|
MIDAZOLAM 5 MG/ML NASAL SOLN (CAMERON)
|
Facility
|
OP
|
$21.33
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
1.40101E+11
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$19.84 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$6.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.51
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$11.60
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$18.41
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$19.84
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$18.77
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$19.63
|
| Rate for Payer: Frontpath All Commercial |
$19.62
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$18.42
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$6.83
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$11.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$16.00
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$16.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.32
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$16.47
|
| Rate for Payer: Signature Care EPO |
$17.70
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$18.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$16.81
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$6.83
|
|
|
MIDAZOLAM 5 MG/ML NASAL SOLN (CAMERON)
|
Facility
|
IP
|
$21.33
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
1.40101E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$19.84 |
| Rate for Payer: Aetna Commercial |
$18.43
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$18.41
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$19.84
|
| Rate for Payer: Coventry All Commercial |
$18.77
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$19.63
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$19.62
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$18.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.20
|
| Rate for Payer: PHCS All Commercial |
$16.00
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$16.18
|
| Rate for Payer: Sagamore Health Network All Products |
$16.47
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$17.70
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$18.77
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$16.81
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJ SOLN
|
Facility
|
IP
|
$6.96
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
166680
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna Commercial |
$6.01
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna All Commercial |
$6.00
|
| Rate for Payer: CORVEL All Commercial |
$6.47
|
| Rate for Payer: Coventry All Commercial |
$6.12
|
| Rate for Payer: Encore All Commercial |
$6.40
|
| Rate for Payer: Frontpath All Commercial |
$6.40
|
| Rate for Payer: Humana ChoiceCare |
$6.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.26
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Sagamore Health Network All Products |
$5.37
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.12
|
| Rate for Payer: United Healthcare Commercial |
$5.48
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJ SOLN
|
Facility
|
OP
|
$6.96
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
166680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna Commercial |
$5.87
|
| Rate for Payer: Aetna Medicare |
$2.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.45
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Centivo All Commercial |
$3.79
|
| Rate for Payer: Cigna All Commercial |
$6.00
|
| Rate for Payer: CORVEL All Commercial |
$6.47
|
| Rate for Payer: Coventry All Commercial |
$6.12
|
| Rate for Payer: Encore All Commercial |
$6.40
|
| Rate for Payer: Frontpath All Commercial |
$6.40
|
| Rate for Payer: Humana ChoiceCare |
$6.01
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Lucent All Commercial |
$3.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.26
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.71
|
| Rate for Payer: Sagamore Health Network All Products |
$5.37
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.91
|
| Rate for Payer: United Healthcare Commercial |
$5.48
|
| Rate for Payer: United Healthcare Medicare |
$2.23
|
|
|
MIDODRINE 2.5 MG ORAL TAB
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 00904681761
|
| Hospital Charge Code |
10609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Aetna Medicare |
$1.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.59
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Centivo All Commercial |
$2.46
|
| Rate for Payer: Cigna All Commercial |
$3.90
|
| Rate for Payer: CORVEL All Commercial |
$4.20
|
| Rate for Payer: Coventry All Commercial |
$3.97
|
| Rate for Payer: Encore All Commercial |
$4.16
|
| Rate for Payer: Frontpath All Commercial |
$4.15
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Humana Medicare |
$1.44
|
| Rate for Payer: Lucent All Commercial |
$2.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.06
|
| Rate for Payer: PHCS All Commercial |
$3.39
|
| Rate for Payer: PHP All Commercial |
$3.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.76
|
| Rate for Payer: Sagamore Health Network All Products |
$3.49
|
| Rate for Payer: Signature Care EPO |
$3.75
|
| Rate for Payer: Signature Care PPO |
$3.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.84
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Medicare |
$1.44
|
|
|
MIDODRINE 2.5 MG ORAL TAB
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 00904681761
|
| Hospital Charge Code |
10609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.39 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna All Commercial |
$3.90
|
| Rate for Payer: CORVEL All Commercial |
$4.20
|
| Rate for Payer: Coventry All Commercial |
$3.97
|
| Rate for Payer: Encore All Commercial |
$4.16
|
| Rate for Payer: Frontpath All Commercial |
$4.15
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.06
|
| Rate for Payer: PHCS All Commercial |
$3.39
|
| Rate for Payer: PHP All Commercial |
$3.42
|
| Rate for Payer: Sagamore Health Network All Products |
$3.49
|
| Rate for Payer: Signature Care EPO |
$3.75
|
| Rate for Payer: Signature Care PPO |
$3.97
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
|
|
MIDODRINE 5 MG ORAL TAB
|
Facility
|
IP
|
$3.07
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Cigna All Commercial |
$2.65
|
| Rate for Payer: CORVEL All Commercial |
$2.86
|
| Rate for Payer: Coventry All Commercial |
$2.70
|
| Rate for Payer: Encore All Commercial |
$2.83
|
| Rate for Payer: Frontpath All Commercial |
$2.83
|
| Rate for Payer: Humana ChoiceCare |
$2.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.77
|
| Rate for Payer: PHCS All Commercial |
$2.30
|
| Rate for Payer: PHP All Commercial |
$2.33
|
| Rate for Payer: Sagamore Health Network All Products |
$2.37
|
| Rate for Payer: Signature Care EPO |
$2.55
|
| Rate for Payer: Signature Care PPO |
$2.70
|
| Rate for Payer: United Healthcare Commercial |
$2.42
|
|
|
MIDODRINE 5 MG ORAL TAB
|
Facility
|
OP
|
$3.07
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna Medicare |
$0.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Centivo All Commercial |
$1.67
|
| Rate for Payer: Cigna All Commercial |
$2.65
|
| Rate for Payer: CORVEL All Commercial |
$2.86
|
| Rate for Payer: Coventry All Commercial |
$2.70
|
| Rate for Payer: Encore All Commercial |
$2.83
|
| Rate for Payer: Frontpath All Commercial |
$2.83
|
| Rate for Payer: Humana ChoiceCare |
$2.65
|
| Rate for Payer: Humana Medicare |
$0.98
|
| Rate for Payer: Lucent All Commercial |
$1.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.77
|
| Rate for Payer: PHCS All Commercial |
$2.30
|
| Rate for Payer: PHP All Commercial |
$2.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2.37
|
| Rate for Payer: Signature Care EPO |
$2.55
|
| Rate for Payer: Signature Care PPO |
$2.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.61
|
| Rate for Payer: United Healthcare Commercial |
$2.42
|
| Rate for Payer: United Healthcare Medicare |
$0.98
|
|
|
MILRINONE 20 MG/100 ML IVPB
|
Facility
|
IP
|
$67.90
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$58.67
|
| Rate for Payer: Cash Price |
$40.74
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
|
|
MILRINONE 20 MG/100 ML IVPB
|
Facility
|
OP
|
$67.90
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$57.31
|
| Rate for Payer: Aetna Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$38.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.90
|
| Rate for Payer: Cash Price |
$40.74
|
| Rate for Payer: Centivo All Commercial |
$36.94
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: Lucent All Commercial |
$36.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.48
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$57.72
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
| Rate for Payer: United Healthcare Medicare |
$21.73
|
|
|
MINERAL OIL-HYDROPHIL PETROLAT TOP OINT
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 61924018416
|
| Hospital Charge Code |
27996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.44 |
| Max. Negotiated Rate |
$65.02 |
| Rate for Payer: Aetna Commercial |
$60.41
|
| Rate for Payer: Cash Price |
$41.95
|
| Rate for Payer: Cigna All Commercial |
$60.34
|
| Rate for Payer: CORVEL All Commercial |
$65.02
|
| Rate for Payer: Coventry All Commercial |
$61.53
|
| Rate for Payer: Encore All Commercial |
$64.36
|
| Rate for Payer: Frontpath All Commercial |
$64.32
|
| Rate for Payer: Humana ChoiceCare |
$60.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.92
|
| Rate for Payer: PHCS All Commercial |
$52.44
|
| Rate for Payer: PHP All Commercial |
$53.02
|
| Rate for Payer: Sagamore Health Network All Products |
$53.98
|
| Rate for Payer: Signature Care EPO |
$58.03
|
| Rate for Payer: Signature Care PPO |
$61.53
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
|
|
MINERAL OIL-HYDROPHIL PETROLAT TOP OINT
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 61924018416
|
| Hospital Charge Code |
27996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.67 |
| Max. Negotiated Rate |
$65.02 |
| Rate for Payer: Aetna Commercial |
$59.01
|
| Rate for Payer: Aetna Medicare |
$22.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$40.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.61
|
| Rate for Payer: Cash Price |
$41.95
|
| Rate for Payer: Centivo All Commercial |
$38.03
|
| Rate for Payer: Cigna All Commercial |
$60.34
|
| Rate for Payer: CORVEL All Commercial |
$65.02
|
| Rate for Payer: Coventry All Commercial |
$61.53
|
| Rate for Payer: Encore All Commercial |
$64.36
|
| Rate for Payer: Frontpath All Commercial |
$64.32
|
| Rate for Payer: Humana ChoiceCare |
$60.39
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Lucent All Commercial |
$38.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.92
|
| Rate for Payer: PHCS All Commercial |
$52.44
|
| Rate for Payer: PHP All Commercial |
$53.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.27
|
| Rate for Payer: Sagamore Health Network All Products |
$53.98
|
| Rate for Payer: Signature Care EPO |
$58.03
|
| Rate for Payer: Signature Care PPO |
$61.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.43
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
| Rate for Payer: United Healthcare Medicare |
$22.37
|
|
|
MINERAL OIL ORAL OIL
|
Facility
|
OP
|
$15.33
|
|
|
Service Code
|
NDC 48433020230
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Aetna Medicare |
$4.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$9.20
|
| Rate for Payer: Centivo All Commercial |
$8.34
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Humana Medicare |
$4.91
|
| Rate for Payer: Lucent All Commercial |
$8.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.03
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
| Rate for Payer: United Healthcare Medicare |
$4.91
|
|
|
MINERAL OIL ORAL OIL
|
Facility
|
IP
|
$15.33
|
|
|
Service Code
|
NDC 48433020230
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$13.25
|
| Rate for Payer: Cash Price |
$9.20
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
|
|
MIRABEGRON 25 MG ORAL TB24
|
Facility
|
IP
|
$86.30
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
158433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.72 |
| Max. Negotiated Rate |
$80.26 |
| Rate for Payer: Aetna Commercial |
$74.56
|
| Rate for Payer: Cash Price |
$51.78
|
| Rate for Payer: Cigna All Commercial |
$74.47
|
| Rate for Payer: CORVEL All Commercial |
$80.26
|
| Rate for Payer: Coventry All Commercial |
$75.94
|
| Rate for Payer: Encore All Commercial |
$79.44
|
| Rate for Payer: Frontpath All Commercial |
$79.39
|
| Rate for Payer: Humana ChoiceCare |
$74.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$77.67
|
| Rate for Payer: PHCS All Commercial |
$64.72
|
| Rate for Payer: PHP All Commercial |
$65.45
|
| Rate for Payer: Sagamore Health Network All Products |
$66.62
|
| Rate for Payer: Signature Care EPO |
$71.63
|
| Rate for Payer: Signature Care PPO |
$75.94
|
| Rate for Payer: United Healthcare Commercial |
$68.00
|
|
|
MIRABEGRON 25 MG ORAL TB24
|
Facility
|
OP
|
$86.30
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
158433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$80.26 |
| Rate for Payer: Aetna Commercial |
$72.83
|
| Rate for Payer: Aetna Medicare |
$27.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$49.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$53.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.38
|
| Rate for Payer: Cash Price |
$51.78
|
| Rate for Payer: Centivo All Commercial |
$46.95
|
| Rate for Payer: Cigna All Commercial |
$74.47
|
| Rate for Payer: CORVEL All Commercial |
$80.26
|
| Rate for Payer: Coventry All Commercial |
$75.94
|
| Rate for Payer: Encore All Commercial |
$79.44
|
| Rate for Payer: Frontpath All Commercial |
$79.39
|
| Rate for Payer: Humana ChoiceCare |
$74.53
|
| Rate for Payer: Humana Medicare |
$27.61
|
| Rate for Payer: Lucent All Commercial |
$46.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$77.67
|
| Rate for Payer: PHCS All Commercial |
$64.72
|
| Rate for Payer: PHP All Commercial |
$65.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$33.66
|
| Rate for Payer: Sagamore Health Network All Products |
$66.62
|
| Rate for Payer: Signature Care EPO |
$71.63
|
| Rate for Payer: Signature Care PPO |
$75.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$73.35
|
| Rate for Payer: United Healthcare Commercial |
$68.00
|
| Rate for Payer: United Healthcare Medicare |
$27.61
|
|
|
MIRABEGRON 50 MG ORAL TB24
|
Facility
|
OP
|
$100.69
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
158434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$93.64 |
| Rate for Payer: Aetna Commercial |
$84.98
|
| Rate for Payer: Aetna Medicare |
$32.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$57.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.44
|
| Rate for Payer: Cash Price |
$60.41
|
| Rate for Payer: Centivo All Commercial |
$54.77
|
| Rate for Payer: Cigna All Commercial |
$86.89
|
| Rate for Payer: CORVEL All Commercial |
$93.64
|
| Rate for Payer: Coventry All Commercial |
$88.61
|
| Rate for Payer: Encore All Commercial |
$92.68
|
| Rate for Payer: Frontpath All Commercial |
$92.63
|
| Rate for Payer: Humana ChoiceCare |
$86.96
|
| Rate for Payer: Humana Medicare |
$32.22
|
| Rate for Payer: Lucent All Commercial |
$54.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.62
|
| Rate for Payer: PHCS All Commercial |
$75.52
|
| Rate for Payer: PHP All Commercial |
$76.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.27
|
| Rate for Payer: Sagamore Health Network All Products |
$77.73
|
| Rate for Payer: Signature Care EPO |
$83.57
|
| Rate for Payer: Signature Care PPO |
$88.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.58
|
| Rate for Payer: United Healthcare Commercial |
$79.34
|
| Rate for Payer: United Healthcare Medicare |
$32.22
|
|
|
MIRABEGRON 50 MG ORAL TB24
|
Facility
|
IP
|
$100.69
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
158434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.52 |
| Max. Negotiated Rate |
$93.64 |
| Rate for Payer: Aetna Commercial |
$86.99
|
| Rate for Payer: Cash Price |
$60.41
|
| Rate for Payer: Cigna All Commercial |
$86.89
|
| Rate for Payer: CORVEL All Commercial |
$93.64
|
| Rate for Payer: Coventry All Commercial |
$88.61
|
| Rate for Payer: Encore All Commercial |
$92.68
|
| Rate for Payer: Frontpath All Commercial |
$92.63
|
| Rate for Payer: Humana ChoiceCare |
$86.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.62
|
| Rate for Payer: PHCS All Commercial |
$75.52
|
| Rate for Payer: PHP All Commercial |
$76.36
|
| Rate for Payer: Sagamore Health Network All Products |
$77.73
|
| Rate for Payer: Signature Care EPO |
$83.57
|
| Rate for Payer: Signature Care PPO |
$88.61
|
| Rate for Payer: United Healthcare Commercial |
$79.34
|
|
|
MIRIKIZUMAB-MRKZ 300 MG/15 ML (20 MG/ML) IV SOLN
|
Facility
|
OP
|
$35,255.06
|
|
|
Service Code
|
HCPCS J2267
|
| Hospital Charge Code |
203340
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$32,787.21 |
| Rate for Payer: Aetna Commercial |
$29,755.27
|
| Rate for Payer: Aetna Medicare |
$11,281.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$33.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10,929.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20,246.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22,037.94
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$33.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12,973.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12,409.78
|
| Rate for Payer: Cash Price |
$21,153.04
|
| Rate for Payer: Cash Price |
$21,153.04
|
| Rate for Payer: Centivo All Commercial |
$19,178.75
|
| Rate for Payer: Cigna All Commercial |
$30,425.12
|
| Rate for Payer: CORVEL All Commercial |
$32,787.21
|
| Rate for Payer: Coventry All Commercial |
$31,024.46
|
| Rate for Payer: Encore All Commercial |
$32,452.29
|
| Rate for Payer: Frontpath All Commercial |
$32,434.66
|
| Rate for Payer: Humana ChoiceCare |
$30,449.80
|
| Rate for Payer: Humana Medicare |
$11,281.62
|
| Rate for Payer: Lucent All Commercial |
$19,178.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31,729.56
|
| Rate for Payer: Managed Health Services Medicaid |
$33.58
|
| Rate for Payer: MDWise Medicaid |
$33.58
|
| Rate for Payer: PHCS All Commercial |
$26,441.30
|
| Rate for Payer: PHP All Commercial |
$26,737.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13,749.47
|
| Rate for Payer: Sagamore Health Network All Products |
$27,216.91
|
| Rate for Payer: Signature Care EPO |
$29,261.70
|
| Rate for Payer: Signature Care PPO |
$31,024.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29,966.80
|
| Rate for Payer: United Healthcare Commercial |
$27,780.99
|
| Rate for Payer: United Healthcare Medicare |
$11,281.62
|
|
|
MIRIKIZUMAB-MRKZ 300 MG/15 ML (20 MG/ML) IV SOLN
|
Facility
|
IP
|
$35,255.06
|
|
|
Service Code
|
HCPCS J2267
|
| Hospital Charge Code |
203340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26,441.30 |
| Max. Negotiated Rate |
$32,787.21 |
| Rate for Payer: Aetna Commercial |
$30,460.37
|
| Rate for Payer: Cash Price |
$21,153.04
|
| Rate for Payer: Cigna All Commercial |
$30,425.12
|
| Rate for Payer: CORVEL All Commercial |
$32,787.21
|
| Rate for Payer: Coventry All Commercial |
$31,024.46
|
| Rate for Payer: Encore All Commercial |
$32,452.29
|
| Rate for Payer: Frontpath All Commercial |
$32,434.66
|
| Rate for Payer: Humana ChoiceCare |
$30,449.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31,729.56
|
| Rate for Payer: PHCS All Commercial |
$26,441.30
|
| Rate for Payer: PHP All Commercial |
$26,737.44
|
| Rate for Payer: Sagamore Health Network All Products |
$27,216.91
|
| Rate for Payer: Signature Care EPO |
$29,261.70
|
| Rate for Payer: Signature Care PPO |
$31,024.46
|
| Rate for Payer: United Healthcare Commercial |
$27,780.99
|
|
|
MIRTAZAPINE 15 MG ORAL TAB
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
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 |
$0.71
|
| 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
|
|
|
MIRTAZAPINE 15 MG ORAL TAB
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Centivo All Commercial |
$0.64
|
| 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 |
$0.38
|
| Rate for Payer: Lucent All Commercial |
$0.64
|
| 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 |
$0.38
|
|
|
MISOPROSTOL 100 MCG ORAL TAB
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
|
|
MISOPROSTOL 100 MCG ORAL TAB
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Aetna Medicare |
$1.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Centivo All Commercial |
$2.35
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Humana Medicare |
$1.38
|
| Rate for Payer: Lucent All Commercial |
$2.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
| Rate for Payer: United Healthcare Medicare |
$1.38
|
|
|
MISOPROSTOL 200 MCG ORAL TAB
|
Facility
|
IP
|
$16.23
|
|
|
Service Code
|
NDC 60687074611
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$15.10 |
| Rate for Payer: Aetna Commercial |
$14.03
|
| Rate for Payer: Cash Price |
$9.74
|
| Rate for Payer: Cigna All Commercial |
$14.01
|
| Rate for Payer: CORVEL All Commercial |
$15.10
|
| Rate for Payer: Coventry All Commercial |
$14.29
|
| Rate for Payer: Encore All Commercial |
$14.94
|
| Rate for Payer: Frontpath All Commercial |
$14.93
|
| Rate for Payer: Humana ChoiceCare |
$14.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.61
|
| Rate for Payer: PHCS All Commercial |
$12.17
|
| Rate for Payer: PHP All Commercial |
$12.31
|
| Rate for Payer: Sagamore Health Network All Products |
$12.53
|
| Rate for Payer: Signature Care EPO |
$13.47
|
| Rate for Payer: Signature Care PPO |
$14.29
|
| Rate for Payer: United Healthcare Commercial |
$12.79
|
|
