|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
IP
|
$497.94
|
|
|
Service Code
|
NDC 49281075221
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$373.46 |
| Max. Negotiated Rate |
$463.08 |
| Rate for Payer: Aetna Commercial |
$430.22
|
| Rate for Payer: Cash Price |
$308.72
|
| Rate for Payer: Cigna All Commercial |
$429.72
|
| Rate for Payer: CORVEL All Commercial |
$463.08
|
| Rate for Payer: Coventry All Commercial |
$438.19
|
| Rate for Payer: Encore All Commercial |
$458.35
|
| Rate for Payer: Frontpath All Commercial |
$458.10
|
| Rate for Payer: Humana ChoiceCare |
$430.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$448.15
|
| Rate for Payer: PHCS All Commercial |
$373.46
|
| Rate for Payer: PHP All Commercial |
$377.64
|
| Rate for Payer: Sagamore Health Network All Products |
$384.41
|
| Rate for Payer: Signature Care EPO |
$413.29
|
| Rate for Payer: Signature Care PPO |
$438.19
|
| Rate for Payer: United Healthcare Commercial |
$392.38
|
|
|
Unlisted laparoscopic procedure, liver
|
Facility
OP
|
$4,211.34
|
|
|
Service Code
|
CPT 47379
|
| Hospital Charge Code |
CPT-47379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,211.34 |
| Max. Negotiated Rate |
$4,211.34 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,211.34
|
| Rate for Payer: Managed Health Services Medicaid |
$4,211.34
|
| Rate for Payer: MDWise Medicaid |
$4,211.34
|
|
|
Unlisted laparoscopy procedure, appendix
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 44979
|
| Hospital Charge Code |
CPT-44979
|
|
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
|
|
|
Unlisted laparoscopy procedure, intestine (except rectum)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 44238
|
| Hospital Charge Code |
CPT-44238
|
|
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
|
|
|
Unlisted procedure, anterior segment of eye
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 66999
|
| Hospital Charge Code |
CPT-66999
|
|
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
|
|
|
Unlisted procedure, hands or fingers
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 26989
|
| Hospital Charge Code |
CPT-26989
|
|
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
|
|
|
Unlisted procedure, lacrimal system
|
Facility
OP
|
$1,044.85
|
|
|
Service Code
|
CPT 68899
|
| Hospital Charge Code |
CPT-68899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,044.85 |
| Max. Negotiated Rate |
$1,044.85 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,044.85
|
| Rate for Payer: Managed Health Services Medicaid |
$1,044.85
|
| Rate for Payer: MDWise Medicaid |
$1,044.85
|
|
|
Unlisted procedure, nervous system
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 64999
|
| Hospital Charge Code |
CPT-64999
|
|
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
|
|
|
Unlisted procedure, stomach
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
CPT-43999
|
|
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
|
|
|
Unlisted procedure, urinary system
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 53899
|
| Hospital Charge Code |
CPT-53899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
URSODIOL 300 MG ORAL CAP
|
Facility
OP
|
$13.08
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Aetna Commercial |
$11.04
|
| Rate for Payer: Aetna Medicare |
$4.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.75
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Centivo All Commercial |
$6.67
|
| Rate for Payer: Cigna All Commercial |
$11.28
|
| Rate for Payer: CORVEL All Commercial |
$12.16
|
| Rate for Payer: Coventry All Commercial |
$11.51
|
| Rate for Payer: Encore All Commercial |
$12.04
|
| Rate for Payer: Frontpath All Commercial |
$12.03
|
| Rate for Payer: Humana ChoiceCare |
$11.29
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Lucent All Commercial |
$6.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.77
|
| Rate for Payer: PHCS All Commercial |
$9.81
|
| Rate for Payer: PHP All Commercial |
$9.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.10
|
| Rate for Payer: Sagamore Health Network All Products |
$10.09
|
| Rate for Payer: Signature Care EPO |
$10.85
|
| Rate for Payer: Signature Care PPO |
$11.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.11
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
| Rate for Payer: United Healthcare Medicare |
$4.32
|
|
|
URSODIOL 300 MG ORAL CAP
|
Facility
IP
|
$13.08
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Aetna Commercial |
$11.30
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Cigna All Commercial |
$11.28
|
| Rate for Payer: CORVEL All Commercial |
$12.16
|
| Rate for Payer: Coventry All Commercial |
$11.51
|
| Rate for Payer: Encore All Commercial |
$12.04
|
| Rate for Payer: Frontpath All Commercial |
$12.03
|
| Rate for Payer: Humana ChoiceCare |
$11.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.77
|
| Rate for Payer: PHCS All Commercial |
$9.81
|
| Rate for Payer: PHP All Commercial |
$9.92
|
| Rate for Payer: Sagamore Health Network All Products |
$10.09
|
| Rate for Payer: Signature Care EPO |
$10.85
|
| Rate for Payer: Signature Care PPO |
$11.51
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
|
|
USTEKINUMAB 130 MG/26 ML IV SOLN
|
Facility
OP
|
$7,082.26
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
179041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.57 |
| Max. Negotiated Rate |
$6,586.50 |
| Rate for Payer: Aetna Commercial |
$5,977.42
|
| Rate for Payer: Aetna Medicare |
$2,337.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,337.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,067.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,427.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$15.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,687.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,570.86
|
| Rate for Payer: Cash Price |
$4,391.00
|
| Rate for Payer: Cash Price |
$4,391.00
|
| Rate for Payer: Centivo All Commercial |
$3,611.95
|
| Rate for Payer: Cigna All Commercial |
$6,111.99
|
| Rate for Payer: CORVEL All Commercial |
$6,586.50
|
| Rate for Payer: Coventry All Commercial |
$6,232.39
|
| Rate for Payer: Encore All Commercial |
$6,519.22
|
| Rate for Payer: Frontpath All Commercial |
$6,515.68
|
| Rate for Payer: Humana ChoiceCare |
$6,116.95
|
| Rate for Payer: Humana Medicare |
$3,611.95
|
| Rate for Payer: Lucent All Commercial |
$3,611.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,374.03
|
| Rate for Payer: Managed Health Services Medicaid |
$15.57
|
| Rate for Payer: MDWise Medicaid |
$15.57
|
| Rate for Payer: PHCS All Commercial |
$5,311.69
|
| Rate for Payer: PHP All Commercial |
$5,371.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,762.08
|
| Rate for Payer: Sagamore Health Network All Products |
$5,467.50
|
| Rate for Payer: Signature Care EPO |
$5,878.27
|
| Rate for Payer: Signature Care PPO |
$6,232.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,019.92
|
| Rate for Payer: United Healthcare Commercial |
$5,580.82
|
| Rate for Payer: United Healthcare Medicare |
$2,337.14
|
|
|
USTEKINUMAB 130 MG/26 ML IV SOLN
|
Facility
IP
|
$7,082.26
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
179041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,311.69 |
| Max. Negotiated Rate |
$6,586.50 |
| Rate for Payer: Aetna Commercial |
$6,119.07
|
| Rate for Payer: Cash Price |
$4,391.00
|
| Rate for Payer: Cigna All Commercial |
$6,111.99
|
| Rate for Payer: CORVEL All Commercial |
$6,586.50
|
| Rate for Payer: Coventry All Commercial |
$6,232.39
|
| Rate for Payer: Encore All Commercial |
$6,519.22
|
| Rate for Payer: Frontpath All Commercial |
$6,515.68
|
| Rate for Payer: Humana ChoiceCare |
$6,116.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,374.03
|
| Rate for Payer: PHCS All Commercial |
$5,311.69
|
| Rate for Payer: PHP All Commercial |
$5,371.18
|
| Rate for Payer: Sagamore Health Network All Products |
$5,467.50
|
| Rate for Payer: Signature Care EPO |
$5,878.27
|
| Rate for Payer: Signature Care PPO |
$6,232.39
|
| Rate for Payer: United Healthcare Commercial |
$5,580.82
|
|
|
USTEKINUMAB 90 MG/ML SUBQ SYRG
|
Facility
OP
|
$95,013.73
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$309.37 |
| Max. Negotiated Rate |
$88,362.77 |
| Rate for Payer: Aetna Commercial |
$80,191.59
|
| Rate for Payer: Aetna Medicare |
$31,354.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31,354.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$54,566.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$59,393.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$309.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36,057.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34,489.98
|
| Rate for Payer: Cash Price |
$58,908.51
|
| Rate for Payer: Cash Price |
$58,908.51
|
| Rate for Payer: Centivo All Commercial |
$48,457.00
|
| Rate for Payer: Cigna All Commercial |
$81,996.85
|
| Rate for Payer: CORVEL All Commercial |
$88,362.77
|
| Rate for Payer: Coventry All Commercial |
$83,612.08
|
| Rate for Payer: Encore All Commercial |
$87,460.14
|
| Rate for Payer: Frontpath All Commercial |
$87,412.63
|
| Rate for Payer: Humana ChoiceCare |
$82,063.36
|
| Rate for Payer: Humana Medicare |
$48,457.00
|
| Rate for Payer: Lucent All Commercial |
$48,457.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85,512.36
|
| Rate for Payer: Managed Health Services Medicaid |
$309.37
|
| Rate for Payer: MDWise Medicaid |
$309.37
|
| Rate for Payer: PHCS All Commercial |
$71,260.30
|
| Rate for Payer: PHP All Commercial |
$72,058.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37,055.35
|
| Rate for Payer: Sagamore Health Network All Products |
$73,350.60
|
| Rate for Payer: Signature Care EPO |
$78,861.40
|
| Rate for Payer: Signature Care PPO |
$83,612.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80,761.67
|
| Rate for Payer: United Healthcare Commercial |
$74,870.82
|
| Rate for Payer: United Healthcare Medicare |
$31,354.53
|
|
|
USTEKINUMAB 90 MG/ML SUBQ SYRG
|
Facility
IP
|
$95,013.73
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
108054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71,260.30 |
| Max. Negotiated Rate |
$88,362.77 |
| Rate for Payer: Aetna Commercial |
$82,091.86
|
| Rate for Payer: Cash Price |
$58,908.51
|
| Rate for Payer: Cigna All Commercial |
$81,996.85
|
| Rate for Payer: CORVEL All Commercial |
$88,362.77
|
| Rate for Payer: Coventry All Commercial |
$83,612.08
|
| Rate for Payer: Encore All Commercial |
$87,460.14
|
| Rate for Payer: Frontpath All Commercial |
$87,412.63
|
| Rate for Payer: Humana ChoiceCare |
$82,063.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85,512.36
|
| Rate for Payer: PHCS All Commercial |
$71,260.30
|
| Rate for Payer: PHP All Commercial |
$72,058.41
|
| Rate for Payer: Sagamore Health Network All Products |
$73,350.60
|
| Rate for Payer: Signature Care EPO |
$78,861.40
|
| Rate for Payer: Signature Care PPO |
$83,612.08
|
| Rate for Payer: United Healthcare Commercial |
$74,870.82
|
|
|
Vaginal hysterectomy, for uterus 250 g or less;
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 58260
|
| Hospital Charge Code |
CPT-58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
VALACYCLOVIR 500 MG ORAL TAB
|
Facility
IP
|
$9.32
|
|
|
Service Code
|
NDC 50268078815
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Aetna Commercial |
$8.06
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cigna All Commercial |
$8.05
|
| Rate for Payer: CORVEL All Commercial |
$8.67
|
| Rate for Payer: Coventry All Commercial |
$8.21
|
| Rate for Payer: Encore All Commercial |
$8.58
|
| Rate for Payer: Frontpath All Commercial |
$8.58
|
| Rate for Payer: Humana ChoiceCare |
$8.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.39
|
| Rate for Payer: PHCS All Commercial |
$6.99
|
| Rate for Payer: PHP All Commercial |
$7.07
|
| Rate for Payer: Sagamore Health Network All Products |
$7.20
|
| Rate for Payer: Signature Care EPO |
$7.74
|
| Rate for Payer: Signature Care PPO |
$8.21
|
| Rate for Payer: United Healthcare Commercial |
$7.35
|
|
|
VALACYCLOVIR 500 MG ORAL TAB
|
Facility
OP
|
$9.32
|
|
|
Service Code
|
NDC 50268078815
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Aetna Commercial |
$7.87
|
| Rate for Payer: Aetna Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.38
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Centivo All Commercial |
$4.76
|
| Rate for Payer: Cigna All Commercial |
$8.05
|
| Rate for Payer: CORVEL All Commercial |
$8.67
|
| Rate for Payer: Coventry All Commercial |
$8.21
|
| Rate for Payer: Encore All Commercial |
$8.58
|
| Rate for Payer: Frontpath All Commercial |
$8.58
|
| Rate for Payer: Humana ChoiceCare |
$8.05
|
| Rate for Payer: Humana Medicare |
$4.76
|
| Rate for Payer: Lucent All Commercial |
$4.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.39
|
| Rate for Payer: PHCS All Commercial |
$6.99
|
| Rate for Payer: PHP All Commercial |
$7.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.64
|
| Rate for Payer: Sagamore Health Network All Products |
$7.20
|
| Rate for Payer: Signature Care EPO |
$7.74
|
| Rate for Payer: Signature Care PPO |
$8.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.93
|
| Rate for Payer: United Healthcare Commercial |
$7.35
|
| Rate for Payer: United Healthcare Medicare |
$3.08
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN
|
Facility
OP
|
$46.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Aetna Commercial |
$39.58
|
| Rate for Payer: Aetna Medicare |
$15.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$26.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.02
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Centivo All Commercial |
$23.92
|
| Rate for Payer: Cigna All Commercial |
$40.47
|
| Rate for Payer: CORVEL All Commercial |
$43.62
|
| Rate for Payer: Coventry All Commercial |
$41.27
|
| Rate for Payer: Encore All Commercial |
$43.17
|
| Rate for Payer: Frontpath All Commercial |
$43.15
|
| Rate for Payer: Humana ChoiceCare |
$40.51
|
| Rate for Payer: Humana Medicare |
$23.92
|
| Rate for Payer: Lucent All Commercial |
$23.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.21
|
| Rate for Payer: PHCS All Commercial |
$35.18
|
| Rate for Payer: PHP All Commercial |
$35.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.29
|
| Rate for Payer: Sagamore Health Network All Products |
$36.21
|
| Rate for Payer: Signature Care EPO |
$38.93
|
| Rate for Payer: Signature Care PPO |
$41.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39.86
|
| Rate for Payer: United Healthcare Commercial |
$36.96
|
| Rate for Payer: United Healthcare Medicare |
$15.48
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN
|
Facility
IP
|
$46.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.18 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Aetna Commercial |
$40.52
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cigna All Commercial |
$40.47
|
| Rate for Payer: CORVEL All Commercial |
$43.62
|
| Rate for Payer: Coventry All Commercial |
$41.27
|
| Rate for Payer: Encore All Commercial |
$43.17
|
| Rate for Payer: Frontpath All Commercial |
$43.15
|
| Rate for Payer: Humana ChoiceCare |
$40.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.21
|
| Rate for Payer: PHCS All Commercial |
$35.18
|
| Rate for Payer: PHP All Commercial |
$35.57
|
| Rate for Payer: Sagamore Health Network All Products |
$36.21
|
| Rate for Payer: Signature Care EPO |
$38.93
|
| Rate for Payer: Signature Care PPO |
$41.27
|
| Rate for Payer: United Healthcare Commercial |
$36.96
|
|
|
VALSARTAN 320 MG ORAL TAB
|
Facility
IP
|
$5.73
|
|
|
Service Code
|
NDC 00378581577
|
| Hospital Charge Code |
31211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
VALSARTAN 320 MG ORAL TAB
|
Facility
OP
|
$5.73
|
|
|
Service Code
|
NDC 00378581577
|
| Hospital Charge Code |
31211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Centivo All Commercial |
$2.92
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Humana Medicare |
$2.92
|
| Rate for Payer: Lucent All Commercial |
$2.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.87
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.89
|
|
|
VALSARTAN 40 MG ORAL TAB
|
Facility
OP
|
$7.22
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.09
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Centivo All Commercial |
$3.68
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.35
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.64
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Humana Medicare |
$3.68
|
| Rate for Payer: Lucent All Commercial |
$3.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.81
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.99
|
| Rate for Payer: Signature Care PPO |
$6.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.13
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
| Rate for Payer: United Healthcare Medicare |
$2.38
|
|
|
VALSARTAN 40 MG ORAL TAB
|
Facility
IP
|
$7.22
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.24
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.35
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.64
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.99
|
| Rate for Payer: Signature Care PPO |
$6.35
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
|
