|
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
152887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.20
|
| Rate for Payer: Encore All Commercial |
$1.25
|
| Rate for Payer: Frontpath All Commercial |
$1.25
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| Rate for Payer: PHCS All Commercial |
$1.02
|
| Rate for Payer: PHP All Commercial |
$1.03
|
| Rate for Payer: Sagamore Health Network All Products |
$1.05
|
| Rate for Payer: Signature Care EPO |
$1.13
|
| Rate for Payer: Signature Care PPO |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
|
|
BENZOCAINE-MENTHOL 20-0.5 % TOP AERO
|
Facility
|
IP
|
$49.69
|
|
|
Service Code
|
NDC 51409000722
|
| Hospital Charge Code |
28048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.26 |
| Max. Negotiated Rate |
$46.21 |
| Rate for Payer: Aetna Commercial |
$42.93
|
| Rate for Payer: Cash Price |
$29.81
|
| Rate for Payer: Cigna All Commercial |
$42.88
|
| Rate for Payer: CORVEL All Commercial |
$46.21
|
| Rate for Payer: Coventry All Commercial |
$43.72
|
| Rate for Payer: Encore All Commercial |
$45.74
|
| Rate for Payer: Frontpath All Commercial |
$45.71
|
| Rate for Payer: Humana ChoiceCare |
$42.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.72
|
| Rate for Payer: PHCS All Commercial |
$37.26
|
| Rate for Payer: PHP All Commercial |
$37.68
|
| Rate for Payer: Sagamore Health Network All Products |
$38.36
|
| Rate for Payer: Signature Care EPO |
$41.24
|
| Rate for Payer: Signature Care PPO |
$43.72
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
|
|
BENZOCAINE-MENTHOL 20-0.5 % TOP AERO
|
Facility
|
OP
|
$49.69
|
|
|
Service Code
|
NDC 51409000722
|
| Hospital Charge Code |
28048
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$46.21 |
| Rate for Payer: Aetna Commercial |
$41.93
|
| Rate for Payer: Aetna Medicare |
$15.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.49
|
| Rate for Payer: Cash Price |
$29.81
|
| Rate for Payer: Centivo All Commercial |
$27.03
|
| Rate for Payer: Cigna All Commercial |
$42.88
|
| Rate for Payer: CORVEL All Commercial |
$46.21
|
| Rate for Payer: Coventry All Commercial |
$43.72
|
| Rate for Payer: Encore All Commercial |
$45.74
|
| Rate for Payer: Frontpath All Commercial |
$45.71
|
| Rate for Payer: Humana ChoiceCare |
$42.91
|
| Rate for Payer: Humana Medicare |
$15.90
|
| Rate for Payer: Lucent All Commercial |
$27.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.72
|
| Rate for Payer: PHCS All Commercial |
$37.26
|
| Rate for Payer: PHP All Commercial |
$37.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.38
|
| Rate for Payer: Sagamore Health Network All Products |
$38.36
|
| Rate for Payer: Signature Care EPO |
$41.24
|
| Rate for Payer: Signature Care PPO |
$43.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.23
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$15.90
|
|
|
BENZOCAINE-MENTHOL MM LOZG S.O. (CAMERON)
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 78112001266
|
| Hospital Charge Code |
140152887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Centivo All Commercial |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.42
|
| Rate for Payer: Lucent All Commercial |
$0.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
|
|
BENZOCAINE-MENTHOL MM LOZG S.O. (CAMERON)
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 78112001266
|
| Hospital Charge Code |
140152887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
BENZONATATE 100 MG ORAL CAP
|
Facility
|
OP
|
$2.91
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.45
|
| Rate for Payer: Aetna Medicare |
$0.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Centivo All Commercial |
$1.58
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.51
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$1.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.13
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.47
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Medicare |
$0.93
|
|
|
BENZONATATE 100 MG ORAL CAP
|
Facility
|
IP
|
$2.91
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
BENZTROPINE 1 MG/ML INJ SOLN
|
Facility
|
OP
|
$164.07
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$152.58 |
| Rate for Payer: Aetna Commercial |
$138.47
|
| Rate for Payer: Aetna Medicare |
$52.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$50.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$94.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$102.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.75
|
| Rate for Payer: Cash Price |
$98.44
|
| Rate for Payer: Centivo All Commercial |
$89.25
|
| Rate for Payer: Cigna All Commercial |
$141.59
|
| Rate for Payer: CORVEL All Commercial |
$152.58
|
| Rate for Payer: Coventry All Commercial |
$144.38
|
| Rate for Payer: Encore All Commercial |
$151.02
|
| Rate for Payer: Frontpath All Commercial |
$150.94
|
| Rate for Payer: Humana ChoiceCare |
$141.70
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Lucent All Commercial |
$89.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$147.66
|
| Rate for Payer: PHCS All Commercial |
$123.05
|
| Rate for Payer: PHP All Commercial |
$124.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$63.99
|
| Rate for Payer: Sagamore Health Network All Products |
$126.66
|
| Rate for Payer: Signature Care EPO |
$136.17
|
| Rate for Payer: Signature Care PPO |
$144.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$139.46
|
| Rate for Payer: United Healthcare Commercial |
$129.28
|
| Rate for Payer: United Healthcare Medicare |
$52.50
|
|
|
BENZTROPINE 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$164.07
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.05 |
| Max. Negotiated Rate |
$152.58 |
| Rate for Payer: Aetna Commercial |
$141.75
|
| Rate for Payer: Cash Price |
$98.44
|
| Rate for Payer: Cigna All Commercial |
$141.59
|
| Rate for Payer: CORVEL All Commercial |
$152.58
|
| Rate for Payer: Coventry All Commercial |
$144.38
|
| Rate for Payer: Encore All Commercial |
$151.02
|
| Rate for Payer: Frontpath All Commercial |
$150.94
|
| Rate for Payer: Humana ChoiceCare |
$141.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$147.66
|
| Rate for Payer: PHCS All Commercial |
$123.05
|
| Rate for Payer: PHP All Commercial |
$124.43
|
| Rate for Payer: Sagamore Health Network All Products |
$126.66
|
| Rate for Payer: Signature Care EPO |
$136.17
|
| Rate for Payer: Signature Care PPO |
$144.38
|
| Rate for Payer: United Healthcare Commercial |
$129.28
|
|
|
BENZTROPINE 1 MG ORAL TAB
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.83
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| Rate for Payer: Signature Care PPO |
$2.88
|
| Rate for Payer: United Healthcare Commercial |
$2.58
|
|
|
BENZTROPINE 1 MG ORAL TAB
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.15
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Centivo All Commercial |
$1.78
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.83
|
| Rate for Payer: Humana Medicare |
$1.05
|
| Rate for Payer: Lucent All Commercial |
$1.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| 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 |
$1.05
|
|
|
BENZYLPENICILLOYL POLYLYSINE 0.25 ML IDRM SOLN
|
Facility
|
IP
|
$832.50
|
|
|
Service Code
|
NDC 49471000105
|
| Hospital Charge Code |
9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.38 |
| Max. Negotiated Rate |
$774.23 |
| Rate for Payer: Aetna Commercial |
$719.28
|
| Rate for Payer: Cash Price |
$499.50
|
| Rate for Payer: Cigna All Commercial |
$718.45
|
| Rate for Payer: CORVEL All Commercial |
$774.23
|
| Rate for Payer: Coventry All Commercial |
$732.60
|
| Rate for Payer: Encore All Commercial |
$766.32
|
| Rate for Payer: Frontpath All Commercial |
$765.90
|
| Rate for Payer: Humana ChoiceCare |
$719.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$749.25
|
| Rate for Payer: PHCS All Commercial |
$624.38
|
| Rate for Payer: PHP All Commercial |
$631.37
|
| Rate for Payer: Sagamore Health Network All Products |
$642.69
|
| Rate for Payer: Signature Care EPO |
$690.98
|
| Rate for Payer: Signature Care PPO |
$732.60
|
| Rate for Payer: United Healthcare Commercial |
$656.01
|
|
|
BENZYLPENICILLOYL POLYLYSINE 0.25 ML IDRM SOLN
|
Facility
|
OP
|
$832.50
|
|
|
Service Code
|
NDC 49471000105
|
| Hospital Charge Code |
9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$774.23 |
| Rate for Payer: Aetna Commercial |
$702.63
|
| Rate for Payer: Aetna Medicare |
$266.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$258.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$478.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$520.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$306.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$293.04
|
| Rate for Payer: Cash Price |
$499.50
|
| Rate for Payer: Cash Price |
$499.50
|
| Rate for Payer: Centivo All Commercial |
$452.88
|
| Rate for Payer: Cigna All Commercial |
$718.45
|
| Rate for Payer: CORVEL All Commercial |
$774.23
|
| Rate for Payer: Coventry All Commercial |
$732.60
|
| Rate for Payer: Encore All Commercial |
$766.32
|
| Rate for Payer: Frontpath All Commercial |
$765.90
|
| Rate for Payer: Humana ChoiceCare |
$719.03
|
| Rate for Payer: Humana Medicare |
$266.40
|
| Rate for Payer: Lucent All Commercial |
$452.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$749.25
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$624.38
|
| Rate for Payer: PHP All Commercial |
$631.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$324.68
|
| Rate for Payer: Sagamore Health Network All Products |
$642.69
|
| Rate for Payer: Signature Care EPO |
$690.98
|
| Rate for Payer: Signature Care PPO |
$732.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$707.62
|
| Rate for Payer: United Healthcare Commercial |
$656.01
|
| Rate for Payer: United Healthcare Medicare |
$266.40
|
|
|
BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP
|
Facility
|
IP
|
$243.46
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
9266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.59 |
| Max. Negotiated Rate |
$226.42 |
| Rate for Payer: Aetna Commercial |
$210.35
|
| Rate for Payer: Cash Price |
$146.08
|
| Rate for Payer: Cigna All Commercial |
$210.11
|
| Rate for Payer: CORVEL All Commercial |
$226.42
|
| Rate for Payer: Coventry All Commercial |
$214.24
|
| Rate for Payer: Encore All Commercial |
$224.10
|
| Rate for Payer: Frontpath All Commercial |
$223.98
|
| Rate for Payer: Humana ChoiceCare |
$210.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.11
|
| Rate for Payer: PHCS All Commercial |
$182.59
|
| Rate for Payer: PHP All Commercial |
$184.64
|
| Rate for Payer: Sagamore Health Network All Products |
$187.95
|
| Rate for Payer: Signature Care EPO |
$202.07
|
| Rate for Payer: Signature Care PPO |
$214.24
|
| Rate for Payer: United Healthcare Commercial |
$191.85
|
|
|
BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP
|
Facility
|
OP
|
$243.46
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
9266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.47 |
| Max. Negotiated Rate |
$226.42 |
| Rate for Payer: Aetna Commercial |
$205.48
|
| Rate for Payer: Aetna Medicare |
$77.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$75.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$139.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$152.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$85.70
|
| Rate for Payer: Cash Price |
$146.08
|
| Rate for Payer: Centivo All Commercial |
$132.44
|
| Rate for Payer: Cigna All Commercial |
$210.11
|
| Rate for Payer: CORVEL All Commercial |
$226.42
|
| Rate for Payer: Coventry All Commercial |
$214.24
|
| Rate for Payer: Encore All Commercial |
$224.10
|
| Rate for Payer: Frontpath All Commercial |
$223.98
|
| Rate for Payer: Humana ChoiceCare |
$210.28
|
| Rate for Payer: Humana Medicare |
$77.91
|
| Rate for Payer: Lucent All Commercial |
$132.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.11
|
| Rate for Payer: PHCS All Commercial |
$182.59
|
| Rate for Payer: PHP All Commercial |
$184.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$94.95
|
| Rate for Payer: Sagamore Health Network All Products |
$187.95
|
| Rate for Payer: Signature Care EPO |
$202.07
|
| Rate for Payer: Signature Care PPO |
$214.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$206.94
|
| Rate for Payer: United Healthcare Commercial |
$191.85
|
| Rate for Payer: United Healthcare Medicare |
$77.91
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP CREA
|
Facility
|
OP
|
$82.43
|
|
|
Service Code
|
NDC 70710123301
|
| Hospital Charge Code |
1027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.55 |
| Max. Negotiated Rate |
$76.66 |
| Rate for Payer: Aetna Commercial |
$69.57
|
| Rate for Payer: Aetna Medicare |
$26.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.01
|
| Rate for Payer: Cash Price |
$49.46
|
| Rate for Payer: Centivo All Commercial |
$44.84
|
| Rate for Payer: Cigna All Commercial |
$71.13
|
| Rate for Payer: CORVEL All Commercial |
$76.66
|
| Rate for Payer: Coventry All Commercial |
$72.53
|
| Rate for Payer: Encore All Commercial |
$75.87
|
| Rate for Payer: Frontpath All Commercial |
$75.83
|
| Rate for Payer: Humana ChoiceCare |
$71.19
|
| Rate for Payer: Humana Medicare |
$26.38
|
| Rate for Payer: Lucent All Commercial |
$44.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.18
|
| Rate for Payer: PHCS All Commercial |
$61.82
|
| Rate for Payer: PHP All Commercial |
$62.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.15
|
| Rate for Payer: Sagamore Health Network All Products |
$63.63
|
| Rate for Payer: Signature Care EPO |
$68.41
|
| Rate for Payer: Signature Care PPO |
$72.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.06
|
| Rate for Payer: United Healthcare Commercial |
$64.95
|
| Rate for Payer: United Healthcare Medicare |
$26.38
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP CREA
|
Facility
|
IP
|
$82.43
|
|
|
Service Code
|
NDC 70710123301
|
| Hospital Charge Code |
1027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.82 |
| Max. Negotiated Rate |
$76.66 |
| Rate for Payer: Aetna Commercial |
$71.22
|
| Rate for Payer: Cash Price |
$49.46
|
| Rate for Payer: Cigna All Commercial |
$71.13
|
| Rate for Payer: CORVEL All Commercial |
$76.66
|
| Rate for Payer: Coventry All Commercial |
$72.53
|
| Rate for Payer: Encore All Commercial |
$75.87
|
| Rate for Payer: Frontpath All Commercial |
$75.83
|
| Rate for Payer: Humana ChoiceCare |
$71.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.18
|
| Rate for Payer: PHCS All Commercial |
$61.82
|
| Rate for Payer: PHP All Commercial |
$62.51
|
| Rate for Payer: Sagamore Health Network All Products |
$63.63
|
| Rate for Payer: Signature Care EPO |
$68.41
|
| Rate for Payer: Signature Care PPO |
$72.53
|
| Rate for Payer: United Healthcare Commercial |
$64.95
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT
|
Facility
|
OP
|
$89.15
|
|
|
Service Code
|
NDC 72578009301
|
| Hospital Charge Code |
1029
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.63 |
| Max. Negotiated Rate |
$82.90 |
| Rate for Payer: Aetna Commercial |
$75.24
|
| Rate for Payer: Aetna Medicare |
$28.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$51.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$55.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31.38
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Centivo All Commercial |
$48.49
|
| Rate for Payer: Cigna All Commercial |
$76.93
|
| Rate for Payer: CORVEL All Commercial |
$82.90
|
| Rate for Payer: Coventry All Commercial |
$78.45
|
| Rate for Payer: Encore All Commercial |
$82.06
|
| Rate for Payer: Frontpath All Commercial |
$82.01
|
| Rate for Payer: Humana ChoiceCare |
$76.99
|
| Rate for Payer: Humana Medicare |
$28.53
|
| Rate for Payer: Lucent All Commercial |
$48.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.23
|
| Rate for Payer: PHCS All Commercial |
$66.86
|
| Rate for Payer: PHP All Commercial |
$67.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.77
|
| Rate for Payer: Sagamore Health Network All Products |
$68.82
|
| Rate for Payer: Signature Care EPO |
$73.99
|
| Rate for Payer: Signature Care PPO |
$78.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$75.77
|
| Rate for Payer: United Healthcare Commercial |
$70.25
|
| Rate for Payer: United Healthcare Medicare |
$28.53
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT
|
Facility
|
IP
|
$89.15
|
|
|
Service Code
|
NDC 72578009301
|
| Hospital Charge Code |
1029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.86 |
| Max. Negotiated Rate |
$82.90 |
| Rate for Payer: Aetna Commercial |
$77.02
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Cigna All Commercial |
$76.93
|
| Rate for Payer: CORVEL All Commercial |
$82.90
|
| Rate for Payer: Coventry All Commercial |
$78.45
|
| Rate for Payer: Encore All Commercial |
$82.06
|
| Rate for Payer: Frontpath All Commercial |
$82.01
|
| Rate for Payer: Humana ChoiceCare |
$76.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.23
|
| Rate for Payer: PHCS All Commercial |
$66.86
|
| Rate for Payer: PHP All Commercial |
$67.61
|
| Rate for Payer: Sagamore Health Network All Products |
$68.82
|
| Rate for Payer: Signature Care EPO |
$73.99
|
| Rate for Payer: Signature Care PPO |
$78.45
|
| Rate for Payer: United Healthcare Commercial |
$70.25
|
|
|
BETAMETHASONE VALERATE 0.1 % TOP LOTN
|
Facility
|
OP
|
$433.44
|
|
|
Service Code
|
NDC 54879000460
|
| Hospital Charge Code |
1032
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.37 |
| Max. Negotiated Rate |
$403.10 |
| Rate for Payer: Aetna Commercial |
$365.82
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$134.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$248.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$270.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$152.57
|
| Rate for Payer: Cash Price |
$260.06
|
| Rate for Payer: Centivo All Commercial |
$235.79
|
| Rate for Payer: Cigna All Commercial |
$374.06
|
| Rate for Payer: CORVEL All Commercial |
$403.10
|
| Rate for Payer: Coventry All Commercial |
$381.43
|
| Rate for Payer: Encore All Commercial |
$398.98
|
| Rate for Payer: Frontpath All Commercial |
$398.76
|
| Rate for Payer: Humana ChoiceCare |
$374.36
|
| Rate for Payer: Humana Medicare |
$138.70
|
| Rate for Payer: Lucent All Commercial |
$235.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$390.10
|
| Rate for Payer: PHCS All Commercial |
$325.08
|
| Rate for Payer: PHP All Commercial |
$328.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$169.04
|
| Rate for Payer: Sagamore Health Network All Products |
$334.62
|
| Rate for Payer: Signature Care EPO |
$359.76
|
| Rate for Payer: Signature Care PPO |
$381.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$368.42
|
| Rate for Payer: United Healthcare Commercial |
$341.55
|
| Rate for Payer: United Healthcare Medicare |
$138.70
|
|
|
BETAMETHASONE VALERATE 0.1 % TOP LOTN
|
Facility
|
IP
|
$433.44
|
|
|
Service Code
|
NDC 54879000460
|
| Hospital Charge Code |
1032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.08 |
| Max. Negotiated Rate |
$403.10 |
| Rate for Payer: Aetna Commercial |
$374.49
|
| Rate for Payer: Cash Price |
$260.06
|
| Rate for Payer: Cigna All Commercial |
$374.06
|
| Rate for Payer: CORVEL All Commercial |
$403.10
|
| Rate for Payer: Coventry All Commercial |
$381.43
|
| Rate for Payer: Encore All Commercial |
$398.98
|
| Rate for Payer: Frontpath All Commercial |
$398.76
|
| Rate for Payer: Humana ChoiceCare |
$374.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$390.10
|
| Rate for Payer: PHCS All Commercial |
$325.08
|
| Rate for Payer: PHP All Commercial |
$328.72
|
| Rate for Payer: Sagamore Health Network All Products |
$334.62
|
| Rate for Payer: Signature Care EPO |
$359.76
|
| Rate for Payer: Signature Care PPO |
$381.43
|
| Rate for Payer: United Healthcare Commercial |
$341.55
|
|
|
BETHANECHOL CHLORIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.25
|
|
|
Service Code
|
NDC 00832051000
|
| Hospital Charge Code |
1045
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna Commercial |
$1.05
|
| Rate for Payer: Aetna Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Centivo All Commercial |
$0.68
|
| Rate for Payer: Cigna All Commercial |
$1.08
|
| Rate for Payer: CORVEL All Commercial |
$1.16
|
| Rate for Payer: Coventry All Commercial |
$1.10
|
| Rate for Payer: Encore All Commercial |
$1.15
|
| Rate for Payer: Frontpath All Commercial |
$1.15
|
| Rate for Payer: Humana ChoiceCare |
$1.08
|
| Rate for Payer: Humana Medicare |
$0.40
|
| Rate for Payer: Lucent All Commercial |
$0.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.12
|
| Rate for Payer: PHCS All Commercial |
$0.93
|
| Rate for Payer: PHP All Commercial |
$0.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.49
|
| Rate for Payer: Sagamore Health Network All Products |
$0.96
|
| Rate for Payer: Signature Care EPO |
$1.03
|
| Rate for Payer: Signature Care PPO |
$1.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$0.98
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
|
|
BETHANECHOL CHLORIDE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
NDC 00832051000
|
| Hospital Charge Code |
1045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna All Commercial |
$1.08
|
| Rate for Payer: CORVEL All Commercial |
$1.16
|
| Rate for Payer: Coventry All Commercial |
$1.10
|
| Rate for Payer: Encore All Commercial |
$1.15
|
| Rate for Payer: Frontpath All Commercial |
$1.15
|
| Rate for Payer: Humana ChoiceCare |
$1.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.12
|
| Rate for Payer: PHCS All Commercial |
$0.93
|
| Rate for Payer: PHP All Commercial |
$0.94
|
| Rate for Payer: Sagamore Health Network All Products |
$0.96
|
| Rate for Payer: Signature Care EPO |
$1.03
|
| Rate for Payer: Signature Care PPO |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$0.98
|
|
|
BIPOLAR DISORDERS
|
Facility
|
IP
|
$7,824.23
|
|
|
Service Code
|
APR-DRG 7534
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$7,824.23 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BIPOLAR DISORDERS
|
Facility
|
IP
|
$1,858.80
|
|
|
Service Code
|
APR-DRG 7531
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$1,858.80 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
