|
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR
|
Facility
|
OP
|
$938.52
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
182723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.58 |
| Max. Negotiated Rate |
$872.82 |
| Rate for Payer: Aetna Commercial |
$792.11
|
| Rate for Payer: Aetna Medicare |
$309.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$309.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$538.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$586.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$192.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$356.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$340.68
|
| Rate for Payer: Cash Price |
$581.88
|
| Rate for Payer: Cash Price |
$581.88
|
| Rate for Payer: Centivo All Commercial |
$478.64
|
| 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: Humana Medicare |
$478.64
|
| Rate for Payer: Lucent All Commercial |
$478.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$844.66
|
| Rate for Payer: Managed Health Services Medicaid |
$192.58
|
| Rate for Payer: MDWise Medicaid |
$192.58
|
| Rate for Payer: PHCS All Commercial |
$703.89
|
| Rate for Payer: PHP All Commercial |
$711.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$366.02
|
| 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: Three Rivers Preferred All Commercial |
$797.74
|
| Rate for Payer: United Healthcare Commercial |
$739.55
|
| Rate for Payer: United Healthcare Medicare |
$309.71
|
|
|
VASOPRESSIN 20 UNITS/ML IV SOLN
|
Facility
|
OP
|
$460.97
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
170714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$428.70 |
| Rate for Payer: Aetna Commercial |
$389.06
|
| Rate for Payer: Aetna Medicare |
$152.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$152.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$264.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$288.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$174.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$167.33
|
| Rate for Payer: Cash Price |
$285.80
|
| Rate for Payer: Cash Price |
$285.80
|
| Rate for Payer: Centivo All Commercial |
$235.09
|
| Rate for Payer: Cigna All Commercial |
$397.82
|
| Rate for Payer: CORVEL All Commercial |
$428.70
|
| Rate for Payer: Coventry All Commercial |
$405.65
|
| Rate for Payer: Encore All Commercial |
$424.32
|
| Rate for Payer: Frontpath All Commercial |
$424.09
|
| Rate for Payer: Humana ChoiceCare |
$398.14
|
| Rate for Payer: Humana Medicare |
$235.09
|
| Rate for Payer: Lucent All Commercial |
$235.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.87
|
| Rate for Payer: Managed Health Services Medicaid |
$1.21
|
| Rate for Payer: MDWise Medicaid |
$1.21
|
| Rate for Payer: PHCS All Commercial |
$345.73
|
| Rate for Payer: PHP All Commercial |
$349.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$179.78
|
| Rate for Payer: Sagamore Health Network All Products |
$355.87
|
| Rate for Payer: Signature Care EPO |
$382.60
|
| Rate for Payer: Signature Care PPO |
$405.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$391.82
|
| Rate for Payer: United Healthcare Commercial |
$363.24
|
| Rate for Payer: United Healthcare Medicare |
$152.12
|
|
|
VASOPRESSIN 20 UNITS/ML IV SOLN
|
Facility
|
IP
|
$460.97
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
170714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$345.73 |
| Max. Negotiated Rate |
$428.70 |
| Rate for Payer: Aetna Commercial |
$398.28
|
| Rate for Payer: Cash Price |
$285.80
|
| Rate for Payer: Cigna All Commercial |
$397.82
|
| Rate for Payer: CORVEL All Commercial |
$428.70
|
| Rate for Payer: Coventry All Commercial |
$405.65
|
| Rate for Payer: Encore All Commercial |
$424.32
|
| Rate for Payer: Frontpath All Commercial |
$424.09
|
| Rate for Payer: Humana ChoiceCare |
$398.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$414.87
|
| Rate for Payer: PHCS All Commercial |
$345.73
|
| Rate for Payer: PHP All Commercial |
$349.60
|
| Rate for Payer: Sagamore Health Network All Products |
$355.87
|
| Rate for Payer: Signature Care EPO |
$382.60
|
| Rate for Payer: Signature Care PPO |
$405.65
|
| Rate for Payer: United Healthcare Commercial |
$363.24
|
|
|
VECURONIUM BROMIDE 10 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11634
|
|
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
|
|
|
VECURONIUM BROMIDE 10 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11634
|
|
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
|
|
|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
OP
|
$30,333.03
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
168378
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.62 |
| Max. Negotiated Rate |
$28,209.72 |
| Rate for Payer: Aetna Commercial |
$25,601.08
|
| Rate for Payer: Aetna Medicare |
$10,009.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10,009.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17,420.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18,961.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$28.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11,511.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11,010.89
|
| Rate for Payer: Cash Price |
$18,806.48
|
| Rate for Payer: Cash Price |
$18,806.48
|
| Rate for Payer: Centivo All Commercial |
$15,469.85
|
| Rate for Payer: Cigna All Commercial |
$26,177.40
|
| Rate for Payer: CORVEL All Commercial |
$28,209.72
|
| Rate for Payer: Coventry All Commercial |
$26,693.07
|
| Rate for Payer: Encore All Commercial |
$27,921.55
|
| Rate for Payer: Frontpath All Commercial |
$27,906.39
|
| Rate for Payer: Humana ChoiceCare |
$26,198.64
|
| Rate for Payer: Humana Medicare |
$15,469.85
|
| Rate for Payer: Lucent All Commercial |
$15,469.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27,299.73
|
| Rate for Payer: Managed Health Services Medicaid |
$28.62
|
| Rate for Payer: MDWise Medicaid |
$28.62
|
| Rate for Payer: PHCS All Commercial |
$22,749.77
|
| Rate for Payer: PHP All Commercial |
$23,004.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11,829.88
|
| Rate for Payer: Sagamore Health Network All Products |
$23,417.10
|
| Rate for Payer: Signature Care EPO |
$25,176.41
|
| Rate for Payer: Signature Care PPO |
$26,693.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25,783.08
|
| Rate for Payer: United Healthcare Commercial |
$23,902.43
|
| Rate for Payer: United Healthcare Medicare |
$10,009.90
|
|
|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
IP
|
$30,333.03
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
168378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22,749.77 |
| Max. Negotiated Rate |
$28,209.72 |
| Rate for Payer: Aetna Commercial |
$26,207.74
|
| Rate for Payer: Cash Price |
$18,806.48
|
| Rate for Payer: Cigna All Commercial |
$26,177.40
|
| Rate for Payer: CORVEL All Commercial |
$28,209.72
|
| Rate for Payer: Coventry All Commercial |
$26,693.07
|
| Rate for Payer: Encore All Commercial |
$27,921.55
|
| Rate for Payer: Frontpath All Commercial |
$27,906.39
|
| Rate for Payer: Humana ChoiceCare |
$26,198.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27,299.73
|
| Rate for Payer: PHCS All Commercial |
$22,749.77
|
| Rate for Payer: PHP All Commercial |
$23,004.57
|
| Rate for Payer: Sagamore Health Network All Products |
$23,417.10
|
| Rate for Payer: Signature Care EPO |
$25,176.41
|
| Rate for Payer: Signature Care PPO |
$26,693.07
|
| Rate for Payer: United Healthcare Commercial |
$23,902.43
|
|
|
VENLAFAXINE 150 MG ORAL CP24
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862069730
|
| Hospital Charge Code |
27859
|
|
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
|
|
|
VENLAFAXINE 150 MG ORAL CP24
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862069730
|
| Hospital Charge Code |
27859
|
|
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
|
|
|
VENLAFAXINE 25 MG ORAL TAB
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 68382001801
|
| Hospital Charge Code |
12203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.89
|
| Rate for Payer: Aetna Medicare |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Centivo All Commercial |
$1.14
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Humana Medicare |
$1.14
|
| Rate for Payer: Lucent All Commercial |
$1.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
|
|
VENLAFAXINE 25 MG ORAL TAB
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 68382001801
|
| Hospital Charge Code |
12203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
|
|
VENLAFAXINE 37.5 MG ORAL CP24
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
27857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cigna All Commercial |
$2.82
|
| Rate for Payer: CORVEL All Commercial |
$3.04
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.01
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.94
|
| Rate for Payer: PHCS All Commercial |
$2.45
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Sagamore Health Network All Products |
$2.52
|
| Rate for Payer: Signature Care EPO |
$2.71
|
| Rate for Payer: Signature Care PPO |
$2.88
|
| Rate for Payer: United Healthcare Commercial |
$2.58
|
|
|
VENLAFAXINE 37.5 MG ORAL CP24
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
27857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna Medicare |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Centivo All Commercial |
$1.67
|
| Rate for Payer: Cigna All Commercial |
$2.82
|
| Rate for Payer: CORVEL All Commercial |
$3.04
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.01
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.82
|
| Rate for Payer: Humana Medicare |
$1.67
|
| Rate for Payer: Lucent All Commercial |
$1.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.94
|
| Rate for Payer: PHCS All Commercial |
$2.45
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.52
|
| Rate for Payer: Signature Care EPO |
$2.71
|
| Rate for Payer: Signature Care PPO |
$2.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.78
|
| Rate for Payer: United Healthcare Commercial |
$2.58
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
|
|
VENLAFAXINE 50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 57664039488
|
| Hospital Charge Code |
12204
|
|
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
|
|
|
VENLAFAXINE 50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 57664039488
|
| Hospital Charge Code |
12204
|
|
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
|
|
|
VERAPAMIL 120 MG ORAL TBER
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
11639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna All Commercial |
$1.29
|
| Rate for Payer: CORVEL All Commercial |
$1.39
|
| Rate for Payer: Coventry All Commercial |
$1.32
|
| Rate for Payer: Encore All Commercial |
$1.38
|
| Rate for Payer: Frontpath All Commercial |
$1.38
|
| Rate for Payer: Humana ChoiceCare |
$1.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.35
|
| Rate for Payer: PHCS All Commercial |
$1.12
|
| Rate for Payer: PHP All Commercial |
$1.14
|
| Rate for Payer: Sagamore Health Network All Products |
$1.16
|
| Rate for Payer: Signature Care EPO |
$1.24
|
| Rate for Payer: Signature Care PPO |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
VERAPAMIL 120 MG ORAL TBER
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
11639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna Commercial |
$1.26
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Centivo All Commercial |
$0.76
|
| Rate for Payer: Cigna All Commercial |
$1.29
|
| Rate for Payer: CORVEL All Commercial |
$1.39
|
| Rate for Payer: Coventry All Commercial |
$1.32
|
| Rate for Payer: Encore All Commercial |
$1.38
|
| Rate for Payer: Frontpath All Commercial |
$1.38
|
| Rate for Payer: Humana ChoiceCare |
$1.29
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Lucent All Commercial |
$0.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.35
|
| Rate for Payer: PHCS All Commercial |
$1.12
|
| Rate for Payer: PHP All Commercial |
$1.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.16
|
| Rate for Payer: Signature Care EPO |
$1.24
|
| Rate for Payer: Signature Care PPO |
$1.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
VERAPAMIL 180 MG ORAL C24P
|
Facility
|
OP
|
$8.58
|
|
|
Service Code
|
NDC 00591288201
|
| Hospital Charge Code |
23150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Aetna Commercial |
$7.24
|
| Rate for Payer: Aetna Medicare |
$2.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.11
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Centivo All Commercial |
$4.37
|
| Rate for Payer: Cigna All Commercial |
$7.40
|
| Rate for Payer: CORVEL All Commercial |
$7.97
|
| Rate for Payer: Coventry All Commercial |
$7.55
|
| Rate for Payer: Encore All Commercial |
$7.89
|
| Rate for Payer: Frontpath All Commercial |
$7.89
|
| Rate for Payer: Humana ChoiceCare |
$7.41
|
| Rate for Payer: Humana Medicare |
$4.37
|
| Rate for Payer: Lucent All Commercial |
$4.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.72
|
| Rate for Payer: PHCS All Commercial |
$6.43
|
| Rate for Payer: PHP All Commercial |
$6.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.34
|
| Rate for Payer: Sagamore Health Network All Products |
$6.62
|
| Rate for Payer: Signature Care EPO |
$7.12
|
| Rate for Payer: Signature Care PPO |
$7.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.29
|
| Rate for Payer: United Healthcare Commercial |
$6.76
|
| Rate for Payer: United Healthcare Medicare |
$2.83
|
|
|
VERAPAMIL 180 MG ORAL C24P
|
Facility
|
IP
|
$8.58
|
|
|
Service Code
|
NDC 00591288201
|
| Hospital Charge Code |
23150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Aetna Commercial |
$7.41
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna All Commercial |
$7.40
|
| Rate for Payer: CORVEL All Commercial |
$7.97
|
| Rate for Payer: Coventry All Commercial |
$7.55
|
| Rate for Payer: Encore All Commercial |
$7.89
|
| Rate for Payer: Frontpath All Commercial |
$7.89
|
| Rate for Payer: Humana ChoiceCare |
$7.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.72
|
| Rate for Payer: PHCS All Commercial |
$6.43
|
| Rate for Payer: PHP All Commercial |
$6.50
|
| Rate for Payer: Sagamore Health Network All Products |
$6.62
|
| Rate for Payer: Signature Care EPO |
$7.12
|
| Rate for Payer: Signature Care PPO |
$7.55
|
| Rate for Payer: United Healthcare Commercial |
$6.76
|
|
|
VERAPAMIL 2.5 MG/ML IV SOLN
|
Facility
|
IP
|
$83.38
|
|
|
Service Code
|
NDC 00409401101
|
| Hospital Charge Code |
8527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.54 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$72.04
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cigna All Commercial |
$71.96
|
| Rate for Payer: CORVEL All Commercial |
$77.55
|
| Rate for Payer: Coventry All Commercial |
$73.38
|
| Rate for Payer: Encore All Commercial |
$76.75
|
| Rate for Payer: Frontpath All Commercial |
$76.71
|
| Rate for Payer: Humana ChoiceCare |
$72.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.05
|
| Rate for Payer: PHCS All Commercial |
$62.54
|
| Rate for Payer: PHP All Commercial |
$63.24
|
| Rate for Payer: Sagamore Health Network All Products |
$64.37
|
| Rate for Payer: Signature Care EPO |
$69.21
|
| Rate for Payer: Signature Care PPO |
$73.38
|
| Rate for Payer: United Healthcare Commercial |
$65.71
|
|
|
VERAPAMIL 2.5 MG/ML IV SOLN
|
Facility
|
OP
|
$83.38
|
|
|
Service Code
|
NDC 00409401101
|
| Hospital Charge Code |
8527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$70.38
|
| Rate for Payer: Aetna Medicare |
$27.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$47.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.27
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Centivo All Commercial |
$42.53
|
| Rate for Payer: Cigna All Commercial |
$71.96
|
| Rate for Payer: CORVEL All Commercial |
$77.55
|
| Rate for Payer: Coventry All Commercial |
$73.38
|
| Rate for Payer: Encore All Commercial |
$76.75
|
| Rate for Payer: Frontpath All Commercial |
$76.71
|
| Rate for Payer: Humana ChoiceCare |
$72.02
|
| Rate for Payer: Humana Medicare |
$42.53
|
| Rate for Payer: Lucent All Commercial |
$42.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.05
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$62.54
|
| Rate for Payer: PHP All Commercial |
$63.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.52
|
| Rate for Payer: Sagamore Health Network All Products |
$64.37
|
| Rate for Payer: Signature Care EPO |
$69.21
|
| Rate for Payer: Signature Care PPO |
$73.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.88
|
| Rate for Payer: United Healthcare Commercial |
$65.71
|
| Rate for Payer: United Healthcare Medicare |
$27.52
|
|
|
VIT A,C AND E-LUTEIN-MINERALS 300 MCG-200 MG-27 MG-2 MG ORAL TAB
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 00536509008
|
| Hospital Charge Code |
118185
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Aetna Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Centivo All Commercial |
$0.22
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.40
|
| Rate for Payer: Frontpath All Commercial |
$0.40
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.22
|
| Rate for Payer: Lucent All Commercial |
$0.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.39
|
| Rate for Payer: PHCS All Commercial |
$0.33
|
| Rate for Payer: PHP All Commercial |
$0.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.17
|
| Rate for Payer: Sagamore Health Network All Products |
$0.34
|
| Rate for Payer: Signature Care EPO |
$0.36
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
|
|
VIT A,C AND E-LUTEIN-MINERALS 300 MCG-200 MG-27 MG-2 MG ORAL TAB
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 00536509008
|
| Hospital Charge Code |
118185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.40
|
| Rate for Payer: Frontpath All Commercial |
$0.40
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.39
|
| Rate for Payer: PHCS All Commercial |
$0.33
|
| Rate for Payer: PHP All Commercial |
$0.33
|
| Rate for Payer: Sagamore Health Network All Products |
$0.34
|
| Rate for Payer: Signature Care EPO |
$0.36
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
|
|
VITAMIN A 10000 UNITS ORAL CAP
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Aetna Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Centivo All Commercial |
$0.12
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.22
|
| Rate for Payer: Coventry All Commercial |
$0.21
|
| Rate for Payer: Encore All Commercial |
$0.22
|
| Rate for Payer: Frontpath All Commercial |
$0.22
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Humana Medicare |
$0.12
|
| Rate for Payer: Lucent All Commercial |
$0.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.21
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.09
|
| Rate for Payer: Sagamore Health Network All Products |
$0.18
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
|
|
VITAMIN A 10000 UNITS ORAL CAP
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.22
|
| Rate for Payer: Coventry All Commercial |
$0.21
|
| Rate for Payer: Encore All Commercial |
$0.22
|
| Rate for Payer: Frontpath All Commercial |
$0.22
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.21
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.18
|
| Rate for Payer: Sagamore Health Network All Products |
$0.18
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
|
