|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
OP
|
$285.08
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.07 |
| Max. Negotiated Rate |
$265.12 |
| Rate for Payer: Aetna Commercial |
$240.60
|
| Rate for Payer: Aetna Medicare |
$94.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$94.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$163.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$178.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$108.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.48
|
| Rate for Payer: Cash Price |
$176.75
|
| Rate for Payer: Centivo All Commercial |
$145.39
|
| Rate for Payer: Cigna All Commercial |
$246.02
|
| Rate for Payer: CORVEL All Commercial |
$265.12
|
| Rate for Payer: Coventry All Commercial |
$250.87
|
| Rate for Payer: Encore All Commercial |
$262.41
|
| Rate for Payer: Frontpath All Commercial |
$262.27
|
| Rate for Payer: Humana ChoiceCare |
$246.22
|
| Rate for Payer: Humana Medicare |
$145.39
|
| Rate for Payer: Lucent All Commercial |
$145.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$256.57
|
| Rate for Payer: PHCS All Commercial |
$213.81
|
| Rate for Payer: PHP All Commercial |
$216.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$111.18
|
| Rate for Payer: Sagamore Health Network All Products |
$220.08
|
| Rate for Payer: Signature Care EPO |
$236.61
|
| Rate for Payer: Signature Care PPO |
$250.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$242.31
|
| Rate for Payer: United Healthcare Commercial |
$224.64
|
| Rate for Payer: United Healthcare Medicare |
$94.07
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
OP
|
$705.20
|
|
|
Service Code
|
NDC 11980001105
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.72 |
| Max. Negotiated Rate |
$655.84 |
| Rate for Payer: Aetna Commercial |
$595.19
|
| Rate for Payer: Aetna Medicare |
$232.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$232.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$405.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$440.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$267.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$255.99
|
| Rate for Payer: Cash Price |
$437.22
|
| Rate for Payer: Centivo All Commercial |
$359.65
|
| 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: Humana Medicare |
$359.65
|
| Rate for Payer: Lucent All Commercial |
$359.65
|
| 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: Plain Church Group Ministry All Commercial |
$275.03
|
| 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: Three Rivers Preferred All Commercial |
$599.42
|
| Rate for Payer: United Healthcare Commercial |
$555.70
|
| Rate for Payer: United Healthcare Medicare |
$232.72
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
IP
|
$285.08
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.81 |
| Max. Negotiated Rate |
$265.12 |
| Rate for Payer: Aetna Commercial |
$246.30
|
| Rate for Payer: Cash Price |
$176.75
|
| Rate for Payer: Cigna All Commercial |
$246.02
|
| Rate for Payer: CORVEL All Commercial |
$265.12
|
| Rate for Payer: Coventry All Commercial |
$250.87
|
| Rate for Payer: Encore All Commercial |
$262.41
|
| Rate for Payer: Frontpath All Commercial |
$262.27
|
| Rate for Payer: Humana ChoiceCare |
$246.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$256.57
|
| Rate for Payer: PHCS All Commercial |
$213.81
|
| Rate for Payer: PHP All Commercial |
$216.20
|
| Rate for Payer: Sagamore Health Network All Products |
$220.08
|
| Rate for Payer: Signature Care EPO |
$236.61
|
| Rate for Payer: Signature Care PPO |
$250.87
|
| Rate for Payer: United Healthcare Commercial |
$224.64
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
OP
|
$301.30
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.43 |
| Max. Negotiated Rate |
$280.21 |
| Rate for Payer: Aetna Commercial |
$254.30
|
| Rate for Payer: Aetna Medicare |
$99.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$99.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$173.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$188.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$114.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$109.37
|
| Rate for Payer: Cash Price |
$186.81
|
| Rate for Payer: Centivo All Commercial |
$153.66
|
| Rate for Payer: Cigna All Commercial |
$260.02
|
| Rate for Payer: CORVEL All Commercial |
$280.21
|
| Rate for Payer: Coventry All Commercial |
$265.14
|
| Rate for Payer: Encore All Commercial |
$277.35
|
| Rate for Payer: Frontpath All Commercial |
$277.20
|
| Rate for Payer: Humana ChoiceCare |
$260.23
|
| Rate for Payer: Humana Medicare |
$153.66
|
| Rate for Payer: Lucent All Commercial |
$153.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$271.17
|
| Rate for Payer: PHCS All Commercial |
$225.98
|
| Rate for Payer: PHP All Commercial |
$228.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$117.51
|
| Rate for Payer: Sagamore Health Network All Products |
$232.60
|
| Rate for Payer: Signature Care EPO |
$250.08
|
| Rate for Payer: Signature Care PPO |
$265.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$256.11
|
| Rate for Payer: United Healthcare Commercial |
$237.43
|
| Rate for Payer: United Healthcare Medicare |
$99.43
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
OP
|
$3.19
|
|
|
Service Code
|
NDC 65862496
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.16
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Centivo All Commercial |
$1.62
|
| Rate for Payer: Cigna All Commercial |
$2.75
|
| Rate for Payer: CORVEL All Commercial |
$2.96
|
| Rate for Payer: Coventry All Commercial |
$2.80
|
| Rate for Payer: Encore All Commercial |
$2.93
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$2.75
|
| Rate for Payer: Humana Medicare |
$1.62
|
| Rate for Payer: Lucent All Commercial |
$1.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.87
|
| Rate for Payer: PHCS All Commercial |
$2.39
|
| Rate for Payer: PHP All Commercial |
$2.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2.46
|
| Rate for Payer: Signature Care EPO |
$2.64
|
| Rate for Payer: Signature Care PPO |
$2.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.71
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.05
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
IP
|
$301.30
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$280.21 |
| Rate for Payer: Aetna Commercial |
$260.32
|
| Rate for Payer: Cash Price |
$186.81
|
| Rate for Payer: Cigna All Commercial |
$260.02
|
| Rate for Payer: CORVEL All Commercial |
$280.21
|
| Rate for Payer: Coventry All Commercial |
$265.14
|
| Rate for Payer: Encore All Commercial |
$277.35
|
| Rate for Payer: Frontpath All Commercial |
$277.20
|
| Rate for Payer: Humana ChoiceCare |
$260.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$271.17
|
| Rate for Payer: PHCS All Commercial |
$225.98
|
| Rate for Payer: PHP All Commercial |
$228.51
|
| Rate for Payer: Sagamore Health Network All Products |
$232.60
|
| Rate for Payer: Signature Care EPO |
$250.08
|
| Rate for Payer: Signature Care PPO |
$265.14
|
| Rate for Payer: United Healthcare Commercial |
$237.43
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
IP
|
$3.19
|
|
|
Service Code
|
NDC 65862496
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cigna All Commercial |
$2.75
|
| Rate for Payer: CORVEL All Commercial |
$2.96
|
| Rate for Payer: Coventry All Commercial |
$2.80
|
| Rate for Payer: Encore All Commercial |
$2.93
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$2.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.87
|
| Rate for Payer: PHCS All Commercial |
$2.39
|
| Rate for Payer: PHP All Commercial |
$2.42
|
| Rate for Payer: Sagamore Health Network All Products |
$2.46
|
| Rate for Payer: Signature Care EPO |
$2.64
|
| Rate for Payer: Signature Care PPO |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN
|
Facility
OP
|
$19.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$16.75
|
| Rate for Payer: Aetna Medicare |
$6.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.20
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Centivo All Commercial |
$10.12
|
| Rate for Payer: Cigna All Commercial |
$17.13
|
| Rate for Payer: CORVEL All Commercial |
$18.46
|
| Rate for Payer: Coventry All Commercial |
$17.46
|
| Rate for Payer: Encore All Commercial |
$18.27
|
| Rate for Payer: Frontpath All Commercial |
$18.26
|
| Rate for Payer: Humana ChoiceCare |
$17.14
|
| Rate for Payer: Humana Medicare |
$10.12
|
| Rate for Payer: Lucent All Commercial |
$10.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.86
|
| Rate for Payer: PHCS All Commercial |
$14.88
|
| Rate for Payer: PHP All Commercial |
$15.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.74
|
| Rate for Payer: Sagamore Health Network All Products |
$15.32
|
| Rate for Payer: Signature Care EPO |
$16.47
|
| Rate for Payer: Signature Care PPO |
$17.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.87
|
| Rate for Payer: United Healthcare Commercial |
$15.64
|
| Rate for Payer: United Healthcare Medicare |
$6.55
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN
|
Facility
IP
|
$19.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.88 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.15
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cigna All Commercial |
$17.13
|
| Rate for Payer: CORVEL All Commercial |
$18.46
|
| Rate for Payer: Coventry All Commercial |
$17.46
|
| Rate for Payer: Encore All Commercial |
$18.27
|
| Rate for Payer: Frontpath All Commercial |
$18.26
|
| Rate for Payer: Humana ChoiceCare |
$17.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.86
|
| Rate for Payer: PHCS All Commercial |
$14.88
|
| Rate for Payer: PHP All Commercial |
$15.05
|
| Rate for Payer: Sagamore Health Network All Products |
$15.32
|
| Rate for Payer: Signature Care EPO |
$16.47
|
| Rate for Payer: Signature Care PPO |
$17.46
|
| Rate for Payer: United Healthcare Commercial |
$15.64
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
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
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
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
|
|
|
SULFASALAZINE 500 MG ORAL TBEC
|
Facility
OP
|
$1.62
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna Commercial |
$1.37
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.40
|
| Rate for Payer: CORVEL All Commercial |
$1.51
|
| Rate for Payer: Coventry All Commercial |
$1.43
|
| Rate for Payer: Encore All Commercial |
$1.49
|
| Rate for Payer: Frontpath All Commercial |
$1.49
|
| Rate for Payer: Humana ChoiceCare |
$1.40
|
| Rate for Payer: Humana Medicare |
$0.83
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.46
|
| Rate for Payer: PHCS All Commercial |
$1.22
|
| Rate for Payer: PHP All Commercial |
$1.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1.25
|
| Rate for Payer: Signature Care EPO |
$1.35
|
| Rate for Payer: Signature Care PPO |
$1.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.38
|
| Rate for Payer: United Healthcare Commercial |
$1.28
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
|
|
SULFASALAZINE 500 MG ORAL TBEC
|
Facility
IP
|
$1.62
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.40
|
| Rate for Payer: CORVEL All Commercial |
$1.51
|
| Rate for Payer: Coventry All Commercial |
$1.43
|
| Rate for Payer: Encore All Commercial |
$1.49
|
| Rate for Payer: Frontpath All Commercial |
$1.49
|
| Rate for Payer: Humana ChoiceCare |
$1.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.46
|
| Rate for Payer: PHCS All Commercial |
$1.22
|
| Rate for Payer: PHP All Commercial |
$1.23
|
| Rate for Payer: Sagamore Health Network All Products |
$1.25
|
| Rate for Payer: Signature Care EPO |
$1.35
|
| Rate for Payer: Signature Care PPO |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.28
|
|
|
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLN
|
Facility
IP
|
$25.76
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Aetna Commercial |
$22.26
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna All Commercial |
$22.23
|
| Rate for Payer: CORVEL All Commercial |
$23.96
|
| Rate for Payer: Coventry All Commercial |
$22.67
|
| Rate for Payer: Encore All Commercial |
$23.71
|
| Rate for Payer: Frontpath All Commercial |
$23.70
|
| Rate for Payer: Humana ChoiceCare |
$22.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.18
|
| Rate for Payer: PHCS All Commercial |
$19.32
|
| Rate for Payer: PHP All Commercial |
$19.54
|
| Rate for Payer: Sagamore Health Network All Products |
$19.89
|
| Rate for Payer: Signature Care EPO |
$21.38
|
| Rate for Payer: Signature Care PPO |
$22.67
|
| Rate for Payer: United Healthcare Commercial |
$20.30
|
|
|
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLN
|
Facility
OP
|
$25.76
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Medicare |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.35
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Centivo All Commercial |
$13.14
|
| Rate for Payer: Cigna All Commercial |
$22.23
|
| Rate for Payer: CORVEL All Commercial |
$23.96
|
| Rate for Payer: Coventry All Commercial |
$22.67
|
| Rate for Payer: Encore All Commercial |
$23.71
|
| Rate for Payer: Frontpath All Commercial |
$23.70
|
| Rate for Payer: Humana ChoiceCare |
$22.25
|
| Rate for Payer: Humana Medicare |
$13.14
|
| Rate for Payer: Lucent All Commercial |
$13.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.18
|
| Rate for Payer: PHCS All Commercial |
$19.32
|
| Rate for Payer: PHP All Commercial |
$19.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.05
|
| Rate for Payer: Sagamore Health Network All Products |
$19.89
|
| Rate for Payer: Signature Care EPO |
$21.38
|
| Rate for Payer: Signature Care PPO |
$22.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.90
|
| Rate for Payer: United Healthcare Commercial |
$20.30
|
| Rate for Payer: United Healthcare Medicare |
$8.50
|
|
|
Suture of quadriceps or hamstring muscle rupture; primary
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27385
|
| Hospital Charge Code |
CPT-27385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
TAMSULOSIN 0.4 MG ORAL CAP
|
Facility
OP
|
$1.76
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.64 |
| 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 |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.10
|
| 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 |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.64
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| 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 |
$1.32
|
| 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 |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.50
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
TAMSULOSIN 0.4 MG ORAL CAP
|
Facility
IP
|
$1.76
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.64
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.32
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
|
|
TECHNETIUM TC 99M DISOFENIN
|
Facility
OP
|
$237.44
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
40840071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$78.36 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna Commercial |
$200.40
|
| Rate for Payer: Aetna Medicare |
$78.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$78.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$136.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.19
|
| Rate for Payer: Cash Price |
$147.21
|
| Rate for Payer: Centivo All Commercial |
$121.09
|
| Rate for Payer: Cigna All Commercial |
$204.91
|
| Rate for Payer: CORVEL All Commercial |
$220.82
|
| Rate for Payer: Coventry All Commercial |
$208.95
|
| Rate for Payer: Encore All Commercial |
$218.56
|
| Rate for Payer: Frontpath All Commercial |
$218.44
|
| Rate for Payer: Humana ChoiceCare |
$205.08
|
| Rate for Payer: Humana Medicare |
$121.09
|
| Rate for Payer: Lucent All Commercial |
$121.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.70
|
| Rate for Payer: PHCS All Commercial |
$178.08
|
| Rate for Payer: PHP All Commercial |
$180.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.60
|
| Rate for Payer: Sagamore Health Network All Products |
$183.30
|
| Rate for Payer: Signature Care EPO |
$197.08
|
| Rate for Payer: Signature Care PPO |
$208.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.82
|
| Rate for Payer: United Healthcare Commercial |
$187.10
|
| Rate for Payer: United Healthcare Medicare |
$78.36
|
|
|
TECHNETIUM TC 99M DISOFENIN
|
Facility
IP
|
$237.44
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
40840071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$178.08 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna Commercial |
$205.15
|
| Rate for Payer: Cash Price |
$147.21
|
| Rate for Payer: Cigna All Commercial |
$204.91
|
| Rate for Payer: CORVEL All Commercial |
$220.82
|
| Rate for Payer: Coventry All Commercial |
$208.95
|
| Rate for Payer: Encore All Commercial |
$218.56
|
| Rate for Payer: Frontpath All Commercial |
$218.44
|
| Rate for Payer: Humana ChoiceCare |
$205.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.70
|
| Rate for Payer: PHCS All Commercial |
$178.08
|
| Rate for Payer: PHP All Commercial |
$180.07
|
| Rate for Payer: Sagamore Health Network All Products |
$183.30
|
| Rate for Payer: Signature Care EPO |
$197.08
|
| Rate for Payer: Signature Care PPO |
$208.95
|
| Rate for Payer: United Healthcare Commercial |
$187.10
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
IP
|
$730.60
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$547.95 |
| Max. Negotiated Rate |
$679.46 |
| Rate for Payer: Aetna Commercial |
$631.24
|
| Rate for Payer: Cash Price |
$452.97
|
| Rate for Payer: Cigna All Commercial |
$630.51
|
| Rate for Payer: CORVEL All Commercial |
$679.46
|
| Rate for Payer: Coventry All Commercial |
$642.93
|
| Rate for Payer: Encore All Commercial |
$672.52
|
| Rate for Payer: Frontpath All Commercial |
$672.15
|
| Rate for Payer: Humana ChoiceCare |
$631.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$657.54
|
| Rate for Payer: PHCS All Commercial |
$547.95
|
| Rate for Payer: PHP All Commercial |
$554.09
|
| Rate for Payer: Sagamore Health Network All Products |
$564.02
|
| Rate for Payer: Signature Care EPO |
$606.40
|
| Rate for Payer: Signature Care PPO |
$642.93
|
| Rate for Payer: United Healthcare Commercial |
$575.71
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
OP
|
$730.60
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$241.10 |
| Max. Negotiated Rate |
$679.46 |
| Rate for Payer: Aetna Commercial |
$616.63
|
| Rate for Payer: Aetna Medicare |
$241.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$241.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$419.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$456.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$277.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$265.21
|
| Rate for Payer: Cash Price |
$452.97
|
| Rate for Payer: Centivo All Commercial |
$372.61
|
| Rate for Payer: Cigna All Commercial |
$630.51
|
| Rate for Payer: CORVEL All Commercial |
$679.46
|
| Rate for Payer: Coventry All Commercial |
$642.93
|
| Rate for Payer: Encore All Commercial |
$672.52
|
| Rate for Payer: Frontpath All Commercial |
$672.15
|
| Rate for Payer: Humana ChoiceCare |
$631.02
|
| Rate for Payer: Humana Medicare |
$372.61
|
| Rate for Payer: Lucent All Commercial |
$372.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$657.54
|
| Rate for Payer: PHCS All Commercial |
$547.95
|
| Rate for Payer: PHP All Commercial |
$554.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$284.93
|
| Rate for Payer: Sagamore Health Network All Products |
$564.02
|
| Rate for Payer: Signature Care EPO |
$606.40
|
| Rate for Payer: Signature Care PPO |
$642.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$621.01
|
| Rate for Payer: United Healthcare Commercial |
$575.71
|
| Rate for Payer: United Healthcare Medicare |
$241.10
|
|
|
TECHNETIUM TC 99M MERTIATIDE
|
Facility
OP
|
$1,008.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
40840068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$332.64 |
| Max. Negotiated Rate |
$937.44 |
| Rate for Payer: Aetna Commercial |
$850.75
|
| Rate for Payer: Aetna Medicare |
$332.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$332.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$578.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$630.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$382.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$365.90
|
| Rate for Payer: Cash Price |
$624.96
|
| Rate for Payer: Centivo All Commercial |
$514.08
|
| Rate for Payer: Cigna All Commercial |
$869.90
|
| Rate for Payer: CORVEL All Commercial |
$937.44
|
| Rate for Payer: Coventry All Commercial |
$887.04
|
| Rate for Payer: Encore All Commercial |
$927.86
|
| Rate for Payer: Frontpath All Commercial |
$927.36
|
| Rate for Payer: Humana ChoiceCare |
$870.61
|
| Rate for Payer: Humana Medicare |
$514.08
|
| Rate for Payer: Lucent All Commercial |
$514.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$907.20
|
| Rate for Payer: PHCS All Commercial |
$756.00
|
| Rate for Payer: PHP All Commercial |
$764.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$393.12
|
| Rate for Payer: Sagamore Health Network All Products |
$778.18
|
| Rate for Payer: Signature Care EPO |
$836.64
|
| Rate for Payer: Signature Care PPO |
$887.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$856.80
|
| Rate for Payer: United Healthcare Commercial |
$794.30
|
| Rate for Payer: United Healthcare Medicare |
$332.64
|
|
|
TECHNETIUM TC 99M MERTIATIDE
|
Facility
IP
|
$1,008.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
40840068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$756.00 |
| Max. Negotiated Rate |
$937.44 |
| Rate for Payer: Aetna Commercial |
$870.91
|
| Rate for Payer: Cash Price |
$624.96
|
| Rate for Payer: Cigna All Commercial |
$869.90
|
| Rate for Payer: CORVEL All Commercial |
$937.44
|
| Rate for Payer: Coventry All Commercial |
$887.04
|
| Rate for Payer: Encore All Commercial |
$927.86
|
| Rate for Payer: Frontpath All Commercial |
$927.36
|
| Rate for Payer: Humana ChoiceCare |
$870.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$907.20
|
| Rate for Payer: PHCS All Commercial |
$756.00
|
| Rate for Payer: PHP All Commercial |
$764.47
|
| Rate for Payer: Sagamore Health Network All Products |
$778.18
|
| Rate for Payer: Signature Care EPO |
$836.64
|
| Rate for Payer: Signature Care PPO |
$887.04
|
| Rate for Payer: United Healthcare Commercial |
$794.30
|
|
|
TECHNETIUM TC 99M OXIDRONATE KIT
|
Facility
IP
|
$315.70
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$236.78 |
| Max. Negotiated Rate |
$293.60 |
| Rate for Payer: Aetna Commercial |
$272.76
|
| Rate for Payer: Cash Price |
$195.73
|
| Rate for Payer: Cigna All Commercial |
$272.45
|
| Rate for Payer: CORVEL All Commercial |
$293.60
|
| Rate for Payer: Coventry All Commercial |
$277.82
|
| Rate for Payer: Encore All Commercial |
$290.60
|
| Rate for Payer: Frontpath All Commercial |
$290.44
|
| Rate for Payer: Humana ChoiceCare |
$272.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$284.13
|
| Rate for Payer: PHCS All Commercial |
$236.78
|
| Rate for Payer: PHP All Commercial |
$239.43
|
| Rate for Payer: Sagamore Health Network All Products |
$243.72
|
| Rate for Payer: Signature Care EPO |
$262.03
|
| Rate for Payer: Signature Care PPO |
$277.82
|
| Rate for Payer: United Healthcare Commercial |
$248.77
|
|
