|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
OP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Aetna Medicare |
$1.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.25
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Centivo All Commercial |
$1.75
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: Lucent All Commercial |
$1.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.92
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
| Rate for Payer: United Healthcare Medicare |
$1.13
|
|
|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
IP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.97
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
IP
|
$160.15
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.11 |
| Max. Negotiated Rate |
$148.94 |
| Rate for Payer: Aetna Commercial |
$138.37
|
| Rate for Payer: Cash Price |
$99.29
|
| Rate for Payer: Cigna All Commercial |
$138.21
|
| Rate for Payer: CORVEL All Commercial |
$148.94
|
| Rate for Payer: Coventry All Commercial |
$140.93
|
| Rate for Payer: Encore All Commercial |
$147.41
|
| Rate for Payer: Frontpath All Commercial |
$147.33
|
| Rate for Payer: Humana ChoiceCare |
$138.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$144.13
|
| Rate for Payer: PHCS All Commercial |
$120.11
|
| Rate for Payer: PHP All Commercial |
$121.45
|
| Rate for Payer: Sagamore Health Network All Products |
$123.63
|
| Rate for Payer: Signature Care EPO |
$132.92
|
| Rate for Payer: Signature Care PPO |
$140.93
|
| Rate for Payer: United Healthcare Commercial |
$126.20
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
OP
|
$160.15
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.85 |
| Max. Negotiated Rate |
$148.94 |
| Rate for Payer: Aetna Commercial |
$135.16
|
| Rate for Payer: Aetna Medicare |
$52.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$91.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$58.13
|
| Rate for Payer: Cash Price |
$99.29
|
| Rate for Payer: Centivo All Commercial |
$81.67
|
| Rate for Payer: Cigna All Commercial |
$138.21
|
| Rate for Payer: CORVEL All Commercial |
$148.94
|
| Rate for Payer: Coventry All Commercial |
$140.93
|
| Rate for Payer: Encore All Commercial |
$147.41
|
| Rate for Payer: Frontpath All Commercial |
$147.33
|
| Rate for Payer: Humana ChoiceCare |
$138.32
|
| Rate for Payer: Humana Medicare |
$81.67
|
| Rate for Payer: Lucent All Commercial |
$81.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$144.13
|
| Rate for Payer: PHCS All Commercial |
$120.11
|
| Rate for Payer: PHP All Commercial |
$121.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.46
|
| Rate for Payer: Sagamore Health Network All Products |
$123.63
|
| Rate for Payer: Signature Care EPO |
$132.92
|
| Rate for Payer: Signature Care PPO |
$140.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$136.12
|
| Rate for Payer: United Healthcare Commercial |
$126.20
|
| Rate for Payer: United Healthcare Medicare |
$52.85
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
OP
|
$7.93
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Aetna Commercial |
$6.69
|
| Rate for Payer: Aetna Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.88
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Centivo All Commercial |
$4.04
|
| Rate for Payer: Cigna All Commercial |
$6.84
|
| Rate for Payer: CORVEL All Commercial |
$7.38
|
| Rate for Payer: Coventry All Commercial |
$6.98
|
| Rate for Payer: Encore All Commercial |
$7.30
|
| Rate for Payer: Frontpath All Commercial |
$7.30
|
| Rate for Payer: Humana ChoiceCare |
$6.85
|
| Rate for Payer: Humana Medicare |
$4.04
|
| Rate for Payer: Lucent All Commercial |
$4.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$5.95
|
| Rate for Payer: PHP All Commercial |
$6.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.09
|
| Rate for Payer: Sagamore Health Network All Products |
$6.12
|
| Rate for Payer: Signature Care EPO |
$6.58
|
| Rate for Payer: Signature Care PPO |
$6.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.74
|
| Rate for Payer: United Healthcare Commercial |
$6.25
|
| Rate for Payer: United Healthcare Medicare |
$2.62
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
IP
|
$7.93
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Aetna Commercial |
$6.85
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna All Commercial |
$6.84
|
| Rate for Payer: CORVEL All Commercial |
$7.38
|
| Rate for Payer: Coventry All Commercial |
$6.98
|
| Rate for Payer: Encore All Commercial |
$7.30
|
| Rate for Payer: Frontpath All Commercial |
$7.30
|
| Rate for Payer: Humana ChoiceCare |
$6.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$5.95
|
| Rate for Payer: PHP All Commercial |
$6.01
|
| Rate for Payer: Sagamore Health Network All Products |
$6.12
|
| Rate for Payer: Signature Care EPO |
$6.58
|
| Rate for Payer: Signature Care PPO |
$6.98
|
| Rate for Payer: United Healthcare Commercial |
$6.25
|
|
|
VANCOMYCIN 1.5 G IV SOLR
|
Facility
|
IP
|
$123.81
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
186918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.86 |
| Max. Negotiated Rate |
$115.15 |
| Rate for Payer: Aetna Commercial |
$106.98
|
| Rate for Payer: Cash Price |
$76.76
|
| Rate for Payer: Cigna All Commercial |
$106.85
|
| Rate for Payer: CORVEL All Commercial |
$115.15
|
| Rate for Payer: Coventry All Commercial |
$108.96
|
| Rate for Payer: Encore All Commercial |
$113.97
|
| Rate for Payer: Frontpath All Commercial |
$113.91
|
| Rate for Payer: Humana ChoiceCare |
$106.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$111.43
|
| Rate for Payer: PHCS All Commercial |
$92.86
|
| Rate for Payer: PHP All Commercial |
$93.90
|
| Rate for Payer: Sagamore Health Network All Products |
$95.58
|
| Rate for Payer: Signature Care EPO |
$102.77
|
| Rate for Payer: Signature Care PPO |
$108.96
|
| Rate for Payer: United Healthcare Commercial |
$97.57
|
|
|
VANCOMYCIN 1.5 G IV SOLR
|
Facility
|
OP
|
$123.81
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
186918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.86 |
| Max. Negotiated Rate |
$115.15 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$40.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$40.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$71.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$77.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.94
|
| Rate for Payer: Cash Price |
$76.76
|
| Rate for Payer: Centivo All Commercial |
$63.15
|
| Rate for Payer: Cigna All Commercial |
$106.85
|
| Rate for Payer: CORVEL All Commercial |
$115.15
|
| Rate for Payer: Coventry All Commercial |
$108.96
|
| Rate for Payer: Encore All Commercial |
$113.97
|
| Rate for Payer: Frontpath All Commercial |
$113.91
|
| Rate for Payer: Humana ChoiceCare |
$106.94
|
| Rate for Payer: Humana Medicare |
$63.15
|
| Rate for Payer: Lucent All Commercial |
$63.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$111.43
|
| Rate for Payer: PHCS All Commercial |
$92.86
|
| Rate for Payer: PHP All Commercial |
$93.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$48.29
|
| Rate for Payer: Sagamore Health Network All Products |
$95.58
|
| Rate for Payer: Signature Care EPO |
$102.77
|
| Rate for Payer: Signature Care PPO |
$108.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$105.24
|
| Rate for Payer: United Healthcare Commercial |
$97.57
|
| Rate for Payer: United Healthcare Medicare |
$40.86
|
|
|
VANCOMYCIN 1.75 G IV SOLR
|
Facility
|
IP
|
$248.66
|
|
|
Service Code
|
HCPCS J3371
|
| Hospital Charge Code |
205716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.50 |
| Max. Negotiated Rate |
$231.25 |
| Rate for Payer: Aetna Commercial |
$214.84
|
| Rate for Payer: Cash Price |
$154.17
|
| Rate for Payer: Cigna All Commercial |
$214.59
|
| Rate for Payer: CORVEL All Commercial |
$231.25
|
| Rate for Payer: Coventry All Commercial |
$218.82
|
| Rate for Payer: Encore All Commercial |
$228.89
|
| Rate for Payer: Frontpath All Commercial |
$228.77
|
| Rate for Payer: Humana ChoiceCare |
$214.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$223.79
|
| Rate for Payer: PHCS All Commercial |
$186.50
|
| Rate for Payer: PHP All Commercial |
$188.58
|
| Rate for Payer: Sagamore Health Network All Products |
$191.97
|
| Rate for Payer: Signature Care EPO |
$206.39
|
| Rate for Payer: Signature Care PPO |
$218.82
|
| Rate for Payer: United Healthcare Commercial |
$195.94
|
|
|
VANCOMYCIN 1.75 G IV SOLR
|
Facility
|
OP
|
$248.66
|
|
|
Service Code
|
HCPCS J3371
|
| Hospital Charge Code |
205716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.06 |
| Max. Negotiated Rate |
$231.25 |
| Rate for Payer: Aetna Commercial |
$209.87
|
| Rate for Payer: Aetna Medicare |
$82.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$142.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$155.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$94.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$90.26
|
| Rate for Payer: Cash Price |
$154.17
|
| Rate for Payer: Centivo All Commercial |
$126.82
|
| Rate for Payer: Cigna All Commercial |
$214.59
|
| Rate for Payer: CORVEL All Commercial |
$231.25
|
| Rate for Payer: Coventry All Commercial |
$218.82
|
| Rate for Payer: Encore All Commercial |
$228.89
|
| Rate for Payer: Frontpath All Commercial |
$228.77
|
| Rate for Payer: Humana ChoiceCare |
$214.77
|
| Rate for Payer: Humana Medicare |
$126.82
|
| Rate for Payer: Lucent All Commercial |
$126.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$223.79
|
| Rate for Payer: PHCS All Commercial |
$186.50
|
| Rate for Payer: PHP All Commercial |
$188.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.98
|
| Rate for Payer: Sagamore Health Network All Products |
$191.97
|
| Rate for Payer: Signature Care EPO |
$206.39
|
| Rate for Payer: Signature Care PPO |
$218.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$211.36
|
| Rate for Payer: United Healthcare Commercial |
$195.94
|
| Rate for Payer: United Healthcare Medicare |
$82.06
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
IP
|
$284.19
|
|
|
Service Code
|
HCPCS J7731
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.14 |
| Max. Negotiated Rate |
$264.29 |
| Rate for Payer: Aetna Commercial |
$245.54
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cigna All Commercial |
$245.25
|
| Rate for Payer: CORVEL All Commercial |
$264.29
|
| Rate for Payer: Coventry All Commercial |
$250.08
|
| Rate for Payer: Encore All Commercial |
$261.59
|
| Rate for Payer: Frontpath All Commercial |
$261.45
|
| Rate for Payer: Humana ChoiceCare |
$245.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.77
|
| Rate for Payer: PHCS All Commercial |
$213.14
|
| Rate for Payer: PHP All Commercial |
$215.53
|
| Rate for Payer: Sagamore Health Network All Products |
$219.39
|
| Rate for Payer: Signature Care EPO |
$235.87
|
| Rate for Payer: Signature Care PPO |
$250.08
|
| Rate for Payer: United Healthcare Commercial |
$223.94
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
OP
|
$284.19
|
|
|
Service Code
|
HCPCS J7731
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.78 |
| Max. Negotiated Rate |
$264.29 |
| Rate for Payer: Aetna Commercial |
$239.85
|
| Rate for Payer: Aetna Medicare |
$93.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$163.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.16
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Centivo All Commercial |
$144.93
|
| Rate for Payer: Cigna All Commercial |
$245.25
|
| Rate for Payer: CORVEL All Commercial |
$264.29
|
| Rate for Payer: Coventry All Commercial |
$250.08
|
| Rate for Payer: Encore All Commercial |
$261.59
|
| Rate for Payer: Frontpath All Commercial |
$261.45
|
| Rate for Payer: Humana ChoiceCare |
$245.45
|
| Rate for Payer: Humana Medicare |
$144.93
|
| Rate for Payer: Lucent All Commercial |
$144.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.77
|
| Rate for Payer: PHCS All Commercial |
$213.14
|
| Rate for Payer: PHP All Commercial |
$215.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.83
|
| Rate for Payer: Sagamore Health Network All Products |
$219.39
|
| Rate for Payer: Signature Care EPO |
$235.87
|
| Rate for Payer: Signature Care PPO |
$250.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.56
|
| Rate for Payer: United Healthcare Commercial |
$223.94
|
| Rate for Payer: United Healthcare Medicare |
$93.78
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
OP
|
$284.19
|
|
|
Service Code
|
HCPCS J3371
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.78 |
| Max. Negotiated Rate |
$264.29 |
| Rate for Payer: Aetna Commercial |
$239.85
|
| Rate for Payer: Aetna Medicare |
$93.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$163.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.16
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Centivo All Commercial |
$144.93
|
| Rate for Payer: Cigna All Commercial |
$245.25
|
| Rate for Payer: CORVEL All Commercial |
$264.29
|
| Rate for Payer: Coventry All Commercial |
$250.08
|
| Rate for Payer: Encore All Commercial |
$261.59
|
| Rate for Payer: Frontpath All Commercial |
$261.45
|
| Rate for Payer: Humana ChoiceCare |
$245.45
|
| Rate for Payer: Humana Medicare |
$144.93
|
| Rate for Payer: Lucent All Commercial |
$144.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.77
|
| Rate for Payer: PHCS All Commercial |
$213.14
|
| Rate for Payer: PHP All Commercial |
$215.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.83
|
| Rate for Payer: Sagamore Health Network All Products |
$219.39
|
| Rate for Payer: Signature Care EPO |
$235.87
|
| Rate for Payer: Signature Care PPO |
$250.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.56
|
| Rate for Payer: United Healthcare Commercial |
$223.94
|
| Rate for Payer: United Healthcare Medicare |
$93.78
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
IP
|
$284.19
|
|
|
Service Code
|
HCPCS J3371
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.14 |
| Max. Negotiated Rate |
$264.29 |
| Rate for Payer: Aetna Commercial |
$245.54
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cigna All Commercial |
$245.25
|
| Rate for Payer: CORVEL All Commercial |
$264.29
|
| Rate for Payer: Coventry All Commercial |
$250.08
|
| Rate for Payer: Encore All Commercial |
$261.59
|
| Rate for Payer: Frontpath All Commercial |
$261.45
|
| Rate for Payer: Humana ChoiceCare |
$245.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.77
|
| Rate for Payer: PHCS All Commercial |
$213.14
|
| Rate for Payer: PHP All Commercial |
$215.53
|
| Rate for Payer: Sagamore Health Network All Products |
$219.39
|
| Rate for Payer: Signature Care EPO |
$235.87
|
| Rate for Payer: Signature Care PPO |
$250.08
|
| Rate for Payer: United Healthcare Commercial |
$223.94
|
|
|
VANCOMYCIN 500 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
8443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
VANCOMYCIN 500 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
8443
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
VANCOMYCIN 50 MG/ML ORAL SOLR
|
Facility
|
IP
|
$774.75
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
11630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.06 |
| Max. Negotiated Rate |
$720.52 |
| Rate for Payer: Aetna Commercial |
$669.38
|
| Rate for Payer: Cash Price |
$480.35
|
| Rate for Payer: Cigna All Commercial |
$668.61
|
| Rate for Payer: CORVEL All Commercial |
$720.52
|
| Rate for Payer: Coventry All Commercial |
$681.78
|
| Rate for Payer: Encore All Commercial |
$713.16
|
| Rate for Payer: Frontpath All Commercial |
$712.77
|
| Rate for Payer: Humana ChoiceCare |
$669.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$697.28
|
| Rate for Payer: PHCS All Commercial |
$581.06
|
| Rate for Payer: PHP All Commercial |
$587.57
|
| Rate for Payer: Sagamore Health Network All Products |
$598.11
|
| Rate for Payer: Signature Care EPO |
$643.04
|
| Rate for Payer: Signature Care PPO |
$681.78
|
| Rate for Payer: United Healthcare Commercial |
$610.50
|
|
|
VANCOMYCIN 50 MG/ML ORAL SOLR
|
Facility
|
OP
|
$774.75
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
11630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$255.67 |
| Max. Negotiated Rate |
$720.52 |
| Rate for Payer: Aetna Commercial |
$653.89
|
| Rate for Payer: Aetna Medicare |
$255.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$255.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$444.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$484.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$294.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$281.23
|
| Rate for Payer: Cash Price |
$480.35
|
| Rate for Payer: Centivo All Commercial |
$395.12
|
| Rate for Payer: Cigna All Commercial |
$668.61
|
| Rate for Payer: CORVEL All Commercial |
$720.52
|
| Rate for Payer: Coventry All Commercial |
$681.78
|
| Rate for Payer: Encore All Commercial |
$713.16
|
| Rate for Payer: Frontpath All Commercial |
$712.77
|
| Rate for Payer: Humana ChoiceCare |
$669.15
|
| Rate for Payer: Humana Medicare |
$395.12
|
| Rate for Payer: Lucent All Commercial |
$395.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$697.28
|
| Rate for Payer: PHCS All Commercial |
$581.06
|
| Rate for Payer: PHP All Commercial |
$587.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$302.15
|
| Rate for Payer: Sagamore Health Network All Products |
$598.11
|
| Rate for Payer: Signature Care EPO |
$643.04
|
| Rate for Payer: Signature Care PPO |
$681.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$658.54
|
| Rate for Payer: United Healthcare Commercial |
$610.50
|
| Rate for Payer: United Healthcare Medicare |
$255.67
|
|
|
VARENICLINE 0.5 MG ORAL TAB
|
Facility
|
IP
|
$55.64
|
|
|
Service Code
|
NDC 00069046856
|
| Hospital Charge Code |
76444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.73 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Aetna Commercial |
$48.08
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna All Commercial |
$48.02
|
| Rate for Payer: CORVEL All Commercial |
$51.75
|
| Rate for Payer: Coventry All Commercial |
$48.97
|
| Rate for Payer: Encore All Commercial |
$51.22
|
| Rate for Payer: Frontpath All Commercial |
$51.19
|
| Rate for Payer: Humana ChoiceCare |
$48.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.08
|
| Rate for Payer: PHCS All Commercial |
$41.73
|
| Rate for Payer: PHP All Commercial |
$42.20
|
| Rate for Payer: Sagamore Health Network All Products |
$42.96
|
| Rate for Payer: Signature Care EPO |
$46.18
|
| Rate for Payer: Signature Care PPO |
$48.97
|
| Rate for Payer: United Healthcare Commercial |
$43.85
|
|
|
VARENICLINE 0.5 MG ORAL TAB
|
Facility
|
OP
|
$55.64
|
|
|
Service Code
|
NDC 00069046856
|
| Hospital Charge Code |
76444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Aetna Commercial |
$46.96
|
| Rate for Payer: Aetna Medicare |
$18.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$31.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$34.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Centivo All Commercial |
$28.38
|
| Rate for Payer: Cigna All Commercial |
$48.02
|
| Rate for Payer: CORVEL All Commercial |
$51.75
|
| Rate for Payer: Coventry All Commercial |
$48.97
|
| Rate for Payer: Encore All Commercial |
$51.22
|
| Rate for Payer: Frontpath All Commercial |
$51.19
|
| Rate for Payer: Humana ChoiceCare |
$48.06
|
| Rate for Payer: Humana Medicare |
$28.38
|
| Rate for Payer: Lucent All Commercial |
$28.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.08
|
| Rate for Payer: PHCS All Commercial |
$41.73
|
| Rate for Payer: PHP All Commercial |
$42.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.70
|
| Rate for Payer: Sagamore Health Network All Products |
$42.96
|
| Rate for Payer: Signature Care EPO |
$46.18
|
| Rate for Payer: Signature Care PPO |
$48.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$47.30
|
| Rate for Payer: United Healthcare Commercial |
$43.85
|
| Rate for Payer: United Healthcare Medicare |
$18.36
|
|
|
VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SUBQ SUSR
|
Facility
|
OP
|
$828.22
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
14757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.25 |
| Max. Negotiated Rate |
$770.24 |
| Rate for Payer: Aetna Commercial |
$699.02
|
| Rate for Payer: Aetna Medicare |
$273.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$273.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$475.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$517.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$182.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$314.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$300.64
|
| Rate for Payer: Cash Price |
$513.50
|
| Rate for Payer: Cash Price |
$513.50
|
| Rate for Payer: Centivo All Commercial |
$422.39
|
| Rate for Payer: Cigna All Commercial |
$714.75
|
| Rate for Payer: CORVEL All Commercial |
$770.24
|
| Rate for Payer: Coventry All Commercial |
$728.83
|
| Rate for Payer: Encore All Commercial |
$762.38
|
| Rate for Payer: Frontpath All Commercial |
$761.96
|
| Rate for Payer: Humana ChoiceCare |
$715.33
|
| Rate for Payer: Humana Medicare |
$422.39
|
| Rate for Payer: Lucent All Commercial |
$422.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$745.40
|
| Rate for Payer: Managed Health Services Medicaid |
$182.25
|
| Rate for Payer: MDWise Medicaid |
$182.25
|
| Rate for Payer: PHCS All Commercial |
$621.16
|
| Rate for Payer: PHP All Commercial |
$628.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$323.01
|
| Rate for Payer: Sagamore Health Network All Products |
$639.39
|
| Rate for Payer: Signature Care EPO |
$687.42
|
| Rate for Payer: Signature Care PPO |
$728.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$703.99
|
| Rate for Payer: United Healthcare Commercial |
$652.64
|
| Rate for Payer: United Healthcare Medicare |
$273.31
|
|
|
VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SUBQ SUSR
|
Facility
|
IP
|
$828.22
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
14757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$621.16 |
| Max. Negotiated Rate |
$770.24 |
| Rate for Payer: Aetna Commercial |
$715.58
|
| Rate for Payer: Cash Price |
$513.50
|
| Rate for Payer: Cigna All Commercial |
$714.75
|
| Rate for Payer: CORVEL All Commercial |
$770.24
|
| Rate for Payer: Coventry All Commercial |
$728.83
|
| Rate for Payer: Encore All Commercial |
$762.38
|
| Rate for Payer: Frontpath All Commercial |
$761.96
|
| Rate for Payer: Humana ChoiceCare |
$715.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$745.40
|
| Rate for Payer: PHCS All Commercial |
$621.16
|
| Rate for Payer: PHP All Commercial |
$628.12
|
| Rate for Payer: Sagamore Health Network All Products |
$639.39
|
| Rate for Payer: Signature Care EPO |
$687.42
|
| Rate for Payer: Signature Care PPO |
$728.83
|
| Rate for Payer: United Healthcare Commercial |
$652.64
|
|
|
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR
|
Facility
|
IP
|
$938.52
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
182723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$703.89 |
| Max. Negotiated Rate |
$872.82 |
| Rate for Payer: Aetna Commercial |
$810.88
|
| Rate for Payer: Cash Price |
$581.88
|
| Rate for Payer: Cigna All Commercial |
$809.94
|
| Rate for Payer: CORVEL All Commercial |
$872.82
|
| Rate for Payer: Coventry All Commercial |
$825.89
|
| Rate for Payer: Encore All Commercial |
$863.90
|
| Rate for Payer: Frontpath All Commercial |
$863.43
|
| Rate for Payer: Humana ChoiceCare |
$810.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$844.66
|
| Rate for Payer: PHCS All Commercial |
$703.89
|
| Rate for Payer: PHP All Commercial |
$711.77
|
| Rate for Payer: Sagamore Health Network All Products |
$724.53
|
| Rate for Payer: Signature Care EPO |
$778.97
|
| Rate for Payer: Signature Care PPO |
$825.89
|
| Rate for Payer: United Healthcare Commercial |
$739.55
|
|
