|
OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN
|
Facility
|
IP
|
$179.70
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$134.77 |
| Max. Negotiated Rate |
$167.12 |
| Rate for Payer: Aetna Commercial |
$155.26
|
| Rate for Payer: Cash Price |
$107.82
|
| Rate for Payer: Cigna All Commercial |
$155.08
|
| Rate for Payer: CORVEL All Commercial |
$167.12
|
| Rate for Payer: Coventry All Commercial |
$158.13
|
| Rate for Payer: Encore All Commercial |
$165.41
|
| Rate for Payer: Frontpath All Commercial |
$165.32
|
| Rate for Payer: Humana ChoiceCare |
$155.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$161.73
|
| Rate for Payer: PHCS All Commercial |
$134.77
|
| Rate for Payer: PHP All Commercial |
$136.28
|
| Rate for Payer: Sagamore Health Network All Products |
$138.73
|
| Rate for Payer: Signature Care EPO |
$149.15
|
| Rate for Payer: Signature Care PPO |
$158.13
|
| Rate for Payer: United Healthcare Commercial |
$141.60
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG IM SERR
|
Facility
|
OP
|
$15,147.23
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
172236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$209.04 |
| Max. Negotiated Rate |
$14,086.92 |
| Rate for Payer: Aetna Commercial |
$12,784.26
|
| Rate for Payer: Aetna Medicare |
$4,847.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$209.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,695.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8,699.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,468.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$209.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,574.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,331.82
|
| Rate for Payer: Cash Price |
$9,088.34
|
| Rate for Payer: Cash Price |
$9,088.34
|
| Rate for Payer: Centivo All Commercial |
$8,240.09
|
| Rate for Payer: Cigna All Commercial |
$13,072.06
|
| Rate for Payer: CORVEL All Commercial |
$14,086.92
|
| Rate for Payer: Coventry All Commercial |
$13,329.56
|
| Rate for Payer: Encore All Commercial |
$13,943.03
|
| Rate for Payer: Frontpath All Commercial |
$13,935.45
|
| Rate for Payer: Humana ChoiceCare |
$13,082.66
|
| Rate for Payer: Humana Medicare |
$4,847.11
|
| Rate for Payer: Lucent All Commercial |
$8,240.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,632.51
|
| Rate for Payer: Managed Health Services Medicaid |
$209.04
|
| Rate for Payer: MDWise Medicaid |
$209.04
|
| Rate for Payer: PHCS All Commercial |
$11,360.42
|
| Rate for Payer: PHP All Commercial |
$11,487.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,907.42
|
| Rate for Payer: Sagamore Health Network All Products |
$11,693.66
|
| Rate for Payer: Signature Care EPO |
$12,572.20
|
| Rate for Payer: Signature Care PPO |
$13,329.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,875.15
|
| Rate for Payer: United Healthcare Commercial |
$11,936.02
|
| Rate for Payer: United Healthcare Medicare |
$4,847.11
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG IM SERR
|
Facility
|
IP
|
$15,147.23
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
172236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,360.42 |
| Max. Negotiated Rate |
$14,086.92 |
| Rate for Payer: Aetna Commercial |
$13,087.21
|
| Rate for Payer: Cash Price |
$9,088.34
|
| Rate for Payer: Cigna All Commercial |
$13,072.06
|
| Rate for Payer: CORVEL All Commercial |
$14,086.92
|
| Rate for Payer: Coventry All Commercial |
$13,329.56
|
| Rate for Payer: Encore All Commercial |
$13,943.03
|
| Rate for Payer: Frontpath All Commercial |
$13,935.45
|
| Rate for Payer: Humana ChoiceCare |
$13,082.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,632.51
|
| Rate for Payer: PHCS All Commercial |
$11,360.42
|
| Rate for Payer: PHP All Commercial |
$11,487.66
|
| Rate for Payer: Sagamore Health Network All Products |
$11,693.66
|
| Rate for Payer: Signature Care EPO |
$12,572.20
|
| Rate for Payer: Signature Care PPO |
$13,329.56
|
| Rate for Payer: United Healthcare Commercial |
$11,936.02
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG IM SERR
|
Facility
|
OP
|
$22,681.86
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
172237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$209.04 |
| Max. Negotiated Rate |
$21,094.13 |
| Rate for Payer: Aetna Commercial |
$19,143.49
|
| Rate for Payer: Aetna Medicare |
$7,258.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$209.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7,031.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13,026.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14,178.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$209.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8,346.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,984.01
|
| Rate for Payer: Cash Price |
$13,609.11
|
| Rate for Payer: Cash Price |
$13,609.11
|
| Rate for Payer: Centivo All Commercial |
$12,338.93
|
| Rate for Payer: Cigna All Commercial |
$19,574.44
|
| Rate for Payer: CORVEL All Commercial |
$21,094.13
|
| Rate for Payer: Coventry All Commercial |
$19,960.03
|
| Rate for Payer: Encore All Commercial |
$20,878.65
|
| Rate for Payer: Frontpath All Commercial |
$20,867.31
|
| Rate for Payer: Humana ChoiceCare |
$19,590.32
|
| Rate for Payer: Humana Medicare |
$7,258.19
|
| Rate for Payer: Lucent All Commercial |
$12,338.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20,413.67
|
| Rate for Payer: Managed Health Services Medicaid |
$209.04
|
| Rate for Payer: MDWise Medicaid |
$209.04
|
| Rate for Payer: PHCS All Commercial |
$17,011.39
|
| Rate for Payer: PHP All Commercial |
$17,201.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,845.92
|
| Rate for Payer: Sagamore Health Network All Products |
$17,510.39
|
| Rate for Payer: Signature Care EPO |
$18,825.94
|
| Rate for Payer: Signature Care PPO |
$19,960.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19,279.58
|
| Rate for Payer: United Healthcare Commercial |
$17,873.30
|
| Rate for Payer: United Healthcare Medicare |
$7,258.19
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG IM SERR
|
Facility
|
IP
|
$22,681.86
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
172237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17,011.39 |
| Max. Negotiated Rate |
$21,094.13 |
| Rate for Payer: Aetna Commercial |
$19,597.12
|
| Rate for Payer: Cash Price |
$13,609.11
|
| Rate for Payer: Cigna All Commercial |
$19,574.44
|
| Rate for Payer: CORVEL All Commercial |
$21,094.13
|
| Rate for Payer: Coventry All Commercial |
$19,960.03
|
| Rate for Payer: Encore All Commercial |
$20,878.65
|
| Rate for Payer: Frontpath All Commercial |
$20,867.31
|
| Rate for Payer: Humana ChoiceCare |
$19,590.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20,413.67
|
| Rate for Payer: PHCS All Commercial |
$17,011.39
|
| Rate for Payer: PHP All Commercial |
$17,201.92
|
| Rate for Payer: Sagamore Health Network All Products |
$17,510.39
|
| Rate for Payer: Signature Care EPO |
$18,825.94
|
| Rate for Payer: Signature Care PPO |
$19,960.03
|
| Rate for Payer: United Healthcare Commercial |
$17,873.30
|
|
|
OFLOXACIN 0.3 % OPHT DROP
|
Facility
|
IP
|
$97.65
|
|
|
Service Code
|
NDC 64980051505
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.24 |
| Max. Negotiated Rate |
$90.81 |
| Rate for Payer: Aetna Commercial |
$84.37
|
| Rate for Payer: Cash Price |
$58.59
|
| Rate for Payer: Cigna All Commercial |
$84.27
|
| Rate for Payer: CORVEL All Commercial |
$90.81
|
| Rate for Payer: Coventry All Commercial |
$85.93
|
| Rate for Payer: Encore All Commercial |
$89.89
|
| Rate for Payer: Frontpath All Commercial |
$89.84
|
| Rate for Payer: Humana ChoiceCare |
$84.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$87.89
|
| Rate for Payer: PHCS All Commercial |
$73.24
|
| Rate for Payer: PHP All Commercial |
$74.06
|
| Rate for Payer: Sagamore Health Network All Products |
$75.39
|
| Rate for Payer: Signature Care EPO |
$81.05
|
| Rate for Payer: Signature Care PPO |
$85.93
|
| Rate for Payer: United Healthcare Commercial |
$76.95
|
|
|
OFLOXACIN 0.3 % OPHT DROP
|
Facility
|
OP
|
$97.65
|
|
|
Service Code
|
NDC 64980051505
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$90.81 |
| Rate for Payer: Aetna Commercial |
$82.42
|
| Rate for Payer: Aetna Medicare |
$31.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$56.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$61.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.37
|
| Rate for Payer: Cash Price |
$58.59
|
| Rate for Payer: Cash Price |
$58.59
|
| Rate for Payer: Centivo All Commercial |
$53.12
|
| Rate for Payer: Cigna All Commercial |
$84.27
|
| Rate for Payer: CORVEL All Commercial |
$90.81
|
| Rate for Payer: Coventry All Commercial |
$85.93
|
| Rate for Payer: Encore All Commercial |
$89.89
|
| Rate for Payer: Frontpath All Commercial |
$89.84
|
| Rate for Payer: Humana ChoiceCare |
$84.34
|
| Rate for Payer: Humana Medicare |
$31.25
|
| Rate for Payer: Lucent All Commercial |
$53.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$87.89
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$73.24
|
| Rate for Payer: PHP All Commercial |
$74.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.08
|
| Rate for Payer: Sagamore Health Network All Products |
$75.39
|
| Rate for Payer: Signature Care EPO |
$81.05
|
| Rate for Payer: Signature Care PPO |
$85.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$83.00
|
| Rate for Payer: United Healthcare Commercial |
$76.95
|
| Rate for Payer: United Healthcare Medicare |
$31.25
|
|
|
OLANZAPINE 10 MG IM SOLR
|
Facility
|
IP
|
$128.87
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.65 |
| Max. Negotiated Rate |
$119.85 |
| Rate for Payer: Aetna Commercial |
$111.34
|
| Rate for Payer: Cash Price |
$77.32
|
| Rate for Payer: Cigna All Commercial |
$111.21
|
| Rate for Payer: CORVEL All Commercial |
$119.85
|
| Rate for Payer: Coventry All Commercial |
$113.41
|
| Rate for Payer: Encore All Commercial |
$118.62
|
| Rate for Payer: Frontpath All Commercial |
$118.56
|
| Rate for Payer: Humana ChoiceCare |
$111.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$115.98
|
| Rate for Payer: PHCS All Commercial |
$96.65
|
| Rate for Payer: PHP All Commercial |
$97.74
|
| Rate for Payer: Sagamore Health Network All Products |
$99.49
|
| Rate for Payer: Signature Care EPO |
$106.96
|
| Rate for Payer: Signature Care PPO |
$113.41
|
| Rate for Payer: United Healthcare Commercial |
$101.55
|
|
|
OLANZAPINE 10 MG IM SOLR
|
Facility
|
OP
|
$128.87
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$119.85 |
| Rate for Payer: Aetna Commercial |
$108.77
|
| Rate for Payer: Aetna Medicare |
$41.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$74.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$80.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.36
|
| Rate for Payer: Cash Price |
$77.32
|
| Rate for Payer: Centivo All Commercial |
$70.11
|
| Rate for Payer: Cigna All Commercial |
$111.21
|
| Rate for Payer: CORVEL All Commercial |
$119.85
|
| Rate for Payer: Coventry All Commercial |
$113.41
|
| Rate for Payer: Encore All Commercial |
$118.62
|
| Rate for Payer: Frontpath All Commercial |
$118.56
|
| Rate for Payer: Humana ChoiceCare |
$111.31
|
| Rate for Payer: Humana Medicare |
$41.24
|
| Rate for Payer: Lucent All Commercial |
$70.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$115.98
|
| Rate for Payer: PHCS All Commercial |
$96.65
|
| Rate for Payer: PHP All Commercial |
$97.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$50.26
|
| Rate for Payer: Sagamore Health Network All Products |
$99.49
|
| Rate for Payer: Signature Care EPO |
$106.96
|
| Rate for Payer: Signature Care PPO |
$113.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$109.54
|
| Rate for Payer: United Healthcare Commercial |
$101.55
|
| Rate for Payer: United Healthcare Medicare |
$41.24
|
|
|
OLANZAPINE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904637761
|
| Hospital Charge Code |
17936
|
|
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
|
|
|
OLANZAPINE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904637761
|
| Hospital Charge Code |
17936
|
|
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
|
|
|
OLOPATADINE 0.1 % OPHT DROP
|
Facility
|
IP
|
$40.11
|
|
|
Service Code
|
NDC 70069001701
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.08 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$34.66
|
| Rate for Payer: Cash Price |
$24.07
|
| Rate for Payer: Cigna All Commercial |
$34.61
|
| Rate for Payer: CORVEL All Commercial |
$37.30
|
| Rate for Payer: Coventry All Commercial |
$35.30
|
| Rate for Payer: Encore All Commercial |
$36.92
|
| Rate for Payer: Frontpath All Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$34.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.10
|
| Rate for Payer: PHCS All Commercial |
$30.08
|
| Rate for Payer: PHP All Commercial |
$30.42
|
| Rate for Payer: Sagamore Health Network All Products |
$30.96
|
| Rate for Payer: Signature Care EPO |
$33.29
|
| Rate for Payer: Signature Care PPO |
$35.30
|
| Rate for Payer: United Healthcare Commercial |
$31.61
|
|
|
OLOPATADINE 0.1 % OPHT DROP
|
Facility
|
OP
|
$40.11
|
|
|
Service Code
|
NDC 70069001701
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$33.85
|
| Rate for Payer: Aetna Medicare |
$12.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$23.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.12
|
| Rate for Payer: Cash Price |
$24.07
|
| Rate for Payer: Centivo All Commercial |
$21.82
|
| Rate for Payer: Cigna All Commercial |
$34.61
|
| Rate for Payer: CORVEL All Commercial |
$37.30
|
| Rate for Payer: Coventry All Commercial |
$35.30
|
| Rate for Payer: Encore All Commercial |
$36.92
|
| Rate for Payer: Frontpath All Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$34.64
|
| Rate for Payer: Humana Medicare |
$12.84
|
| Rate for Payer: Lucent All Commercial |
$21.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.10
|
| Rate for Payer: PHCS All Commercial |
$30.08
|
| Rate for Payer: PHP All Commercial |
$30.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.64
|
| Rate for Payer: Sagamore Health Network All Products |
$30.96
|
| Rate for Payer: Signature Care EPO |
$33.29
|
| Rate for Payer: Signature Care PPO |
$35.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34.09
|
| Rate for Payer: United Healthcare Commercial |
$31.61
|
| Rate for Payer: United Healthcare Medicare |
$12.84
|
|
|
OMALIZUMAB 150 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$4,966.33
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
186619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,724.75 |
| Max. Negotiated Rate |
$4,618.69 |
| Rate for Payer: Aetna Commercial |
$4,290.91
|
| Rate for Payer: Cash Price |
$2,979.80
|
| Rate for Payer: Cigna All Commercial |
$4,285.95
|
| Rate for Payer: CORVEL All Commercial |
$4,618.69
|
| Rate for Payer: Coventry All Commercial |
$4,370.37
|
| Rate for Payer: Encore All Commercial |
$4,571.51
|
| Rate for Payer: Frontpath All Commercial |
$4,569.03
|
| Rate for Payer: Humana ChoiceCare |
$4,289.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,469.70
|
| Rate for Payer: PHCS All Commercial |
$3,724.75
|
| Rate for Payer: PHP All Commercial |
$3,766.47
|
| Rate for Payer: Sagamore Health Network All Products |
$3,834.01
|
| Rate for Payer: Signature Care EPO |
$4,122.06
|
| Rate for Payer: Signature Care PPO |
$4,370.37
|
| Rate for Payer: United Healthcare Commercial |
$3,913.47
|
|
|
OMALIZUMAB 150 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$4,966.33
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
186619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.56 |
| Max. Negotiated Rate |
$4,618.69 |
| Rate for Payer: Aetna Commercial |
$4,191.59
|
| Rate for Payer: Aetna Medicare |
$1,589.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$49.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,539.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,852.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,104.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$49.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,827.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,748.15
|
| Rate for Payer: Cash Price |
$2,979.80
|
| Rate for Payer: Cash Price |
$2,979.80
|
| Rate for Payer: Centivo All Commercial |
$2,701.69
|
| Rate for Payer: Cigna All Commercial |
$4,285.95
|
| Rate for Payer: CORVEL All Commercial |
$4,618.69
|
| Rate for Payer: Coventry All Commercial |
$4,370.37
|
| Rate for Payer: Encore All Commercial |
$4,571.51
|
| Rate for Payer: Frontpath All Commercial |
$4,569.03
|
| Rate for Payer: Humana ChoiceCare |
$4,289.42
|
| Rate for Payer: Humana Medicare |
$1,589.23
|
| Rate for Payer: Lucent All Commercial |
$2,701.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,469.70
|
| Rate for Payer: Managed Health Services Medicaid |
$49.56
|
| Rate for Payer: MDWise Medicaid |
$49.56
|
| Rate for Payer: PHCS All Commercial |
$3,724.75
|
| Rate for Payer: PHP All Commercial |
$3,766.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,936.87
|
| Rate for Payer: Sagamore Health Network All Products |
$3,834.01
|
| Rate for Payer: Signature Care EPO |
$4,122.06
|
| Rate for Payer: Signature Care PPO |
$4,370.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,221.38
|
| Rate for Payer: United Healthcare Commercial |
$3,913.47
|
| Rate for Payer: United Healthcare Medicare |
$1,589.23
|
|
|
OMALIZUMAB 150 MG SUBQ SOLR
|
Facility
|
OP
|
$4,956.53
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.56 |
| Max. Negotiated Rate |
$4,609.57 |
| Rate for Payer: Aetna Commercial |
$4,183.31
|
| Rate for Payer: Aetna Medicare |
$1,586.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$49.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,536.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,846.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,098.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$49.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,824.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,744.70
|
| Rate for Payer: Cash Price |
$2,973.92
|
| Rate for Payer: Cash Price |
$2,973.92
|
| Rate for Payer: Centivo All Commercial |
$2,696.35
|
| Rate for Payer: Cigna All Commercial |
$4,277.48
|
| Rate for Payer: CORVEL All Commercial |
$4,609.57
|
| Rate for Payer: Coventry All Commercial |
$4,361.74
|
| Rate for Payer: Encore All Commercial |
$4,562.48
|
| Rate for Payer: Frontpath All Commercial |
$4,560.00
|
| Rate for Payer: Humana ChoiceCare |
$4,280.95
|
| Rate for Payer: Humana Medicare |
$1,586.09
|
| Rate for Payer: Lucent All Commercial |
$2,696.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,460.87
|
| Rate for Payer: Managed Health Services Medicaid |
$49.56
|
| Rate for Payer: MDWise Medicaid |
$49.56
|
| Rate for Payer: PHCS All Commercial |
$3,717.39
|
| Rate for Payer: PHP All Commercial |
$3,759.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,933.04
|
| Rate for Payer: Sagamore Health Network All Products |
$3,826.44
|
| Rate for Payer: Signature Care EPO |
$4,113.92
|
| Rate for Payer: Signature Care PPO |
$4,361.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,213.05
|
| Rate for Payer: United Healthcare Commercial |
$3,905.74
|
| Rate for Payer: United Healthcare Medicare |
$1,586.09
|
|
|
OMALIZUMAB 150 MG SUBQ SOLR
|
Facility
|
IP
|
$4,956.53
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
36151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,717.39 |
| Max. Negotiated Rate |
$4,609.57 |
| Rate for Payer: Aetna Commercial |
$4,282.44
|
| Rate for Payer: Cash Price |
$2,973.92
|
| Rate for Payer: Cigna All Commercial |
$4,277.48
|
| Rate for Payer: CORVEL All Commercial |
$4,609.57
|
| Rate for Payer: Coventry All Commercial |
$4,361.74
|
| Rate for Payer: Encore All Commercial |
$4,562.48
|
| Rate for Payer: Frontpath All Commercial |
$4,560.00
|
| Rate for Payer: Humana ChoiceCare |
$4,280.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,460.87
|
| Rate for Payer: PHCS All Commercial |
$3,717.39
|
| Rate for Payer: PHP All Commercial |
$3,759.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3,826.44
|
| Rate for Payer: Signature Care EPO |
$4,113.92
|
| Rate for Payer: Signature Care PPO |
$4,361.74
|
| Rate for Payer: United Healthcare Commercial |
$3,905.74
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 60-90-500 MG ORAL CPDR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 11845014479
|
| Hospital Charge Code |
119301
|
|
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
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 60-90-500 MG ORAL CPDR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 11845014479
|
| Hospital Charge Code |
119301
|
|
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
|
|
|
OMEPRAZOLE 20 MG ORAL TBLD
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 70000038102
|
| Hospital Charge Code |
184898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Centivo All Commercial |
$1.55
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.65
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.62
|
| Rate for Payer: Humana ChoiceCare |
$2.46
|
| Rate for Payer: Humana Medicare |
$0.91
|
| Rate for Payer: Lucent All Commercial |
$1.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
| Rate for Payer: United Healthcare Medicare |
$0.91
|
|
|
OMEPRAZOLE 20 MG ORAL TBLD
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
NDC 70000038102
|
| Hospital Charge Code |
184898
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.65
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.62
|
| Rate for Payer: Humana ChoiceCare |
$2.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
|
|
ONABOTULINUMTOXINA 100 UNITS INJ SOLR
|
Facility
|
OP
|
$2,584.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
32700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.78 |
| Max. Negotiated Rate |
$2,403.12 |
| Rate for Payer: Aetna Commercial |
$2,180.90
|
| Rate for Payer: Aetna Medicare |
$826.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$6.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$801.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,483.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,615.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$6.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$950.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$909.57
|
| Rate for Payer: Cash Price |
$1,550.40
|
| Rate for Payer: Cash Price |
$1,550.40
|
| Rate for Payer: Centivo All Commercial |
$1,405.70
|
| Rate for Payer: Cigna All Commercial |
$2,229.99
|
| Rate for Payer: CORVEL All Commercial |
$2,403.12
|
| Rate for Payer: Coventry All Commercial |
$2,273.92
|
| Rate for Payer: Encore All Commercial |
$2,378.57
|
| Rate for Payer: Frontpath All Commercial |
$2,377.28
|
| Rate for Payer: Humana ChoiceCare |
$2,231.80
|
| Rate for Payer: Humana Medicare |
$826.88
|
| Rate for Payer: Lucent All Commercial |
$1,405.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,325.60
|
| Rate for Payer: Managed Health Services Medicaid |
$6.78
|
| Rate for Payer: MDWise Medicaid |
$6.78
|
| Rate for Payer: PHCS All Commercial |
$1,938.00
|
| Rate for Payer: PHP All Commercial |
$1,959.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,007.76
|
| Rate for Payer: Sagamore Health Network All Products |
$1,994.85
|
| Rate for Payer: Signature Care EPO |
$2,144.72
|
| Rate for Payer: Signature Care PPO |
$2,273.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,196.40
|
| Rate for Payer: United Healthcare Commercial |
$2,036.19
|
| Rate for Payer: United Healthcare Medicare |
$826.88
|
|
|
ONABOTULINUMTOXINA 100 UNITS INJ SOLR
|
Facility
|
IP
|
$2,584.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
32700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,938.00 |
| Max. Negotiated Rate |
$2,403.12 |
| Rate for Payer: Aetna Commercial |
$2,232.58
|
| Rate for Payer: Cash Price |
$1,550.40
|
| Rate for Payer: Cigna All Commercial |
$2,229.99
|
| Rate for Payer: CORVEL All Commercial |
$2,403.12
|
| Rate for Payer: Coventry All Commercial |
$2,273.92
|
| Rate for Payer: Encore All Commercial |
$2,378.57
|
| Rate for Payer: Frontpath All Commercial |
$2,377.28
|
| Rate for Payer: Humana ChoiceCare |
$2,231.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,325.60
|
| Rate for Payer: PHCS All Commercial |
$1,938.00
|
| Rate for Payer: PHP All Commercial |
$1,959.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1,994.85
|
| Rate for Payer: Signature Care EPO |
$2,144.72
|
| Rate for Payer: Signature Care PPO |
$2,273.92
|
| Rate for Payer: United Healthcare Commercial |
$2,036.19
|
|
|
ONDANSETRON 4 MG ORAL TBDL
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.19
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| Rate for Payer: PHCS All Commercial |
$1.01
|
| Rate for Payer: PHP All Commercial |
$1.02
|
| Rate for Payer: Sagamore Health Network All Products |
$1.04
|
| Rate for Payer: Signature Care EPO |
$1.12
|
| Rate for Payer: Signature Care PPO |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
|
|
ONDANSETRON 4 MG ORAL TBDL
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.14
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Centivo All Commercial |
$0.73
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.19
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Humana Medicare |
$0.43
|
| Rate for Payer: Lucent All Commercial |
$0.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| Rate for Payer: PHCS All Commercial |
$1.01
|
| Rate for Payer: PHP All Commercial |
$1.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1.04
|
| Rate for Payer: Signature Care EPO |
$1.12
|
| Rate for Payer: Signature Care PPO |
$1.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
