|
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
| Hospital Charge Code |
24216
|
|
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
|
|
|
SERTRALINE 50 MG ORAL TAB
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna All Commercial |
$1.43
|
| Rate for Payer: CORVEL All Commercial |
$1.54
|
| Rate for Payer: Coventry All Commercial |
$1.46
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.49
|
| Rate for Payer: PHCS All Commercial |
$1.24
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1.28
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
|
|
SERTRALINE 50 MG ORAL TAB
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| Rate for Payer: Cigna All Commercial |
$1.43
|
| Rate for Payer: CORVEL All Commercial |
$1.54
|
| Rate for Payer: Coventry All Commercial |
$1.46
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.43
|
| Rate for Payer: Humana Medicare |
$0.53
|
| Rate for Payer: Lucent All Commercial |
$0.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.49
|
| Rate for Payer: PHCS All Commercial |
$1.24
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1.28
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.41
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
SEVELAMER HCL 800 MG ORAL TAB
|
Facility
|
OP
|
$49.38
|
|
|
Service Code
|
NDC 58468002101
|
| Hospital Charge Code |
28715
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$45.92 |
| Rate for Payer: Aetna Commercial |
$41.68
|
| Rate for Payer: Aetna Medicare |
$15.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.38
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Centivo All Commercial |
$26.86
|
| Rate for Payer: Cigna All Commercial |
$42.61
|
| Rate for Payer: CORVEL All Commercial |
$45.92
|
| Rate for Payer: Coventry All Commercial |
$43.45
|
| Rate for Payer: Encore All Commercial |
$45.45
|
| Rate for Payer: Frontpath All Commercial |
$45.43
|
| Rate for Payer: Humana ChoiceCare |
$42.65
|
| Rate for Payer: Humana Medicare |
$15.80
|
| Rate for Payer: Lucent All Commercial |
$26.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.44
|
| Rate for Payer: PHCS All Commercial |
$37.03
|
| Rate for Payer: PHP All Commercial |
$37.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.26
|
| Rate for Payer: Sagamore Health Network All Products |
$38.12
|
| Rate for Payer: Signature Care EPO |
$40.98
|
| Rate for Payer: Signature Care PPO |
$43.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.97
|
| Rate for Payer: United Healthcare Commercial |
$38.91
|
| Rate for Payer: United Healthcare Medicare |
$15.80
|
|
|
SEVELAMER HCL 800 MG ORAL TAB
|
Facility
|
IP
|
$49.38
|
|
|
Service Code
|
NDC 58468002101
|
| Hospital Charge Code |
28715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$45.92 |
| Rate for Payer: Aetna Commercial |
$42.66
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Cigna All Commercial |
$42.61
|
| Rate for Payer: CORVEL All Commercial |
$45.92
|
| Rate for Payer: Coventry All Commercial |
$43.45
|
| Rate for Payer: Encore All Commercial |
$45.45
|
| Rate for Payer: Frontpath All Commercial |
$45.43
|
| Rate for Payer: Humana ChoiceCare |
$42.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.44
|
| Rate for Payer: PHCS All Commercial |
$37.03
|
| Rate for Payer: PHP All Commercial |
$37.45
|
| Rate for Payer: Sagamore Health Network All Products |
$38.12
|
| Rate for Payer: Signature Care EPO |
$40.98
|
| Rate for Payer: Signature Care PPO |
$43.45
|
| Rate for Payer: United Healthcare Commercial |
$38.91
|
|
|
SEVOFLURANE 99.97 % INHL LIQD
|
Facility
|
IP
|
$881.25
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$660.94 |
| Max. Negotiated Rate |
$819.56 |
| Rate for Payer: Aetna Commercial |
$761.40
|
| Rate for Payer: Cash Price |
$546.38
|
| Rate for Payer: Cigna All Commercial |
$760.52
|
| Rate for Payer: CORVEL All Commercial |
$819.56
|
| Rate for Payer: Coventry All Commercial |
$775.50
|
| Rate for Payer: Encore All Commercial |
$811.19
|
| Rate for Payer: Frontpath All Commercial |
$810.75
|
| Rate for Payer: Humana ChoiceCare |
$761.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$793.12
|
| Rate for Payer: PHCS All Commercial |
$660.94
|
| Rate for Payer: PHP All Commercial |
$668.34
|
| Rate for Payer: Sagamore Health Network All Products |
$680.33
|
| Rate for Payer: Signature Care EPO |
$731.44
|
| Rate for Payer: Signature Care PPO |
$775.50
|
| Rate for Payer: United Healthcare Commercial |
$694.42
|
|
|
SEVOFLURANE 99.97 % INHL LIQD
|
Facility
|
OP
|
$881.25
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$819.56 |
| Rate for Payer: Aetna Commercial |
$743.77
|
| Rate for Payer: Aetna Medicare |
$282.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$273.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$506.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$550.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$324.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$310.20
|
| Rate for Payer: Cash Price |
$546.38
|
| Rate for Payer: Cash Price |
$546.38
|
| Rate for Payer: Centivo All Commercial |
$479.40
|
| Rate for Payer: Cigna All Commercial |
$760.52
|
| Rate for Payer: CORVEL All Commercial |
$819.56
|
| Rate for Payer: Coventry All Commercial |
$775.50
|
| Rate for Payer: Encore All Commercial |
$811.19
|
| Rate for Payer: Frontpath All Commercial |
$810.75
|
| Rate for Payer: Humana ChoiceCare |
$761.14
|
| Rate for Payer: Humana Medicare |
$282.00
|
| Rate for Payer: Lucent All Commercial |
$479.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$793.12
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$660.94
|
| Rate for Payer: PHP All Commercial |
$668.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$343.69
|
| Rate for Payer: Sagamore Health Network All Products |
$680.33
|
| Rate for Payer: Signature Care EPO |
$731.44
|
| Rate for Payer: Signature Care PPO |
$775.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$749.06
|
| Rate for Payer: United Healthcare Commercial |
$694.42
|
| Rate for Payer: United Healthcare Medicare |
$282.00
|
|
|
SILVER NITRATE APPLICATORS 75-25 % TOP STCK (CAMERON)
|
Facility
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
140100011359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna All Commercial |
$1.36
|
| Rate for Payer: CORVEL All Commercial |
$1.46
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.45
|
| Rate for Payer: Frontpath All Commercial |
$1.45
|
| Rate for Payer: Humana ChoiceCare |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: PHCS All Commercial |
$1.18
|
| Rate for Payer: PHP All Commercial |
$1.19
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
|
|
SILVER NITRATE APPLICATORS 75-25 % TOP STCK (CAMERON)
|
Facility
|
OP
|
$1.58
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
140100011359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Centivo All Commercial |
$0.86
|
| Rate for Payer: Cigna All Commercial |
$1.36
|
| Rate for Payer: CORVEL All Commercial |
$1.46
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.45
|
| Rate for Payer: Frontpath All Commercial |
$1.45
|
| Rate for Payer: Humana ChoiceCare |
$1.36
|
| Rate for Payer: Humana Medicare |
$0.50
|
| Rate for Payer: Lucent All Commercial |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.18
|
| Rate for Payer: PHP All Commercial |
$1.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
|
OP
|
$341.60
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.90 |
| Max. Negotiated Rate |
$317.69 |
| Rate for Payer: Aetna Commercial |
$288.31
|
| Rate for Payer: Aetna Medicare |
$109.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$196.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.24
|
| Rate for Payer: Cash Price |
$211.79
|
| Rate for Payer: Centivo All Commercial |
$185.83
|
| Rate for Payer: Cigna All Commercial |
$294.80
|
| Rate for Payer: CORVEL All Commercial |
$317.69
|
| Rate for Payer: Coventry All Commercial |
$300.61
|
| Rate for Payer: Encore All Commercial |
$314.44
|
| Rate for Payer: Frontpath All Commercial |
$314.27
|
| Rate for Payer: Humana ChoiceCare |
$295.04
|
| Rate for Payer: Humana Medicare |
$109.31
|
| Rate for Payer: Lucent All Commercial |
$185.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.44
|
| Rate for Payer: PHCS All Commercial |
$256.20
|
| Rate for Payer: PHP All Commercial |
$259.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.22
|
| Rate for Payer: Sagamore Health Network All Products |
$263.72
|
| Rate for Payer: Signature Care EPO |
$283.53
|
| Rate for Payer: Signature Care PPO |
$300.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.36
|
| Rate for Payer: United Healthcare Commercial |
$269.18
|
| Rate for Payer: United Healthcare Medicare |
$109.31
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
|
IP
|
$341.60
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$317.69 |
| Rate for Payer: Aetna Commercial |
$295.14
|
| Rate for Payer: Cash Price |
$211.79
|
| Rate for Payer: Cigna All Commercial |
$294.80
|
| Rate for Payer: CORVEL All Commercial |
$317.69
|
| Rate for Payer: Coventry All Commercial |
$300.61
|
| Rate for Payer: Encore All Commercial |
$314.44
|
| Rate for Payer: Frontpath All Commercial |
$314.27
|
| Rate for Payer: Humana ChoiceCare |
$295.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.44
|
| Rate for Payer: PHCS All Commercial |
$256.20
|
| Rate for Payer: PHP All Commercial |
$259.07
|
| Rate for Payer: Sagamore Health Network All Products |
$263.72
|
| Rate for Payer: Signature Care EPO |
$283.53
|
| Rate for Payer: Signature Care PPO |
$300.61
|
| Rate for Payer: United Healthcare Commercial |
$269.18
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.32
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Centivo All Commercial |
$19.04
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$11.20
|
| Rate for Payer: Lucent All Commercial |
$19.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DRPS
|
Facility
|
IP
|
$32.24
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$29.98 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cigna All Commercial |
$27.82
|
| Rate for Payer: CORVEL All Commercial |
$29.98
|
| Rate for Payer: Coventry All Commercial |
$28.37
|
| Rate for Payer: Encore All Commercial |
$29.67
|
| Rate for Payer: Frontpath All Commercial |
$29.66
|
| Rate for Payer: Humana ChoiceCare |
$27.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.01
|
| Rate for Payer: PHCS All Commercial |
$24.18
|
| Rate for Payer: PHP All Commercial |
$24.45
|
| Rate for Payer: Sagamore Health Network All Products |
$24.89
|
| Rate for Payer: Signature Care EPO |
$26.76
|
| Rate for Payer: Signature Care PPO |
$28.37
|
| Rate for Payer: United Healthcare Commercial |
$25.40
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DRPS
|
Facility
|
OP
|
$32.24
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$29.98 |
| Rate for Payer: Aetna Commercial |
$27.21
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.35
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Centivo All Commercial |
$17.54
|
| Rate for Payer: Cigna All Commercial |
$27.82
|
| Rate for Payer: CORVEL All Commercial |
$29.98
|
| Rate for Payer: Coventry All Commercial |
$28.37
|
| Rate for Payer: Encore All Commercial |
$29.67
|
| Rate for Payer: Frontpath All Commercial |
$29.66
|
| Rate for Payer: Humana ChoiceCare |
$27.84
|
| Rate for Payer: Humana Medicare |
$10.32
|
| Rate for Payer: Lucent All Commercial |
$17.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.01
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$24.18
|
| Rate for Payer: PHP All Commercial |
$24.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.57
|
| Rate for Payer: Sagamore Health Network All Products |
$24.89
|
| Rate for Payer: Signature Care EPO |
$26.76
|
| Rate for Payer: Signature Care PPO |
$28.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.40
|
| Rate for Payer: United Healthcare Commercial |
$25.40
|
| Rate for Payer: United Healthcare Medicare |
$10.32
|
|
|
SIMETHICONE 80 MG ORAL CHEW
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Aetna Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Centivo All Commercial |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.98
|
| Rate for Payer: Humana Medicare |
$0.36
|
| Rate for Payer: Lucent All Commercial |
$0.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.02
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.44
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
|
|
SIMETHICONE 80 MG ORAL CHEW
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.98
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.02
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.86
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
|
|
SINCALIDE 5 MCG INJ SOLR
|
Facility
|
OP
|
$618.55
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.75 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$522.06
|
| Rate for Payer: Aetna Medicare |
$197.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$191.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$355.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$386.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.73
|
| Rate for Payer: Cash Price |
$383.50
|
| Rate for Payer: Centivo All Commercial |
$336.49
|
| Rate for Payer: Cigna All Commercial |
$533.81
|
| Rate for Payer: CORVEL All Commercial |
$575.25
|
| Rate for Payer: Coventry All Commercial |
$544.32
|
| Rate for Payer: Encore All Commercial |
$569.38
|
| Rate for Payer: Frontpath All Commercial |
$569.07
|
| Rate for Payer: Humana ChoiceCare |
$534.24
|
| Rate for Payer: Humana Medicare |
$197.94
|
| Rate for Payer: Lucent All Commercial |
$336.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$556.70
|
| Rate for Payer: PHCS All Commercial |
$463.91
|
| Rate for Payer: PHP All Commercial |
$469.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$241.23
|
| Rate for Payer: Sagamore Health Network All Products |
$477.52
|
| Rate for Payer: Signature Care EPO |
$513.40
|
| Rate for Payer: Signature Care PPO |
$544.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$525.77
|
| Rate for Payer: United Healthcare Commercial |
$487.42
|
| Rate for Payer: United Healthcare Medicare |
$197.94
|
|
|
SINCALIDE 5 MCG INJ SOLR
|
Facility
|
IP
|
$618.55
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$463.91 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$534.43
|
| Rate for Payer: Cash Price |
$383.50
|
| Rate for Payer: Cigna All Commercial |
$533.81
|
| Rate for Payer: CORVEL All Commercial |
$575.25
|
| Rate for Payer: Coventry All Commercial |
$544.32
|
| Rate for Payer: Encore All Commercial |
$569.38
|
| Rate for Payer: Frontpath All Commercial |
$569.07
|
| Rate for Payer: Humana ChoiceCare |
$534.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$556.70
|
| Rate for Payer: PHCS All Commercial |
$463.91
|
| Rate for Payer: PHP All Commercial |
$469.11
|
| Rate for Payer: Sagamore Health Network All Products |
$477.52
|
| Rate for Payer: Signature Care EPO |
$513.40
|
| Rate for Payer: Signature Care PPO |
$544.32
|
| Rate for Payer: United Healthcare Commercial |
$487.42
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB
|
Facility
|
IP
|
$72.18
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.13 |
| Max. Negotiated Rate |
$67.12 |
| Rate for Payer: Aetna Commercial |
$62.36
|
| Rate for Payer: Cash Price |
$44.75
|
| Rate for Payer: Cigna All Commercial |
$62.29
|
| Rate for Payer: CORVEL All Commercial |
$67.12
|
| Rate for Payer: Coventry All Commercial |
$63.52
|
| Rate for Payer: Encore All Commercial |
$66.44
|
| Rate for Payer: Frontpath All Commercial |
$66.40
|
| Rate for Payer: Humana ChoiceCare |
$62.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.96
|
| Rate for Payer: PHCS All Commercial |
$54.13
|
| Rate for Payer: PHP All Commercial |
$54.74
|
| Rate for Payer: Sagamore Health Network All Products |
$55.72
|
| Rate for Payer: Signature Care EPO |
$59.91
|
| Rate for Payer: Signature Care PPO |
$63.52
|
| Rate for Payer: United Healthcare Commercial |
$56.88
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB
|
Facility
|
OP
|
$72.18
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$67.12 |
| Rate for Payer: Aetna Commercial |
$60.92
|
| Rate for Payer: Aetna Medicare |
$23.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$41.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.41
|
| Rate for Payer: Cash Price |
$44.75
|
| Rate for Payer: Centivo All Commercial |
$39.26
|
| Rate for Payer: Cigna All Commercial |
$62.29
|
| Rate for Payer: CORVEL All Commercial |
$67.12
|
| Rate for Payer: Coventry All Commercial |
$63.52
|
| Rate for Payer: Encore All Commercial |
$66.44
|
| Rate for Payer: Frontpath All Commercial |
$66.40
|
| Rate for Payer: Humana ChoiceCare |
$62.34
|
| Rate for Payer: Humana Medicare |
$23.10
|
| Rate for Payer: Lucent All Commercial |
$39.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.96
|
| Rate for Payer: PHCS All Commercial |
$54.13
|
| Rate for Payer: PHP All Commercial |
$54.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.15
|
| Rate for Payer: Sagamore Health Network All Products |
$55.72
|
| Rate for Payer: Signature Care EPO |
$59.91
|
| Rate for Payer: Signature Care PPO |
$63.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$61.35
|
| Rate for Payer: United Healthcare Commercial |
$56.88
|
| Rate for Payer: United Healthcare Medicare |
$23.10
|
|
|
SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$1,106.60
|
|
|
Service Code
|
CPT 44376
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,106.60 |
| Max. Negotiated Rate |
$1,106.60 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,106.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,106.60
|
| Rate for Payer: Managed Health Services Medicaid |
$1,106.60
|
| Rate for Payer: MDWise Medicaid |
$1,106.60
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21-1.53 GRAM/4 GRAM ORAL GREP
|
Facility
|
OP
|
$24.80
|
|
|
Service Code
|
NDC 10361079301
|
| Hospital Charge Code |
159143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna Commercial |
$20.93
|
| Rate for Payer: Aetna Medicare |
$7.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.73
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Centivo All Commercial |
$13.49
|
| Rate for Payer: Cigna All Commercial |
$21.40
|
| Rate for Payer: CORVEL All Commercial |
$23.06
|
| Rate for Payer: Coventry All Commercial |
$21.82
|
| Rate for Payer: Encore All Commercial |
$22.83
|
| Rate for Payer: Frontpath All Commercial |
$22.82
|
| Rate for Payer: Humana ChoiceCare |
$21.42
|
| Rate for Payer: Humana Medicare |
$7.94
|
| Rate for Payer: Lucent All Commercial |
$13.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.32
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$18.60
|
| Rate for Payer: PHP All Commercial |
$18.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.67
|
| Rate for Payer: Sagamore Health Network All Products |
$19.15
|
| Rate for Payer: Signature Care EPO |
$20.58
|
| Rate for Payer: Signature Care PPO |
$21.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.08
|
| Rate for Payer: United Healthcare Commercial |
$19.54
|
| Rate for Payer: United Healthcare Medicare |
$7.94
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21-1.53 GRAM/4 GRAM ORAL GREP
|
Facility
|
IP
|
$24.80
|
|
|
Service Code
|
NDC 10361079301
|
| Hospital Charge Code |
159143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna Commercial |
$21.43
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cigna All Commercial |
$21.40
|
| Rate for Payer: CORVEL All Commercial |
$23.06
|
| Rate for Payer: Coventry All Commercial |
$21.82
|
| Rate for Payer: Encore All Commercial |
$22.83
|
| Rate for Payer: Frontpath All Commercial |
$22.82
|
| Rate for Payer: Humana ChoiceCare |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.32
|
| Rate for Payer: PHCS All Commercial |
$18.60
|
| Rate for Payer: PHP All Commercial |
$18.81
|
| Rate for Payer: Sagamore Health Network All Products |
$19.15
|
| Rate for Payer: Signature Care EPO |
$20.58
|
| Rate for Payer: Signature Care PPO |
$21.82
|
| Rate for Payer: United Healthcare Commercial |
$19.54
|
|
|
SOD BORATE-BORIC AC-NACL-WATER OPHT IRSL
|
Facility
|
IP
|
$29.74
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
163510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.30 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Aetna Commercial |
$25.69
|
| Rate for Payer: Cash Price |
$18.44
|
| Rate for Payer: Cigna All Commercial |
$25.66
|
| Rate for Payer: CORVEL All Commercial |
$27.65
|
| Rate for Payer: Coventry All Commercial |
$26.17
|
| Rate for Payer: Encore All Commercial |
$27.37
|
| Rate for Payer: Frontpath All Commercial |
$27.36
|
| Rate for Payer: Humana ChoiceCare |
$25.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.76
|
| Rate for Payer: PHCS All Commercial |
$22.30
|
| Rate for Payer: PHP All Commercial |
$22.55
|
| Rate for Payer: Sagamore Health Network All Products |
$22.96
|
| Rate for Payer: Signature Care EPO |
$24.68
|
| Rate for Payer: Signature Care PPO |
$26.17
|
| Rate for Payer: United Healthcare Commercial |
$23.43
|
|
