial |
$42.36
|
| Rate for Payer: Humana ChoiceCare |
$39.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.44
|
| Rate for Payer: PHCS All Commercial |
$34.53
|
| Rate for Payer: PHP All Commercial |
$34.92
|
| Rate for Payer: Sagamore Health Network All Products |
$35.55
|
| Rate for Payer: Signature Care EPO |
$38.22
|
| Rate for Payer: Signature Care PPO |
$40.52
|
| Rate for Payer: United Healthcare Commercial |
$36.28
|
|
|
SEMAGLUTIDE 2 MG/DOSE (8 MG/3 ML) SUBQ PNIJ
|
Facility
IP
|
$3,674.56
|
|
|
Service Code
|
NDC 00169477212
|
| Hospital Charge Code |
197585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,755.92 |
| Max. Negotiated Rate |
$3,417.34 |
| Rate for Payer: Aetna Commercial |
$3,174.82
|
| Rate for Payer: Cash Price |
$2,278.22
|
| Rate for Payer: Cigna All Commercial |
$3,171.14
|
| Rate for Payer: CORVEL All Commercial |
$3,417.34
|
| Rate for Payer: Coventry All Commercial |
$3,233.61
|
| Rate for Payer: Encore All Commercial |
$3,382.43
|
| Rate for Payer: Frontpath All Commercial |
$3,380.59
|
| Rate for Payer: Humana ChoiceCare |
$3,173.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,307.10
|
| Rate for Payer: PHCS All Commercial |
$2,755.92
|
| Rate for Payer: PHP All Commercial |
$2,786.78
|
| Rate for Payer: Sagamore Health Network All Products |
$2,836.76
|
| Rate for Payer: Signature Care EPO |
$3,049.88
|
| Rate for Payer: Signature Care PPO |
$3,233.61
|
| Rate for Payer: United Healthcare Commercial |
$2,895.55
|
|
|
SEMAGLUTIDE 2 MG/DOSE (8 MG/3 ML) SUBQ PNIJ
|
Facility
OP
|
$3,674.56
|
|
|
Service Code
|
NDC 00169477212
|
| Hospital Charge Code |
197585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$3,417.34 |
| Rate for Payer: Aetna Commercial |
$3,101.33
|
| Rate for Payer: Aetna Medicare |
$1,212.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,212.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,110.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,296.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,394.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,333.86
|
| Rate for Payer: Cash Price |
$2,278.22
|
| Rate for Payer: Cash Price |
$2,278.22
|
| Rate for Payer: Centivo All Commercial |
$1,874.02
|
| Rate for Payer: Cigna All Commercial |
$3,171.14
|
| Rate for Payer: CORVEL All Commercial |
$3,417.34
|
| Rate for Payer: Coventry All Commercial |
$3,233.61
|
| Rate for Payer: Encore All Commercial |
$3,382.43
|
| Rate for Payer: Frontpath All Commercial |
$3,380.59
|
| Rate for Payer: Humana ChoiceCare |
$3,173.71
|
| Rate for Payer: Humana Medicare |
$1,874.02
|
| Rate for Payer: Lucent All Commercial |
$1,874.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,307.10
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$2,755.92
|
| Rate for Payer: PHP All Commercial |
$2,786.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,433.08
|
| Rate for Payer: Sagamore Health Network All Products |
$2,836.76
|
| Rate for Payer: Signature Care EPO |
$3,049.88
|
| Rate for Payer: Signature Care PPO |
$3,233.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,123.37
|
| Rate for Payer: United Healthcare Commercial |
$2,895.55
|
| Rate for Payer: United Healthcare Medicare |
$1,212.60
|
|
|
SENNOSIDES 8.6 MG ORAL TAB
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 00904725261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.24
|
| Rate for Payer: Aetna Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Centivo All Commercial |
$0.15
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Humana Medicare |
$0.15
|
| Rate for Payer: Lucent All Commercial |
$0.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.11
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
|
|
SENNOSIDES 8.6 MG ORAL TAB
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 00904725261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
|
|
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
| Hospital Charge Code |
24216
|
|
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
|
|
|
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
| Hospital Charge Code |
24216
|
|
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
|
|
|
SERTRALINE 50 MG ORAL TAB
|
Facility
IP
|
$2.07
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna Commercial |
$1.79
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna All Commercial |
$1.79
|
| Rate for Payer: CORVEL All Commercial |
$1.93
|
| Rate for Payer: Coventry All Commercial |
$1.82
|
| Rate for Payer: Encore All Commercial |
$1.91
|
| Rate for Payer: Frontpath All Commercial |
$1.91
|
| Rate for Payer: Humana ChoiceCare |
$1.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.86
|
| Rate for Payer: PHCS All Commercial |
$1.55
|
| Rate for Payer: PHP All Commercial |
$1.57
|
| Rate for Payer: Sagamore Health Network All Products |
$1.60
|
| Rate for Payer: Signature Care EPO |
$1.72
|
| Rate for Payer: Signature Care PPO |
$1.82
|
| Rate for Payer: United Healthcare Commercial |
$1.63
|
|
|
SERTRALINE 50 MG ORAL TAB
|
Facility
OP
|
$2.07
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna Commercial |
$1.75
|
| Rate for Payer: Aetna Medicare |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Centivo All Commercial |
$1.06
|
| Rate for Payer: Cigna All Commercial |
$1.79
|
| Rate for Payer: CORVEL All Commercial |
$1.93
|
| Rate for Payer: Coventry All Commercial |
$1.82
|
| Rate for Payer: Encore All Commercial |
$1.91
|
| Rate for Payer: Frontpath All Commercial |
$1.91
|
| Rate for Payer: Humana ChoiceCare |
$1.79
|
| Rate for Payer: Humana Medicare |
$1.06
|
| Rate for Payer: Lucent All Commercial |
$1.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.86
|
| Rate for Payer: PHCS All Commercial |
$1.55
|
| Rate for Payer: PHP All Commercial |
$1.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.81
|
| Rate for Payer: Sagamore Health Network All Products |
$1.60
|
| Rate for Payer: Signature Care EPO |
$1.72
|
| Rate for Payer: Signature Care PPO |
$1.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$1.63
|
| Rate for Payer: United Healthcare Medicare |
$0.68
|
|
|
SEVELAMER HCL 800 MG ORAL TAB
|
Facility
IP
|
$49.38
|
|
|
Service Code
|
NDC 58468002101
|
| Hospital Charge Code |
28715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$45.92 |
| Rate for Payer: Aetna Commercial |
$42.66
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Cigna All Commercial |
$42.61
|
| Rate for Payer: CORVEL All Commercial |
$45.92
|
| Rate for Payer: Coventry All Commercial |
$43.45
|
| Rate for Payer: Encore All Commercial |
$45.45
|
| Rate for Payer: Frontpath All Commercial |
$45.43
|
| Rate for Payer: Humana ChoiceCare |
$42.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.44
|
| Rate for Payer: PHCS All Commercial |
$37.03
|
| Rate for Payer: PHP All Commercial |
$37.45
|
| Rate for Payer: Sagamore Health Network All Products |
$38.12
|
| Rate for Payer: Signature Care EPO |
$40.98
|
| Rate for Payer: Signature Care PPO |
$43.45
|
| Rate for Payer: United Healthcare Commercial |
$38.91
|
|
|
SEVELAMER HCL 800 MG ORAL TAB
|
Facility
OP
|
$49.38
|
|
|
Service Code
|
NDC 58468002101
|
| Hospital Charge Code |
28715
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$45.92 |
| Rate for Payer: Aetna Commercial |
$41.68
|
| Rate for Payer: Aetna Medicare |
$16.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.92
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Centivo All Commercial |
$25.18
|
| Rate for Payer: Cigna All Commercial |
$42.61
|
| Rate for Payer: CORVEL All Commercial |
$45.92
|
| Rate for Payer: Coventry All Commercial |
$43.45
|
| Rate for Payer: Encore All Commercial |
$45.45
|
| Rate for Payer: Frontpath All Commercial |
$45.43
|
| Rate for Payer: Humana ChoiceCare |
$42.65
|
| Rate for Payer: Humana Medicare |
$25.18
|
| Rate for Payer: Lucent All Commercial |
$25.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.44
|
| Rate for Payer: PHCS All Commercial |
$37.03
|
| Rate for Payer: PHP All Commercial |
$37.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.26
|
| Rate for Payer: Sagamore Health Network All Products |
$38.12
|
| Rate for Payer: Signature Care EPO |
$40.98
|
| Rate for Payer: Signature Care PPO |
$43.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.97
|
| Rate for Payer: United Healthcare Commercial |
$38.91
|
| Rate for Payer: United Healthcare Medicare |
$16.29
|
|
|
SEVOFLURANE INHL LIQD
|
Facility
OP
|
$891.25
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$828.86 |
| Rate for Payer: Aetna Commercial |
$752.22
|
| Rate for Payer: Aetna Medicare |
$294.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$294.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$511.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$557.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$338.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$323.52
|
| Rate for Payer: Cash Price |
$552.58
|
| Rate for Payer: Cash Price |
$552.58
|
| Rate for Payer: Centivo All Commercial |
$454.54
|
| Rate for Payer: Cigna All Commercial |
$769.15
|
| Rate for Payer: CORVEL All Commercial |
$828.86
|
| Rate for Payer: Coventry All Commercial |
$784.30
|
| Rate for Payer: Encore All Commercial |
$820.40
|
| Rate for Payer: Frontpath All Commercial |
$819.95
|
| Rate for Payer: Humana ChoiceCare |
$769.77
|
| Rate for Payer: Humana Medicare |
$454.54
|
| Rate for Payer: Lucent All Commercial |
$454.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$802.12
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$668.44
|
| Rate for Payer: PHP All Commercial |
$675.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$347.59
|
| Rate for Payer: Sagamore Health Network All Products |
$688.04
|
| Rate for Payer: Signature Care EPO |
$739.74
|
| Rate for Payer: Signature Care PPO |
$784.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$757.56
|
| Rate for Payer: United Healthcare Commercial |
$702.30
|
| Rate for Payer: United Healthcare Medicare |
$294.11
|
|
|
SEVOFLURANE INHL LIQD
|
Facility
IP
|
$891.25
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$668.44 |
| Max. Negotiated Rate |
$828.86 |
| Rate for Payer: Aetna Commercial |
$770.04
|
| Rate for Payer: Cash Price |
$552.58
|
| Rate for Payer: Cigna All Commercial |
$769.15
|
| Rate for Payer: CORVEL All Commercial |
$828.86
|
| Rate for Payer: Coventry All Commercial |
$784.30
|
| Rate for Payer: Encore All Commercial |
$820.40
|
| Rate for Payer: Frontpath All Commercial |
$819.95
|
| Rate for Payer: Humana ChoiceCare |
$769.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$802.12
|
| Rate for Payer: PHCS All Commercial |
$668.44
|
| Rate for Payer: PHP All Commercial |
$675.92
|
| Rate for Payer: Sagamore Health Network All Products |
$688.04
|
| Rate for Payer: Signature Care EPO |
$739.74
|
| Rate for Payer: Signature Care PPO |
$784.30
|
| Rate for Payer: United Healthcare Commercial |
$702.30
|
|
|
Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 45330
|
| Hospital Charge Code |
CPT-45330
|
|
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
|
|
|
Sigmoidoscopy, flexible; with biopsy, single or multiple
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 45331
|
| Hospital Charge Code |
CPT-45331
|
|
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
|
|
|
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 45335
|
| Hospital Charge Code |
CPT-45335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Sigmoidoscopy, flexible; with removal of foreign body(s)
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45332
|
| Hospital Charge Code |
CPT-45332
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45338
|
| Hospital Charge Code |
CPT-45338
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
