|
RADIOPAQUE PVC MARKERS-BARIUM 24 MARKERS ORAL CAP
|
Facility
|
OP
|
$639.36
|
|
|
Service Code
|
NDC 10858008110
|
| Hospital Charge Code |
21381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$594.60 |
| Rate for Payer: Aetna Commercial |
$539.62
|
| Rate for Payer: Aetna Medicare |
$204.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$198.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$367.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$399.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$235.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$225.05
|
| Rate for Payer: Cash Price |
$383.62
|
| Rate for Payer: Cash Price |
$383.62
|
| Rate for Payer: Centivo All Commercial |
$347.81
|
| Rate for Payer: Cigna All Commercial |
$551.77
|
| Rate for Payer: CORVEL All Commercial |
$594.60
|
| Rate for Payer: Coventry All Commercial |
$562.64
|
| Rate for Payer: Encore All Commercial |
$588.53
|
| Rate for Payer: Frontpath All Commercial |
$588.21
|
| Rate for Payer: Humana ChoiceCare |
$552.22
|
| Rate for Payer: Humana Medicare |
$204.60
|
| Rate for Payer: Lucent All Commercial |
$347.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$575.42
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$479.52
|
| Rate for Payer: PHP All Commercial |
$484.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$249.35
|
| Rate for Payer: Sagamore Health Network All Products |
$493.59
|
| Rate for Payer: Signature Care EPO |
$530.67
|
| Rate for Payer: Signature Care PPO |
$562.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$543.46
|
| Rate for Payer: United Healthcare Commercial |
$503.82
|
| Rate for Payer: United Healthcare Medicare |
$204.60
|
|
|
RADIOPAQUE PVC MARKERS-BARIUM 24 MARKERS ORAL CAP
|
Facility
|
IP
|
$639.36
|
|
|
Service Code
|
NDC 10858008110
|
| Hospital Charge Code |
21381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$479.52 |
| Max. Negotiated Rate |
$594.60 |
| Rate for Payer: Aetna Commercial |
$552.41
|
| Rate for Payer: Cash Price |
$383.62
|
| Rate for Payer: Cigna All Commercial |
$551.77
|
| Rate for Payer: CORVEL All Commercial |
$594.60
|
| Rate for Payer: Coventry All Commercial |
$562.64
|
| Rate for Payer: Encore All Commercial |
$588.53
|
| Rate for Payer: Frontpath All Commercial |
$588.21
|
| Rate for Payer: Humana ChoiceCare |
$552.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$575.42
|
| Rate for Payer: PHCS All Commercial |
$479.52
|
| Rate for Payer: PHP All Commercial |
$484.89
|
| Rate for Payer: Sagamore Health Network All Products |
$493.59
|
| Rate for Payer: Signature Care EPO |
$530.67
|
| Rate for Payer: Signature Care PPO |
$562.64
|
| Rate for Payer: United Healthcare Commercial |
$503.82
|
|
|
RALTEGRAVIR 400 MG ORAL TAB
|
Facility
|
OP
|
$236.96
|
|
|
Service Code
|
NDC 00006022761
|
| Hospital Charge Code |
88608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.46 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$200.00
|
| Rate for Payer: Aetna Medicare |
$75.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$136.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$87.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.41
|
| Rate for Payer: Cash Price |
$142.18
|
| Rate for Payer: Centivo All Commercial |
$128.91
|
| Rate for Payer: Cigna All Commercial |
$204.50
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Humana Medicare |
$75.83
|
| Rate for Payer: Lucent All Commercial |
$128.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.72
|
| Rate for Payer: PHP All Commercial |
$179.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.42
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.68
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.42
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
| Rate for Payer: United Healthcare Medicare |
$75.83
|
|
|
RALTEGRAVIR 400 MG ORAL TAB
|
Facility
|
IP
|
$236.96
|
|
|
Service Code
|
NDC 00006022761
|
| Hospital Charge Code |
88608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.72 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$204.74
|
| Rate for Payer: Cash Price |
$142.18
|
| Rate for Payer: Cigna All Commercial |
$204.50
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.72
|
| Rate for Payer: PHP All Commercial |
$179.71
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.68
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 60687054921
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: Aetna Medicare |
$3.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.58
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Centivo All Commercial |
$5.53
|
| Rate for Payer: Cigna All Commercial |
$8.78
|
| Rate for Payer: CORVEL All Commercial |
$9.46
|
| Rate for Payer: Coventry All Commercial |
$8.95
|
| Rate for Payer: Encore All Commercial |
$9.36
|
| Rate for Payer: Frontpath All Commercial |
$9.36
|
| Rate for Payer: Humana ChoiceCare |
$8.78
|
| Rate for Payer: Humana Medicare |
$3.25
|
| Rate for Payer: Lucent All Commercial |
$5.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.15
|
| Rate for Payer: PHCS All Commercial |
$7.63
|
| Rate for Payer: PHP All Commercial |
$7.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.97
|
| Rate for Payer: Sagamore Health Network All Products |
$7.85
|
| Rate for Payer: Signature Care EPO |
$8.44
|
| Rate for Payer: Signature Care PPO |
$8.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$8.01
|
| Rate for Payer: United Healthcare Medicare |
$3.25
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
NDC 60687054911
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$8.79
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna All Commercial |
$8.78
|
| Rate for Payer: CORVEL All Commercial |
$9.46
|
| Rate for Payer: Coventry All Commercial |
$8.95
|
| Rate for Payer: Encore All Commercial |
$9.36
|
| Rate for Payer: Frontpath All Commercial |
$9.36
|
| Rate for Payer: Humana ChoiceCare |
$8.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.15
|
| Rate for Payer: PHCS All Commercial |
$7.63
|
| Rate for Payer: PHP All Commercial |
$7.71
|
| Rate for Payer: Sagamore Health Network All Products |
$7.85
|
| Rate for Payer: Signature Care EPO |
$8.44
|
| Rate for Payer: Signature Care PPO |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$8.01
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
NDC 60687054921
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$8.79
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna All Commercial |
$8.78
|
| Rate for Payer: CORVEL All Commercial |
$9.46
|
| Rate for Payer: Coventry All Commercial |
$8.95
|
| Rate for Payer: Encore All Commercial |
$9.36
|
| Rate for Payer: Frontpath All Commercial |
$9.36
|
| Rate for Payer: Humana ChoiceCare |
$8.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.15
|
| Rate for Payer: PHCS All Commercial |
$7.63
|
| Rate for Payer: PHP All Commercial |
$7.71
|
| Rate for Payer: Sagamore Health Network All Products |
$7.85
|
| Rate for Payer: Signature Care EPO |
$8.44
|
| Rate for Payer: Signature Care PPO |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$8.01
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 60687054911
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$9.46 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: Aetna Medicare |
$3.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.58
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Centivo All Commercial |
$5.53
|
| Rate for Payer: Cigna All Commercial |
$8.78
|
| Rate for Payer: CORVEL All Commercial |
$9.46
|
| Rate for Payer: Coventry All Commercial |
$8.95
|
| Rate for Payer: Encore All Commercial |
$9.36
|
| Rate for Payer: Frontpath All Commercial |
$9.36
|
| Rate for Payer: Humana ChoiceCare |
$8.78
|
| Rate for Payer: Humana Medicare |
$3.25
|
| Rate for Payer: Lucent All Commercial |
$5.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.15
|
| Rate for Payer: PHCS All Commercial |
$7.63
|
| Rate for Payer: PHP All Commercial |
$7.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.97
|
| Rate for Payer: Sagamore Health Network All Products |
$7.85
|
| Rate for Payer: Signature Care EPO |
$8.44
|
| Rate for Payer: Signature Care PPO |
$8.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$8.01
|
| Rate for Payer: United Healthcare Medicare |
$3.25
|
|
|
REGADENOSON 0.4 MG/5 ML IV SYRG
|
Facility
|
OP
|
$1,123.70
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
91408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$1,045.04 |
| Rate for Payer: Aetna Commercial |
$948.40
|
| Rate for Payer: Aetna Medicare |
$359.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$348.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$645.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$702.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$2.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$413.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$395.54
|
| Rate for Payer: Cash Price |
$674.22
|
| Rate for Payer: Cash Price |
$674.22
|
| Rate for Payer: Centivo All Commercial |
$611.29
|
| Rate for Payer: Cigna All Commercial |
$969.75
|
| Rate for Payer: CORVEL All Commercial |
$1,045.04
|
| Rate for Payer: Coventry All Commercial |
$988.86
|
| Rate for Payer: Encore All Commercial |
$1,034.37
|
| Rate for Payer: Frontpath All Commercial |
$1,033.80
|
| Rate for Payer: Humana ChoiceCare |
$970.54
|
| Rate for Payer: Humana Medicare |
$359.58
|
| Rate for Payer: Lucent All Commercial |
$611.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,011.33
|
| Rate for Payer: Managed Health Services Medicaid |
$2.29
|
| Rate for Payer: MDWise Medicaid |
$2.29
|
| Rate for Payer: PHCS All Commercial |
$842.77
|
| Rate for Payer: PHP All Commercial |
$852.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$438.24
|
| Rate for Payer: Sagamore Health Network All Products |
$867.50
|
| Rate for Payer: Signature Care EPO |
$932.67
|
| Rate for Payer: Signature Care PPO |
$988.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$955.14
|
| Rate for Payer: United Healthcare Commercial |
$885.48
|
| Rate for Payer: United Healthcare Medicare |
$359.58
|
|
|
REGADENOSON 0.4 MG/5 ML IV SYRG
|
Facility
|
IP
|
$1,123.70
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
91408
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$842.77 |
| Max. Negotiated Rate |
$1,045.04 |
| Rate for Payer: Aetna Commercial |
$970.88
|
| Rate for Payer: Cash Price |
$674.22
|
| Rate for Payer: Cigna All Commercial |
$969.75
|
| Rate for Payer: CORVEL All Commercial |
$1,045.04
|
| Rate for Payer: Coventry All Commercial |
$988.86
|
| Rate for Payer: Encore All Commercial |
$1,034.37
|
| Rate for Payer: Frontpath All Commercial |
$1,033.80
|
| Rate for Payer: Humana ChoiceCare |
$970.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,011.33
|
| Rate for Payer: PHCS All Commercial |
$842.77
|
| Rate for Payer: PHP All Commercial |
$852.21
|
| Rate for Payer: Sagamore Health Network All Products |
$867.50
|
| Rate for Payer: Signature Care EPO |
$932.67
|
| Rate for Payer: Signature Care PPO |
$988.86
|
| Rate for Payer: United Healthcare Commercial |
$885.48
|
|
|
REHABILITATION
|
Facility
|
IP
|
$4,884.74
|
|
|
Service Code
|
APR-DRG 8601
|
| Min. Negotiated Rate |
$667.00 |
| Max. Negotiated Rate |
$4,884.74 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$667.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$667.00
|
| Rate for Payer: Managed Health Services Medicaid |
$667.00
|
| Rate for Payer: MDWise Medicaid |
$667.00
|
|
|
REHABILITATION
|
Facility
|
IP
|
$6,354.49
|
|
|
Service Code
|
APR-DRG 8602
|
| Min. Negotiated Rate |
$667.00 |
| Max. Negotiated Rate |
$6,354.49 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$667.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$667.00
|
| Rate for Payer: Managed Health Services Medicaid |
$667.00
|
| Rate for Payer: MDWise Medicaid |
$667.00
|
|
|
REHABILITATION
|
Facility
|
IP
|
$8,386.19
|
|
|
Service Code
|
APR-DRG 8603
|
| Min. Negotiated Rate |
$667.00 |
| Max. Negotiated Rate |
$8,386.19 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$667.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$667.00
|
| Rate for Payer: Managed Health Services Medicaid |
$667.00
|
| Rate for Payer: MDWise Medicaid |
$667.00
|
|
|
REHABILITATION
|
Facility
|
IP
|
$10,417.90
|
|
|
Service Code
|
APR-DRG 8604
|
| Min. Negotiated Rate |
$667.00 |
| Max. Negotiated Rate |
$10,417.90 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$667.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$667.00
|
| Rate for Payer: Managed Health Services Medicaid |
$667.00
|
| Rate for Payer: MDWise Medicaid |
$667.00
|
|
|
REMDESIVIR 100 MG IV SOLR
|
Facility
|
IP
|
$2,539.40
|
|
|
Service Code
|
HCPCS J0248
|
| Hospital Charge Code |
191228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,904.55 |
| Max. Negotiated Rate |
$2,361.64 |
| Rate for Payer: Aetna Commercial |
$2,194.04
|
| Rate for Payer: Cash Price |
$1,523.64
|
| Rate for Payer: Cigna All Commercial |
$2,191.50
|
| Rate for Payer: CORVEL All Commercial |
$2,361.64
|
| Rate for Payer: Coventry All Commercial |
$2,234.67
|
| Rate for Payer: Encore All Commercial |
$2,337.52
|
| Rate for Payer: Frontpath All Commercial |
$2,336.25
|
| Rate for Payer: Humana ChoiceCare |
$2,193.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,285.46
|
| Rate for Payer: PHCS All Commercial |
$1,904.55
|
| Rate for Payer: PHP All Commercial |
$1,925.88
|
| Rate for Payer: Sagamore Health Network All Products |
$1,960.42
|
| Rate for Payer: Signature Care EPO |
$2,107.70
|
| Rate for Payer: Signature Care PPO |
$2,234.67
|
| Rate for Payer: United Healthcare Commercial |
$2,001.05
|
|
|
REMDESIVIR 100 MG IV SOLR
|
Facility
|
OP
|
$2,539.40
|
|
|
Service Code
|
HCPCS J0248
|
| Hospital Charge Code |
191228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$2,361.64 |
| Rate for Payer: Aetna Commercial |
$2,143.25
|
| Rate for Payer: Aetna Medicare |
$812.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$5.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$787.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,458.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,587.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$5.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$934.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$893.87
|
| Rate for Payer: Cash Price |
$1,523.64
|
| Rate for Payer: Cash Price |
$1,523.64
|
| Rate for Payer: Centivo All Commercial |
$1,381.43
|
| Rate for Payer: Cigna All Commercial |
$2,191.50
|
| Rate for Payer: CORVEL All Commercial |
$2,361.64
|
| Rate for Payer: Coventry All Commercial |
$2,234.67
|
| Rate for Payer: Encore All Commercial |
$2,337.52
|
| Rate for Payer: Frontpath All Commercial |
$2,336.25
|
| Rate for Payer: Humana ChoiceCare |
$2,193.28
|
| Rate for Payer: Humana Medicare |
$812.61
|
| Rate for Payer: Lucent All Commercial |
$1,381.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,285.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.46
|
| Rate for Payer: MDWise Medicaid |
$5.46
|
| Rate for Payer: PHCS All Commercial |
$1,904.55
|
| Rate for Payer: PHP All Commercial |
$1,925.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$990.37
|
| Rate for Payer: Sagamore Health Network All Products |
$1,960.42
|
| Rate for Payer: Signature Care EPO |
$2,107.70
|
| Rate for Payer: Signature Care PPO |
$2,234.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,158.49
|
| Rate for Payer: United Healthcare Commercial |
$2,001.05
|
| Rate for Payer: United Healthcare Medicare |
$812.61
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJ SYRG
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS J2791
|
| Hospital Charge Code |
38072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.83 |
| Max. Negotiated Rate |
$418.50 |
| Rate for Payer: Aetna Commercial |
$379.80
|
| Rate for Payer: Aetna Medicare |
$144.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$10.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$139.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$258.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$281.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$10.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$165.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$158.40
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Centivo All Commercial |
$244.80
|
| Rate for Payer: Cigna All Commercial |
$388.35
|
| Rate for Payer: CORVEL All Commercial |
$418.50
|
| Rate for Payer: Coventry All Commercial |
$396.00
|
| Rate for Payer: Encore All Commercial |
$414.23
|
| Rate for Payer: Frontpath All Commercial |
$414.00
|
| Rate for Payer: Humana ChoiceCare |
$388.67
|
| Rate for Payer: Humana Medicare |
$144.00
|
| Rate for Payer: Lucent All Commercial |
$244.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$405.00
|
| Rate for Payer: Managed Health Services Medicaid |
$10.83
|
| Rate for Payer: MDWise Medicaid |
$10.83
|
| Rate for Payer: PHCS All Commercial |
$337.50
|
| Rate for Payer: PHP All Commercial |
$341.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$175.50
|
| Rate for Payer: Sagamore Health Network All Products |
$347.40
|
| Rate for Payer: Signature Care EPO |
$373.50
|
| Rate for Payer: Signature Care PPO |
$396.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$382.50
|
| Rate for Payer: United Healthcare Commercial |
$354.60
|
| Rate for Payer: United Healthcare Medicare |
$144.00
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJ SYRG
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS J2791
|
| Hospital Charge Code |
38072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$337.50 |
| Max. Negotiated Rate |
$418.50 |
| Rate for Payer: Aetna Commercial |
$388.80
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna All Commercial |
$388.35
|
| Rate for Payer: CORVEL All Commercial |
$418.50
|
| Rate for Payer: Coventry All Commercial |
$396.00
|
| Rate for Payer: Encore All Commercial |
$414.23
|
| Rate for Payer: Frontpath All Commercial |
$414.00
|
| Rate for Payer: Humana ChoiceCare |
$388.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$405.00
|
| Rate for Payer: PHCS All Commercial |
$337.50
|
| Rate for Payer: PHP All Commercial |
$341.28
|
| Rate for Payer: Sagamore Health Network All Products |
$347.40
|
| Rate for Payer: Signature Care EPO |
$373.50
|
| Rate for Payer: Signature Care PPO |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$354.60
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) IM SYRG
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$333.00 |
| Max. Negotiated Rate |
$412.92 |
| Rate for Payer: Aetna Commercial |
$383.62
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna All Commercial |
$383.17
|
| Rate for Payer: CORVEL All Commercial |
$412.92
|
| Rate for Payer: Coventry All Commercial |
$390.72
|
| Rate for Payer: Encore All Commercial |
$408.70
|
| Rate for Payer: Frontpath All Commercial |
$408.48
|
| Rate for Payer: Humana ChoiceCare |
$383.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$399.60
|
| Rate for Payer: PHCS All Commercial |
$333.00
|
| Rate for Payer: PHP All Commercial |
$336.73
|
| Rate for Payer: Sagamore Health Network All Products |
$342.77
|
| Rate for Payer: Signature Care EPO |
$368.52
|
| Rate for Payer: Signature Care PPO |
$390.72
|
| Rate for Payer: United Healthcare Commercial |
$349.87
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) IM SYRG
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.97 |
| Max. Negotiated Rate |
$412.92 |
| Rate for Payer: Aetna Commercial |
$374.74
|
| Rate for Payer: Aetna Medicare |
$142.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$86.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$254.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$277.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$86.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$163.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$156.29
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Centivo All Commercial |
$241.54
|
| Rate for Payer: Cigna All Commercial |
$383.17
|
| Rate for Payer: CORVEL All Commercial |
$412.92
|
| Rate for Payer: Coventry All Commercial |
$390.72
|
| Rate for Payer: Encore All Commercial |
$408.70
|
| Rate for Payer: Frontpath All Commercial |
$408.48
|
| Rate for Payer: Humana ChoiceCare |
$383.48
|
| Rate for Payer: Humana Medicare |
$142.08
|
| Rate for Payer: Lucent All Commercial |
$241.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$399.60
|
| Rate for Payer: Managed Health Services Medicaid |
$86.97
|
| Rate for Payer: MDWise Medicaid |
$86.97
|
| Rate for Payer: PHCS All Commercial |
$333.00
|
| Rate for Payer: PHP All Commercial |
$336.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$173.16
|
| Rate for Payer: Sagamore Health Network All Products |
$342.77
|
| Rate for Payer: Signature Care EPO |
$368.52
|
| Rate for Payer: Signature Care PPO |
$390.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$377.40
|
| Rate for Payer: United Healthcare Commercial |
$349.87
|
| Rate for Payer: United Healthcare Medicare |
$142.08
|
|
|
RIFAMPIN 150 MG ORAL CAP
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 68180065806
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.57
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.91
|
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Centivo All Commercial |
$2.95
|
| Rate for Payer: Cigna All Commercial |
$4.68
|
| Rate for Payer: CORVEL All Commercial |
$5.04
|
| Rate for Payer: Coventry All Commercial |
$4.77
|
| Rate for Payer: Encore All Commercial |
$4.99
|
| Rate for Payer: Frontpath All Commercial |
$4.98
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Humana Medicare |
$1.73
|
| Rate for Payer: Lucent All Commercial |
$2.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.88
|
| Rate for Payer: PHCS All Commercial |
$4.06
|
| Rate for Payer: PHP All Commercial |
$4.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.11
|
| Rate for Payer: Sagamore Health Network All Products |
$4.18
|
| Rate for Payer: Signature Care EPO |
$4.50
|
| Rate for Payer: Signature Care PPO |
$4.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.61
|
| Rate for Payer: United Healthcare Commercial |
$4.27
|
| Rate for Payer: United Healthcare Medicare |
$1.73
|
|
|
RIFAMPIN 150 MG ORAL CAP
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 68180065806
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Cigna All Commercial |
$4.68
|
| Rate for Payer: CORVEL All Commercial |
$5.04
|
| Rate for Payer: Coventry All Commercial |
$4.77
|
| Rate for Payer: Encore All Commercial |
$4.99
|
| Rate for Payer: Frontpath All Commercial |
$4.98
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.88
|
| Rate for Payer: PHCS All Commercial |
$4.06
|
| Rate for Payer: PHP All Commercial |
$4.11
|
| Rate for Payer: Sagamore Health Network All Products |
$4.18
|
| Rate for Payer: Signature Care EPO |
$4.50
|
| Rate for Payer: Signature Care PPO |
$4.77
|
| Rate for Payer: United Healthcare Commercial |
$4.27
|
|
|
RIFAXIMIN 200 MG ORAL TAB
|
Facility
|
OP
|
$73.67
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
39063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.84 |
| Max. Negotiated Rate |
$68.51 |
| Rate for Payer: Aetna Commercial |
$62.18
|
| Rate for Payer: Aetna Medicare |
$23.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$42.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.93
|
| Rate for Payer: Cash Price |
$44.20
|
| Rate for Payer: Centivo All Commercial |
$40.08
|
| Rate for Payer: Cigna All Commercial |
$63.58
|
| Rate for Payer: CORVEL All Commercial |
$68.51
|
| Rate for Payer: Coventry All Commercial |
$64.83
|
| Rate for Payer: Encore All Commercial |
$67.81
|
| Rate for Payer: Frontpath All Commercial |
$67.77
|
| Rate for Payer: Humana ChoiceCare |
$63.63
|
| Rate for Payer: Humana Medicare |
$23.57
|
| Rate for Payer: Lucent All Commercial |
$40.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.30
|
| Rate for Payer: PHCS All Commercial |
$55.25
|
| Rate for Payer: PHP All Commercial |
$55.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.73
|
| Rate for Payer: Sagamore Health Network All Products |
$56.87
|
| Rate for Payer: Signature Care EPO |
$61.14
|
| Rate for Payer: Signature Care PPO |
$64.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.62
|
| Rate for Payer: United Healthcare Commercial |
$58.05
|
| Rate for Payer: United Healthcare Medicare |
$23.57
|
|
|
RIFAXIMIN 200 MG ORAL TAB
|
Facility
|
IP
|
$73.67
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
39063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$68.51 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Cash Price |
$44.20
|
| Rate for Payer: Cigna All Commercial |
$63.58
|
| Rate for Payer: CORVEL All Commercial |
$68.51
|
| Rate for Payer: Coventry All Commercial |
$64.83
|
| Rate for Payer: Encore All Commercial |
$67.81
|
| Rate for Payer: Frontpath All Commercial |
$67.77
|
| Rate for Payer: Humana ChoiceCare |
$63.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.30
|
| Rate for Payer: PHCS All Commercial |
$55.25
|
| Rate for Payer: PHP All Commercial |
$55.87
|
| Rate for Payer: Sagamore Health Network All Products |
$56.87
|
| Rate for Payer: Signature Care EPO |
$61.14
|
| Rate for Payer: Signature Care PPO |
$64.83
|
| Rate for Payer: United Healthcare Commercial |
$58.05
|
|
|
RIFAXIMIN 550 MG ORAL TAB
|
Facility
|
IP
|
$324.68
|
|
|
Service Code
|
NDC 65649030302
|
| Hospital Charge Code |
104604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$243.51 |
| Max. Negotiated Rate |
$301.95 |
| Rate for Payer: Aetna Commercial |
$280.52
|
| Rate for Payer: Cash Price |
$194.81
|
| Rate for Payer: Cigna All Commercial |
$280.20
|
| Rate for Payer: CORVEL All Commercial |
$301.95
|
| Rate for Payer: Coventry All Commercial |
$285.72
|
| Rate for Payer: Encore All Commercial |
$298.87
|
| Rate for Payer: Frontpath All Commercial |
$298.70
|
| Rate for Payer: Humana ChoiceCare |
$280.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$292.21
|
| Rate for Payer: PHCS All Commercial |
$243.51
|
| Rate for Payer: PHP All Commercial |
$246.24
|
| Rate for Payer: Sagamore Health Network All Products |
$250.65
|
| Rate for Payer: Signature Care EPO |
$269.48
|
| Rate for Payer: Signature Care PPO |
$285.72
|
| Rate for Payer: United Healthcare Commercial |
$255.85
|
|
