|
GLUCAGON 1 MG/ML INJ SOLR S.O. (CAMERON)
|
Facility
|
OP
|
$1,108.20
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
140121354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,030.63 |
| Rate for Payer: Aetna Commercial |
$935.32
|
| Rate for Payer: Aetna Medicare |
$365.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$365.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$636.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$692.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$420.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$402.28
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Centivo All Commercial |
$565.18
|
| Rate for Payer: Cigna All Commercial |
$956.38
|
| Rate for Payer: CORVEL All Commercial |
$1,030.63
|
| Rate for Payer: Coventry All Commercial |
$975.22
|
| Rate for Payer: Encore All Commercial |
$1,020.10
|
| Rate for Payer: Frontpath All Commercial |
$1,019.54
|
| Rate for Payer: Humana ChoiceCare |
$957.15
|
| Rate for Payer: Humana Medicare |
$565.18
|
| Rate for Payer: Lucent All Commercial |
$565.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$997.38
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$831.15
|
| Rate for Payer: PHP All Commercial |
$840.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$432.20
|
| Rate for Payer: Sagamore Health Network All Products |
$855.53
|
| Rate for Payer: Signature Care EPO |
$919.81
|
| Rate for Payer: Signature Care PPO |
$975.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$941.97
|
| Rate for Payer: United Healthcare Commercial |
$873.26
|
| Rate for Payer: United Healthcare Medicare |
$365.71
|
|
|
GLYBURIDE 1.25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 23155005601
|
| Hospital Charge Code |
10125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
GLYBURIDE 1.25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 23155005601
|
| Hospital Charge Code |
10125
|
|
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 |
$0.62
|
| 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
|
|
|
GLYBURIDE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 23155005801
|
| Hospital Charge Code |
3489
|
|
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 |
$0.62
|
| 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
|
|
|
GLYBURIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 23155005801
|
| Hospital Charge Code |
3489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
GLYCERIN (ADULT) RECT SUPP
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 58980041012
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Centivo All Commercial |
$0.56
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
|
|
GLYCERIN (ADULT) RECT SUPP
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 58980041012
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
|
|
GLYCERIN (CHILD) RECT SUPP
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna All Commercial |
$0.51
|
| Rate for Payer: CORVEL All Commercial |
$0.55
|
| Rate for Payer: Coventry All Commercial |
$0.52
|
| Rate for Payer: Encore All Commercial |
$0.54
|
| Rate for Payer: Frontpath All Commercial |
$0.54
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.53
|
| Rate for Payer: PHCS All Commercial |
$0.44
|
| Rate for Payer: PHP All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.45
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
|
|
GLYCERIN (CHILD) RECT SUPP
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: Aetna Medicare |
$0.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Centivo All Commercial |
$0.30
|
| Rate for Payer: Cigna All Commercial |
$0.51
|
| Rate for Payer: CORVEL All Commercial |
$0.55
|
| Rate for Payer: Coventry All Commercial |
$0.52
|
| Rate for Payer: Encore All Commercial |
$0.54
|
| Rate for Payer: Frontpath All Commercial |
$0.54
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Humana Medicare |
$0.30
|
| Rate for Payer: Lucent All Commercial |
$0.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.53
|
| Rate for Payer: PHCS All Commercial |
$0.44
|
| Rate for Payer: PHP All Commercial |
$0.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.23
|
| Rate for Payer: Sagamore Health Network All Products |
$0.45
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.50
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECT SOLN
|
Facility
|
OP
|
$5.38
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
120948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$4.54
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Centivo All Commercial |
$2.74
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Humana Medicare |
$2.74
|
| Rate for Payer: Lucent All Commercial |
$2.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.10
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.57
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
| Rate for Payer: United Healthcare Medicare |
$1.77
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECT SOLN
|
Facility
|
IP
|
$5.38
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
120948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
|
|
GLYCERIN-WITCH HAZEL 12.5-50 % TOP PADM
|
Facility
|
IP
|
$17.64
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
117736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Cigna All Commercial |
$15.22
|
| Rate for Payer: CORVEL All Commercial |
$16.41
|
| Rate for Payer: Coventry All Commercial |
$15.52
|
| Rate for Payer: Encore All Commercial |
$16.24
|
| Rate for Payer: Frontpath All Commercial |
$16.23
|
| Rate for Payer: Humana ChoiceCare |
$15.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.88
|
| Rate for Payer: PHCS All Commercial |
$13.23
|
| Rate for Payer: PHP All Commercial |
$13.38
|
| Rate for Payer: Sagamore Health Network All Products |
$13.62
|
| Rate for Payer: Signature Care EPO |
$14.64
|
| Rate for Payer: Signature Care PPO |
$15.52
|
| Rate for Payer: United Healthcare Commercial |
$13.90
|
|
|
GLYCERIN-WITCH HAZEL 12.5-50 % TOP PADM
|
Facility
|
OP
|
$17.64
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
117736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$14.89
|
| Rate for Payer: Aetna Medicare |
$5.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.40
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Centivo All Commercial |
$9.00
|
| Rate for Payer: Cigna All Commercial |
$15.22
|
| Rate for Payer: CORVEL All Commercial |
$16.41
|
| Rate for Payer: Coventry All Commercial |
$15.52
|
| Rate for Payer: Encore All Commercial |
$16.24
|
| Rate for Payer: Frontpath All Commercial |
$16.23
|
| Rate for Payer: Humana ChoiceCare |
$15.24
|
| Rate for Payer: Humana Medicare |
$9.00
|
| Rate for Payer: Lucent All Commercial |
$9.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.88
|
| Rate for Payer: PHCS All Commercial |
$13.23
|
| Rate for Payer: PHP All Commercial |
$13.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.88
|
| Rate for Payer: Sagamore Health Network All Products |
$13.62
|
| Rate for Payer: Signature Care EPO |
$14.64
|
| Rate for Payer: Signature Care PPO |
$15.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14.99
|
| Rate for Payer: United Healthcare Commercial |
$13.90
|
| Rate for Payer: United Healthcare Medicare |
$5.82
|
|
|
GLYCINE UROLOGIC SOLUTION 1.5 % IR SOLN
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
NDC 00990797408
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$72.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.74
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Centivo All Commercial |
$64.26
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Humana Medicare |
$64.26
|
| Rate for Payer: Lucent All Commercial |
$64.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.14
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
| Rate for Payer: United Healthcare Medicare |
$41.58
|
|
|
GLYCINE UROLOGIC SOLUTION 1.5 % IR SOLN
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 00990797408
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
GOLIMUMAB 12.5 MG/ML IV SOLN
|
Facility
|
OP
|
$6,818.84
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
165235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.98 |
| Max. Negotiated Rate |
$6,341.52 |
| Rate for Payer: Aetna Commercial |
$5,755.10
|
| Rate for Payer: Aetna Medicare |
$2,250.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,250.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,916.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,262.46
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$41.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,587.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,475.24
|
| Rate for Payer: Cash Price |
$4,227.68
|
| Rate for Payer: Cash Price |
$4,227.68
|
| Rate for Payer: Centivo All Commercial |
$3,477.61
|
| Rate for Payer: Cigna All Commercial |
$5,884.66
|
| Rate for Payer: CORVEL All Commercial |
$6,341.52
|
| Rate for Payer: Coventry All Commercial |
$6,000.58
|
| Rate for Payer: Encore All Commercial |
$6,276.74
|
| Rate for Payer: Frontpath All Commercial |
$6,273.33
|
| Rate for Payer: Humana ChoiceCare |
$5,889.43
|
| Rate for Payer: Humana Medicare |
$3,477.61
|
| Rate for Payer: Lucent All Commercial |
$3,477.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,136.96
|
| Rate for Payer: Managed Health Services Medicaid |
$41.98
|
| Rate for Payer: MDWise Medicaid |
$41.98
|
| Rate for Payer: PHCS All Commercial |
$5,114.13
|
| Rate for Payer: PHP All Commercial |
$5,171.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,659.35
|
| Rate for Payer: Sagamore Health Network All Products |
$5,264.14
|
| Rate for Payer: Signature Care EPO |
$5,659.64
|
| Rate for Payer: Signature Care PPO |
$6,000.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,796.01
|
| Rate for Payer: United Healthcare Commercial |
$5,373.25
|
| Rate for Payer: United Healthcare Medicare |
$2,250.22
|
|
|
GOLIMUMAB 12.5 MG/ML IV SOLN
|
Facility
|
IP
|
$6,818.84
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
165235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,114.13 |
| Max. Negotiated Rate |
$6,341.52 |
| Rate for Payer: Aetna Commercial |
$5,891.48
|
| Rate for Payer: Cash Price |
$4,227.68
|
| Rate for Payer: Cigna All Commercial |
$5,884.66
|
| Rate for Payer: CORVEL All Commercial |
$6,341.52
|
| Rate for Payer: Coventry All Commercial |
$6,000.58
|
| Rate for Payer: Encore All Commercial |
$6,276.74
|
| Rate for Payer: Frontpath All Commercial |
$6,273.33
|
| Rate for Payer: Humana ChoiceCare |
$5,889.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,136.96
|
| Rate for Payer: PHCS All Commercial |
$5,114.13
|
| Rate for Payer: PHP All Commercial |
$5,171.41
|
| Rate for Payer: Sagamore Health Network All Products |
$5,264.14
|
| Rate for Payer: Signature Care EPO |
$5,659.64
|
| Rate for Payer: Signature Care PPO |
$6,000.58
|
| Rate for Payer: United Healthcare Commercial |
$5,373.25
|
|
|
GOLIMUMAB 50 MG/0.5 ML SUBQ PNIJ
|
Facility
|
IP
|
$19,782.35
|
|
|
Service Code
|
NDC 57894007002
|
| Hospital Charge Code |
120455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,836.76 |
| Max. Negotiated Rate |
$18,397.59 |
| Rate for Payer: Aetna Commercial |
$17,091.95
|
| Rate for Payer: Cash Price |
$12,265.06
|
| Rate for Payer: Cigna All Commercial |
$17,072.17
|
| Rate for Payer: CORVEL All Commercial |
$18,397.59
|
| Rate for Payer: Coventry All Commercial |
$17,408.47
|
| Rate for Payer: Encore All Commercial |
$18,209.65
|
| Rate for Payer: Frontpath All Commercial |
$18,199.76
|
| Rate for Payer: Humana ChoiceCare |
$17,086.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,804.12
|
| Rate for Payer: PHCS All Commercial |
$14,836.76
|
| Rate for Payer: PHP All Commercial |
$15,002.93
|
| Rate for Payer: Sagamore Health Network All Products |
$15,271.97
|
| Rate for Payer: Signature Care EPO |
$16,419.35
|
| Rate for Payer: Signature Care PPO |
$17,408.47
|
| Rate for Payer: United Healthcare Commercial |
$15,588.49
|
|
|
GOLIMUMAB 50 MG/0.5 ML SUBQ PNIJ
|
Facility
|
OP
|
$19,782.35
|
|
|
Service Code
|
NDC 57894007002
|
| Hospital Charge Code |
120455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$18,397.59 |
| Rate for Payer: Aetna Commercial |
$16,696.30
|
| Rate for Payer: Aetna Medicare |
$6,528.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,528.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11,361.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,365.95
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,507.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,180.99
|
| Rate for Payer: Cash Price |
$12,265.06
|
| Rate for Payer: Cash Price |
$12,265.06
|
| Rate for Payer: Centivo All Commercial |
$10,089.00
|
| Rate for Payer: Cigna All Commercial |
$17,072.17
|
| Rate for Payer: CORVEL All Commercial |
$18,397.59
|
| Rate for Payer: Coventry All Commercial |
$17,408.47
|
| Rate for Payer: Encore All Commercial |
$18,209.65
|
| Rate for Payer: Frontpath All Commercial |
$18,199.76
|
| Rate for Payer: Humana ChoiceCare |
$17,086.02
|
| Rate for Payer: Humana Medicare |
$10,089.00
|
| Rate for Payer: Lucent All Commercial |
$10,089.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,804.12
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$14,836.76
|
| Rate for Payer: PHP All Commercial |
$15,002.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,715.12
|
| Rate for Payer: Sagamore Health Network All Products |
$15,271.97
|
| Rate for Payer: Signature Care EPO |
$16,419.35
|
| Rate for Payer: Signature Care PPO |
$17,408.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16,815.00
|
| Rate for Payer: United Healthcare Commercial |
$15,588.49
|
| Rate for Payer: United Healthcare Medicare |
$6,528.18
|
|
|
GOSERELIN 10.8 MG SUBQ IMPL
|
Facility
|
IP
|
$9,742.71
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
16254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,307.03 |
| Max. Negotiated Rate |
$9,060.72 |
| Rate for Payer: Aetna Commercial |
$8,417.70
|
| Rate for Payer: Cash Price |
$6,040.48
|
| Rate for Payer: Cigna All Commercial |
$8,407.95
|
| Rate for Payer: CORVEL All Commercial |
$9,060.72
|
| Rate for Payer: Coventry All Commercial |
$8,573.58
|
| Rate for Payer: Encore All Commercial |
$8,968.16
|
| Rate for Payer: Frontpath All Commercial |
$8,963.29
|
| Rate for Payer: Humana ChoiceCare |
$8,414.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,768.43
|
| Rate for Payer: PHCS All Commercial |
$7,307.03
|
| Rate for Payer: PHP All Commercial |
$7,388.87
|
| Rate for Payer: Sagamore Health Network All Products |
$7,521.37
|
| Rate for Payer: Signature Care EPO |
$8,086.45
|
| Rate for Payer: Signature Care PPO |
$8,573.58
|
| Rate for Payer: United Healthcare Commercial |
$7,677.25
|
|
|
GOSERELIN 10.8 MG SUBQ IMPL
|
Facility
|
OP
|
$9,742.71
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
16254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,215.09 |
| Max. Negotiated Rate |
$9,060.72 |
| Rate for Payer: Aetna Commercial |
$8,222.84
|
| Rate for Payer: Aetna Medicare |
$3,215.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,215.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,595.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,090.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,697.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,536.60
|
| Rate for Payer: Cash Price |
$6,040.48
|
| Rate for Payer: Centivo All Commercial |
$4,968.78
|
| Rate for Payer: Cigna All Commercial |
$8,407.95
|
| Rate for Payer: CORVEL All Commercial |
$9,060.72
|
| Rate for Payer: Coventry All Commercial |
$8,573.58
|
| Rate for Payer: Encore All Commercial |
$8,968.16
|
| Rate for Payer: Frontpath All Commercial |
$8,963.29
|
| Rate for Payer: Humana ChoiceCare |
$8,414.77
|
| Rate for Payer: Humana Medicare |
$4,968.78
|
| Rate for Payer: Lucent All Commercial |
$4,968.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,768.43
|
| Rate for Payer: PHCS All Commercial |
$7,307.03
|
| Rate for Payer: PHP All Commercial |
$7,388.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,799.65
|
| Rate for Payer: Sagamore Health Network All Products |
$7,521.37
|
| Rate for Payer: Signature Care EPO |
$8,086.45
|
| Rate for Payer: Signature Care PPO |
$8,573.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,281.30
|
| Rate for Payer: United Healthcare Commercial |
$7,677.25
|
| Rate for Payer: United Healthcare Medicare |
$3,215.09
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQD
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 00121174400
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: PHCS All Commercial |
$9.76
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQD
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 00121174400
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$10.99
|
| Rate for Payer: Aetna Medicare |
$4.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.73
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Centivo All Commercial |
$6.64
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Humana Medicare |
$6.64
|
| Rate for Payer: Lucent All Commercial |
$6.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: PHCS All Commercial |
$9.76
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.08
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
| Rate for Payer: United Healthcare Medicare |
$4.30
|
|
