|
SOTALOL 120 MG ORAL TAB
|
Facility
OP
|
$2.49
|
|
|
Service Code
|
NDC 00093106001
|
| Hospital Charge Code |
15723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Centivo All Commercial |
$1.27
|
| Rate for Payer: Cigna All Commercial |
$2.15
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Humana Medicare |
$1.27
|
| Rate for Payer: Lucent All Commercial |
$1.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.97
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.12
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Medicare |
$0.82
|
|
|
SOTALOL 120 MG ORAL TAB
|
Facility
IP
|
$2.49
|
|
|
Service Code
|
NDC 00093106001
|
| Hospital Charge Code |
15723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna All Commercial |
$2.15
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.89
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
SOTALOL 80 MG ORAL TAB
|
Facility
OP
|
$4.99
|
|
|
Service Code
|
NDC 00904714361
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$4.21
|
| Rate for Payer: Aetna Medicare |
$1.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.81
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Centivo All Commercial |
$2.55
|
| Rate for Payer: Cigna All Commercial |
$4.31
|
| Rate for Payer: CORVEL All Commercial |
$4.64
|
| Rate for Payer: Coventry All Commercial |
$4.39
|
| Rate for Payer: Encore All Commercial |
$4.59
|
| Rate for Payer: Frontpath All Commercial |
$4.59
|
| Rate for Payer: Humana ChoiceCare |
$4.31
|
| Rate for Payer: Humana Medicare |
$2.55
|
| Rate for Payer: Lucent All Commercial |
$2.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.49
|
| Rate for Payer: PHCS All Commercial |
$3.74
|
| Rate for Payer: PHP All Commercial |
$3.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.95
|
| Rate for Payer: Sagamore Health Network All Products |
$3.85
|
| Rate for Payer: Signature Care EPO |
$4.14
|
| Rate for Payer: Signature Care PPO |
$4.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.24
|
| Rate for Payer: United Healthcare Commercial |
$3.93
|
| Rate for Payer: United Healthcare Medicare |
$1.65
|
|
|
SOTALOL 80 MG ORAL TAB
|
Facility
IP
|
$4.99
|
|
|
Service Code
|
NDC 00904714361
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$4.31
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cigna All Commercial |
$4.31
|
| Rate for Payer: CORVEL All Commercial |
$4.64
|
| Rate for Payer: Coventry All Commercial |
$4.39
|
| Rate for Payer: Encore All Commercial |
$4.59
|
| Rate for Payer: Frontpath All Commercial |
$4.59
|
| Rate for Payer: Humana ChoiceCare |
$4.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.49
|
| Rate for Payer: PHCS All Commercial |
$3.74
|
| Rate for Payer: PHP All Commercial |
$3.79
|
| Rate for Payer: Sagamore Health Network All Products |
$3.85
|
| Rate for Payer: Signature Care EPO |
$4.14
|
| Rate for Payer: Signature Care PPO |
$4.39
|
| Rate for Payer: United Healthcare Commercial |
$3.93
|
|
|
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) IV SOLN
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
195267
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) IV SOLN
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
195267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
SPIRONOLACTONE 25 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
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
|
|
|
SPIRONOLACTONE 25 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
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
|
|
|
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
121308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
121308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
OP
|
$68.67
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$57.96
|
| Rate for Payer: Aetna Medicare |
$22.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.93
|
| Rate for Payer: Cash Price |
$42.58
|
| Rate for Payer: Centivo All Commercial |
$35.02
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Humana Medicare |
$35.02
|
| Rate for Payer: Lucent All Commercial |
$35.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.78
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.37
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
| Rate for Payer: United Healthcare Medicare |
$22.66
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
IP
|
$68.67
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Cash Price |
$42.58
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML S.O.
|
Facility
IP
|
$68.67
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
420790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Cash Price |
$42.58
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML S.O.
|
Facility
OP
|
$68.67
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
420790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$57.96
|
| Rate for Payer: Aetna Medicare |
$22.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.93
|
| Rate for Payer: Cash Price |
$42.58
|
| Rate for Payer: Centivo All Commercial |
$35.02
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Humana Medicare |
$35.02
|
| Rate for Payer: Lucent All Commercial |
$35.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.78
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.37
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
| Rate for Payer: United Healthcare Medicare |
$22.66
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML SYRINGE S.O.
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
140121308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML SYRINGE S.O.
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
140121308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$72.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.74
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Centivo All Commercial |
$64.26
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Humana Medicare |
$64.26
|
| Rate for Payer: Lucent All Commercial |
$64.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.14
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
| Rate for Payer: United Healthcare Medicare |
$41.58
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
177642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$72.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.74
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Centivo All Commercial |
$64.26
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Humana Medicare |
$64.26
|
| Rate for Payer: Lucent All Commercial |
$64.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.14
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
| Rate for Payer: United Healthcare Medicare |
$41.58
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
177642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 20 MG/ML INJ SOLN
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
193039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 20 MG/ML INJ SOLN
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
193039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SUCRALFATE 1 G ORAL TAB
|
Facility
OP
|
$1.77
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.49
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Humana Medicare |
$0.90
|
| Rate for Payer: Lucent All Commercial |
$0.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
SUCRALFATE 1 G ORAL TAB
|
Facility
IP
|
$1.77
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
|
|
SUGAMMADEX 100 MG/ML IV SOLN
|
Facility
IP
|
$614.89
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
175535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$461.17 |
| Max. Negotiated Rate |
$571.85 |
| Rate for Payer: Aetna Commercial |
$531.26
|
| Rate for Payer: Cash Price |
$381.23
|
| Rate for Payer: Cigna All Commercial |
$530.65
|
| Rate for Payer: CORVEL All Commercial |
$571.85
|
| Rate for Payer: Coventry All Commercial |
$541.10
|
| Rate for Payer: Encore All Commercial |
$566.01
|
| Rate for Payer: Frontpath All Commercial |
$565.70
|
| Rate for Payer: Humana ChoiceCare |
$531.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$553.40
|
| Rate for Payer: PHCS All Commercial |
$461.17
|
| Rate for Payer: PHP All Commercial |
$466.33
|
| Rate for Payer: Sagamore Health Network All Products |
$474.70
|
| Rate for Payer: Signature Care EPO |
$510.36
|
| Rate for Payer: Signature Care PPO |
$541.10
|
| Rate for Payer: United Healthcare Commercial |
$484.53
|
|
|
SUGAMMADEX 100 MG/ML IV SOLN
|
Facility
OP
|
$614.89
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
175535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$571.85 |
| Rate for Payer: Aetna Commercial |
$518.97
|
| Rate for Payer: Aetna Medicare |
$202.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$202.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$353.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$384.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$233.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$223.21
|
| Rate for Payer: Cash Price |
$381.23
|
| Rate for Payer: Cash Price |
$381.23
|
| Rate for Payer: Centivo All Commercial |
$313.59
|
| Rate for Payer: Cigna All Commercial |
$530.65
|
| Rate for Payer: CORVEL All Commercial |
$571.85
|
| Rate for Payer: Coventry All Commercial |
$541.10
|
| Rate for Payer: Encore All Commercial |
$566.01
|
| Rate for Payer: Frontpath All Commercial |
$565.70
|
| Rate for Payer: Humana ChoiceCare |
$531.08
|
| Rate for Payer: Humana Medicare |
$313.59
|
| Rate for Payer: Lucent All Commercial |
$313.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$553.40
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$461.17
|
| Rate for Payer: PHP All Commercial |
$466.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$239.81
|
| Rate for Payer: Sagamore Health Network All Products |
$474.70
|
| Rate for Payer: Signature Care EPO |
$510.36
|
| Rate for Payer: Signature Care PPO |
$541.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$522.66
|
| Rate for Payer: United Healthcare Commercial |
$484.53
|
| Rate for Payer: United Healthcare Medicare |
$202.91
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
IP
|
$705.20
|
|
|
Service Code
|
NDC 11980001105
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$528.90 |
| Max. Negotiated Rate |
$655.84 |
| Rate for Payer: Aetna Commercial |
$609.29
|
| Rate for Payer: Cash Price |
$437.22
|
| Rate for Payer: Cigna All Commercial |
$608.59
|
| Rate for Payer: CORVEL All Commercial |
$655.84
|
| Rate for Payer: Coventry All Commercial |
$620.58
|
| Rate for Payer: Encore All Commercial |
$649.14
|
| Rate for Payer: Frontpath All Commercial |
$648.78
|
| Rate for Payer: Humana ChoiceCare |
$609.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$634.68
|
| Rate for Payer: PHCS All Commercial |
$528.90
|
| Rate for Payer: PHP All Commercial |
$534.82
|
| Rate for Payer: Sagamore Health Network All Products |
$544.41
|
| Rate for Payer: Signature Care EPO |
$585.32
|
| Rate for Payer: Signature Care PPO |
$620.58
|
| Rate for Payer: United Healthcare Commercial |
$555.70
|
|
