|
CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG ORAL TAB
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 77333093810
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Centivo All Commercial |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Humana Medicare |
$0.60
|
| Rate for Payer: Lucent All Commercial |
$0.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
|
|
CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG ORAL TAB
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 77333093810
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$1.02
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
|
|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 60687055811
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 60687055811
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Centivo All Commercial |
$0.89
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Humana Medicare |
$0.89
|
| Rate for Payer: Lucent All Commercial |
$0.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
CYCLOBENZAPRINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Centivo All Commercial |
$0.89
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Humana Medicare |
$0.89
|
| Rate for Payer: Lucent All Commercial |
$0.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
OP
|
$20.30
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Aetna Medicare |
$6.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.37
|
| Rate for Payer: Cash Price |
$12.59
|
| Rate for Payer: Cash Price |
$12.59
|
| Rate for Payer: Centivo All Commercial |
$10.35
|
| Rate for Payer: Cigna All Commercial |
$17.52
|
| Rate for Payer: CORVEL All Commercial |
$18.88
|
| Rate for Payer: Coventry All Commercial |
$17.86
|
| Rate for Payer: Encore All Commercial |
$18.69
|
| Rate for Payer: Frontpath All Commercial |
$18.68
|
| Rate for Payer: Humana ChoiceCare |
$17.53
|
| Rate for Payer: Humana Medicare |
$10.35
|
| Rate for Payer: Lucent All Commercial |
$10.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.27
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$15.22
|
| Rate for Payer: PHP All Commercial |
$15.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.92
|
| Rate for Payer: Sagamore Health Network All Products |
$15.67
|
| Rate for Payer: Signature Care EPO |
$16.85
|
| Rate for Payer: Signature Care PPO |
$17.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.26
|
| Rate for Payer: United Healthcare Commercial |
$16.00
|
| Rate for Payer: United Healthcare Medicare |
$6.70
|
|
|
CYCLOPENTOLATE 1 % OPHT DROP
|
Facility
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.22 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Aetna Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$12.59
|
| Rate for Payer: Cigna All Commercial |
$17.52
|
| Rate for Payer: CORVEL All Commercial |
$18.88
|
| Rate for Payer: Coventry All Commercial |
$17.86
|
| Rate for Payer: Encore All Commercial |
$18.69
|
| Rate for Payer: Frontpath All Commercial |
$18.68
|
| Rate for Payer: Humana ChoiceCare |
$17.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.27
|
| Rate for Payer: PHCS All Commercial |
$15.22
|
| Rate for Payer: PHP All Commercial |
$15.40
|
| Rate for Payer: Sagamore Health Network All Products |
$15.67
|
| Rate for Payer: Signature Care EPO |
$16.85
|
| Rate for Payer: Signature Care PPO |
$17.86
|
| Rate for Payer: United Healthcare Commercial |
$16.00
|
|
|
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 52005
|
| Hospital Charge Code |
CPT-52005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
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 |
$26.04
|
| 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 |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| 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 |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| 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 |
$13.86
|
|
|
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 |
$26.04
|
| 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 (IN ML/KG/HR)
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| 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 |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| 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 |
$13.86
|
|
|
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 |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| 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 |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| 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 |
$13.86
|
|
|
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 |
$26.04
|
| 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
|
$20.86
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Aetna Commercial |
$17.61
|
| Rate for Payer: Aetna Medicare |
$6.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.57
|
| Rate for Payer: Cash Price |
$12.93
|
| Rate for Payer: Centivo All Commercial |
$10.64
|
| Rate for Payer: Cigna All Commercial |
$18.00
|
| Rate for Payer: CORVEL All Commercial |
$19.40
|
| Rate for Payer: Coventry All Commercial |
$18.36
|
| Rate for Payer: Encore All Commercial |
$19.20
|
| Rate for Payer: Frontpath All Commercial |
$19.19
|
| Rate for Payer: Humana ChoiceCare |
$18.02
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Lucent All Commercial |
$10.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.77
|
| Rate for Payer: PHCS All Commercial |
$15.64
|
| Rate for Payer: PHP All Commercial |
$15.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.14
|
| Rate for Payer: Sagamore Health Network All Products |
$16.10
|
| Rate for Payer: Signature Care EPO |
$17.31
|
| Rate for Payer: Signature Care PPO |
$18.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.73
|
| Rate for Payer: United Healthcare Commercial |
$16.44
|
| Rate for Payer: United Healthcare Medicare |
$6.88
|
|
|
DABIGATRAN ETEXILATE 75 MG ORAL CAP
|
Facility
|
IP
|
$20.86
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.64 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Aetna Commercial |
$18.02
|
| Rate for Payer: Cash Price |
$12.93
|
| Rate for Payer: Cigna All Commercial |
$18.00
|
| Rate for Payer: CORVEL All Commercial |
$19.40
|
| Rate for Payer: Coventry All Commercial |
$18.36
|
| Rate for Payer: Encore All Commercial |
$19.20
|
| Rate for Payer: Frontpath All Commercial |
$19.19
|
| Rate for Payer: Humana ChoiceCare |
$18.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.77
|
| Rate for Payer: PHCS All Commercial |
$15.64
|
| Rate for Payer: PHP All Commercial |
$15.82
|
| Rate for Payer: Sagamore Health Network All Products |
$16.10
|
| Rate for Payer: Signature Care EPO |
$17.31
|
| Rate for Payer: Signature Care PPO |
$18.36
|
| Rate for Payer: United Healthcare Commercial |
$16.44
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
IP
|
$5,729.08
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
168767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,296.81 |
| Max. Negotiated Rate |
$5,328.04 |
| Rate for Payer: Aetna Commercial |
$4,949.93
|
| Rate for Payer: Cash Price |
$3,552.03
|
| Rate for Payer: Cigna All Commercial |
$4,944.20
|
| Rate for Payer: CORVEL All Commercial |
$5,328.04
|
| Rate for Payer: Coventry All Commercial |
$5,041.59
|
| Rate for Payer: Encore All Commercial |
$5,273.62
|
| Rate for Payer: Frontpath All Commercial |
$5,270.75
|
| Rate for Payer: Humana ChoiceCare |
$4,948.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,156.17
|
| Rate for Payer: PHCS All Commercial |
$4,296.81
|
| Rate for Payer: PHP All Commercial |
$4,344.93
|
| Rate for Payer: Sagamore Health Network All Products |
$4,422.85
|
| Rate for Payer: Signature Care EPO |
$4,755.14
|
| Rate for Payer: Signature Care PPO |
$5,041.59
|
| Rate for Payer: United Healthcare Commercial |
$4,514.52
|
|
|
DALBAVANCIN 500 MG IV SOLN
|
Facility
|
OP
|
$5,729.08
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
168767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$5,328.04 |
| Rate for Payer: Aetna Commercial |
$4,835.34
|
| Rate for Payer: Aetna Medicare |
$1,890.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,890.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,290.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,581.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$18.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,174.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,079.66
|
| Rate for Payer: Cash Price |
$3,552.03
|
| Rate for Payer: Cash Price |
$3,552.03
|
| Rate for Payer: Centivo All Commercial |
$2,921.83
|
| Rate for Payer: Cigna All Commercial |
$4,944.20
|
| Rate for Payer: CORVEL All Commercial |
$5,328.04
|
| Rate for Payer: Coventry All Commercial |
$5,041.59
|
| Rate for Payer: Encore All Commercial |
$5,273.62
|
| Rate for Payer: Frontpath All Commercial |
$5,270.75
|
| Rate for Payer: Humana ChoiceCare |
$4,948.21
|
| Rate for Payer: Humana Medicare |
$2,921.83
|
| Rate for Payer: Lucent All Commercial |
$2,921.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,156.17
|
| Rate for Payer: Managed Health Services Medicaid |
$18.14
|
| Rate for Payer: MDWise Medicaid |
$18.14
|
| Rate for Payer: PHCS All Commercial |
$4,296.81
|
| Rate for Payer: PHP All Commercial |
$4,344.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,234.34
|
| Rate for Payer: Sagamore Health Network All Products |
$4,422.85
|
| Rate for Payer: Signature Care EPO |
$4,755.14
|
| Rate for Payer: Signature Care PPO |
$5,041.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,869.72
|
| Rate for Payer: United Healthcare Commercial |
$4,514.52
|
| Rate for Payer: United Healthcare Medicare |
$1,890.60
|
|
|
DANTROLENE 20 MG IV SOLR
|
Facility
|
OP
|
$369.92
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$344.02 |
| Rate for Payer: Aetna Commercial |
$312.21
|
| Rate for Payer: Aetna Medicare |
$122.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$122.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$212.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$231.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$140.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$134.28
|
| Rate for Payer: Cash Price |
$229.35
|
| Rate for Payer: Cash Price |
$229.35
|
| Rate for Payer: Centivo All Commercial |
$188.66
|
| Rate for Payer: Cigna All Commercial |
$319.24
|
| Rate for Payer: CORVEL All Commercial |
$344.02
|
| Rate for Payer: Coventry All Commercial |
$325.53
|
| Rate for Payer: Encore All Commercial |
$340.51
|
| Rate for Payer: Frontpath All Commercial |
$340.32
|
| Rate for Payer: Humana ChoiceCare |
$319.50
|
| Rate for Payer: Humana Medicare |
$188.66
|
| Rate for Payer: Lucent All Commercial |
$188.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$332.93
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$277.44
|
| Rate for Payer: PHP All Commercial |
$280.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$144.27
|
| Rate for Payer: Sagamore Health Network All Products |
$285.58
|
| Rate for Payer: Signature Care EPO |
$307.03
|
| Rate for Payer: Signature Care PPO |
$325.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$314.43
|
| Rate for Payer: United Healthcare Commercial |
$291.50
|
| Rate for Payer: United Healthcare Medicare |
$122.07
|
|
|
DANTROLENE 20 MG IV SOLR
|
Facility
|
IP
|
$369.92
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$277.44 |
| Max. Negotiated Rate |
$344.02 |
| Rate for Payer: Aetna Commercial |
$319.61
|
| Rate for Payer: Cash Price |
$229.35
|
| Rate for Payer: Cigna All Commercial |
$319.24
|
| Rate for Payer: CORVEL All Commercial |
$344.02
|
| Rate for Payer: Coventry All Commercial |
$325.53
|
| Rate for Payer: Encore All Commercial |
$340.51
|
| Rate for Payer: Frontpath All Commercial |
$340.32
|
| Rate for Payer: Humana ChoiceCare |
$319.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$332.93
|
| Rate for Payer: PHCS All Commercial |
$277.44
|
| Rate for Payer: PHP All Commercial |
$280.55
|
| Rate for Payer: Sagamore Health Network All Products |
$285.58
|
| Rate for Payer: Signature Care EPO |
$307.03
|
| Rate for Payer: Signature Care PPO |
$325.53
|
| Rate for Payer: United Healthcare Commercial |
$291.50
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB
|
Facility
|
OP
|
$105.67
|
|
|
Service Code
|
NDC 00310621030
|
| Hospital Charge Code |
167231
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.87 |
| Max. Negotiated Rate |
$98.27 |
| Rate for Payer: Aetna Commercial |
$89.18
|
| Rate for Payer: Aetna Medicare |
$34.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.36
|
| Rate for Payer: Cash Price |
$65.51
|
| Rate for Payer: Centivo All Commercial |
$53.89
|
| Rate for Payer: Cigna All Commercial |
$91.19
|
| Rate for Payer: CORVEL All Commercial |
$98.27
|
| Rate for Payer: Coventry All Commercial |
$92.99
|
| Rate for Payer: Encore All Commercial |
$97.26
|
| Rate for Payer: Frontpath All Commercial |
$97.21
|
| Rate for Payer: Humana ChoiceCare |
$91.26
|
| Rate for Payer: Humana Medicare |
$53.89
|
| Rate for Payer: Lucent All Commercial |
$53.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.10
|
| Rate for Payer: PHCS All Commercial |
$79.25
|
| Rate for Payer: PHP All Commercial |
$80.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.21
|
| Rate for Payer: Sagamore Health Network All Products |
$81.57
|
| Rate for Payer: Signature Care EPO |
$87.70
|
| Rate for Payer: Signature Care PPO |
$92.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.82
|
| Rate for Payer: United Healthcare Commercial |
$83.26
|
| Rate for Payer: United Healthcare Medicare |
$34.87
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB
|
Facility
|
IP
|
$105.67
|
|
|
Service Code
|
NDC 00310621030
|
| Hospital Charge Code |
167231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.25 |
| Max. Negotiated Rate |
$98.27 |
| Rate for Payer: Aetna Commercial |
$91.29
|
| Rate for Payer: Cash Price |
$65.51
|
| Rate for Payer: Cigna All Commercial |
$91.19
|
| Rate for Payer: CORVEL All Commercial |
$98.27
|
| Rate for Payer: Coventry All Commercial |
$92.99
|
| Rate for Payer: Encore All Commercial |
$97.26
|
| Rate for Payer: Frontpath All Commercial |
$97.21
|
| Rate for Payer: Humana ChoiceCare |
$91.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.10
|
| Rate for Payer: PHCS All Commercial |
$79.25
|
| Rate for Payer: PHP All Commercial |
$80.14
|
| Rate for Payer: Sagamore Health Network All Products |
$81.57
|
| Rate for Payer: Signature Care EPO |
$87.70
|
| Rate for Payer: Signature Care PPO |
$92.99
|
| Rate for Payer: United Healthcare Commercial |
$83.26
|
|
|
DAPTOMYCIN 500 MG IV SOLR
|
Facility
|
IP
|
$225.61
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.21 |
| Max. Negotiated Rate |
$209.82 |
| Rate for Payer: Aetna Commercial |
$194.93
|
| Rate for Payer: Cash Price |
$139.88
|
| Rate for Payer: Cigna All Commercial |
$194.70
|
| Rate for Payer: CORVEL All Commercial |
$209.82
|
| Rate for Payer: Coventry All Commercial |
$198.54
|
| Rate for Payer: Encore All Commercial |
$207.67
|
| Rate for Payer: Frontpath All Commercial |
$207.56
|
| Rate for Payer: Humana ChoiceCare |
$194.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.05
|
| Rate for Payer: PHCS All Commercial |
$169.21
|
| Rate for Payer: PHP All Commercial |
$171.10
|
| Rate for Payer: Sagamore Health Network All Products |
$174.17
|
| Rate for Payer: Signature Care EPO |
$187.26
|
| Rate for Payer: Signature Care PPO |
$198.54
|
| Rate for Payer: United Healthcare Commercial |
$177.78
|
|
