|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 60687055811
|
| Hospital Charge Code |
2017
|
|
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
|
|
|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
2017
|
|
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
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
OP
|
$23.80
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.09
|
| Rate for Payer: Aetna Medicare |
$7.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.38
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Centivo All Commercial |
$12.95
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Humana Medicare |
$7.62
|
| Rate for Payer: Lucent All Commercial |
$12.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.28
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.23
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$7.62
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
IP
|
$23.80
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9814
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP (IN ML/KG/HR)
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
|
|
D5 %-0.45 % SODIUM CHLORIDE IV SOLP (IN ML/KG/HR)
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
9815
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
|
|
D5 % AND 0.9 % SODIUM CHLORIDE IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
9815
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
DABIGATRAN ETEXILATE 75 MG ORAL CAP
|
Facility
|
OP
|
$21.70
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$20.18 |
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Aetna Medicare |
$6.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.64
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Centivo All Commercial |
$11.80
|
| Rate for Payer: Cigna All Commercial |
$18.73
|
| Rate for Payer: CORVEL All Commercial |
$20.18
|
| Rate for Payer: Coventry All Commercial |
$19.10
|
| Rate for Payer: Encore All Commercial |
$19.97
|
| Rate for Payer: Frontpath All Commercial |
$19.96
|
| Rate for Payer: Humana ChoiceCare |
$18.74
|
| Rate for Payer: Humana Medicare |
$6.94
|
| Rate for Payer: Lucent All Commercial |
$11.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.53
|
| Rate for Payer: PHCS All Commercial |
$16.27
|
| Rate for Payer: PHP All Commercial |
$16.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.46
|
| Rate for Payer: Sagamore Health Network All Products |
$16.75
|
| Rate for Payer: Signature Care EPO |
$18.01
|
| Rate for Payer: Signature Care PPO |
$19.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
| Rate for Payer: United Healthcare Medicare |
$6.94
|
|
|
DABIGATRAN ETEXILATE 75 MG ORAL CAP
|
Facility
|
IP
|
$21.70
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.27 |
| Max. Negotiated Rate |
$20.18 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Cigna All Commercial |
$18.73
|
| Rate for Payer: CORVEL All Commercial |
$20.18
|
| Rate for Payer: Coventry All Commercial |
$19.10
|
| Rate for Payer: Encore All Commercial |
$19.97
|
| Rate for Payer: Frontpath All Commercial |
$19.96
|
| Rate for Payer: Humana ChoiceCare |
$18.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.53
|
| Rate for Payer: PHCS All Commercial |
$16.27
|
| Rate for Payer: PHP All Commercial |
$16.46
|
| Rate for Payer: Sagamore Health Network All Products |
$16.75
|
| Rate for Payer: Signature Care EPO |
$18.01
|
| Rate for Payer: Signature Care PPO |
$19.10
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
OP
|
$5,662.65
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
168767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$5,266.26 |
| Rate for Payer: Aetna Commercial |
$4,779.28
|
| Rate for Payer: Aetna Medicare |
$1,812.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$18.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,755.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,252.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,539.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$18.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,083.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,993.25
|
| Rate for Payer: Cash Price |
$3,397.59
|
| Rate for Payer: Cash Price |
$3,397.59
|
| Rate for Payer: Centivo All Commercial |
$3,080.48
|
| Rate for Payer: Cigna All Commercial |
$4,886.87
|
| Rate for Payer: CORVEL All Commercial |
$5,266.26
|
| Rate for Payer: Coventry All Commercial |
$4,983.13
|
| Rate for Payer: Encore All Commercial |
$5,212.47
|
| Rate for Payer: Frontpath All Commercial |
$5,209.64
|
| Rate for Payer: Humana ChoiceCare |
$4,890.83
|
| Rate for Payer: Humana Medicare |
$1,812.05
|
| Rate for Payer: Lucent All Commercial |
$3,080.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,096.39
|
| Rate for Payer: Managed Health Services Medicaid |
$18.68
|
| Rate for Payer: MDWise Medicaid |
$18.68
|
| Rate for Payer: PHCS All Commercial |
$4,246.99
|
| Rate for Payer: PHP All Commercial |
$4,294.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,208.43
|
| Rate for Payer: Sagamore Health Network All Products |
$4,371.57
|
| Rate for Payer: Signature Care EPO |
$4,700.00
|
| Rate for Payer: Signature Care PPO |
$4,983.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,813.25
|
| Rate for Payer: United Healthcare Commercial |
$4,462.17
|
| Rate for Payer: United Healthcare Medicare |
$1,812.05
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
IP
|
$5,662.65
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
168767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,246.99 |
| Max. Negotiated Rate |
$5,266.26 |
| Rate for Payer: Aetna Commercial |
$4,892.53
|
| Rate for Payer: Cash Price |
$3,397.59
|
| Rate for Payer: Cigna All Commercial |
$4,886.87
|
| Rate for Payer: CORVEL All Commercial |
$5,266.26
|
| Rate for Payer: Coventry All Commercial |
$4,983.13
|
| Rate for Payer: Encore All Commercial |
$5,212.47
|
| Rate for Payer: Frontpath All Commercial |
$5,209.64
|
| Rate for Payer: Humana ChoiceCare |
$4,890.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,096.39
|
| Rate for Payer: PHCS All Commercial |
$4,246.99
|
| Rate for Payer: PHP All Commercial |
$4,294.55
|
| Rate for Payer: Sagamore Health Network All Products |
$4,371.57
|
| Rate for Payer: Signature Care EPO |
$4,700.00
|
| Rate for Payer: Signature Care PPO |
$4,983.13
|
| Rate for Payer: United Healthcare Commercial |
$4,462.17
|
|
|
DANTROLENE 20 MG IV SOLR
|
Facility
|
OP
|
$365.63
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$340.03 |
| Rate for Payer: Aetna Commercial |
$308.59
|
| Rate for Payer: Aetna Medicare |
$117.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$113.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$209.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$228.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$134.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$128.70
|
| Rate for Payer: Cash Price |
$219.38
|
| Rate for Payer: Cash Price |
$219.38
|
| Rate for Payer: Centivo All Commercial |
$198.90
|
| Rate for Payer: Cigna All Commercial |
$315.54
|
| Rate for Payer: CORVEL All Commercial |
$340.03
|
| Rate for Payer: Coventry All Commercial |
$321.75
|
| Rate for Payer: Encore All Commercial |
$336.56
|
| Rate for Payer: Frontpath All Commercial |
$336.38
|
| Rate for Payer: Humana ChoiceCare |
$315.79
|
| Rate for Payer: Humana Medicare |
$117.00
|
| Rate for Payer: Lucent All Commercial |
$198.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$329.07
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$274.22
|
| Rate for Payer: PHP All Commercial |
$277.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$142.59
|
| Rate for Payer: Sagamore Health Network All Products |
$282.26
|
| Rate for Payer: Signature Care EPO |
$303.47
|
| Rate for Payer: Signature Care PPO |
$321.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$310.78
|
| Rate for Payer: United Healthcare Commercial |
$288.11
|
| Rate for Payer: United Healthcare Medicare |
$117.00
|
|
|
DANTROLENE 20 MG IV SOLR
|
Facility
|
IP
|
$365.63
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$274.22 |
| Max. Negotiated Rate |
$340.03 |
| Rate for Payer: Aetna Commercial |
$315.90
|
| Rate for Payer: Cash Price |
$219.38
|
| Rate for Payer: Cigna All Commercial |
$315.54
|
| Rate for Payer: CORVEL All Commercial |
$340.03
|
| Rate for Payer: Coventry All Commercial |
$321.75
|
| Rate for Payer: Encore All Commercial |
$336.56
|
| Rate for Payer: Frontpath All Commercial |
$336.38
|
| Rate for Payer: Humana ChoiceCare |
$315.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$329.07
|
| Rate for Payer: PHCS All Commercial |
$274.22
|
| Rate for Payer: PHP All Commercial |
$277.29
|
| Rate for Payer: Sagamore Health Network All Products |
$282.26
|
| Rate for Payer: Signature Care EPO |
$303.47
|
| Rate for Payer: Signature Care PPO |
$321.75
|
| Rate for Payer: United Healthcare Commercial |
$288.11
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB
|
Facility
|
OP
|
$107.58
|
|
|
Service Code
|
NDC 00310621030
|
| Hospital Charge Code |
167231
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.35 |
| Max. Negotiated Rate |
$100.05 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Medicare |
$34.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$61.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.87
|
| Rate for Payer: Cash Price |
$64.55
|
| Rate for Payer: Centivo All Commercial |
$58.52
|
| Rate for Payer: Cigna All Commercial |
$92.84
|
| Rate for Payer: CORVEL All Commercial |
$100.05
|
| Rate for Payer: Coventry All Commercial |
$94.67
|
| Rate for Payer: Encore All Commercial |
$99.02
|
| Rate for Payer: Frontpath All Commercial |
$98.97
|
| Rate for Payer: Humana ChoiceCare |
$92.91
|
| Rate for Payer: Humana Medicare |
$34.42
|
| Rate for Payer: Lucent All Commercial |
$58.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.82
|
| Rate for Payer: PHCS All Commercial |
$80.68
|
| Rate for Payer: PHP All Commercial |
$81.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.95
|
| Rate for Payer: Sagamore Health Network All Products |
$83.05
|
| Rate for Payer: Signature Care EPO |
$89.29
|
| Rate for Payer: Signature Care PPO |
$94.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.44
|
| Rate for Payer: United Healthcare Commercial |
$84.77
|
| Rate for Payer: United Healthcare Medicare |
$34.42
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB
|
Facility
|
IP
|
$107.58
|
|
|
Service Code
|
NDC 00310621030
|
| Hospital Charge Code |
167231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.68 |
| Max. Negotiated Rate |
$100.05 |
| Rate for Payer: Aetna Commercial |
$92.95
|
| Rate for Payer: Cash Price |
$64.55
|
| Rate for Payer: Cigna All Commercial |
$92.84
|
| Rate for Payer: CORVEL All Commercial |
$100.05
|
| Rate for Payer: Coventry All Commercial |
$94.67
|
| Rate for Payer: Encore All Commercial |
$99.02
|
| Rate for Payer: Frontpath All Commercial |
$98.97
|
| Rate for Payer: Humana ChoiceCare |
$92.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.82
|
| Rate for Payer: PHCS All Commercial |
$80.68
|
| Rate for Payer: PHP All Commercial |
$81.59
|
| Rate for Payer: Sagamore Health Network All Products |
$83.05
|
| Rate for Payer: Signature Care EPO |
$89.29
|
| Rate for Payer: Signature Care PPO |
$94.67
|
| Rate for Payer: United Healthcare Commercial |
$84.77
|
|
|
DAPTOMYCIN 500 MG IV SOLR
|
Facility
|
OP
|
$223.02
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$207.41 |
| Rate for Payer: Aetna Commercial |
$188.23
|
| Rate for Payer: Aetna Medicare |
$71.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$69.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$128.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$139.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$82.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$78.50
|
| Rate for Payer: Cash Price |
$133.81
|
| Rate for Payer: Cash Price |
$133.81
|
| Rate for Payer: Centivo All Commercial |
$121.32
|
| Rate for Payer: Cigna All Commercial |
$192.47
|
| Rate for Payer: CORVEL All Commercial |
$207.41
|
| Rate for Payer: Coventry All Commercial |
$196.26
|
| Rate for Payer: Encore All Commercial |
$205.29
|
| Rate for Payer: Frontpath All Commercial |
$205.18
|
| Rate for Payer: Humana ChoiceCare |
$192.62
|
| Rate for Payer: Humana Medicare |
$71.37
|
| Rate for Payer: Lucent All Commercial |
$121.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$200.72
|
| Rate for Payer: Managed Health Services Medicaid |
$0.04
|
| Rate for Payer: MDWise Medicaid |
$0.04
|
| Rate for Payer: PHCS All Commercial |
$167.26
|
| Rate for Payer: PHP All Commercial |
$169.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$86.98
|
| Rate for Payer: Sagamore Health Network All Products |
$172.17
|
| Rate for Payer: Signature Care EPO |
$185.11
|
| Rate for Payer: Signature Care PPO |
$196.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$189.57
|
| Rate for Payer: United Healthcare Commercial |
$175.74
|
| Rate for Payer: United Healthcare Medicare |
$71.37
|
|
|
DAPTOMYCIN 500 MG IV SOLR
|
Facility
|
IP
|
$223.02
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.26 |
| Max. Negotiated Rate |
$207.41 |
| Rate for Payer: Aetna Commercial |
$192.69
|
| Rate for Payer: Cash Price |
$133.81
|
| Rate for Payer: Cigna All Commercial |
$192.47
|
| Rate for Payer: CORVEL All Commercial |
$207.41
|
| Rate for Payer: Coventry All Commercial |
$196.26
|
| Rate for Payer: Encore All Commercial |
$205.29
|
| Rate for Payer: Frontpath All Commercial |
$205.18
|
| Rate for Payer: Humana ChoiceCare |
$192.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$200.72
|
| Rate for Payer: PHCS All Commercial |
$167.26
|
| Rate for Payer: PHP All Commercial |
$169.14
|
| Rate for Payer: Sagamore Health Network All Products |
$172.17
|
| Rate for Payer: Signature Care EPO |
$185.11
|
| Rate for Payer: Signature Care PPO |
$196.26
|
| Rate for Payer: United Healthcare Commercial |
$175.74
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$3,015.58
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$2,804.49 |
| Rate for Payer: Aetna Commercial |
$2,545.15
|
| Rate for Payer: Aetna Medicare |
$964.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$934.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,731.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,885.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,109.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,061.48
|
| Rate for Payer: Cash Price |
$1,809.35
|
| Rate for Payer: Cash Price |
$1,809.35
|
| Rate for Payer: Centivo All Commercial |
$1,640.48
|
| Rate for Payer: Cigna All Commercial |
$2,602.45
|
| Rate for Payer: CORVEL All Commercial |
$2,804.49
|
| Rate for Payer: Coventry All Commercial |
$2,653.71
|
| Rate for Payer: Encore All Commercial |
$2,775.84
|
| Rate for Payer: Frontpath All Commercial |
$2,774.33
|
| Rate for Payer: Humana ChoiceCare |
$2,604.56
|
| Rate for Payer: Humana Medicare |
$964.99
|
| Rate for Payer: Lucent All Commercial |
$1,640.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,714.02
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$2,261.68
|
| Rate for Payer: PHP All Commercial |
$2,287.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,176.08
|
| Rate for Payer: Sagamore Health Network All Products |
$2,328.03
|
| Rate for Payer: Signature Care EPO |
$2,502.93
|
| Rate for Payer: Signature Care PPO |
$2,653.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,563.24
|
| Rate for Payer: United Healthcare Commercial |
$2,376.28
|
| Rate for Payer: United Healthcare Medicare |
$964.99
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$3,015.58
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,261.68 |
| Max. Negotiated Rate |
$2,804.49 |
| Rate for Payer: Aetna Commercial |
$2,605.46
|
| Rate for Payer: Cash Price |
$1,809.35
|
| Rate for Payer: Cigna All Commercial |
$2,602.45
|
| Rate for Payer: CORVEL All Commercial |
$2,804.49
|
| Rate for Payer: Coventry All Commercial |
$2,653.71
|
| Rate for Payer: Encore All Commercial |
$2,775.84
|
| Rate for Payer: Frontpath All Commercial |
$2,774.33
|
| Rate for Payer: Humana ChoiceCare |
$2,604.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,714.02
|
| Rate for Payer: PHCS All Commercial |
$2,261.68
|
| Rate for Payer: PHP All Commercial |
$2,287.02
|
| Rate for Payer: Sagamore Health Network All Products |
$2,328.03
|
| Rate for Payer: Signature Care EPO |
$2,502.93
|
| Rate for Payer: Signature Care PPO |
$2,653.71
|
| Rate for Payer: United Healthcare Commercial |
$2,376.28
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYRG
|
Facility
|
IP
|
$3,957.96
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,968.47 |
| Max. Negotiated Rate |
$3,680.90 |
| Rate for Payer: Aetna Commercial |
$3,419.68
|
| Rate for Payer: Cash Price |
$2,374.77
|
| Rate for Payer: Cigna All Commercial |
$3,415.72
|
| Rate for Payer: CORVEL All Commercial |
$3,680.90
|
| Rate for Payer: Coventry All Commercial |
$3,483.00
|
| Rate for Payer: Encore All Commercial |
$3,643.30
|
| Rate for Payer: Frontpath All Commercial |
$3,641.32
|
| Rate for Payer: Humana ChoiceCare |
$3,418.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,562.16
|
| Rate for Payer: PHCS All Commercial |
$2,968.47
|
| Rate for Payer: PHP All Commercial |
$3,001.72
|
| Rate for Payer: Sagamore Health Network All Products |
$3,055.54
|
| Rate for Payer: Signature Care EPO |
$3,285.11
|
| Rate for Payer: Signature Care PPO |
$3,483.00
|
| Rate for Payer: United Healthcare Commercial |
$3,118.87
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYRG
|
Facility
|
OP
|
$3,957.96
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$3,680.90 |
| Rate for Payer: Aetna Commercial |
$3,340.52
|
| Rate for Payer: Aetna Medicare |
$1,266.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,226.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,273.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,474.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,456.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,393.20
|
| Rate for Payer: Cash Price |
$2,374.77
|
| Rate for Payer: Cash Price |
$2,374.77
|
| Rate for Payer: Centivo All Commercial |
$2,153.13
|
| Rate for Payer: Cigna All Commercial |
$3,415.72
|
| Rate for Payer: CORVEL All Commercial |
$3,680.90
|
| Rate for Payer: Coventry All Commercial |
$3,483.00
|
| Rate for Payer: Encore All Commercial |
$3,643.30
|
| Rate for Payer: Frontpath All Commercial |
$3,641.32
|
| Rate for Payer: Humana ChoiceCare |
$3,418.49
|
| Rate for Payer: Humana Medicare |
$1,266.55
|
| Rate for Payer: Lucent All Commercial |
$2,153.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,562.16
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$2,968.47
|
| Rate for Payer: PHP All Commercial |
$3,001.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,543.60
|
| Rate for Payer: Sagamore Health Network All Products |
$3,055.54
|
| Rate for Payer: Signature Care EPO |
$3,285.11
|
| Rate for Payer: Signature Care PPO |
$3,483.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,364.26
|
| Rate for Payer: United Healthcare Commercial |
$3,118.87
|
| Rate for Payer: United Healthcare Medicare |
$1,266.55
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG
|
Facility
|
OP
|
$5,277.27
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$4,907.86 |
| Rate for Payer: Aetna Commercial |
$4,454.01
|
| Rate for Payer: Aetna Medicare |
$1,688.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,635.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,030.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,298.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,942.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,857.60
|
| Rate for Payer: Cash Price |
$3,166.36
|
| Rate for Payer: Cash Price |
$3,166.36
|
| Rate for Payer: Centivo All Commercial |
$2,870.83
|
| Rate for Payer: Cigna All Commercial |
$4,554.28
|
| Rate for Payer: CORVEL All Commercial |
$4,907.86
|
| Rate for Payer: Coventry All Commercial |
$4,643.99
|
| Rate for Payer: Encore All Commercial |
$4,857.72
|
| Rate for Payer: Frontpath All Commercial |
$4,855.08
|
| Rate for Payer: Humana ChoiceCare |
$4,557.97
|
| Rate for Payer: Humana Medicare |
$1,688.72
|
| Rate for Payer: Lucent All Commercial |
$2,870.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,749.54
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$3,957.95
|
| Rate for Payer: PHP All Commercial |
$4,002.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,058.13
|
| Rate for Payer: Sagamore Health Network All Products |
$4,074.05
|
| Rate for Payer: Signature Care EPO |
$4,380.13
|
| Rate for Payer: Signature Care PPO |
$4,643.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,485.68
|
| Rate for Payer: United Healthcare Commercial |
$4,158.48
|
| Rate for Payer: United Healthcare Medicare |
$1,688.72
|
|
