|
MEDROXYPROGESTERONE 150 MG/ML IM S.O.
|
Facility
|
IP
|
$401.76
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
420792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$301.32 |
| Max. Negotiated Rate |
$373.64 |
| Rate for Payer: Aetna Commercial |
$347.12
|
| Rate for Payer: Cash Price |
$241.06
|
| Rate for Payer: Cigna All Commercial |
$346.72
|
| Rate for Payer: CORVEL All Commercial |
$373.64
|
| Rate for Payer: Coventry All Commercial |
$353.55
|
| Rate for Payer: Encore All Commercial |
$369.82
|
| Rate for Payer: Frontpath All Commercial |
$369.62
|
| Rate for Payer: Humana ChoiceCare |
$347.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$361.58
|
| Rate for Payer: PHCS All Commercial |
$301.32
|
| Rate for Payer: PHP All Commercial |
$304.69
|
| Rate for Payer: Sagamore Health Network All Products |
$310.16
|
| Rate for Payer: Signature Care EPO |
$333.46
|
| Rate for Payer: Signature Care PPO |
$353.55
|
| Rate for Payer: United Healthcare Commercial |
$316.59
|
|
|
MEDROXYPROGESTERONE 150 MG/ML IM SYRG
|
Facility
|
IP
|
$401.76
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
114250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$301.32 |
| Max. Negotiated Rate |
$373.64 |
| Rate for Payer: Aetna Commercial |
$347.12
|
| Rate for Payer: Cash Price |
$241.06
|
| Rate for Payer: Cigna All Commercial |
$346.72
|
| Rate for Payer: CORVEL All Commercial |
$373.64
|
| Rate for Payer: Coventry All Commercial |
$353.55
|
| Rate for Payer: Encore All Commercial |
$369.82
|
| Rate for Payer: Frontpath All Commercial |
$369.62
|
| Rate for Payer: Humana ChoiceCare |
$347.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$361.58
|
| Rate for Payer: PHCS All Commercial |
$301.32
|
| Rate for Payer: PHP All Commercial |
$304.69
|
| Rate for Payer: Sagamore Health Network All Products |
$310.16
|
| Rate for Payer: Signature Care EPO |
$333.46
|
| Rate for Payer: Signature Care PPO |
$353.55
|
| Rate for Payer: United Healthcare Commercial |
$316.59
|
|
|
MEDROXYPROGESTERONE 150 MG/ML IM SYRG
|
Facility
|
OP
|
$401.76
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
114250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.55 |
| Max. Negotiated Rate |
$373.64 |
| Rate for Payer: Aetna Commercial |
$339.09
|
| Rate for Payer: Aetna Medicare |
$128.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$124.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$230.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$251.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$147.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$141.42
|
| Rate for Payer: Cash Price |
$241.06
|
| Rate for Payer: Centivo All Commercial |
$218.56
|
| Rate for Payer: Cigna All Commercial |
$346.72
|
| Rate for Payer: CORVEL All Commercial |
$373.64
|
| Rate for Payer: Coventry All Commercial |
$353.55
|
| Rate for Payer: Encore All Commercial |
$369.82
|
| Rate for Payer: Frontpath All Commercial |
$369.62
|
| Rate for Payer: Humana ChoiceCare |
$347.00
|
| Rate for Payer: Humana Medicare |
$128.56
|
| Rate for Payer: Lucent All Commercial |
$218.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$361.58
|
| Rate for Payer: PHCS All Commercial |
$301.32
|
| Rate for Payer: PHP All Commercial |
$304.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$156.69
|
| Rate for Payer: Sagamore Health Network All Products |
$310.16
|
| Rate for Payer: Signature Care EPO |
$333.46
|
| Rate for Payer: Signature Care PPO |
$353.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$341.50
|
| Rate for Payer: United Healthcare Commercial |
$316.59
|
| Rate for Payer: United Healthcare Medicare |
$128.56
|
|
|
MEGESTROL 20 MG ORAL TAB
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
HCPCS J8999
|
| Hospital Charge Code |
4870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.65
|
| Rate for Payer: Frontpath All Commercial |
$1.65
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
MEGESTROL 20 MG ORAL TAB
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
HCPCS J8999
|
| Hospital Charge Code |
4870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.12
|
| 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 |
$0.97
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.65
|
| Rate for Payer: Frontpath All Commercial |
$1.65
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP
|
Facility
|
OP
|
$38.71
|
|
|
Service Code
|
NDC 68094006362
|
| Hospital Charge Code |
159414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$32.67
|
| Rate for Payer: Aetna Medicare |
$12.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.63
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Centivo All Commercial |
$21.06
|
| Rate for Payer: Cigna All Commercial |
$33.41
|
| Rate for Payer: CORVEL All Commercial |
$36.00
|
| Rate for Payer: Coventry All Commercial |
$34.06
|
| Rate for Payer: Encore All Commercial |
$35.63
|
| Rate for Payer: Frontpath All Commercial |
$35.61
|
| Rate for Payer: Humana ChoiceCare |
$33.43
|
| Rate for Payer: Humana Medicare |
$12.39
|
| Rate for Payer: Lucent All Commercial |
$21.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.84
|
| Rate for Payer: PHCS All Commercial |
$29.03
|
| Rate for Payer: PHP All Commercial |
$29.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.10
|
| Rate for Payer: Sagamore Health Network All Products |
$29.88
|
| Rate for Payer: Signature Care EPO |
$32.13
|
| Rate for Payer: Signature Care PPO |
$34.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.90
|
| Rate for Payer: United Healthcare Commercial |
$30.50
|
| Rate for Payer: United Healthcare Medicare |
$12.39
|
|
|
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP
|
Facility
|
IP
|
$38.71
|
|
|
Service Code
|
NDC 68094006362
|
| Hospital Charge Code |
159414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.03 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$33.45
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Cigna All Commercial |
$33.41
|
| Rate for Payer: CORVEL All Commercial |
$36.00
|
| Rate for Payer: Coventry All Commercial |
$34.06
|
| Rate for Payer: Encore All Commercial |
$35.63
|
| Rate for Payer: Frontpath All Commercial |
$35.61
|
| Rate for Payer: Humana ChoiceCare |
$33.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.84
|
| Rate for Payer: PHCS All Commercial |
$29.03
|
| Rate for Payer: PHP All Commercial |
$29.36
|
| Rate for Payer: Sagamore Health Network All Products |
$29.88
|
| Rate for Payer: Signature Care EPO |
$32.13
|
| Rate for Payer: Signature Care PPO |
$34.06
|
| Rate for Payer: United Healthcare Commercial |
$30.50
|
|
|
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP
|
Facility
|
IP
|
$38.71
|
|
|
Service Code
|
NDC 68094006359
|
| Hospital Charge Code |
159414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.03 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$33.45
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Cigna All Commercial |
$33.41
|
| Rate for Payer: CORVEL All Commercial |
$36.00
|
| Rate for Payer: Coventry All Commercial |
$34.06
|
| Rate for Payer: Encore All Commercial |
$35.63
|
| Rate for Payer: Frontpath All Commercial |
$35.61
|
| Rate for Payer: Humana ChoiceCare |
$33.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.84
|
| Rate for Payer: PHCS All Commercial |
$29.03
|
| Rate for Payer: PHP All Commercial |
$29.36
|
| Rate for Payer: Sagamore Health Network All Products |
$29.88
|
| Rate for Payer: Signature Care EPO |
$32.13
|
| Rate for Payer: Signature Care PPO |
$34.06
|
| Rate for Payer: United Healthcare Commercial |
$30.50
|
|
|
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP
|
Facility
|
OP
|
$38.71
|
|
|
Service Code
|
NDC 68094006359
|
| Hospital Charge Code |
159414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$32.67
|
| Rate for Payer: Aetna Medicare |
$12.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.63
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Centivo All Commercial |
$21.06
|
| Rate for Payer: Cigna All Commercial |
$33.41
|
| Rate for Payer: CORVEL All Commercial |
$36.00
|
| Rate for Payer: Coventry All Commercial |
$34.06
|
| Rate for Payer: Encore All Commercial |
$35.63
|
| Rate for Payer: Frontpath All Commercial |
$35.61
|
| Rate for Payer: Humana ChoiceCare |
$33.43
|
| Rate for Payer: Humana Medicare |
$12.39
|
| Rate for Payer: Lucent All Commercial |
$21.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.84
|
| Rate for Payer: PHCS All Commercial |
$29.03
|
| Rate for Payer: PHP All Commercial |
$29.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.10
|
| Rate for Payer: Sagamore Health Network All Products |
$29.88
|
| Rate for Payer: Signature Care EPO |
$32.13
|
| Rate for Payer: Signature Care PPO |
$34.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.90
|
| Rate for Payer: United Healthcare Commercial |
$30.50
|
| Rate for Payer: United Healthcare Medicare |
$12.39
|
|
|
MELATONIN 3 MG ORAL TAB
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 77333051610
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.23
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.51
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Centivo All Commercial |
$0.79
|
| Rate for Payer: Cigna All Commercial |
$1.26
|
| Rate for Payer: CORVEL All Commercial |
$1.35
|
| Rate for Payer: Coventry All Commercial |
$1.28
|
| Rate for Payer: Encore All Commercial |
$1.34
|
| Rate for Payer: Frontpath All Commercial |
$1.34
|
| Rate for Payer: Humana ChoiceCare |
$1.26
|
| Rate for Payer: Humana Medicare |
$0.47
|
| Rate for Payer: Lucent All Commercial |
$0.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.31
|
| Rate for Payer: PHCS All Commercial |
$1.09
|
| Rate for Payer: PHP All Commercial |
$1.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.57
|
| Rate for Payer: Sagamore Health Network All Products |
$1.12
|
| Rate for Payer: Signature Care EPO |
$1.21
|
| Rate for Payer: Signature Care PPO |
$1.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
|
|
MELATONIN 3 MG ORAL TAB
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 77333051610
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.26
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna All Commercial |
$1.26
|
| Rate for Payer: CORVEL All Commercial |
$1.35
|
| Rate for Payer: Coventry All Commercial |
$1.28
|
| Rate for Payer: Encore All Commercial |
$1.34
|
| Rate for Payer: Frontpath All Commercial |
$1.34
|
| Rate for Payer: Humana ChoiceCare |
$1.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.31
|
| Rate for Payer: PHCS All Commercial |
$1.09
|
| Rate for Payer: PHP All Commercial |
$1.10
|
| Rate for Payer: Sagamore Health Network All Products |
$1.12
|
| Rate for Payer: Signature Care EPO |
$1.21
|
| Rate for Payer: Signature Care PPO |
$1.28
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
|
|
MELOXICAM 7.5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 50268052515
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
MELOXICAM 7.5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 50268052515
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
MEMANTINE 5 MG ORAL TAB
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 00591387044
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Aetna Medicare |
$1.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Centivo All Commercial |
$2.34
|
| Rate for Payer: Cigna All Commercial |
$3.71
|
| Rate for Payer: CORVEL All Commercial |
$4.00
|
| Rate for Payer: Coventry All Commercial |
$3.78
|
| Rate for Payer: Encore All Commercial |
$3.96
|
| Rate for Payer: Frontpath All Commercial |
$3.95
|
| Rate for Payer: Humana ChoiceCare |
$3.71
|
| Rate for Payer: Humana Medicare |
$1.38
|
| Rate for Payer: Lucent All Commercial |
$2.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.87
|
| Rate for Payer: PHCS All Commercial |
$3.22
|
| Rate for Payer: PHP All Commercial |
$3.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3.32
|
| Rate for Payer: Signature Care EPO |
$3.57
|
| Rate for Payer: Signature Care PPO |
$3.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.65
|
| Rate for Payer: United Healthcare Commercial |
$3.39
|
| Rate for Payer: United Healthcare Medicare |
$1.38
|
|
|
MEMANTINE 5 MG ORAL TAB
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 00591387044
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna All Commercial |
$3.71
|
| Rate for Payer: CORVEL All Commercial |
$4.00
|
| Rate for Payer: Coventry All Commercial |
$3.78
|
| Rate for Payer: Encore All Commercial |
$3.96
|
| Rate for Payer: Frontpath All Commercial |
$3.95
|
| Rate for Payer: Humana ChoiceCare |
$3.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.87
|
| Rate for Payer: PHCS All Commercial |
$3.22
|
| Rate for Payer: PHP All Commercial |
$3.26
|
| Rate for Payer: Sagamore Health Network All Products |
$3.32
|
| Rate for Payer: Signature Care EPO |
$3.57
|
| Rate for Payer: Signature Care PPO |
$3.78
|
| Rate for Payer: United Healthcare Commercial |
$3.39
|
|
|
MENINGOCOCCAL B VACCINE,4-COMP 50-50-50-25 MCG/0.5 ML IM SYRG
|
Facility
|
OP
|
$1,111.77
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
171239
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.19 |
| Max. Negotiated Rate |
$1,033.94 |
| Rate for Payer: Aetna Commercial |
$938.33
|
| Rate for Payer: Aetna Medicare |
$355.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$248.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$344.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$638.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$694.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$248.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$409.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$391.34
|
| Rate for Payer: Cash Price |
$667.06
|
| Rate for Payer: Cash Price |
$667.06
|
| Rate for Payer: Centivo All Commercial |
$604.80
|
| Rate for Payer: Cigna All Commercial |
$959.45
|
| Rate for Payer: CORVEL All Commercial |
$1,033.94
|
| Rate for Payer: Coventry All Commercial |
$978.35
|
| Rate for Payer: Encore All Commercial |
$1,023.38
|
| Rate for Payer: Frontpath All Commercial |
$1,022.82
|
| Rate for Payer: Humana ChoiceCare |
$960.23
|
| Rate for Payer: Humana Medicare |
$355.76
|
| Rate for Payer: Lucent All Commercial |
$604.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,000.59
|
| Rate for Payer: Managed Health Services Medicaid |
$248.19
|
| Rate for Payer: MDWise Medicaid |
$248.19
|
| Rate for Payer: PHCS All Commercial |
$833.82
|
| Rate for Payer: PHP All Commercial |
$843.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$433.59
|
| Rate for Payer: Sagamore Health Network All Products |
$858.28
|
| Rate for Payer: Signature Care EPO |
$922.76
|
| Rate for Payer: Signature Care PPO |
$978.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$945.00
|
| Rate for Payer: United Healthcare Commercial |
$876.07
|
| Rate for Payer: United Healthcare Medicare |
$355.76
|
|
|
MENINGOCOCCAL B VACCINE,4-COMP 50-50-50-25 MCG/0.5 ML IM SYRG
|
Facility
|
IP
|
$1,111.77
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
171239
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$833.82 |
| Max. Negotiated Rate |
$1,033.94 |
| Rate for Payer: Aetna Commercial |
$960.56
|
| Rate for Payer: Cash Price |
$667.06
|
| Rate for Payer: Cigna All Commercial |
$959.45
|
| Rate for Payer: CORVEL All Commercial |
$1,033.94
|
| Rate for Payer: Coventry All Commercial |
$978.35
|
| Rate for Payer: Encore All Commercial |
$1,023.38
|
| Rate for Payer: Frontpath All Commercial |
$1,022.82
|
| Rate for Payer: Humana ChoiceCare |
$960.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,000.59
|
| Rate for Payer: PHCS All Commercial |
$833.82
|
| Rate for Payer: PHP All Commercial |
$843.16
|
| Rate for Payer: Sagamore Health Network All Products |
$858.28
|
| Rate for Payer: Signature Care EPO |
$922.76
|
| Rate for Payer: Signature Care PPO |
$978.35
|
| Rate for Payer: United Healthcare Commercial |
$876.07
|
|
|
MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT
|
Facility
|
IP
|
$781.87
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
101034
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$586.40 |
| Max. Negotiated Rate |
$727.14 |
| Rate for Payer: Aetna Commercial |
$675.54
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Cigna All Commercial |
$674.75
|
| Rate for Payer: CORVEL All Commercial |
$727.14
|
| Rate for Payer: Coventry All Commercial |
$688.05
|
| Rate for Payer: Encore All Commercial |
$719.71
|
| Rate for Payer: Frontpath All Commercial |
$719.32
|
| Rate for Payer: Humana ChoiceCare |
$675.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.68
|
| Rate for Payer: PHCS All Commercial |
$586.40
|
| Rate for Payer: PHP All Commercial |
$592.97
|
| Rate for Payer: Sagamore Health Network All Products |
$603.60
|
| Rate for Payer: Signature Care EPO |
$648.95
|
| Rate for Payer: Signature Care PPO |
$688.05
|
| Rate for Payer: United Healthcare Commercial |
$616.11
|
|
|
MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT
|
Facility
|
OP
|
$781.87
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
101034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.50 |
| Max. Negotiated Rate |
$727.14 |
| Rate for Payer: Aetna Commercial |
$659.90
|
| Rate for Payer: Aetna Medicare |
$250.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$102.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$242.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$449.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$488.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$102.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$287.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$275.22
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Centivo All Commercial |
$425.34
|
| Rate for Payer: Cigna All Commercial |
$674.75
|
| Rate for Payer: CORVEL All Commercial |
$727.14
|
| Rate for Payer: Coventry All Commercial |
$688.05
|
| Rate for Payer: Encore All Commercial |
$719.71
|
| Rate for Payer: Frontpath All Commercial |
$719.32
|
| Rate for Payer: Humana ChoiceCare |
$675.30
|
| Rate for Payer: Humana Medicare |
$250.20
|
| Rate for Payer: Lucent All Commercial |
$425.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.68
|
| Rate for Payer: Managed Health Services Medicaid |
$102.50
|
| Rate for Payer: MDWise Medicaid |
$102.50
|
| Rate for Payer: PHCS All Commercial |
$586.40
|
| Rate for Payer: PHP All Commercial |
$592.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$304.93
|
| Rate for Payer: Sagamore Health Network All Products |
$603.60
|
| Rate for Payer: Signature Care EPO |
$648.95
|
| Rate for Payer: Signature Care PPO |
$688.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$664.59
|
| Rate for Payer: United Healthcare Commercial |
$616.11
|
| Rate for Payer: United Healthcare Medicare |
$250.20
|
|
|
MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN
|
Facility
|
IP
|
$781.86
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
199622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$586.39 |
| Max. Negotiated Rate |
$727.13 |
| Rate for Payer: Aetna Commercial |
$675.53
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Cigna All Commercial |
$674.75
|
| Rate for Payer: CORVEL All Commercial |
$727.13
|
| Rate for Payer: Coventry All Commercial |
$688.04
|
| Rate for Payer: Encore All Commercial |
$719.70
|
| Rate for Payer: Frontpath All Commercial |
$719.31
|
| Rate for Payer: Humana ChoiceCare |
$675.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.67
|
| Rate for Payer: PHCS All Commercial |
$586.39
|
| Rate for Payer: PHP All Commercial |
$592.96
|
| Rate for Payer: Sagamore Health Network All Products |
$603.60
|
| Rate for Payer: Signature Care EPO |
$648.94
|
| Rate for Payer: Signature Care PPO |
$688.04
|
| Rate for Payer: United Healthcare Commercial |
$616.11
|
|
|
MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN
|
Facility
|
OP
|
$781.86
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
199622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.50 |
| Max. Negotiated Rate |
$727.13 |
| Rate for Payer: Aetna Commercial |
$659.89
|
| Rate for Payer: Aetna Medicare |
$250.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$102.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$242.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$449.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$488.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$102.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$287.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$275.21
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Cash Price |
$469.12
|
| Rate for Payer: Centivo All Commercial |
$425.33
|
| Rate for Payer: Cigna All Commercial |
$674.75
|
| Rate for Payer: CORVEL All Commercial |
$727.13
|
| Rate for Payer: Coventry All Commercial |
$688.04
|
| Rate for Payer: Encore All Commercial |
$719.70
|
| Rate for Payer: Frontpath All Commercial |
$719.31
|
| Rate for Payer: Humana ChoiceCare |
$675.29
|
| Rate for Payer: Humana Medicare |
$250.20
|
| Rate for Payer: Lucent All Commercial |
$425.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.67
|
| Rate for Payer: Managed Health Services Medicaid |
$102.50
|
| Rate for Payer: MDWise Medicaid |
$102.50
|
| Rate for Payer: PHCS All Commercial |
$586.39
|
| Rate for Payer: PHP All Commercial |
$592.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$304.93
|
| Rate for Payer: Sagamore Health Network All Products |
$603.60
|
| Rate for Payer: Signature Care EPO |
$648.94
|
| Rate for Payer: Signature Care PPO |
$688.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$664.58
|
| Rate for Payer: United Healthcare Commercial |
$616.11
|
| Rate for Payer: United Healthcare Medicare |
$250.20
|
|
|
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE
|
Facility
|
IP
|
$3,804.05
|
|
|
Service Code
|
APR-DRG 7401
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$3,804.05 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE
|
Facility
|
IP
|
$11,152.77
|
|
|
Service Code
|
APR-DRG 7403
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$11,152.77 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE
|
Facility
|
IP
|
$24,207.57
|
|
|
Service Code
|
APR-DRG 7404
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$24,207.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE
|
Facility
|
IP
|
$6,354.49
|
|
|
Service Code
|
APR-DRG 7402
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$6,354.49 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
