|
BACITRACIN 500 UNIT/GRAM TOP PACK
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802006000
|
| Hospital Charge Code |
115118
|
|
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
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OINT
|
Facility
OP
|
$110.08
|
|
|
Service Code
|
NDC 16784011761
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.32 |
| Max. Negotiated Rate |
$102.37 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: Aetna Medicare |
$36.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$63.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$68.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.96
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Centivo All Commercial |
$56.14
|
| Rate for Payer: Cigna All Commercial |
$94.99
|
| Rate for Payer: CORVEL All Commercial |
$102.37
|
| Rate for Payer: Coventry All Commercial |
$96.87
|
| Rate for Payer: Encore All Commercial |
$101.32
|
| Rate for Payer: Frontpath All Commercial |
$101.27
|
| Rate for Payer: Humana ChoiceCare |
$95.07
|
| Rate for Payer: Humana Medicare |
$56.14
|
| Rate for Payer: Lucent All Commercial |
$56.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.07
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$82.56
|
| Rate for Payer: PHP All Commercial |
$83.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.93
|
| Rate for Payer: Sagamore Health Network All Products |
$84.98
|
| Rate for Payer: Signature Care EPO |
$91.36
|
| Rate for Payer: Signature Care PPO |
$96.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$93.56
|
| Rate for Payer: United Healthcare Commercial |
$86.74
|
| Rate for Payer: United Healthcare Medicare |
$36.32
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OINT
|
Facility
IP
|
$110.08
|
|
|
Service Code
|
NDC 16784011761
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$102.37 |
| Rate for Payer: Aetna Commercial |
$95.10
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cigna All Commercial |
$94.99
|
| Rate for Payer: CORVEL All Commercial |
$102.37
|
| Rate for Payer: Coventry All Commercial |
$96.87
|
| Rate for Payer: Encore All Commercial |
$101.32
|
| Rate for Payer: Frontpath All Commercial |
$101.27
|
| Rate for Payer: Humana ChoiceCare |
$95.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.07
|
| Rate for Payer: PHCS All Commercial |
$82.56
|
| Rate for Payer: PHP All Commercial |
$83.48
|
| Rate for Payer: Sagamore Health Network All Products |
$84.98
|
| Rate for Payer: Signature Care EPO |
$91.36
|
| Rate for Payer: Signature Care PPO |
$96.87
|
| Rate for Payer: United Healthcare Commercial |
$86.74
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OIPK
|
Facility
OP
|
$0.71
|
|
|
Service Code
|
NDC 00904702367
|
| Hospital Charge Code |
115117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$0.60
|
| Rate for Payer: Aetna Medicare |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Centivo All Commercial |
$0.36
|
| Rate for Payer: Cigna All Commercial |
$0.61
|
| Rate for Payer: CORVEL All Commercial |
$0.66
|
| Rate for Payer: Coventry All Commercial |
$0.62
|
| Rate for Payer: Encore All Commercial |
$0.65
|
| Rate for Payer: Frontpath All Commercial |
$0.65
|
| Rate for Payer: Humana ChoiceCare |
$0.61
|
| Rate for Payer: Humana Medicare |
$0.36
|
| Rate for Payer: Lucent All Commercial |
$0.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.64
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$0.53
|
| Rate for Payer: PHP All Commercial |
$0.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.28
|
| Rate for Payer: Sagamore Health Network All Products |
$0.55
|
| Rate for Payer: Signature Care EPO |
$0.59
|
| Rate for Payer: Signature Care PPO |
$0.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.60
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OIPK
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 00904702367
|
| Hospital Charge Code |
115117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna All Commercial |
$0.61
|
| Rate for Payer: CORVEL All Commercial |
$0.66
|
| Rate for Payer: Coventry All Commercial |
$0.62
|
| Rate for Payer: Encore All Commercial |
$0.65
|
| Rate for Payer: Frontpath All Commercial |
$0.65
|
| Rate for Payer: Humana ChoiceCare |
$0.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.64
|
| Rate for Payer: PHCS All Commercial |
$0.53
|
| Rate for Payer: PHP All Commercial |
$0.54
|
| Rate for Payer: Sagamore Health Network All Products |
$0.55
|
| Rate for Payer: Signature Care EPO |
$0.59
|
| Rate for Payer: Signature Care PPO |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
|
|
BACLOFEN 10 MG ORAL TAB
|
Facility
IP
|
$2.09
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna All Commercial |
$1.80
|
| Rate for Payer: CORVEL All Commercial |
$1.94
|
| Rate for Payer: Coventry All Commercial |
$1.84
|
| Rate for Payer: Encore All Commercial |
$1.92
|
| Rate for Payer: Frontpath All Commercial |
$1.92
|
| Rate for Payer: Humana ChoiceCare |
$1.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.88
|
| Rate for Payer: PHCS All Commercial |
$1.56
|
| Rate for Payer: PHP All Commercial |
$1.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.61
|
| Rate for Payer: Signature Care EPO |
$1.73
|
| Rate for Payer: Signature Care PPO |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
|
|
BACLOFEN 10 MG ORAL TAB
|
Facility
OP
|
$2.09
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: Aetna Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Centivo All Commercial |
$1.06
|
| Rate for Payer: Cigna All Commercial |
$1.80
|
| Rate for Payer: CORVEL All Commercial |
$1.94
|
| Rate for Payer: Coventry All Commercial |
$1.84
|
| Rate for Payer: Encore All Commercial |
$1.92
|
| Rate for Payer: Frontpath All Commercial |
$1.92
|
| Rate for Payer: Humana ChoiceCare |
$1.80
|
| Rate for Payer: Humana Medicare |
$1.06
|
| Rate for Payer: Lucent All Commercial |
$1.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.88
|
| Rate for Payer: PHCS All Commercial |
$1.56
|
| Rate for Payer: PHP All Commercial |
$1.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.81
|
| Rate for Payer: Sagamore Health Network All Products |
$1.61
|
| Rate for Payer: Signature Care EPO |
$1.73
|
| Rate for Payer: Signature Care PPO |
$1.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.77
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$0.69
|
|
|
BALANCED SALT SOLN NO.1 IRRIG. IO SOLN
|
Facility
IP
|
$527.50
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$395.62 |
| Max. Negotiated Rate |
$490.58 |
| Rate for Payer: Aetna Commercial |
$455.76
|
| Rate for Payer: Cash Price |
$327.05
|
| Rate for Payer: Cigna All Commercial |
$455.23
|
| Rate for Payer: CORVEL All Commercial |
$490.58
|
| Rate for Payer: Coventry All Commercial |
$464.20
|
| Rate for Payer: Encore All Commercial |
$485.56
|
| Rate for Payer: Frontpath All Commercial |
$485.30
|
| Rate for Payer: Humana ChoiceCare |
$455.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$474.75
|
| Rate for Payer: PHCS All Commercial |
$395.62
|
| Rate for Payer: PHP All Commercial |
$400.06
|
| Rate for Payer: Sagamore Health Network All Products |
$407.23
|
| Rate for Payer: Signature Care EPO |
$437.82
|
| Rate for Payer: Signature Care PPO |
$464.20
|
| Rate for Payer: United Healthcare Commercial |
$415.67
|
|
|
BALANCED SALT SOLN NO.1 IRRIG. IO SOLN
|
Facility
OP
|
$527.50
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$490.58 |
| Rate for Payer: Aetna Commercial |
$445.21
|
| Rate for Payer: Aetna Medicare |
$174.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$174.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$302.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$329.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$200.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$191.48
|
| Rate for Payer: Cash Price |
$327.05
|
| Rate for Payer: Cash Price |
$327.05
|
| Rate for Payer: Centivo All Commercial |
$269.02
|
| Rate for Payer: Cigna All Commercial |
$455.23
|
| Rate for Payer: CORVEL All Commercial |
$490.58
|
| Rate for Payer: Coventry All Commercial |
$464.20
|
| Rate for Payer: Encore All Commercial |
$485.56
|
| Rate for Payer: Frontpath All Commercial |
$485.30
|
| Rate for Payer: Humana ChoiceCare |
$455.60
|
| Rate for Payer: Humana Medicare |
$269.02
|
| Rate for Payer: Lucent All Commercial |
$269.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$474.75
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$395.62
|
| Rate for Payer: PHP All Commercial |
$400.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$205.72
|
| Rate for Payer: Sagamore Health Network All Products |
$407.23
|
| Rate for Payer: Signature Care EPO |
$437.82
|
| Rate for Payer: Signature Care PPO |
$464.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$448.38
|
| Rate for Payer: United Healthcare Commercial |
$415.67
|
| Rate for Payer: United Healthcare Medicare |
$174.08
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
IP
|
$276.50
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$207.38 |
| Max. Negotiated Rate |
$257.14 |
| Rate for Payer: Aetna Commercial |
$238.90
|
| Rate for Payer: Cash Price |
$171.43
|
| Rate for Payer: Cigna All Commercial |
$238.62
|
| Rate for Payer: CORVEL All Commercial |
$257.14
|
| Rate for Payer: Coventry All Commercial |
$243.32
|
| Rate for Payer: Encore All Commercial |
$254.52
|
| Rate for Payer: Frontpath All Commercial |
$254.38
|
| Rate for Payer: Humana ChoiceCare |
$238.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$248.85
|
| Rate for Payer: PHCS All Commercial |
$207.38
|
| Rate for Payer: PHP All Commercial |
$209.70
|
| Rate for Payer: Sagamore Health Network All Products |
$213.46
|
| Rate for Payer: Signature Care EPO |
$229.50
|
| Rate for Payer: Signature Care PPO |
$243.32
|
| Rate for Payer: United Healthcare Commercial |
$217.88
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
OP
|
$276.50
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$257.14 |
| Rate for Payer: Aetna Commercial |
$233.37
|
| Rate for Payer: Aetna Medicare |
$91.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$91.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$158.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$172.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$100.37
|
| Rate for Payer: Cash Price |
$171.43
|
| Rate for Payer: Cash Price |
$171.43
|
| Rate for Payer: Centivo All Commercial |
$141.02
|
| Rate for Payer: Cigna All Commercial |
$238.62
|
| Rate for Payer: CORVEL All Commercial |
$257.14
|
| Rate for Payer: Coventry All Commercial |
$243.32
|
| Rate for Payer: Encore All Commercial |
$254.52
|
| Rate for Payer: Frontpath All Commercial |
$254.38
|
| Rate for Payer: Humana ChoiceCare |
$238.81
|
| Rate for Payer: Humana Medicare |
$141.02
|
| Rate for Payer: Lucent All Commercial |
$141.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$248.85
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$207.38
|
| Rate for Payer: PHP All Commercial |
$209.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$107.84
|
| Rate for Payer: Sagamore Health Network All Products |
$213.46
|
| Rate for Payer: Signature Care EPO |
$229.50
|
| Rate for Payer: Signature Care PPO |
$243.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$235.02
|
| Rate for Payer: United Healthcare Commercial |
$217.88
|
| Rate for Payer: United Healthcare Medicare |
$91.24
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
OP
|
$80.75
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$68.15
|
| Rate for Payer: Aetna Medicare |
$26.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$46.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.31
|
| Rate for Payer: Cash Price |
$50.06
|
| Rate for Payer: Cash Price |
$50.06
|
| Rate for Payer: Centivo All Commercial |
$41.18
|
| Rate for Payer: Cigna All Commercial |
$69.68
|
| Rate for Payer: CORVEL All Commercial |
$75.09
|
| Rate for Payer: Coventry All Commercial |
$71.06
|
| Rate for Payer: Encore All Commercial |
$74.33
|
| Rate for Payer: Frontpath All Commercial |
$74.29
|
| Rate for Payer: Humana ChoiceCare |
$69.74
|
| Rate for Payer: Humana Medicare |
$41.18
|
| Rate for Payer: Lucent All Commercial |
$41.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.67
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$60.56
|
| Rate for Payer: PHP All Commercial |
$61.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.49
|
| Rate for Payer: Sagamore Health Network All Products |
$62.34
|
| Rate for Payer: Signature Care EPO |
$67.02
|
| Rate for Payer: Signature Care PPO |
$71.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$68.63
|
| Rate for Payer: United Healthcare Commercial |
$63.63
|
| Rate for Payer: United Healthcare Medicare |
$26.65
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
IP
|
$80.75
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.56 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$69.76
|
| Rate for Payer: Cash Price |
$50.06
|
| Rate for Payer: Cigna All Commercial |
$69.68
|
| Rate for Payer: CORVEL All Commercial |
$75.09
|
| Rate for Payer: Coventry All Commercial |
$71.06
|
| Rate for Payer: Encore All Commercial |
$74.33
|
| Rate for Payer: Frontpath All Commercial |
$74.29
|
| Rate for Payer: Humana ChoiceCare |
$69.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.67
|
| Rate for Payer: PHCS All Commercial |
$60.56
|
| Rate for Payer: PHP All Commercial |
$61.24
|
| Rate for Payer: Sagamore Health Network All Products |
$62.34
|
| Rate for Payer: Signature Care EPO |
$67.02
|
| Rate for Payer: Signature Care PPO |
$71.06
|
| Rate for Payer: United Healthcare Commercial |
$63.63
|
|
|
BARICITINIB (EUA) 2 MG ORAL TAB (CMCH)
|
Facility
IP
|
$526.28
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
140118480101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.71 |
| Max. Negotiated Rate |
$489.44 |
| Rate for Payer: Aetna Commercial |
$454.71
|
| Rate for Payer: Cash Price |
$326.30
|
| Rate for Payer: Cigna All Commercial |
$454.18
|
| Rate for Payer: CORVEL All Commercial |
$489.44
|
| Rate for Payer: Coventry All Commercial |
$463.13
|
| Rate for Payer: Encore All Commercial |
$484.44
|
| Rate for Payer: Frontpath All Commercial |
$484.18
|
| Rate for Payer: Humana ChoiceCare |
$454.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$473.66
|
| Rate for Payer: PHCS All Commercial |
$394.71
|
| Rate for Payer: PHP All Commercial |
$399.13
|
| Rate for Payer: Sagamore Health Network All Products |
$406.29
|
| Rate for Payer: Signature Care EPO |
$436.82
|
| Rate for Payer: Signature Care PPO |
$463.13
|
| Rate for Payer: United Healthcare Commercial |
$414.71
|
|
|
BARICITINIB (EUA) 2 MG ORAL TAB (CMCH)
|
Facility
OP
|
$526.28
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
140118480101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.67 |
| Max. Negotiated Rate |
$489.44 |
| Rate for Payer: Aetna Commercial |
$444.18
|
| Rate for Payer: Aetna Medicare |
$173.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$302.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$328.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$199.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$191.04
|
| Rate for Payer: Cash Price |
$326.30
|
| Rate for Payer: Centivo All Commercial |
$268.40
|
| Rate for Payer: Cigna All Commercial |
$454.18
|
| Rate for Payer: CORVEL All Commercial |
$489.44
|
| Rate for Payer: Coventry All Commercial |
$463.13
|
| Rate for Payer: Encore All Commercial |
$484.44
|
| Rate for Payer: Frontpath All Commercial |
$484.18
|
| Rate for Payer: Humana ChoiceCare |
$454.55
|
| Rate for Payer: Humana Medicare |
$268.40
|
| Rate for Payer: Lucent All Commercial |
$268.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$473.66
|
| Rate for Payer: PHCS All Commercial |
$394.71
|
| Rate for Payer: PHP All Commercial |
$399.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$205.25
|
| Rate for Payer: Sagamore Health Network All Products |
$406.29
|
| Rate for Payer: Signature Care EPO |
$436.82
|
| Rate for Payer: Signature Care PPO |
$463.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$447.34
|
| Rate for Payer: United Healthcare Commercial |
$414.71
|
| Rate for Payer: United Healthcare Medicare |
$173.67
|
|
|
BARIUM SULFATE 0.1 % ORAL SUSP 450 ML BTL
|
Facility
OP
|
$47.25
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
93052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.59 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$39.88
|
| Rate for Payer: Aetna Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.15
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Centivo All Commercial |
$24.10
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Humana Medicare |
$24.10
|
| Rate for Payer: Lucent All Commercial |
$24.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.43
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
| Rate for Payer: United Healthcare Medicare |
$15.59
|
|
|
BARIUM SULFATE 0.1 % ORAL SUSP 450 ML BTL
|
Facility
IP
|
$47.25
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
93052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.44 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
|
|
BARIUM SULFATE 105 % (W/V) ORAL SUSP BTL
|
Facility
IP
|
$115.50
|
|
|
Service Code
|
NDC 32909016755
|
| Hospital Charge Code |
97296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.62 |
| Max. Negotiated Rate |
$107.42 |
| Rate for Payer: Aetna Commercial |
$99.79
|
| Rate for Payer: Cash Price |
$71.61
|
| Rate for Payer: Cigna All Commercial |
$99.68
|
| Rate for Payer: CORVEL All Commercial |
$107.42
|
| Rate for Payer: Coventry All Commercial |
$101.64
|
| Rate for Payer: Encore All Commercial |
$106.32
|
| Rate for Payer: Frontpath All Commercial |
$106.26
|
| Rate for Payer: Humana ChoiceCare |
$99.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.95
|
| Rate for Payer: PHCS All Commercial |
$86.62
|
| Rate for Payer: PHP All Commercial |
$87.60
|
| Rate for Payer: Sagamore Health Network All Products |
$89.17
|
| Rate for Payer: Signature Care EPO |
$95.86
|
| Rate for Payer: Signature Care PPO |
$101.64
|
| Rate for Payer: United Healthcare Commercial |
$91.01
|
|
|
BARIUM SULFATE 105 % (W/V) ORAL SUSP BTL
|
Facility
OP
|
$115.50
|
|
|
Service Code
|
NDC 32909016755
|
| Hospital Charge Code |
97296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$107.42 |
| Rate for Payer: Aetna Commercial |
$97.48
|
| Rate for Payer: Aetna Medicare |
$38.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$38.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$66.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$43.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$41.93
|
| Rate for Payer: Cash Price |
$71.61
|
| Rate for Payer: Cash Price |
$71.61
|
| Rate for Payer: Centivo All Commercial |
$58.90
|
| Rate for Payer: Cigna All Commercial |
$99.68
|
| Rate for Payer: CORVEL All Commercial |
$107.42
|
| Rate for Payer: Coventry All Commercial |
$101.64
|
| Rate for Payer: Encore All Commercial |
$106.32
|
| Rate for Payer: Frontpath All Commercial |
$106.26
|
| Rate for Payer: Humana ChoiceCare |
$99.76
|
| Rate for Payer: Humana Medicare |
$58.90
|
| Rate for Payer: Lucent All Commercial |
$58.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.95
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$86.62
|
| Rate for Payer: PHP All Commercial |
$87.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.04
|
| Rate for Payer: Sagamore Health Network All Products |
$89.17
|
| Rate for Payer: Signature Care EPO |
$95.86
|
| Rate for Payer: Signature Care PPO |
$101.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.18
|
| Rate for Payer: United Healthcare Commercial |
$91.01
|
| Rate for Payer: United Healthcare Medicare |
$38.12
|
|
|
BARIUM SULFATE 60 % ORAL CREA 454 G TUBE
|
Facility
IP
|
$101.70
|
|
|
Service Code
|
NDC 32909077001
|
| Hospital Charge Code |
96947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$94.58 |
| Rate for Payer: Aetna Commercial |
$87.87
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cigna All Commercial |
$87.76
|
| Rate for Payer: CORVEL All Commercial |
$94.58
|
| Rate for Payer: Coventry All Commercial |
$89.49
|
| Rate for Payer: Encore All Commercial |
$93.61
|
| Rate for Payer: Frontpath All Commercial |
$93.56
|
| Rate for Payer: Humana ChoiceCare |
$87.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.53
|
| Rate for Payer: PHCS All Commercial |
$76.27
|
| Rate for Payer: PHP All Commercial |
$77.13
|
| Rate for Payer: Sagamore Health Network All Products |
$78.51
|
| Rate for Payer: Signature Care EPO |
$84.41
|
| Rate for Payer: Signature Care PPO |
$89.49
|
| Rate for Payer: United Healthcare Commercial |
$80.14
|
|
|
BARIUM SULFATE 60 % ORAL CREA 454 G TUBE
|
Facility
OP
|
$101.70
|
|
|
Service Code
|
NDC 32909077001
|
| Hospital Charge Code |
96947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.56 |
| Max. Negotiated Rate |
$94.58 |
| Rate for Payer: Centivo All Commercial |
$51.86
|
| Rate for Payer: Aetna Commercial |
$85.83
|
| Rate for Payer: Aetna Medicare |
$33.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$58.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.92
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cigna All Commercial |
$87.76
|
| Rate for Payer: CORVEL All Commercial |
$94.58
|
| Rate for Payer: Coventry All Commercial |
$89.49
|
| Rate for Payer: Encore All Commercial |
$93.61
|
| Rate for Payer: Frontpath All Commercial |
$93.56
|
| Rate for Payer: Humana ChoiceCare |
$87.83
|
| Rate for Payer: Humana Medicare |
$51.86
|
| Rate for Payer: Lucent All Commercial |
$51.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.53
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$76.27
|
| Rate for Payer: PHP All Commercial |
$77.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.66
|
| Rate for Payer: Sagamore Health Network All Products |
$78.51
|
| Rate for Payer: Signature Care EPO |
$84.41
|
| Rate for Payer: Signature Care PPO |
$89.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.44
|
| Rate for Payer: United Healthcare Commercial |
$80.14
|
| Rate for Payer: United Healthcare Medicare |
$33.56
|
|
|
BARIUM SULFATE 700 MG ORAL TAB
|
Facility
IP
|
$18.10
|
|
|
Service Code
|
NDC 10361077831
|
| Hospital Charge Code |
100992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$16.83 |
| Rate for Payer: Aetna Commercial |
$15.64
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cigna All Commercial |
$15.62
|
| Rate for Payer: CORVEL All Commercial |
$16.83
|
| Rate for Payer: Coventry All Commercial |
$15.93
|
| Rate for Payer: Encore All Commercial |
$16.66
|
| Rate for Payer: Frontpath All Commercial |
$16.65
|
| Rate for Payer: Humana ChoiceCare |
$15.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.29
|
| Rate for Payer: PHCS All Commercial |
$13.58
|
| Rate for Payer: PHP All Commercial |
$13.73
|
| Rate for Payer: Sagamore Health Network All Products |
$13.97
|
| Rate for Payer: Signature Care EPO |
$15.02
|
| Rate for Payer: Signature Care PPO |
$15.93
|
| Rate for Payer: United Healthcare Commercial |
$14.26
|
|
|
BARIUM SULFATE 700 MG ORAL TAB
|
Facility
OP
|
$18.10
|
|
|
Service Code
|
NDC 10361077831
|
| Hospital Charge Code |
100992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.97 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: Aetna Medicare |
$5.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.57
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Centivo All Commercial |
$9.23
|
| Rate for Payer: Cigna All Commercial |
$15.62
|
| Rate for Payer: CORVEL All Commercial |
$16.83
|
| Rate for Payer: Coventry All Commercial |
$15.93
|
| Rate for Payer: Encore All Commercial |
$16.66
|
| Rate for Payer: Frontpath All Commercial |
$16.65
|
| Rate for Payer: Humana ChoiceCare |
$15.63
|
| Rate for Payer: Humana Medicare |
$9.23
|
| Rate for Payer: Lucent All Commercial |
$9.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.29
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$13.58
|
| Rate for Payer: PHP All Commercial |
$13.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.06
|
| Rate for Payer: Sagamore Health Network All Products |
$13.97
|
| Rate for Payer: Signature Care EPO |
$15.02
|
| Rate for Payer: Signature Care PPO |
$15.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.39
|
| Rate for Payer: United Healthcare Commercial |
$14.26
|
| Rate for Payer: United Healthcare Medicare |
$5.97
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL SUSR 176 G BTL
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 32909075003
|
| Hospital Charge Code |
13031
|
|
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
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL SUSR 176 G BTL
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 32909075003
|
| Hospital Charge Code |
13031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$37.28 |
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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
|
|
