|
GADOXETATE 2.5 MMOL/10 ML IV SOLN 10 ML VIAL
|
Facility
|
OP
|
$709.80
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$220.04 |
| Max. Negotiated Rate |
$660.11 |
| Rate for Payer: Aetna Commercial |
$599.07
|
| Rate for Payer: Aetna Medicare |
$227.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$220.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$407.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$443.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$261.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$249.85
|
| Rate for Payer: Cash Price |
$425.88
|
| Rate for Payer: Centivo All Commercial |
$386.13
|
| Rate for Payer: Cigna All Commercial |
$612.56
|
| Rate for Payer: CORVEL All Commercial |
$660.11
|
| Rate for Payer: Coventry All Commercial |
$624.62
|
| Rate for Payer: Encore All Commercial |
$653.37
|
| Rate for Payer: Frontpath All Commercial |
$653.02
|
| Rate for Payer: Humana ChoiceCare |
$613.05
|
| Rate for Payer: Humana Medicare |
$227.14
|
| Rate for Payer: Lucent All Commercial |
$386.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$638.82
|
| Rate for Payer: PHCS All Commercial |
$532.35
|
| Rate for Payer: PHP All Commercial |
$538.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$276.82
|
| Rate for Payer: Sagamore Health Network All Products |
$547.97
|
| Rate for Payer: Signature Care EPO |
$589.13
|
| Rate for Payer: Signature Care PPO |
$624.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$603.33
|
| Rate for Payer: United Healthcare Commercial |
$559.32
|
| Rate for Payer: United Healthcare Medicare |
$227.14
|
|
|
GADOXETATE 2.5 MMOL/10 ML IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$709.80
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$532.35 |
| Max. Negotiated Rate |
$660.11 |
| Rate for Payer: Aetna Commercial |
$613.27
|
| Rate for Payer: Cash Price |
$425.88
|
| Rate for Payer: Cigna All Commercial |
$612.56
|
| Rate for Payer: CORVEL All Commercial |
$660.11
|
| Rate for Payer: Coventry All Commercial |
$624.62
|
| Rate for Payer: Encore All Commercial |
$653.37
|
| Rate for Payer: Frontpath All Commercial |
$653.02
|
| Rate for Payer: Humana ChoiceCare |
$613.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$638.82
|
| Rate for Payer: PHCS All Commercial |
$532.35
|
| Rate for Payer: PHP All Commercial |
$538.31
|
| Rate for Payer: Sagamore Health Network All Products |
$547.97
|
| Rate for Payer: Signature Care EPO |
$589.13
|
| Rate for Payer: Signature Care PPO |
$624.62
|
| Rate for Payer: United Healthcare Commercial |
$559.32
|
|
|
GELATIN ABSORBABLE MM POWD
|
Facility
|
IP
|
$1,047.12
|
|
|
Service Code
|
NDC 63713001978
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$785.34 |
| Max. Negotiated Rate |
$973.82 |
| Rate for Payer: Aetna Commercial |
$904.71
|
| Rate for Payer: Cash Price |
$628.27
|
| Rate for Payer: Cigna All Commercial |
$903.66
|
| Rate for Payer: CORVEL All Commercial |
$973.82
|
| Rate for Payer: Coventry All Commercial |
$921.46
|
| Rate for Payer: Encore All Commercial |
$963.87
|
| Rate for Payer: Frontpath All Commercial |
$963.35
|
| Rate for Payer: Humana ChoiceCare |
$904.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$942.40
|
| Rate for Payer: PHCS All Commercial |
$785.34
|
| Rate for Payer: PHP All Commercial |
$794.13
|
| Rate for Payer: Sagamore Health Network All Products |
$808.37
|
| Rate for Payer: Signature Care EPO |
$869.11
|
| Rate for Payer: Signature Care PPO |
$921.46
|
| Rate for Payer: United Healthcare Commercial |
$825.13
|
|
|
GELATIN ABSORBABLE MM POWD
|
Facility
|
OP
|
$1,047.12
|
|
|
Service Code
|
NDC 63713001978
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$973.82 |
| Rate for Payer: Aetna Commercial |
$883.77
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$324.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$601.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$654.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$385.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$368.58
|
| Rate for Payer: Cash Price |
$628.27
|
| Rate for Payer: Cash Price |
$628.27
|
| Rate for Payer: Centivo All Commercial |
$569.63
|
| Rate for Payer: Cigna All Commercial |
$903.66
|
| Rate for Payer: CORVEL All Commercial |
$973.82
|
| Rate for Payer: Coventry All Commercial |
$921.46
|
| Rate for Payer: Encore All Commercial |
$963.87
|
| Rate for Payer: Frontpath All Commercial |
$963.35
|
| Rate for Payer: Humana ChoiceCare |
$904.39
|
| Rate for Payer: Humana Medicare |
$335.08
|
| Rate for Payer: Lucent All Commercial |
$569.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$942.40
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$785.34
|
| Rate for Payer: PHP All Commercial |
$794.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$408.37
|
| Rate for Payer: Sagamore Health Network All Products |
$808.37
|
| Rate for Payer: Signature Care EPO |
$869.11
|
| Rate for Payer: Signature Care PPO |
$921.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$890.05
|
| Rate for Payer: United Healthcare Commercial |
$825.13
|
| Rate for Payer: United Healthcare Medicare |
$335.08
|
|
|
GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TOP SPGE
|
Facility
|
OP
|
$83.95
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$78.07 |
| Rate for Payer: Aetna Commercial |
$70.85
|
| Rate for Payer: Aetna Medicare |
$26.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$48.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.55
|
| Rate for Payer: Cash Price |
$50.37
|
| Rate for Payer: Cash Price |
$50.37
|
| Rate for Payer: Centivo All Commercial |
$45.67
|
| Rate for Payer: Cigna All Commercial |
$72.45
|
| Rate for Payer: CORVEL All Commercial |
$78.07
|
| Rate for Payer: Coventry All Commercial |
$73.88
|
| Rate for Payer: Encore All Commercial |
$77.28
|
| Rate for Payer: Frontpath All Commercial |
$77.23
|
| Rate for Payer: Humana ChoiceCare |
$72.51
|
| Rate for Payer: Humana Medicare |
$26.86
|
| Rate for Payer: Lucent All Commercial |
$45.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$62.96
|
| Rate for Payer: PHP All Commercial |
$63.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.74
|
| Rate for Payer: Sagamore Health Network All Products |
$64.81
|
| Rate for Payer: Signature Care EPO |
$69.68
|
| Rate for Payer: Signature Care PPO |
$73.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.36
|
| Rate for Payer: United Healthcare Commercial |
$66.15
|
| Rate for Payer: United Healthcare Medicare |
$26.86
|
|
|
GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TOP SPGE
|
Facility
|
IP
|
$83.95
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.96 |
| Max. Negotiated Rate |
$78.07 |
| Rate for Payer: Aetna Commercial |
$72.53
|
| Rate for Payer: Cash Price |
$50.37
|
| Rate for Payer: Cigna All Commercial |
$72.45
|
| Rate for Payer: CORVEL All Commercial |
$78.07
|
| Rate for Payer: Coventry All Commercial |
$73.88
|
| Rate for Payer: Encore All Commercial |
$77.28
|
| Rate for Payer: Frontpath All Commercial |
$77.23
|
| Rate for Payer: Humana ChoiceCare |
$72.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.56
|
| Rate for Payer: PHCS All Commercial |
$62.96
|
| Rate for Payer: PHP All Commercial |
$63.67
|
| Rate for Payer: Sagamore Health Network All Products |
$64.81
|
| Rate for Payer: Signature Care EPO |
$69.68
|
| Rate for Payer: Signature Care PPO |
$73.88
|
| Rate for Payer: United Healthcare Commercial |
$66.15
|
|
|
GEMCITABINE 1 G IN NS BLADDER IRRIGATION - *COMPOUND* (CAMERON)
|
Facility
|
IP
|
$1,373.36
|
|
|
Service Code
|
NDC 00000011259
|
| Hospital Charge Code |
1.403E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,030.02 |
| Max. Negotiated Rate |
$1,277.22 |
| Rate for Payer: Aetna Commercial |
$1,186.58
|
| Rate for Payer: Cash Price |
$824.02
|
| Rate for Payer: Cigna All Commercial |
$1,185.21
|
| Rate for Payer: CORVEL All Commercial |
$1,277.22
|
| Rate for Payer: Coventry All Commercial |
$1,208.56
|
| Rate for Payer: Encore All Commercial |
$1,264.18
|
| Rate for Payer: Frontpath All Commercial |
$1,263.49
|
| Rate for Payer: Humana ChoiceCare |
$1,186.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,236.02
|
| Rate for Payer: PHCS All Commercial |
$1,030.02
|
| Rate for Payer: PHP All Commercial |
$1,041.56
|
| Rate for Payer: Sagamore Health Network All Products |
$1,060.23
|
| Rate for Payer: Signature Care EPO |
$1,139.89
|
| Rate for Payer: Signature Care PPO |
$1,208.56
|
| Rate for Payer: United Healthcare Commercial |
$1,082.21
|
|
|
GEMCITABINE 1 G IN NS BLADDER IRRIGATION - *COMPOUND* (CAMERON)
|
Facility
|
OP
|
$1,373.36
|
|
|
Service Code
|
NDC 00000011259
|
| Hospital Charge Code |
1.403E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,277.22 |
| Rate for Payer: Aetna Commercial |
$1,159.12
|
| Rate for Payer: Aetna Medicare |
$439.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$425.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$788.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$858.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$505.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$483.42
|
| Rate for Payer: Cash Price |
$824.02
|
| Rate for Payer: Cash Price |
$824.02
|
| Rate for Payer: Centivo All Commercial |
$747.11
|
| Rate for Payer: Cigna All Commercial |
$1,185.21
|
| Rate for Payer: CORVEL All Commercial |
$1,277.22
|
| Rate for Payer: Coventry All Commercial |
$1,208.56
|
| Rate for Payer: Encore All Commercial |
$1,264.18
|
| Rate for Payer: Frontpath All Commercial |
$1,263.49
|
| Rate for Payer: Humana ChoiceCare |
$1,186.17
|
| Rate for Payer: Humana Medicare |
$439.48
|
| Rate for Payer: Lucent All Commercial |
$747.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,236.02
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1,030.02
|
| Rate for Payer: PHP All Commercial |
$1,041.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$535.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1,060.23
|
| Rate for Payer: Signature Care EPO |
$1,139.89
|
| Rate for Payer: Signature Care PPO |
$1,208.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,167.36
|
| Rate for Payer: United Healthcare Commercial |
$1,082.21
|
| Rate for Payer: United Healthcare Medicare |
$439.48
|
|
|
GEMCITABINE 2 G IN NS BLADDER IRRIGATION - *COMPOUND* (CAMERON)
|
Facility
|
IP
|
$1,524.36
|
|
|
Service Code
|
NDC 00000011260
|
| Hospital Charge Code |
1.403E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,143.27 |
| Max. Negotiated Rate |
$1,417.65 |
| Rate for Payer: Aetna Commercial |
$1,317.05
|
| Rate for Payer: Cash Price |
$914.62
|
| Rate for Payer: Cigna All Commercial |
$1,315.52
|
| Rate for Payer: CORVEL All Commercial |
$1,417.65
|
| Rate for Payer: Coventry All Commercial |
$1,341.44
|
| Rate for Payer: Encore All Commercial |
$1,403.17
|
| Rate for Payer: Frontpath All Commercial |
$1,402.41
|
| Rate for Payer: Humana ChoiceCare |
$1,316.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,371.92
|
| Rate for Payer: PHCS All Commercial |
$1,143.27
|
| Rate for Payer: PHP All Commercial |
$1,156.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1,176.81
|
| Rate for Payer: Signature Care EPO |
$1,265.22
|
| Rate for Payer: Signature Care PPO |
$1,341.44
|
| Rate for Payer: United Healthcare Commercial |
$1,201.20
|
|
|
GEMCITABINE 2 G IN NS BLADDER IRRIGATION - *COMPOUND* (CAMERON)
|
Facility
|
OP
|
$1,524.36
|
|
|
Service Code
|
NDC 00000011260
|
| Hospital Charge Code |
1.403E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,417.65 |
| Rate for Payer: Aetna Commercial |
$1,286.56
|
| Rate for Payer: Aetna Medicare |
$487.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$472.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$875.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$952.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$560.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$536.57
|
| Rate for Payer: Cash Price |
$914.62
|
| Rate for Payer: Cash Price |
$914.62
|
| Rate for Payer: Centivo All Commercial |
$829.25
|
| Rate for Payer: Cigna All Commercial |
$1,315.52
|
| Rate for Payer: CORVEL All Commercial |
$1,417.65
|
| Rate for Payer: Coventry All Commercial |
$1,341.44
|
| Rate for Payer: Encore All Commercial |
$1,403.17
|
| Rate for Payer: Frontpath All Commercial |
$1,402.41
|
| Rate for Payer: Humana ChoiceCare |
$1,316.59
|
| Rate for Payer: Humana Medicare |
$487.80
|
| Rate for Payer: Lucent All Commercial |
$829.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,371.92
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1,143.27
|
| Rate for Payer: PHP All Commercial |
$1,156.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$594.50
|
| Rate for Payer: Sagamore Health Network All Products |
$1,176.81
|
| Rate for Payer: Signature Care EPO |
$1,265.22
|
| Rate for Payer: Signature Care PPO |
$1,341.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,295.71
|
| Rate for Payer: United Healthcare Commercial |
$1,201.20
|
| Rate for Payer: United Healthcare Medicare |
$487.80
|
|
|
GEMFIBROZIL 600 MG ORAL TAB
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 69097082103
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna Commercial |
$0.88
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna All Commercial |
$0.88
|
| Rate for Payer: CORVEL All Commercial |
$0.95
|
| Rate for Payer: Coventry All Commercial |
$0.90
|
| Rate for Payer: Encore All Commercial |
$0.94
|
| Rate for Payer: Frontpath All Commercial |
$0.94
|
| Rate for Payer: Humana ChoiceCare |
$0.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.92
|
| Rate for Payer: PHCS All Commercial |
$0.77
|
| Rate for Payer: PHP All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$0.79
|
| Rate for Payer: Signature Care EPO |
$0.85
|
| Rate for Payer: Signature Care PPO |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
|
|
GEMFIBROZIL 600 MG ORAL TAB
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 69097082103
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Centivo All Commercial |
$0.56
|
| Rate for Payer: Cigna All Commercial |
$0.88
|
| Rate for Payer: CORVEL All Commercial |
$0.95
|
| Rate for Payer: Coventry All Commercial |
$0.90
|
| Rate for Payer: Encore All Commercial |
$0.94
|
| Rate for Payer: Frontpath All Commercial |
$0.94
|
| Rate for Payer: Humana ChoiceCare |
$0.88
|
| Rate for Payer: Humana Medicare |
$0.33
|
| Rate for Payer: Lucent All Commercial |
$0.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.92
|
| Rate for Payer: PHCS All Commercial |
$0.77
|
| Rate for Payer: PHP All Commercial |
$0.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.40
|
| Rate for Payer: Sagamore Health Network All Products |
$0.79
|
| Rate for Payer: Signature Care EPO |
$0.85
|
| Rate for Payer: Signature Care PPO |
$0.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
|
IP
|
$30.38
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.79 |
| Max. Negotiated Rate |
$28.25 |
| Rate for Payer: Aetna Commercial |
$26.25
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna All Commercial |
$26.22
|
| Rate for Payer: CORVEL All Commercial |
$28.25
|
| Rate for Payer: Coventry All Commercial |
$26.73
|
| Rate for Payer: Encore All Commercial |
$27.96
|
| Rate for Payer: Frontpath All Commercial |
$27.95
|
| Rate for Payer: Humana ChoiceCare |
$26.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.34
|
| Rate for Payer: PHCS All Commercial |
$22.79
|
| Rate for Payer: PHP All Commercial |
$23.04
|
| Rate for Payer: Sagamore Health Network All Products |
$23.45
|
| Rate for Payer: Signature Care EPO |
$25.22
|
| Rate for Payer: Signature Care PPO |
$26.73
|
| Rate for Payer: United Healthcare Commercial |
$23.94
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
|
OP
|
$30.38
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$28.25 |
| Rate for Payer: Aetna Commercial |
$25.64
|
| Rate for Payer: Aetna Medicare |
$9.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.69
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Centivo All Commercial |
$16.53
|
| Rate for Payer: Cigna All Commercial |
$26.22
|
| Rate for Payer: CORVEL All Commercial |
$28.25
|
| Rate for Payer: Coventry All Commercial |
$26.73
|
| Rate for Payer: Encore All Commercial |
$27.96
|
| Rate for Payer: Frontpath All Commercial |
$27.95
|
| Rate for Payer: Humana ChoiceCare |
$26.24
|
| Rate for Payer: Humana Medicare |
$9.72
|
| Rate for Payer: Lucent All Commercial |
$16.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.34
|
| Rate for Payer: PHCS All Commercial |
$22.79
|
| Rate for Payer: PHP All Commercial |
$23.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.85
|
| Rate for Payer: Sagamore Health Network All Products |
$23.45
|
| Rate for Payer: Signature Care EPO |
$25.22
|
| Rate for Payer: Signature Care PPO |
$26.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.82
|
| Rate for Payer: United Healthcare Commercial |
$23.94
|
| Rate for Payer: United Healthcare Medicare |
$9.72
|
|
|
GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN
|
Facility
|
OP
|
$43.19
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
119249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$40.17 |
| Rate for Payer: Aetna Commercial |
$36.45
|
| Rate for Payer: Aetna Medicare |
$13.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.20
|
| Rate for Payer: Cash Price |
$25.91
|
| Rate for Payer: Centivo All Commercial |
$23.50
|
| Rate for Payer: Cigna All Commercial |
$37.27
|
| Rate for Payer: CORVEL All Commercial |
$40.17
|
| Rate for Payer: Coventry All Commercial |
$38.01
|
| Rate for Payer: Encore All Commercial |
$39.76
|
| Rate for Payer: Frontpath All Commercial |
$39.73
|
| Rate for Payer: Humana ChoiceCare |
$37.30
|
| Rate for Payer: Humana Medicare |
$13.82
|
| Rate for Payer: Lucent All Commercial |
$23.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.87
|
| Rate for Payer: PHCS All Commercial |
$32.39
|
| Rate for Payer: PHP All Commercial |
$32.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.84
|
| Rate for Payer: Sagamore Health Network All Products |
$33.34
|
| Rate for Payer: Signature Care EPO |
$35.85
|
| Rate for Payer: Signature Care PPO |
$38.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$36.71
|
| Rate for Payer: United Healthcare Commercial |
$34.03
|
| Rate for Payer: United Healthcare Medicare |
$13.82
|
|
|
GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN
|
Facility
|
IP
|
$43.19
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
119249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$40.17 |
| Rate for Payer: Aetna Commercial |
$37.32
|
| Rate for Payer: Cash Price |
$25.91
|
| Rate for Payer: Cigna All Commercial |
$37.27
|
| Rate for Payer: CORVEL All Commercial |
$40.17
|
| Rate for Payer: Coventry All Commercial |
$38.01
|
| Rate for Payer: Encore All Commercial |
$39.76
|
| Rate for Payer: Frontpath All Commercial |
$39.73
|
| Rate for Payer: Humana ChoiceCare |
$37.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.87
|
| Rate for Payer: PHCS All Commercial |
$32.39
|
| Rate for Payer: PHP All Commercial |
$32.76
|
| Rate for Payer: Sagamore Health Network All Products |
$33.34
|
| Rate for Payer: Signature Care EPO |
$35.85
|
| Rate for Payer: Signature Care PPO |
$38.01
|
| Rate for Payer: United Healthcare Commercial |
$34.03
|
|
|
GENTIAN VIOLET 1 % TOP SOLN
|
Facility
|
IP
|
$49.97
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.48 |
| Max. Negotiated Rate |
$46.47 |
| Rate for Payer: Aetna Commercial |
$43.18
|
| Rate for Payer: Cash Price |
$29.98
|
| Rate for Payer: Cigna All Commercial |
$43.13
|
| Rate for Payer: CORVEL All Commercial |
$46.47
|
| Rate for Payer: Coventry All Commercial |
$43.98
|
| Rate for Payer: Encore All Commercial |
$46.00
|
| Rate for Payer: Frontpath All Commercial |
$45.98
|
| Rate for Payer: Humana ChoiceCare |
$43.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.98
|
| Rate for Payer: PHCS All Commercial |
$37.48
|
| Rate for Payer: PHP All Commercial |
$37.90
|
| Rate for Payer: Sagamore Health Network All Products |
$38.58
|
| Rate for Payer: Signature Care EPO |
$41.48
|
| Rate for Payer: Signature Care PPO |
$43.98
|
| Rate for Payer: United Healthcare Commercial |
$39.38
|
|
|
GENTIAN VIOLET 1 % TOP SOLN
|
Facility
|
OP
|
$49.97
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$46.47 |
| Rate for Payer: Aetna Commercial |
$42.18
|
| Rate for Payer: Aetna Medicare |
$15.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.59
|
| Rate for Payer: Cash Price |
$29.98
|
| Rate for Payer: Cash Price |
$29.98
|
| Rate for Payer: Centivo All Commercial |
$27.19
|
| Rate for Payer: Cigna All Commercial |
$43.13
|
| Rate for Payer: CORVEL All Commercial |
$46.47
|
| Rate for Payer: Coventry All Commercial |
$43.98
|
| Rate for Payer: Encore All Commercial |
$46.00
|
| Rate for Payer: Frontpath All Commercial |
$45.98
|
| Rate for Payer: Humana ChoiceCare |
$43.16
|
| Rate for Payer: Humana Medicare |
$15.99
|
| Rate for Payer: Lucent All Commercial |
$27.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.98
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$37.48
|
| Rate for Payer: PHP All Commercial |
$37.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.49
|
| Rate for Payer: Sagamore Health Network All Products |
$38.58
|
| Rate for Payer: Signature Care EPO |
$41.48
|
| Rate for Payer: Signature Care PPO |
$43.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.48
|
| Rate for Payer: United Healthcare Commercial |
$39.38
|
| Rate for Payer: United Healthcare Medicare |
$15.99
|
|
|
GLIMEPIRIDE 2 MG ORAL TAB
|
Facility
|
OP
|
$2.91
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| 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 |
$1.03
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Centivo All Commercial |
$1.58
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$1.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.14
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.48
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Medicare |
$0.93
|
|
|
GLIMEPIRIDE 2 MG ORAL TAB
|
Facility
|
IP
|
$2.91
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
|
IP
|
$8.23
|
|
|
Service Code
|
NDC 60687076821
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.11
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.57
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.40
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: United Healthcare Commercial |
$6.48
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
|
IP
|
$8.23
|
|
|
Service Code
|
NDC 60687076811
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.11
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.57
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.40
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: United Healthcare Commercial |
$6.48
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
|
OP
|
$8.23
|
|
|
Service Code
|
NDC 60687076811
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna Medicare |
$2.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.90
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Centivo All Commercial |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.57
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.10
|
| Rate for Payer: Humana Medicare |
$2.63
|
| Rate for Payer: Lucent All Commercial |
$4.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.40
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.21
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.99
|
| Rate for Payer: United Healthcare Commercial |
$6.48
|
| Rate for Payer: United Healthcare Medicare |
$2.63
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
|
OP
|
$8.23
|
|
|
Service Code
|
NDC 60687076821
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna Medicare |
$2.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.90
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Centivo All Commercial |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.57
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.10
|
| Rate for Payer: Humana Medicare |
$2.63
|
| Rate for Payer: Lucent All Commercial |
$4.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.40
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.21
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.99
|
| Rate for Payer: United Healthcare Commercial |
$6.48
|
| Rate for Payer: United Healthcare Medicare |
$2.63
|
|
|
GLIPIZIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Centivo All Commercial |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.23
|
| Rate for Payer: CORVEL All Commercial |
$1.32
|
| Rate for Payer: Coventry All Commercial |
$1.25
|
| Rate for Payer: Encore All Commercial |
$1.31
|
| Rate for Payer: Frontpath All Commercial |
$1.31
|
| Rate for Payer: Humana ChoiceCare |
$1.23
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: Lucent All Commercial |
$0.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.28
|
| Rate for Payer: PHCS All Commercial |
$1.07
|
| Rate for Payer: PHP All Commercial |
$1.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.55
|
| Rate for Payer: Sagamore Health Network All Products |
$1.10
|
| Rate for Payer: Signature Care EPO |
$1.18
|
| Rate for Payer: Signature Care PPO |
$1.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
|
