|
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
|
OP
|
$27.93
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
152796
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$23.57
|
| Rate for Payer: Aetna Medicare |
$8.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.46
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.83
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Centivo All Commercial |
$15.19
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Humana Medicare |
$8.94
|
| Rate for Payer: Lucent All Commercial |
$15.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: Managed Health Services Medicaid |
$0.04
|
| Rate for Payer: MDWise Medicaid |
$0.04
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.89
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.74
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
| Rate for Payer: United Healthcare Medicare |
$8.94
|
|
|
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
|
IP
|
$27.93
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
152796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$24.13
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
|
|
ROSUVASTATIN 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 13668018030
|
| Hospital Charge Code |
35134
|
|
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 |
$0.62
|
| 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
|
|
|
ROSUVASTATIN 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 13668018030
|
| Hospital Charge Code |
35134
|
|
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
|
|
|
ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP
|
Facility
|
OP
|
$689.39
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
200244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$213.71 |
| Max. Negotiated Rate |
$641.14 |
| Rate for Payer: Aetna Commercial |
$581.85
|
| Rate for Payer: Aetna Medicare |
$220.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$213.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$395.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$430.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$253.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$242.67
|
| Rate for Payer: Cash Price |
$427.42
|
| Rate for Payer: Centivo All Commercial |
$375.03
|
| Rate for Payer: Cigna All Commercial |
$594.95
|
| Rate for Payer: CORVEL All Commercial |
$641.14
|
| Rate for Payer: Coventry All Commercial |
$606.67
|
| Rate for Payer: Encore All Commercial |
$634.59
|
| Rate for Payer: Frontpath All Commercial |
$634.24
|
| Rate for Payer: Humana ChoiceCare |
$595.43
|
| Rate for Payer: Humana Medicare |
$220.61
|
| Rate for Payer: Lucent All Commercial |
$375.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$620.45
|
| Rate for Payer: PHCS All Commercial |
$517.04
|
| Rate for Payer: PHP All Commercial |
$522.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$268.86
|
| Rate for Payer: Sagamore Health Network All Products |
$532.21
|
| Rate for Payer: Signature Care EPO |
$572.20
|
| Rate for Payer: Signature Care PPO |
$606.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$585.98
|
| Rate for Payer: United Healthcare Commercial |
$543.24
|
| Rate for Payer: United Healthcare Medicare |
$220.61
|
|
|
ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP
|
Facility
|
IP
|
$689.39
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
200244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$517.04 |
| Max. Negotiated Rate |
$641.14 |
| Rate for Payer: Aetna Commercial |
$595.64
|
| Rate for Payer: Cash Price |
$427.42
|
| Rate for Payer: Cigna All Commercial |
$594.95
|
| Rate for Payer: CORVEL All Commercial |
$641.14
|
| Rate for Payer: Coventry All Commercial |
$606.67
|
| Rate for Payer: Encore All Commercial |
$634.59
|
| Rate for Payer: Frontpath All Commercial |
$634.24
|
| Rate for Payer: Humana ChoiceCare |
$595.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$620.45
|
| Rate for Payer: PHCS All Commercial |
$517.04
|
| Rate for Payer: PHP All Commercial |
$522.84
|
| Rate for Payer: Sagamore Health Network All Products |
$532.21
|
| Rate for Payer: Signature Care EPO |
$572.20
|
| Rate for Payer: Signature Care PPO |
$606.67
|
| Rate for Payer: United Healthcare Commercial |
$543.24
|
|
|
ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SOLN
|
Facility
|
IP
|
$495.46
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
70476
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$371.59 |
| Max. Negotiated Rate |
$460.77 |
| Rate for Payer: Aetna Commercial |
$428.07
|
| Rate for Payer: Cash Price |
$307.18
|
| Rate for Payer: Cigna All Commercial |
$427.58
|
| Rate for Payer: CORVEL All Commercial |
$460.77
|
| Rate for Payer: Coventry All Commercial |
$436.00
|
| Rate for Payer: Encore All Commercial |
$456.07
|
| Rate for Payer: Frontpath All Commercial |
$455.82
|
| Rate for Payer: Humana ChoiceCare |
$427.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.91
|
| Rate for Payer: PHCS All Commercial |
$371.59
|
| Rate for Payer: PHP All Commercial |
$375.75
|
| Rate for Payer: Sagamore Health Network All Products |
$382.49
|
| Rate for Payer: Signature Care EPO |
$411.23
|
| Rate for Payer: Signature Care PPO |
$436.00
|
| Rate for Payer: United Healthcare Commercial |
$390.42
|
|
|
ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SOLN
|
Facility
|
OP
|
$495.46
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
70476
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.97 |
| Max. Negotiated Rate |
$460.77 |
| Rate for Payer: Aetna Commercial |
$418.16
|
| Rate for Payer: Aetna Medicare |
$158.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$102.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$153.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$284.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$309.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$102.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$182.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$174.40
|
| Rate for Payer: Cash Price |
$307.18
|
| Rate for Payer: Cash Price |
$307.18
|
| Rate for Payer: Centivo All Commercial |
$269.53
|
| Rate for Payer: Cigna All Commercial |
$427.58
|
| Rate for Payer: CORVEL All Commercial |
$460.77
|
| Rate for Payer: Coventry All Commercial |
$436.00
|
| Rate for Payer: Encore All Commercial |
$456.07
|
| Rate for Payer: Frontpath All Commercial |
$455.82
|
| Rate for Payer: Humana ChoiceCare |
$427.93
|
| Rate for Payer: Humana Medicare |
$158.55
|
| Rate for Payer: Lucent All Commercial |
$269.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.91
|
| Rate for Payer: Managed Health Services Medicaid |
$102.97
|
| Rate for Payer: MDWise Medicaid |
$102.97
|
| Rate for Payer: PHCS All Commercial |
$371.59
|
| Rate for Payer: PHP All Commercial |
$375.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$193.23
|
| Rate for Payer: Sagamore Health Network All Products |
$382.49
|
| Rate for Payer: Signature Care EPO |
$411.23
|
| Rate for Payer: Signature Care PPO |
$436.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$421.14
|
| Rate for Payer: United Healthcare Commercial |
$390.42
|
| Rate for Payer: United Healthcare Medicare |
$158.55
|
|
|
RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR
|
Facility
|
OP
|
$1,104.48
|
|
|
Service Code
|
HCPCS 90678
|
| Hospital Charge Code |
202248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$342.39 |
| Max. Negotiated Rate |
$1,027.17 |
| Rate for Payer: Aetna Commercial |
$932.18
|
| Rate for Payer: Aetna Medicare |
$353.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$342.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$634.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$690.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$406.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$388.78
|
| Rate for Payer: Cash Price |
$684.78
|
| Rate for Payer: Centivo All Commercial |
$600.84
|
| Rate for Payer: Cigna All Commercial |
$953.17
|
| Rate for Payer: CORVEL All Commercial |
$1,027.17
|
| Rate for Payer: Coventry All Commercial |
$971.94
|
| Rate for Payer: Encore All Commercial |
$1,016.67
|
| Rate for Payer: Frontpath All Commercial |
$1,016.12
|
| Rate for Payer: Humana ChoiceCare |
$953.94
|
| Rate for Payer: Humana Medicare |
$353.43
|
| Rate for Payer: Lucent All Commercial |
$600.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$994.03
|
| Rate for Payer: PHCS All Commercial |
$828.36
|
| Rate for Payer: PHP All Commercial |
$837.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$430.75
|
| Rate for Payer: Sagamore Health Network All Products |
$852.66
|
| Rate for Payer: Signature Care EPO |
$916.72
|
| Rate for Payer: Signature Care PPO |
$971.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$938.81
|
| Rate for Payer: United Healthcare Commercial |
$870.33
|
| Rate for Payer: United Healthcare Medicare |
$353.43
|
|
|
RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR
|
Facility
|
IP
|
$1,104.48
|
|
|
Service Code
|
HCPCS 90678
|
| Hospital Charge Code |
202248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$828.36 |
| Max. Negotiated Rate |
$1,027.17 |
| Rate for Payer: Aetna Commercial |
$954.27
|
| Rate for Payer: Cash Price |
$684.78
|
| Rate for Payer: Cigna All Commercial |
$953.17
|
| Rate for Payer: CORVEL All Commercial |
$1,027.17
|
| Rate for Payer: Coventry All Commercial |
$971.94
|
| Rate for Payer: Encore All Commercial |
$1,016.67
|
| Rate for Payer: Frontpath All Commercial |
$1,016.12
|
| Rate for Payer: Humana ChoiceCare |
$953.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$994.03
|
| Rate for Payer: PHCS All Commercial |
$828.36
|
| Rate for Payer: PHP All Commercial |
$837.64
|
| Rate for Payer: Sagamore Health Network All Products |
$852.66
|
| Rate for Payer: Signature Care EPO |
$916.72
|
| Rate for Payer: Signature Care PPO |
$971.94
|
| Rate for Payer: United Healthcare Commercial |
$870.33
|
|
|
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB
|
Facility
|
OP
|
$76.36
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
173291
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.67 |
| Max. Negotiated Rate |
$71.02 |
| Rate for Payer: Aetna Commercial |
$64.45
|
| Rate for Payer: Aetna Medicare |
$24.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$43.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.88
|
| Rate for Payer: Cash Price |
$47.35
|
| Rate for Payer: Centivo All Commercial |
$41.54
|
| Rate for Payer: Cigna All Commercial |
$65.90
|
| Rate for Payer: CORVEL All Commercial |
$71.02
|
| Rate for Payer: Coventry All Commercial |
$67.20
|
| Rate for Payer: Encore All Commercial |
$70.29
|
| Rate for Payer: Frontpath All Commercial |
$70.25
|
| Rate for Payer: Humana ChoiceCare |
$65.95
|
| Rate for Payer: Humana Medicare |
$24.44
|
| Rate for Payer: Lucent All Commercial |
$41.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$68.73
|
| Rate for Payer: PHCS All Commercial |
$57.27
|
| Rate for Payer: PHP All Commercial |
$57.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.78
|
| Rate for Payer: Sagamore Health Network All Products |
$58.95
|
| Rate for Payer: Signature Care EPO |
$63.38
|
| Rate for Payer: Signature Care PPO |
$67.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$64.91
|
| Rate for Payer: United Healthcare Commercial |
$60.17
|
| Rate for Payer: United Healthcare Medicare |
$24.44
|
|
|
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB
|
Facility
|
IP
|
$76.36
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
173291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.27 |
| Max. Negotiated Rate |
$71.02 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: Cash Price |
$47.35
|
| Rate for Payer: Cigna All Commercial |
$65.90
|
| Rate for Payer: CORVEL All Commercial |
$71.02
|
| Rate for Payer: Coventry All Commercial |
$67.20
|
| Rate for Payer: Encore All Commercial |
$70.29
|
| Rate for Payer: Frontpath All Commercial |
$70.25
|
| Rate for Payer: Humana ChoiceCare |
$65.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$68.73
|
| Rate for Payer: PHCS All Commercial |
$57.27
|
| Rate for Payer: PHP All Commercial |
$57.91
|
| Rate for Payer: Sagamore Health Network All Products |
$58.95
|
| Rate for Payer: Signature Care EPO |
$63.38
|
| Rate for Payer: Signature Care PPO |
$67.20
|
| Rate for Payer: United Healthcare Commercial |
$60.17
|
|
|
SALINE SYRINGE FOR PLEURODESIS
|
Facility
|
IP
|
$14.49
|
|
|
Service Code
|
NDC 00409488812
|
| Hospital Charge Code |
800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Cigna All Commercial |
$12.50
|
| Rate for Payer: CORVEL All Commercial |
$13.48
|
| Rate for Payer: Coventry All Commercial |
$12.75
|
| Rate for Payer: Encore All Commercial |
$13.34
|
| Rate for Payer: Frontpath All Commercial |
$13.33
|
| Rate for Payer: Humana ChoiceCare |
$12.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.04
|
| Rate for Payer: PHCS All Commercial |
$10.87
|
| Rate for Payer: PHP All Commercial |
$10.99
|
| Rate for Payer: Sagamore Health Network All Products |
$11.19
|
| Rate for Payer: Signature Care EPO |
$12.03
|
| Rate for Payer: Signature Care PPO |
$12.75
|
| Rate for Payer: United Healthcare Commercial |
$11.42
|
|
|
SALINE SYRINGE FOR PLEURODESIS
|
Facility
|
OP
|
$14.49
|
|
|
Service Code
|
NDC 00409488812
|
| Hospital Charge Code |
800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Aetna Commercial |
$12.23
|
| Rate for Payer: Aetna Medicare |
$4.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.10
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Centivo All Commercial |
$7.88
|
| Rate for Payer: Cigna All Commercial |
$12.50
|
| Rate for Payer: CORVEL All Commercial |
$13.48
|
| Rate for Payer: Coventry All Commercial |
$12.75
|
| Rate for Payer: Encore All Commercial |
$13.34
|
| Rate for Payer: Frontpath All Commercial |
$13.33
|
| Rate for Payer: Humana ChoiceCare |
$12.52
|
| Rate for Payer: Humana Medicare |
$4.64
|
| Rate for Payer: Lucent All Commercial |
$7.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.04
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$10.87
|
| Rate for Payer: PHP All Commercial |
$10.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.65
|
| Rate for Payer: Sagamore Health Network All Products |
$11.19
|
| Rate for Payer: Signature Care EPO |
$12.03
|
| Rate for Payer: Signature Care PPO |
$12.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.32
|
| Rate for Payer: United Healthcare Commercial |
$11.42
|
| Rate for Payer: United Healthcare Medicare |
$4.64
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$3,933.73
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$3,933.73 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$9,293.98
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$9,293.98 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$4,841.51
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,841.51 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$3,069.17
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$3,069.17 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D
|
Facility
|
OP
|
$48.86
|
|
|
Service Code
|
NDC 50742050504
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$45.44 |
| Rate for Payer: Aetna Commercial |
$41.24
|
| Rate for Payer: Aetna Medicare |
$15.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.20
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Centivo All Commercial |
$26.58
|
| Rate for Payer: Cigna All Commercial |
$42.17
|
| Rate for Payer: CORVEL All Commercial |
$45.44
|
| Rate for Payer: Coventry All Commercial |
$43.00
|
| Rate for Payer: Encore All Commercial |
$44.98
|
| Rate for Payer: Frontpath All Commercial |
$44.95
|
| Rate for Payer: Humana ChoiceCare |
$42.20
|
| Rate for Payer: Humana Medicare |
$15.64
|
| Rate for Payer: Lucent All Commercial |
$26.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.97
|
| Rate for Payer: PHCS All Commercial |
$36.65
|
| Rate for Payer: PHP All Commercial |
$37.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.06
|
| Rate for Payer: Sagamore Health Network All Products |
$37.72
|
| Rate for Payer: Signature Care EPO |
$40.55
|
| Rate for Payer: Signature Care PPO |
$43.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.53
|
| Rate for Payer: United Healthcare Commercial |
$38.50
|
| Rate for Payer: United Healthcare Medicare |
$15.64
|
|
|
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D
|
Facility
|
IP
|
$48.86
|
|
|
Service Code
|
NDC 50742050504
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.65 |
| Max. Negotiated Rate |
$45.44 |
| Rate for Payer: Aetna Commercial |
$42.22
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Cigna All Commercial |
$42.17
|
| Rate for Payer: CORVEL All Commercial |
$45.44
|
| Rate for Payer: Coventry All Commercial |
$43.00
|
| Rate for Payer: Encore All Commercial |
$44.98
|
| Rate for Payer: Frontpath All Commercial |
$44.95
|
| Rate for Payer: Humana ChoiceCare |
$42.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.97
|
| Rate for Payer: PHCS All Commercial |
$36.65
|
| Rate for Payer: PHP All Commercial |
$37.06
|
| Rate for Payer: Sagamore Health Network All Products |
$37.72
|
| Rate for Payer: Signature Care EPO |
$40.55
|
| Rate for Payer: Signature Care PPO |
$43.00
|
| Rate for Payer: United Healthcare Commercial |
$38.50
|
|
|
SEMAGLUTIDE 2 MG/DOSE (8 MG/3 ML) SUBQ PNIJ
|
Facility
|
OP
|
$3,890.56
|
|
|
Service Code
|
NDC 00169477212
|
| Hospital Charge Code |
197585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$3,618.22 |
| Rate for Payer: Aetna Commercial |
$3,283.63
|
| Rate for Payer: Aetna Medicare |
$1,244.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,206.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,234.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,431.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,431.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,369.48
|
| Rate for Payer: Cash Price |
$2,412.14
|
| Rate for Payer: Cash Price |
$2,412.14
|
| Rate for Payer: Centivo All Commercial |
$2,116.46
|
| Rate for Payer: Cigna All Commercial |
$3,357.55
|
| Rate for Payer: CORVEL All Commercial |
$3,618.22
|
| Rate for Payer: Coventry All Commercial |
$3,423.69
|
| Rate for Payer: Encore All Commercial |
$3,581.26
|
| Rate for Payer: Frontpath All Commercial |
$3,579.31
|
| Rate for Payer: Humana ChoiceCare |
$3,360.27
|
| Rate for Payer: Humana Medicare |
$1,244.98
|
| Rate for Payer: Lucent All Commercial |
$2,116.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,501.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$2,917.92
|
| Rate for Payer: PHP All Commercial |
$2,950.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,517.32
|
| Rate for Payer: Sagamore Health Network All Products |
$3,003.51
|
| Rate for Payer: Signature Care EPO |
$3,229.16
|
| Rate for Payer: Signature Care PPO |
$3,423.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,306.97
|
| Rate for Payer: United Healthcare Commercial |
$3,065.76
|
| Rate for Payer: United Healthcare Medicare |
$1,244.98
|
|
|
SEMAGLUTIDE 2 MG/DOSE (8 MG/3 ML) SUBQ PNIJ
|
Facility
|
IP
|
$3,890.56
|
|
|
Service Code
|
NDC 00169477212
|
| Hospital Charge Code |
197585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,917.92 |
| Max. Negotiated Rate |
$3,618.22 |
| Rate for Payer: Aetna Commercial |
$3,361.44
|
| Rate for Payer: Cash Price |
$2,412.14
|
| Rate for Payer: Cigna All Commercial |
$3,357.55
|
| Rate for Payer: CORVEL All Commercial |
$3,618.22
|
| Rate for Payer: Coventry All Commercial |
$3,423.69
|
| Rate for Payer: Encore All Commercial |
$3,581.26
|
| Rate for Payer: Frontpath All Commercial |
$3,579.31
|
| Rate for Payer: Humana ChoiceCare |
$3,360.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,501.50
|
| Rate for Payer: PHCS All Commercial |
$2,917.92
|
| Rate for Payer: PHP All Commercial |
$2,950.60
|
| Rate for Payer: Sagamore Health Network All Products |
$3,003.51
|
| Rate for Payer: Signature Care EPO |
$3,229.16
|
| Rate for Payer: Signature Care PPO |
$3,423.69
|
| Rate for Payer: United Healthcare Commercial |
$3,065.76
|
|
|
SENNOSIDES 8.6 MG ORAL TAB
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 00904725261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.24
|
| Rate for Payer: Aetna Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Centivo All Commercial |
$0.16
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Humana Medicare |
$0.09
|
| Rate for Payer: Lucent All Commercial |
$0.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.11
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
|
|
SENNOSIDES 8.6 MG ORAL TAB
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 00904725261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
|
|
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
| Hospital Charge Code |
24216
|
|
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 |
$0.62
|
| 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
|
|
