|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLN
|
Facility
OP
|
$4,531.49
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$4,214.28 |
| Rate for Payer: Aetna Commercial |
$3,824.57
|
| Rate for Payer: Aetna Medicare |
$1,495.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,495.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,602.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,832.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,719.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,644.93
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Centivo All Commercial |
$2,311.06
|
| Rate for Payer: Cigna All Commercial |
$3,910.67
|
| Rate for Payer: CORVEL All Commercial |
$4,214.28
|
| Rate for Payer: Coventry All Commercial |
$3,987.71
|
| Rate for Payer: Encore All Commercial |
$4,171.23
|
| Rate for Payer: Frontpath All Commercial |
$4,168.97
|
| Rate for Payer: Humana ChoiceCare |
$3,913.84
|
| Rate for Payer: Humana Medicare |
$2,311.06
|
| Rate for Payer: Lucent All Commercial |
$2,311.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,078.34
|
| Rate for Payer: Managed Health Services Medicaid |
$6.97
|
| Rate for Payer: MDWise Medicaid |
$6.97
|
| Rate for Payer: PHCS All Commercial |
$3,398.61
|
| Rate for Payer: PHP All Commercial |
$3,436.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,767.28
|
| Rate for Payer: Sagamore Health Network All Products |
$3,498.31
|
| Rate for Payer: Signature Care EPO |
$3,761.13
|
| Rate for Payer: Signature Care PPO |
$3,987.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,851.76
|
| Rate for Payer: United Healthcare Commercial |
$3,570.81
|
| Rate for Payer: United Healthcare Medicare |
$1,495.39
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLN
|
Facility
IP
|
$4,531.49
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,398.61 |
| Max. Negotiated Rate |
$4,214.28 |
| Rate for Payer: Aetna Commercial |
$3,915.20
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Cigna All Commercial |
$3,910.67
|
| Rate for Payer: CORVEL All Commercial |
$4,214.28
|
| Rate for Payer: Coventry All Commercial |
$3,987.71
|
| Rate for Payer: Encore All Commercial |
$4,171.23
|
| Rate for Payer: Frontpath All Commercial |
$4,168.97
|
| Rate for Payer: Humana ChoiceCare |
$3,913.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,078.34
|
| Rate for Payer: PHCS All Commercial |
$3,398.61
|
| Rate for Payer: PHP All Commercial |
$3,436.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3,498.31
|
| Rate for Payer: Signature Care EPO |
$3,761.13
|
| Rate for Payer: Signature Care PPO |
$3,987.71
|
| Rate for Payer: United Healthcare Commercial |
$3,570.81
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN
|
Facility
IP
|
$2,071.52
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,553.64 |
| Max. Negotiated Rate |
$1,926.51 |
| Rate for Payer: Aetna Commercial |
$1,789.79
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Cigna All Commercial |
$1,787.72
|
| Rate for Payer: CORVEL All Commercial |
$1,926.51
|
| Rate for Payer: Coventry All Commercial |
$1,822.94
|
| Rate for Payer: Encore All Commercial |
$1,906.83
|
| Rate for Payer: Frontpath All Commercial |
$1,905.80
|
| Rate for Payer: Humana ChoiceCare |
$1,789.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,864.37
|
| Rate for Payer: PHCS All Commercial |
$1,553.64
|
| Rate for Payer: PHP All Commercial |
$1,571.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1,599.21
|
| Rate for Payer: Signature Care EPO |
$1,719.36
|
| Rate for Payer: Signature Care PPO |
$1,822.94
|
| Rate for Payer: United Healthcare Commercial |
$1,632.36
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN
|
Facility
OP
|
$2,071.52
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$1,926.51 |
| Rate for Payer: Aetna Commercial |
$1,748.36
|
| Rate for Payer: Aetna Medicare |
$683.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$683.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,189.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,294.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$786.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$751.96
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Centivo All Commercial |
$1,056.48
|
| Rate for Payer: Cigna All Commercial |
$1,787.72
|
| Rate for Payer: CORVEL All Commercial |
$1,926.51
|
| Rate for Payer: Coventry All Commercial |
$1,822.94
|
| Rate for Payer: Encore All Commercial |
$1,906.83
|
| Rate for Payer: Frontpath All Commercial |
$1,905.80
|
| Rate for Payer: Humana ChoiceCare |
$1,789.17
|
| Rate for Payer: Humana Medicare |
$1,056.48
|
| Rate for Payer: Lucent All Commercial |
$1,056.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,864.37
|
| Rate for Payer: Managed Health Services Medicaid |
$6.97
|
| Rate for Payer: MDWise Medicaid |
$6.97
|
| Rate for Payer: PHCS All Commercial |
$1,553.64
|
| Rate for Payer: PHP All Commercial |
$1,571.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$807.89
|
| Rate for Payer: Sagamore Health Network All Products |
$1,599.21
|
| Rate for Payer: Signature Care EPO |
$1,719.36
|
| Rate for Payer: Signature Care PPO |
$1,822.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,760.79
|
| Rate for Payer: United Healthcare Commercial |
$1,632.36
|
| Rate for Payer: United Healthcare Medicare |
$683.60
|
|
|
TOLTERODINE 2 MG ORAL CP24
|
Facility
OP
|
$37.81
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
29434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna Commercial |
$31.92
|
| Rate for Payer: Aetna Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.73
|
| Rate for Payer: Cash Price |
$23.44
|
| Rate for Payer: Centivo All Commercial |
$19.29
|
| Rate for Payer: Cigna All Commercial |
$32.63
|
| Rate for Payer: CORVEL All Commercial |
$35.17
|
| Rate for Payer: Coventry All Commercial |
$33.28
|
| Rate for Payer: Encore All Commercial |
$34.81
|
| Rate for Payer: Frontpath All Commercial |
$34.79
|
| Rate for Payer: Humana ChoiceCare |
$32.66
|
| Rate for Payer: Humana Medicare |
$19.29
|
| Rate for Payer: Lucent All Commercial |
$19.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.03
|
| Rate for Payer: PHCS All Commercial |
$28.36
|
| Rate for Payer: PHP All Commercial |
$28.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.75
|
| Rate for Payer: Sagamore Health Network All Products |
$29.19
|
| Rate for Payer: Signature Care EPO |
$31.39
|
| Rate for Payer: Signature Care PPO |
$33.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.14
|
| Rate for Payer: United Healthcare Commercial |
$29.80
|
| Rate for Payer: United Healthcare Medicare |
$12.48
|
|
|
TOLTERODINE 2 MG ORAL CP24
|
Facility
IP
|
$37.81
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
29434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.36 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna Commercial |
$32.67
|
| Rate for Payer: Cash Price |
$23.44
|
| Rate for Payer: Cigna All Commercial |
$32.63
|
| Rate for Payer: CORVEL All Commercial |
$35.17
|
| Rate for Payer: Coventry All Commercial |
$33.28
|
| Rate for Payer: Encore All Commercial |
$34.81
|
| Rate for Payer: Frontpath All Commercial |
$34.79
|
| Rate for Payer: Humana ChoiceCare |
$32.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.03
|
| Rate for Payer: PHCS All Commercial |
$28.36
|
| Rate for Payer: PHP All Commercial |
$28.68
|
| Rate for Payer: Sagamore Health Network All Products |
$29.19
|
| Rate for Payer: Signature Care EPO |
$31.39
|
| Rate for Payer: Signature Care PPO |
$33.28
|
| Rate for Payer: United Healthcare Commercial |
$29.80
|
|
|
TOLTERODINE 2 MG ORAL TAB
|
Facility
IP
|
$2.95
|
|
|
Service Code
|
NDC 16571012706
|
| Hospital Charge Code |
22783
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.55
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna All Commercial |
$2.55
|
| Rate for Payer: CORVEL All Commercial |
$2.75
|
| Rate for Payer: Coventry All Commercial |
$2.60
|
| Rate for Payer: Encore All Commercial |
$2.72
|
| Rate for Payer: Frontpath All Commercial |
$2.72
|
| Rate for Payer: Humana ChoiceCare |
$2.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.66
|
| Rate for Payer: PHCS All Commercial |
$2.22
|
| Rate for Payer: PHP All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2.28
|
| Rate for Payer: Signature Care EPO |
$2.45
|
| Rate for Payer: Signature Care PPO |
$2.60
|
| Rate for Payer: United Healthcare Commercial |
$2.33
|
|
|
TOLTERODINE 2 MG ORAL TAB
|
Facility
OP
|
$2.95
|
|
|
Service Code
|
NDC 16571012706
|
| Hospital Charge Code |
22783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Centivo All Commercial |
$1.51
|
| Rate for Payer: Cigna All Commercial |
$2.55
|
| Rate for Payer: CORVEL All Commercial |
$2.75
|
| Rate for Payer: Coventry All Commercial |
$2.60
|
| Rate for Payer: Encore All Commercial |
$2.72
|
| Rate for Payer: Frontpath All Commercial |
$2.72
|
| Rate for Payer: Humana ChoiceCare |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.51
|
| Rate for Payer: Lucent All Commercial |
$1.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.66
|
| Rate for Payer: PHCS All Commercial |
$2.22
|
| Rate for Payer: PHP All Commercial |
$2.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2.28
|
| Rate for Payer: Signature Care EPO |
$2.45
|
| Rate for Payer: Signature Care PPO |
$2.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$2.33
|
| Rate for Payer: United Healthcare Medicare |
$0.97
|
|
|
TOLVAPTAN 15 MG ORAL TAB
|
Facility
OP
|
$359.99
|
|
|
Service Code
|
NDC 31722086803
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.80 |
| Max. Negotiated Rate |
$334.79 |
| Rate for Payer: Aetna Commercial |
$303.83
|
| Rate for Payer: Aetna Medicare |
$118.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$118.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$206.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$225.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$136.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$130.68
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Centivo All Commercial |
$183.60
|
| Rate for Payer: Cigna All Commercial |
$310.67
|
| Rate for Payer: CORVEL All Commercial |
$334.79
|
| Rate for Payer: Coventry All Commercial |
$316.79
|
| Rate for Payer: Encore All Commercial |
$331.37
|
| Rate for Payer: Frontpath All Commercial |
$331.19
|
| Rate for Payer: Humana ChoiceCare |
$310.93
|
| Rate for Payer: Humana Medicare |
$183.60
|
| Rate for Payer: Lucent All Commercial |
$183.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.99
|
| Rate for Payer: PHCS All Commercial |
$270.00
|
| Rate for Payer: PHP All Commercial |
$273.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$140.40
|
| Rate for Payer: Sagamore Health Network All Products |
$277.92
|
| Rate for Payer: Signature Care EPO |
$298.80
|
| Rate for Payer: Signature Care PPO |
$316.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.99
|
| Rate for Payer: United Healthcare Commercial |
$283.68
|
| Rate for Payer: United Healthcare Medicare |
$118.80
|
|
|
TOLVAPTAN 15 MG ORAL TAB
|
Facility
IP
|
$359.99
|
|
|
Service Code
|
NDC 31722086803
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$270.00 |
| Max. Negotiated Rate |
$334.79 |
| Rate for Payer: Aetna Commercial |
$311.03
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Cigna All Commercial |
$310.67
|
| Rate for Payer: CORVEL All Commercial |
$334.79
|
| Rate for Payer: Coventry All Commercial |
$316.79
|
| Rate for Payer: Encore All Commercial |
$331.37
|
| Rate for Payer: Frontpath All Commercial |
$331.19
|
| Rate for Payer: Humana ChoiceCare |
$310.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.99
|
| Rate for Payer: PHCS All Commercial |
$270.00
|
| Rate for Payer: PHP All Commercial |
$273.02
|
| Rate for Payer: Sagamore Health Network All Products |
$277.92
|
| Rate for Payer: Signature Care EPO |
$298.80
|
| Rate for Payer: Signature Care PPO |
$316.79
|
| Rate for Payer: United Healthcare Commercial |
$283.68
|
|
|
TOPIRAMATE 25 MG ORAL TAB
|
Facility
IP
|
$1.54
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
TOPIRAMATE 25 MG ORAL TAB
|
Facility
OP
|
$1.54
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.30
|
| Rate for Payer: Aetna Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Centivo All Commercial |
$0.79
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Humana Medicare |
$0.79
|
| Rate for Payer: Lucent All Commercial |
$0.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
|
|
TORSEMIDE 20 MG ORAL TAB
|
Facility
IP
|
$2.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna Commercial |
$1.89
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna All Commercial |
$1.88
|
| Rate for Payer: CORVEL All Commercial |
$2.03
|
| Rate for Payer: Coventry All Commercial |
$1.92
|
| Rate for Payer: Encore All Commercial |
$2.01
|
| Rate for Payer: Frontpath All Commercial |
$2.01
|
| Rate for Payer: Humana ChoiceCare |
$1.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.97
|
| Rate for Payer: PHCS All Commercial |
$1.64
|
| Rate for Payer: PHP All Commercial |
$1.66
|
| Rate for Payer: Sagamore Health Network All Products |
$1.69
|
| Rate for Payer: Signature Care EPO |
$1.81
|
| Rate for Payer: Signature Care PPO |
$1.92
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
|
|
TORSEMIDE 20 MG ORAL TAB
|
Facility
OP
|
$2.18
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna Commercial |
$1.84
|
| Rate for Payer: Aetna Medicare |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Centivo All Commercial |
$1.11
|
| Rate for Payer: Cigna All Commercial |
$1.88
|
| Rate for Payer: CORVEL All Commercial |
$2.03
|
| Rate for Payer: Coventry All Commercial |
$1.92
|
| Rate for Payer: Encore All Commercial |
$2.01
|
| Rate for Payer: Frontpath All Commercial |
$2.01
|
| Rate for Payer: Humana ChoiceCare |
$1.89
|
| Rate for Payer: Humana Medicare |
$1.11
|
| Rate for Payer: Lucent All Commercial |
$1.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.97
|
| Rate for Payer: PHCS All Commercial |
$1.64
|
| Rate for Payer: PHP All Commercial |
$1.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1.69
|
| Rate for Payer: Signature Care EPO |
$1.81
|
| Rate for Payer: Signature Care PPO |
$1.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.86
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
| Rate for Payer: United Healthcare Medicare |
$0.72
|
|
|
TRAMADOL 50 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084080801
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
TRAMADOL 50 MG ORAL TAB
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084080801
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
TRAMADOL 50 MG TABLET #4 ED PACK (CAMERON)
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084808
|
| Hospital Charge Code |
1401000800207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
TRAMADOL 50 MG TABLET #4 ED PACK (CAMERON)
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084808
|
| Hospital Charge Code |
1401000800207
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
IP
|
$38.50
|
|
|
Service Code
|
NDC 39822100001
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
OP
|
$38.50
|
|
|
Service Code
|
NDC 39822100001
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.98
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Centivo All Commercial |
$19.64
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$19.64
|
| Rate for Payer: Lucent All Commercial |
$19.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.72
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
|
|
TRAZODONE 50 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
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
|
|
|
TRAZODONE 50 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
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
|
|
|
Treatment of incomplete abortion, any trimester, completed surgically
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 59812
|
| Hospital Charge Code |
CPT-59812
|
|
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
|
|
|
Treatment of missed abortion, completed surgically; first trimester
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 59820
|
| Hospital Charge Code |
CPT-59820
|
|
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
|
|
|
Treatment of missed abortion, completed surgically; second trimester
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 59821
|
| Hospital Charge Code |
CPT-59821
|
|
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
|
|
