|
BARIUM SULFATE 98 % ORAL SUSR 340 ML BTL
|
Facility
|
OP
|
$99.96
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$92.96 |
| Rate for Payer: Aetna Commercial |
$84.37
|
| Rate for Payer: Aetna Medicare |
$32.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$57.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.29
|
| Rate for Payer: Cash Price |
$61.98
|
| Rate for Payer: Cash Price |
$61.98
|
| Rate for Payer: Centivo All Commercial |
$50.98
|
| Rate for Payer: Cigna All Commercial |
$86.27
|
| Rate for Payer: CORVEL All Commercial |
$92.96
|
| Rate for Payer: Coventry All Commercial |
$87.96
|
| Rate for Payer: Encore All Commercial |
$92.01
|
| Rate for Payer: Frontpath All Commercial |
$91.96
|
| Rate for Payer: Humana ChoiceCare |
$86.34
|
| Rate for Payer: Humana Medicare |
$50.98
|
| Rate for Payer: Lucent All Commercial |
$50.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.96
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$74.97
|
| Rate for Payer: PHP All Commercial |
$75.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.98
|
| Rate for Payer: Sagamore Health Network All Products |
$77.17
|
| Rate for Payer: Signature Care EPO |
$82.97
|
| Rate for Payer: Signature Care PPO |
$87.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$84.97
|
| Rate for Payer: United Healthcare Commercial |
$78.77
|
| Rate for Payer: United Healthcare Medicare |
$32.99
|
|
|
BARIUM SULFATE 98 % ORAL SUSR 340 ML BTL
|
Facility
|
IP
|
$99.96
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$92.96 |
| Rate for Payer: Aetna Commercial |
$86.37
|
| Rate for Payer: Cash Price |
$61.98
|
| Rate for Payer: Cigna All Commercial |
$86.27
|
| Rate for Payer: CORVEL All Commercial |
$92.96
|
| Rate for Payer: Coventry All Commercial |
$87.96
|
| Rate for Payer: Encore All Commercial |
$92.01
|
| Rate for Payer: Frontpath All Commercial |
$91.96
|
| Rate for Payer: Humana ChoiceCare |
$86.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.96
|
| Rate for Payer: PHCS All Commercial |
$74.97
|
| Rate for Payer: PHP All Commercial |
$75.81
|
| Rate for Payer: Sagamore Health Network All Products |
$77.17
|
| Rate for Payer: Signature Care EPO |
$82.97
|
| Rate for Payer: Signature Care PPO |
$87.96
|
| Rate for Payer: United Healthcare Commercial |
$78.77
|
|
|
BENRALIZUMAB 30 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$17,583.72
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
183039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.90 |
| Max. Negotiated Rate |
$16,352.86 |
| Rate for Payer: Aetna Commercial |
$14,840.66
|
| Rate for Payer: Aetna Medicare |
$5,802.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,802.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10,098.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,991.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$192.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,673.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,382.89
|
| Rate for Payer: Cash Price |
$10,901.91
|
| Rate for Payer: Cash Price |
$10,901.91
|
| Rate for Payer: Centivo All Commercial |
$8,967.70
|
| Rate for Payer: Cigna All Commercial |
$15,174.75
|
| Rate for Payer: CORVEL All Commercial |
$16,352.86
|
| Rate for Payer: Coventry All Commercial |
$15,473.67
|
| Rate for Payer: Encore All Commercial |
$16,185.81
|
| Rate for Payer: Frontpath All Commercial |
$16,177.02
|
| Rate for Payer: Humana ChoiceCare |
$15,187.06
|
| Rate for Payer: Humana Medicare |
$8,967.70
|
| Rate for Payer: Lucent All Commercial |
$8,967.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,825.35
|
| Rate for Payer: Managed Health Services Medicaid |
$192.90
|
| Rate for Payer: MDWise Medicaid |
$192.90
|
| Rate for Payer: PHCS All Commercial |
$13,187.79
|
| Rate for Payer: PHP All Commercial |
$13,335.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,857.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13,574.63
|
| Rate for Payer: Signature Care EPO |
$14,594.49
|
| Rate for Payer: Signature Care PPO |
$15,473.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,946.16
|
| Rate for Payer: United Healthcare Commercial |
$13,855.97
|
| Rate for Payer: United Healthcare Medicare |
$5,802.63
|
|
|
BENRALIZUMAB 30 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$17,583.72
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
183039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,187.79 |
| Max. Negotiated Rate |
$16,352.86 |
| Rate for Payer: Aetna Commercial |
$15,192.33
|
| Rate for Payer: Cash Price |
$10,901.91
|
| Rate for Payer: Cigna All Commercial |
$15,174.75
|
| Rate for Payer: CORVEL All Commercial |
$16,352.86
|
| Rate for Payer: Coventry All Commercial |
$15,473.67
|
| Rate for Payer: Encore All Commercial |
$16,185.81
|
| Rate for Payer: Frontpath All Commercial |
$16,177.02
|
| Rate for Payer: Humana ChoiceCare |
$15,187.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,825.35
|
| Rate for Payer: PHCS All Commercial |
$13,187.79
|
| Rate for Payer: PHP All Commercial |
$13,335.49
|
| Rate for Payer: Sagamore Health Network All Products |
$13,574.63
|
| Rate for Payer: Signature Care EPO |
$14,594.49
|
| Rate for Payer: Signature Care PPO |
$15,473.67
|
| Rate for Payer: United Healthcare Commercial |
$13,855.97
|
|
|
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
152887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Centivo All Commercial |
$0.58
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.98
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.02
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.44
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
|
|
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
152887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.98
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.02
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.86
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
|
|
BENZOCAINE-MENTHOL 20-0.5 % TOP AERO
|
Facility
|
OP
|
$41.50
|
|
|
Service Code
|
NDC 51409000722
|
| Hospital Charge Code |
28048
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.69 |
| Max. Negotiated Rate |
$38.59 |
| Rate for Payer: Aetna Commercial |
$35.02
|
| Rate for Payer: Aetna Medicare |
$13.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.06
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Centivo All Commercial |
$21.16
|
| Rate for Payer: Cigna All Commercial |
$35.81
|
| Rate for Payer: CORVEL All Commercial |
$38.59
|
| Rate for Payer: Coventry All Commercial |
$36.52
|
| Rate for Payer: Encore All Commercial |
$38.20
|
| Rate for Payer: Frontpath All Commercial |
$38.18
|
| Rate for Payer: Humana ChoiceCare |
$35.84
|
| Rate for Payer: Humana Medicare |
$21.16
|
| Rate for Payer: Lucent All Commercial |
$21.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.35
|
| Rate for Payer: PHCS All Commercial |
$31.12
|
| Rate for Payer: PHP All Commercial |
$31.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.18
|
| Rate for Payer: Sagamore Health Network All Products |
$32.03
|
| Rate for Payer: Signature Care EPO |
$34.44
|
| Rate for Payer: Signature Care PPO |
$36.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.27
|
| Rate for Payer: United Healthcare Commercial |
$32.70
|
| Rate for Payer: United Healthcare Medicare |
$13.69
|
|
|
BENZOCAINE-MENTHOL 20-0.5 % TOP AERO
|
Facility
|
IP
|
$41.50
|
|
|
Service Code
|
NDC 51409000722
|
| Hospital Charge Code |
28048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.12 |
| Max. Negotiated Rate |
$38.59 |
| Rate for Payer: Aetna Commercial |
$35.85
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cigna All Commercial |
$35.81
|
| Rate for Payer: CORVEL All Commercial |
$38.59
|
| Rate for Payer: Coventry All Commercial |
$36.52
|
| Rate for Payer: Encore All Commercial |
$38.20
|
| Rate for Payer: Frontpath All Commercial |
$38.18
|
| Rate for Payer: Humana ChoiceCare |
$35.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.35
|
| Rate for Payer: PHCS All Commercial |
$31.12
|
| Rate for Payer: PHP All Commercial |
$31.47
|
| Rate for Payer: Sagamore Health Network All Products |
$32.03
|
| Rate for Payer: Signature Care EPO |
$34.44
|
| Rate for Payer: Signature Care PPO |
$36.52
|
| Rate for Payer: United Healthcare Commercial |
$32.70
|
|
|
BENZONATATE 100 MG ORAL CAP
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.55
|
| Rate for Payer: Coventry All Commercial |
$2.41
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.52
|
| Rate for Payer: Humana ChoiceCare |
$2.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.47
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.08
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.41
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
|
|
BENZONATATE 100 MG ORAL CAP
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Centivo All Commercial |
$1.40
|
| Rate for Payer: Cigna All Commercial |
$2.37
|
| Rate for Payer: CORVEL All Commercial |
$2.55
|
| Rate for Payer: Coventry All Commercial |
$2.41
|
| Rate for Payer: Encore All Commercial |
$2.53
|
| Rate for Payer: Frontpath All Commercial |
$2.52
|
| Rate for Payer: Humana ChoiceCare |
$2.37
|
| Rate for Payer: Humana Medicare |
$1.40
|
| Rate for Payer: Lucent All Commercial |
$1.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.47
|
| Rate for Payer: PHCS All Commercial |
$2.06
|
| Rate for Payer: PHP All Commercial |
$2.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$2.12
|
| Rate for Payer: Signature Care EPO |
$2.28
|
| Rate for Payer: Signature Care PPO |
$2.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.33
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$0.91
|
|
|
BENZTROPINE 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$307.32
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.49 |
| Max. Negotiated Rate |
$285.81 |
| Rate for Payer: Aetna Commercial |
$265.52
|
| Rate for Payer: Cash Price |
$190.54
|
| Rate for Payer: Cigna All Commercial |
$265.22
|
| Rate for Payer: CORVEL All Commercial |
$285.81
|
| Rate for Payer: Coventry All Commercial |
$270.44
|
| Rate for Payer: Encore All Commercial |
$282.89
|
| Rate for Payer: Frontpath All Commercial |
$282.73
|
| Rate for Payer: Humana ChoiceCare |
$265.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.59
|
| Rate for Payer: PHCS All Commercial |
$230.49
|
| Rate for Payer: PHP All Commercial |
$233.07
|
| Rate for Payer: Sagamore Health Network All Products |
$237.25
|
| Rate for Payer: Signature Care EPO |
$255.08
|
| Rate for Payer: Signature Care PPO |
$270.44
|
| Rate for Payer: United Healthcare Commercial |
$242.17
|
|
|
BENZTROPINE 1 MG/ML INJ SOLN
|
Facility
|
OP
|
$307.32
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.42 |
| Max. Negotiated Rate |
$285.81 |
| Rate for Payer: Aetna Commercial |
$259.38
|
| Rate for Payer: Aetna Medicare |
$101.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$101.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$176.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$192.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$116.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$111.56
|
| Rate for Payer: Cash Price |
$190.54
|
| Rate for Payer: Centivo All Commercial |
$156.73
|
| Rate for Payer: Cigna All Commercial |
$265.22
|
| Rate for Payer: CORVEL All Commercial |
$285.81
|
| Rate for Payer: Coventry All Commercial |
$270.44
|
| Rate for Payer: Encore All Commercial |
$282.89
|
| Rate for Payer: Frontpath All Commercial |
$282.73
|
| Rate for Payer: Humana ChoiceCare |
$265.43
|
| Rate for Payer: Humana Medicare |
$156.73
|
| Rate for Payer: Lucent All Commercial |
$156.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.59
|
| Rate for Payer: PHCS All Commercial |
$230.49
|
| Rate for Payer: PHP All Commercial |
$233.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$119.85
|
| Rate for Payer: Sagamore Health Network All Products |
$237.25
|
| Rate for Payer: Signature Care EPO |
$255.08
|
| Rate for Payer: Signature Care PPO |
$270.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$261.22
|
| Rate for Payer: United Healthcare Commercial |
$242.17
|
| Rate for Payer: United Healthcare Medicare |
$101.42
|
|
|
BENZTROPINE 1 MG ORAL TAB
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna All Commercial |
$2.80
|
| Rate for Payer: CORVEL All Commercial |
$3.01
|
| Rate for Payer: Coventry All Commercial |
$2.85
|
| Rate for Payer: Encore All Commercial |
$2.98
|
| Rate for Payer: Frontpath All Commercial |
$2.98
|
| Rate for Payer: Humana ChoiceCare |
$2.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.92
|
| Rate for Payer: PHCS All Commercial |
$2.43
|
| Rate for Payer: PHP All Commercial |
$2.46
|
| Rate for Payer: Sagamore Health Network All Products |
$2.50
|
| Rate for Payer: Signature Care EPO |
$2.69
|
| Rate for Payer: Signature Care PPO |
$2.85
|
| Rate for Payer: United Healthcare Commercial |
$2.55
|
|
|
BENZTROPINE 1 MG ORAL TAB
|
Facility
|
OP
|
$3.24
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: Aetna Commercial |
$2.74
|
| Rate for Payer: Aetna Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Centivo All Commercial |
$1.65
|
| Rate for Payer: Cigna All Commercial |
$2.80
|
| Rate for Payer: CORVEL All Commercial |
$3.01
|
| Rate for Payer: Coventry All Commercial |
$2.85
|
| Rate for Payer: Encore All Commercial |
$2.98
|
| Rate for Payer: Frontpath All Commercial |
$2.98
|
| Rate for Payer: Humana ChoiceCare |
$2.80
|
| Rate for Payer: Humana Medicare |
$1.65
|
| Rate for Payer: Lucent All Commercial |
$1.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.92
|
| Rate for Payer: PHCS All Commercial |
$2.43
|
| Rate for Payer: PHP All Commercial |
$2.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.26
|
| Rate for Payer: Sagamore Health Network All Products |
$2.50
|
| Rate for Payer: Signature Care EPO |
$2.69
|
| Rate for Payer: Signature Care PPO |
$2.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.75
|
| Rate for Payer: United Healthcare Commercial |
$2.55
|
| Rate for Payer: United Healthcare Medicare |
$1.07
|
|
|
BENZYLPENICILLOYL POLYLYSINE 0.25 ML IDRM SOLN
|
Facility
|
OP
|
$801.48
|
|
|
Service Code
|
NDC 49471000105
|
| Hospital Charge Code |
9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$745.38 |
| Rate for Payer: Aetna Commercial |
$676.45
|
| Rate for Payer: Aetna Medicare |
$264.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$264.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$460.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$501.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$304.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$290.94
|
| Rate for Payer: Cash Price |
$496.92
|
| Rate for Payer: Cash Price |
$496.92
|
| Rate for Payer: Centivo All Commercial |
$408.75
|
| Rate for Payer: Cigna All Commercial |
$691.68
|
| Rate for Payer: CORVEL All Commercial |
$745.38
|
| Rate for Payer: Coventry All Commercial |
$705.30
|
| Rate for Payer: Encore All Commercial |
$737.76
|
| Rate for Payer: Frontpath All Commercial |
$737.36
|
| Rate for Payer: Humana ChoiceCare |
$692.24
|
| Rate for Payer: Humana Medicare |
$408.75
|
| Rate for Payer: Lucent All Commercial |
$408.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$721.33
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$601.11
|
| Rate for Payer: PHP All Commercial |
$607.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$312.58
|
| Rate for Payer: Sagamore Health Network All Products |
$618.74
|
| Rate for Payer: Signature Care EPO |
$665.23
|
| Rate for Payer: Signature Care PPO |
$705.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$681.26
|
| Rate for Payer: United Healthcare Commercial |
$631.57
|
| Rate for Payer: United Healthcare Medicare |
$264.49
|
|
|
BENZYLPENICILLOYL POLYLYSINE 0.25 ML IDRM SOLN
|
Facility
|
IP
|
$801.48
|
|
|
Service Code
|
NDC 49471000105
|
| Hospital Charge Code |
9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$601.11 |
| Max. Negotiated Rate |
$745.38 |
| Rate for Payer: Aetna Commercial |
$692.48
|
| Rate for Payer: Cash Price |
$496.92
|
| Rate for Payer: Cigna All Commercial |
$691.68
|
| Rate for Payer: CORVEL All Commercial |
$745.38
|
| Rate for Payer: Coventry All Commercial |
$705.30
|
| Rate for Payer: Encore All Commercial |
$737.76
|
| Rate for Payer: Frontpath All Commercial |
$737.36
|
| Rate for Payer: Humana ChoiceCare |
$692.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$721.33
|
| Rate for Payer: PHCS All Commercial |
$601.11
|
| Rate for Payer: PHP All Commercial |
$607.84
|
| Rate for Payer: Sagamore Health Network All Products |
$618.74
|
| Rate for Payer: Signature Care EPO |
$665.23
|
| Rate for Payer: Signature Care PPO |
$705.30
|
| Rate for Payer: United Healthcare Commercial |
$631.57
|
|
|
BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP
|
Facility
|
OP
|
$246.33
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
9266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.29 |
| Max. Negotiated Rate |
$229.09 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Medicare |
$81.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$141.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$153.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$93.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$89.42
|
| Rate for Payer: Cash Price |
$152.72
|
| Rate for Payer: Centivo All Commercial |
$125.63
|
| Rate for Payer: Cigna All Commercial |
$212.58
|
| Rate for Payer: CORVEL All Commercial |
$229.09
|
| Rate for Payer: Coventry All Commercial |
$216.77
|
| Rate for Payer: Encore All Commercial |
$226.75
|
| Rate for Payer: Frontpath All Commercial |
$226.62
|
| Rate for Payer: Humana ChoiceCare |
$212.76
|
| Rate for Payer: Humana Medicare |
$125.63
|
| Rate for Payer: Lucent All Commercial |
$125.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.70
|
| Rate for Payer: PHCS All Commercial |
$184.75
|
| Rate for Payer: PHP All Commercial |
$186.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.07
|
| Rate for Payer: Sagamore Health Network All Products |
$190.17
|
| Rate for Payer: Signature Care EPO |
$204.45
|
| Rate for Payer: Signature Care PPO |
$216.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$209.38
|
| Rate for Payer: United Healthcare Commercial |
$194.11
|
| Rate for Payer: United Healthcare Medicare |
$81.29
|
|
|
BETAMETHASONE ACET,SOD PHOS 6 MG/ML INJ SUSP
|
Facility
|
IP
|
$246.33
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
9266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.75 |
| Max. Negotiated Rate |
$229.09 |
| Rate for Payer: Aetna Commercial |
$212.83
|
| Rate for Payer: Cash Price |
$152.72
|
| Rate for Payer: Cigna All Commercial |
$212.58
|
| Rate for Payer: CORVEL All Commercial |
$229.09
|
| Rate for Payer: Coventry All Commercial |
$216.77
|
| Rate for Payer: Encore All Commercial |
$226.75
|
| Rate for Payer: Frontpath All Commercial |
$226.62
|
| Rate for Payer: Humana ChoiceCare |
$212.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.70
|
| Rate for Payer: PHCS All Commercial |
$184.75
|
| Rate for Payer: PHP All Commercial |
$186.82
|
| Rate for Payer: Sagamore Health Network All Products |
$190.17
|
| Rate for Payer: Signature Care EPO |
$204.45
|
| Rate for Payer: Signature Care PPO |
$216.77
|
| Rate for Payer: United Healthcare Commercial |
$194.11
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP CREA
|
Facility
|
IP
|
$92.61
|
|
|
Service Code
|
NDC 70710123301
|
| Hospital Charge Code |
1027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.46 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna Commercial |
$80.02
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cigna All Commercial |
$79.92
|
| Rate for Payer: CORVEL All Commercial |
$86.13
|
| Rate for Payer: Coventry All Commercial |
$81.50
|
| Rate for Payer: Encore All Commercial |
$85.25
|
| Rate for Payer: Frontpath All Commercial |
$85.20
|
| Rate for Payer: Humana ChoiceCare |
$79.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$83.35
|
| Rate for Payer: PHCS All Commercial |
$69.46
|
| Rate for Payer: PHP All Commercial |
$70.24
|
| Rate for Payer: Sagamore Health Network All Products |
$71.49
|
| Rate for Payer: Signature Care EPO |
$76.87
|
| Rate for Payer: Signature Care PPO |
$81.50
|
| Rate for Payer: United Healthcare Commercial |
$72.98
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP CREA
|
Facility
|
OP
|
$92.61
|
|
|
Service Code
|
NDC 70710123301
|
| Hospital Charge Code |
1027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.56 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna Commercial |
$78.16
|
| Rate for Payer: Aetna Medicare |
$30.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$53.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$57.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.62
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Centivo All Commercial |
$47.23
|
| Rate for Payer: Cigna All Commercial |
$79.92
|
| Rate for Payer: CORVEL All Commercial |
$86.13
|
| Rate for Payer: Coventry All Commercial |
$81.50
|
| Rate for Payer: Encore All Commercial |
$85.25
|
| Rate for Payer: Frontpath All Commercial |
$85.20
|
| Rate for Payer: Humana ChoiceCare |
$79.99
|
| Rate for Payer: Humana Medicare |
$47.23
|
| Rate for Payer: Lucent All Commercial |
$47.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$83.35
|
| Rate for Payer: PHCS All Commercial |
$69.46
|
| Rate for Payer: PHP All Commercial |
$70.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$36.12
|
| Rate for Payer: Sagamore Health Network All Products |
$71.49
|
| Rate for Payer: Signature Care EPO |
$76.87
|
| Rate for Payer: Signature Care PPO |
$81.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$78.72
|
| Rate for Payer: United Healthcare Commercial |
$72.98
|
| Rate for Payer: United Healthcare Medicare |
$30.56
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT
|
Facility
|
OP
|
$116.03
|
|
|
Service Code
|
NDC 72578009301
|
| Hospital Charge Code |
1029
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.29 |
| Max. Negotiated Rate |
$107.90 |
| Rate for Payer: Aetna Commercial |
$97.93
|
| Rate for Payer: Aetna Medicare |
$38.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$38.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$66.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.12
|
| Rate for Payer: Cash Price |
$71.94
|
| Rate for Payer: Centivo All Commercial |
$59.17
|
| Rate for Payer: Cigna All Commercial |
$100.13
|
| Rate for Payer: CORVEL All Commercial |
$107.90
|
| Rate for Payer: Coventry All Commercial |
$102.10
|
| Rate for Payer: Encore All Commercial |
$106.80
|
| Rate for Payer: Frontpath All Commercial |
$106.74
|
| Rate for Payer: Humana ChoiceCare |
$100.21
|
| Rate for Payer: Humana Medicare |
$59.17
|
| Rate for Payer: Lucent All Commercial |
$59.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.42
|
| Rate for Payer: PHCS All Commercial |
$87.02
|
| Rate for Payer: PHP All Commercial |
$87.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.25
|
| Rate for Payer: Sagamore Health Network All Products |
$89.57
|
| Rate for Payer: Signature Care EPO |
$96.30
|
| Rate for Payer: Signature Care PPO |
$102.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.62
|
| Rate for Payer: United Healthcare Commercial |
$91.43
|
| Rate for Payer: United Healthcare Medicare |
$38.29
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT
|
Facility
|
IP
|
$116.03
|
|
|
Service Code
|
NDC 72578009301
|
| Hospital Charge Code |
1029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.02 |
| Max. Negotiated Rate |
$107.90 |
| Rate for Payer: Aetna Commercial |
$100.25
|
| Rate for Payer: Cash Price |
$71.94
|
| Rate for Payer: Cigna All Commercial |
$100.13
|
| Rate for Payer: CORVEL All Commercial |
$107.90
|
| Rate for Payer: Coventry All Commercial |
$102.10
|
| Rate for Payer: Encore All Commercial |
$106.80
|
| Rate for Payer: Frontpath All Commercial |
$106.74
|
| Rate for Payer: Humana ChoiceCare |
$100.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.42
|
| Rate for Payer: PHCS All Commercial |
$87.02
|
| Rate for Payer: PHP All Commercial |
$87.99
|
| Rate for Payer: Sagamore Health Network All Products |
$89.57
|
| Rate for Payer: Signature Care EPO |
$96.30
|
| Rate for Payer: Signature Care PPO |
$102.10
|
| Rate for Payer: United Healthcare Commercial |
$91.43
|
|
|
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 |
$143.04 |
| Max. Negotiated Rate |
$403.10 |
| Rate for Payer: Aetna Commercial |
$365.82
|
| Rate for Payer: Aetna Medicare |
$143.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$143.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$248.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$270.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$164.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$157.34
|
| Rate for Payer: Cash Price |
$268.73
|
| Rate for Payer: Centivo All Commercial |
$221.05
|
| 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 |
$221.05
|
| Rate for Payer: Lucent All Commercial |
$221.05
|
| 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 |
$143.04
|
|
|
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 |
$268.73
|
| 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
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00832051000
|
| Hospital Charge Code |
1045
|
|
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
|
|
