|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 20 MG/ML INJ SOLN
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
193039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SUCRALFATE 1 G ORAL TAB
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.51
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.54
|
| Rate for Payer: Encore All Commercial |
$1.61
|
| Rate for Payer: Frontpath All Commercial |
$1.61
|
| Rate for Payer: Humana ChoiceCare |
$1.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| Rate for Payer: Signature Care PPO |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
SUCRALFATE 1 G ORAL TAB
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Centivo All Commercial |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.51
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.54
|
| Rate for Payer: Encore All Commercial |
$1.61
|
| Rate for Payer: Frontpath All Commercial |
$1.61
|
| Rate for Payer: Humana ChoiceCare |
$1.51
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| Rate for Payer: Signature Care PPO |
$1.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.49
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
SUGAMMADEX 100 MG/ML IV SOLN
|
Facility
|
IP
|
$638.14
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
175535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$478.61 |
| Max. Negotiated Rate |
$593.47 |
| Rate for Payer: Aetna Commercial |
$551.35
|
| Rate for Payer: Cash Price |
$382.88
|
| Rate for Payer: Cigna All Commercial |
$550.71
|
| Rate for Payer: CORVEL All Commercial |
$593.47
|
| Rate for Payer: Coventry All Commercial |
$561.56
|
| Rate for Payer: Encore All Commercial |
$587.41
|
| Rate for Payer: Frontpath All Commercial |
$587.09
|
| Rate for Payer: Humana ChoiceCare |
$551.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$574.33
|
| Rate for Payer: PHCS All Commercial |
$478.61
|
| Rate for Payer: PHP All Commercial |
$483.97
|
| Rate for Payer: Sagamore Health Network All Products |
$492.64
|
| Rate for Payer: Signature Care EPO |
$529.66
|
| Rate for Payer: Signature Care PPO |
$561.56
|
| Rate for Payer: United Healthcare Commercial |
$502.85
|
|
|
SUGAMMADEX 100 MG/ML IV SOLN
|
Facility
|
OP
|
$638.14
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
175535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.82 |
| Max. Negotiated Rate |
$593.47 |
| Rate for Payer: Aetna Commercial |
$538.59
|
| Rate for Payer: Aetna Medicare |
$204.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$197.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$366.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$398.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$234.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$224.63
|
| Rate for Payer: Cash Price |
$382.88
|
| Rate for Payer: Centivo All Commercial |
$347.15
|
| Rate for Payer: Cigna All Commercial |
$550.71
|
| Rate for Payer: CORVEL All Commercial |
$593.47
|
| Rate for Payer: Coventry All Commercial |
$561.56
|
| Rate for Payer: Encore All Commercial |
$587.41
|
| Rate for Payer: Frontpath All Commercial |
$587.09
|
| Rate for Payer: Humana ChoiceCare |
$551.16
|
| Rate for Payer: Humana Medicare |
$204.20
|
| Rate for Payer: Lucent All Commercial |
$347.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$574.33
|
| Rate for Payer: PHCS All Commercial |
$478.61
|
| Rate for Payer: PHP All Commercial |
$483.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$248.87
|
| Rate for Payer: Sagamore Health Network All Products |
$492.64
|
| Rate for Payer: Signature Care EPO |
$529.66
|
| Rate for Payer: Signature Care PPO |
$561.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$542.42
|
| Rate for Payer: United Healthcare Commercial |
$502.85
|
| Rate for Payer: United Healthcare Medicare |
$204.20
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
|
OP
|
$288.54
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.45 |
| Max. Negotiated Rate |
$268.34 |
| Rate for Payer: Aetna Commercial |
$243.53
|
| Rate for Payer: Aetna Medicare |
$92.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$89.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$165.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.57
|
| Rate for Payer: Cash Price |
$173.12
|
| Rate for Payer: Centivo All Commercial |
$156.97
|
| Rate for Payer: Cigna All Commercial |
$249.01
|
| Rate for Payer: CORVEL All Commercial |
$268.34
|
| Rate for Payer: Coventry All Commercial |
$253.92
|
| Rate for Payer: Encore All Commercial |
$265.60
|
| Rate for Payer: Frontpath All Commercial |
$265.46
|
| Rate for Payer: Humana ChoiceCare |
$249.21
|
| Rate for Payer: Humana Medicare |
$92.33
|
| Rate for Payer: Lucent All Commercial |
$156.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.69
|
| Rate for Payer: PHCS All Commercial |
$216.41
|
| Rate for Payer: PHP All Commercial |
$218.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.53
|
| Rate for Payer: Sagamore Health Network All Products |
$222.75
|
| Rate for Payer: Signature Care EPO |
$239.49
|
| Rate for Payer: Signature Care PPO |
$253.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$245.26
|
| Rate for Payer: United Healthcare Commercial |
$227.37
|
| Rate for Payer: United Healthcare Medicare |
$92.33
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
|
IP
|
$288.54
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$216.41 |
| Max. Negotiated Rate |
$268.34 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Cash Price |
$173.12
|
| Rate for Payer: Cigna All Commercial |
$249.01
|
| Rate for Payer: CORVEL All Commercial |
$268.34
|
| Rate for Payer: Coventry All Commercial |
$253.92
|
| Rate for Payer: Encore All Commercial |
$265.60
|
| Rate for Payer: Frontpath All Commercial |
$265.46
|
| Rate for Payer: Humana ChoiceCare |
$249.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.69
|
| Rate for Payer: PHCS All Commercial |
$216.41
|
| Rate for Payer: PHP All Commercial |
$218.83
|
| Rate for Payer: Sagamore Health Network All Products |
$222.75
|
| Rate for Payer: Signature Care EPO |
$239.49
|
| Rate for Payer: Signature Care PPO |
$253.92
|
| Rate for Payer: United Healthcare Commercial |
$227.37
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 65862496
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna All Commercial |
$2.75
|
| Rate for Payer: CORVEL All Commercial |
$2.96
|
| Rate for Payer: Coventry All Commercial |
$2.80
|
| Rate for Payer: Encore All Commercial |
$2.93
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$2.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.87
|
| Rate for Payer: PHCS All Commercial |
$2.39
|
| Rate for Payer: PHP All Commercial |
$2.42
|
| Rate for Payer: Sagamore Health Network All Products |
$2.46
|
| Rate for Payer: Signature Care EPO |
$2.64
|
| Rate for Payer: Signature Care PPO |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$301.30
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.40 |
| Max. Negotiated Rate |
$280.21 |
| Rate for Payer: Aetna Commercial |
$254.30
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$173.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$188.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$110.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$106.06
|
| Rate for Payer: Cash Price |
$180.78
|
| Rate for Payer: Centivo All Commercial |
$163.91
|
| Rate for Payer: Cigna All Commercial |
$260.02
|
| Rate for Payer: CORVEL All Commercial |
$280.21
|
| Rate for Payer: Coventry All Commercial |
$265.14
|
| Rate for Payer: Encore All Commercial |
$277.35
|
| Rate for Payer: Frontpath All Commercial |
$277.20
|
| Rate for Payer: Humana ChoiceCare |
$260.23
|
| Rate for Payer: Humana Medicare |
$96.42
|
| Rate for Payer: Lucent All Commercial |
$163.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$271.17
|
| Rate for Payer: PHCS All Commercial |
$225.98
|
| Rate for Payer: PHP All Commercial |
$228.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$117.51
|
| Rate for Payer: Sagamore Health Network All Products |
$232.60
|
| Rate for Payer: Signature Care EPO |
$250.08
|
| Rate for Payer: Signature Care PPO |
$265.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$256.11
|
| Rate for Payer: United Healthcare Commercial |
$237.43
|
| Rate for Payer: United Healthcare Medicare |
$96.42
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 65862496
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna Medicare |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.12
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Centivo All Commercial |
$1.73
|
| Rate for Payer: Cigna All Commercial |
$2.75
|
| Rate for Payer: CORVEL All Commercial |
$2.96
|
| Rate for Payer: Coventry All Commercial |
$2.80
|
| Rate for Payer: Encore All Commercial |
$2.93
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$2.75
|
| Rate for Payer: Humana Medicare |
$1.02
|
| Rate for Payer: Lucent All Commercial |
$1.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.87
|
| Rate for Payer: PHCS All Commercial |
$2.39
|
| Rate for Payer: PHP All Commercial |
$2.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2.46
|
| Rate for Payer: Signature Care EPO |
$2.64
|
| Rate for Payer: Signature Care PPO |
$2.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.71
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$301.30
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$280.21 |
| Rate for Payer: Aetna Commercial |
$260.32
|
| Rate for Payer: Cash Price |
$180.78
|
| Rate for Payer: Cigna All Commercial |
$260.02
|
| Rate for Payer: CORVEL All Commercial |
$280.21
|
| Rate for Payer: Coventry All Commercial |
$265.14
|
| Rate for Payer: Encore All Commercial |
$277.35
|
| Rate for Payer: Frontpath All Commercial |
$277.20
|
| Rate for Payer: Humana ChoiceCare |
$260.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$271.17
|
| Rate for Payer: PHCS All Commercial |
$225.98
|
| Rate for Payer: PHP All Commercial |
$228.51
|
| Rate for Payer: Sagamore Health Network All Products |
$232.60
|
| Rate for Payer: Signature Care EPO |
$250.08
|
| Rate for Payer: Signature Care PPO |
$265.14
|
| Rate for Payer: United Healthcare Commercial |
$237.43
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$19.53 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna All Commercial |
$18.12
|
| Rate for Payer: CORVEL All Commercial |
$19.53
|
| Rate for Payer: Coventry All Commercial |
$18.48
|
| Rate for Payer: Encore All Commercial |
$19.33
|
| Rate for Payer: Frontpath All Commercial |
$19.32
|
| Rate for Payer: Humana ChoiceCare |
$18.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.90
|
| Rate for Payer: PHCS All Commercial |
$15.75
|
| Rate for Payer: PHP All Commercial |
$15.93
|
| Rate for Payer: Sagamore Health Network All Products |
$16.21
|
| Rate for Payer: Signature Care EPO |
$17.43
|
| Rate for Payer: Signature Care PPO |
$18.48
|
| Rate for Payer: United Healthcare Commercial |
$16.55
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$19.53 |
| Rate for Payer: Aetna Commercial |
$17.72
|
| Rate for Payer: Aetna Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.39
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Centivo All Commercial |
$11.42
|
| Rate for Payer: Cigna All Commercial |
$18.12
|
| Rate for Payer: CORVEL All Commercial |
$19.53
|
| Rate for Payer: Coventry All Commercial |
$18.48
|
| Rate for Payer: Encore All Commercial |
$19.33
|
| Rate for Payer: Frontpath All Commercial |
$19.32
|
| Rate for Payer: Humana ChoiceCare |
$18.14
|
| Rate for Payer: Humana Medicare |
$6.72
|
| Rate for Payer: Lucent All Commercial |
$11.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.90
|
| Rate for Payer: PHCS All Commercial |
$15.75
|
| Rate for Payer: PHP All Commercial |
$15.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.19
|
| Rate for Payer: Sagamore Health Network All Products |
$16.21
|
| Rate for Payer: Signature Care EPO |
$17.43
|
| Rate for Payer: Signature Care PPO |
$18.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.85
|
| Rate for Payer: United Healthcare Commercial |
$16.55
|
| Rate for Payer: United Healthcare Medicare |
$6.72
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
SULFASALAZINE 500 MG ORAL TBEC
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna Commercial |
$1.56
|
| Rate for Payer: Aetna Medicare |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Centivo All Commercial |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.59
|
| Rate for Payer: CORVEL All Commercial |
$1.72
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.70
|
| Rate for Payer: Frontpath All Commercial |
$1.70
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Humana Medicare |
$0.59
|
| Rate for Payer: Lucent All Commercial |
$1.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.66
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.72
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.53
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
| Rate for Payer: United Healthcare Medicare |
$0.59
|
|
|
SULFASALAZINE 500 MG ORAL TBEC
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna All Commercial |
$1.59
|
| Rate for Payer: CORVEL All Commercial |
$1.72
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.70
|
| Rate for Payer: Frontpath All Commercial |
$1.70
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.66
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.40
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.53
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
|
|
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLN
|
Facility
|
IP
|
$25.47
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$23.68 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Cash Price |
$15.28
|
| Rate for Payer: Cigna All Commercial |
$21.98
|
| Rate for Payer: CORVEL All Commercial |
$23.68
|
| Rate for Payer: Coventry All Commercial |
$22.41
|
| Rate for Payer: Encore All Commercial |
$23.44
|
| Rate for Payer: Frontpath All Commercial |
$23.43
|
| Rate for Payer: Humana ChoiceCare |
$21.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.92
|
| Rate for Payer: PHCS All Commercial |
$19.10
|
| Rate for Payer: PHP All Commercial |
$19.31
|
| Rate for Payer: Sagamore Health Network All Products |
$19.66
|
| Rate for Payer: Signature Care EPO |
$21.14
|
| Rate for Payer: Signature Care PPO |
$22.41
|
| Rate for Payer: United Healthcare Commercial |
$20.07
|
|
|
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLN
|
Facility
|
OP
|
$25.47
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$23.68 |
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.96
|
| Rate for Payer: Cash Price |
$15.28
|
| Rate for Payer: Centivo All Commercial |
$13.85
|
| Rate for Payer: Cigna All Commercial |
$21.98
|
| Rate for Payer: CORVEL All Commercial |
$23.68
|
| Rate for Payer: Coventry All Commercial |
$22.41
|
| Rate for Payer: Encore All Commercial |
$23.44
|
| Rate for Payer: Frontpath All Commercial |
$23.43
|
| Rate for Payer: Humana ChoiceCare |
$21.99
|
| Rate for Payer: Humana Medicare |
$8.15
|
| Rate for Payer: Lucent All Commercial |
$13.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.92
|
| Rate for Payer: PHCS All Commercial |
$19.10
|
| Rate for Payer: PHP All Commercial |
$19.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.93
|
| Rate for Payer: Sagamore Health Network All Products |
$19.66
|
| Rate for Payer: Signature Care EPO |
$21.14
|
| Rate for Payer: Signature Care PPO |
$22.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.65
|
| Rate for Payer: United Healthcare Commercial |
$20.07
|
| Rate for Payer: United Healthcare Medicare |
$8.15
|
|
|
TAMSULOSIN 0.4 MG ORAL CAP
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.71
|
| Rate for Payer: Aetna Medicare |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Centivo All Commercial |
$1.10
|
| Rate for Payer: Cigna All Commercial |
$1.75
|
| Rate for Payer: CORVEL All Commercial |
$1.88
|
| Rate for Payer: Coventry All Commercial |
$1.78
|
| Rate for Payer: Encore All Commercial |
$1.86
|
| Rate for Payer: Frontpath All Commercial |
$1.86
|
| Rate for Payer: Humana ChoiceCare |
$1.75
|
| Rate for Payer: Humana Medicare |
$0.65
|
| Rate for Payer: Lucent All Commercial |
$1.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.82
|
| Rate for Payer: PHCS All Commercial |
$1.52
|
| Rate for Payer: PHP All Commercial |
$1.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.79
|
| Rate for Payer: Sagamore Health Network All Products |
$1.56
|
| Rate for Payer: Signature Care EPO |
$1.68
|
| Rate for Payer: Signature Care PPO |
$1.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$1.59
|
| Rate for Payer: United Healthcare Medicare |
$0.65
|
|
|
TAMSULOSIN 0.4 MG ORAL CAP
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.75
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna All Commercial |
$1.75
|
| Rate for Payer: CORVEL All Commercial |
$1.88
|
| Rate for Payer: Coventry All Commercial |
$1.78
|
| Rate for Payer: Encore All Commercial |
$1.86
|
| Rate for Payer: Frontpath All Commercial |
$1.86
|
| Rate for Payer: Humana ChoiceCare |
$1.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.82
|
| Rate for Payer: PHCS All Commercial |
$1.52
|
| Rate for Payer: PHP All Commercial |
$1.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1.56
|
| Rate for Payer: Signature Care EPO |
$1.68
|
| Rate for Payer: Signature Care PPO |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$1.59
|
|
|
TECHNETIUM TC 99M DISOFENIN
|
Facility
|
OP
|
$237.44
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
40840071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.61 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna Commercial |
$200.40
|
| Rate for Payer: Aetna Medicare |
$75.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$136.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$87.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.58
|
| Rate for Payer: Cash Price |
$142.46
|
| Rate for Payer: Centivo All Commercial |
$129.17
|
| Rate for Payer: Cigna All Commercial |
$204.91
|
| Rate for Payer: CORVEL All Commercial |
$220.82
|
| Rate for Payer: Coventry All Commercial |
$208.95
|
| Rate for Payer: Encore All Commercial |
$218.56
|
| Rate for Payer: Frontpath All Commercial |
$218.44
|
| Rate for Payer: Humana ChoiceCare |
$205.08
|
| Rate for Payer: Humana Medicare |
$75.98
|
| Rate for Payer: Lucent All Commercial |
$129.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.70
|
| Rate for Payer: PHCS All Commercial |
$178.08
|
| Rate for Payer: PHP All Commercial |
$180.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.60
|
| Rate for Payer: Sagamore Health Network All Products |
$183.30
|
| Rate for Payer: Signature Care EPO |
$197.08
|
| Rate for Payer: Signature Care PPO |
$208.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.82
|
| Rate for Payer: United Healthcare Commercial |
$187.10
|
| Rate for Payer: United Healthcare Medicare |
$75.98
|
|
|
TECHNETIUM TC 99M DISOFENIN
|
Facility
|
IP
|
$237.44
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
40840071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$178.08 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna Commercial |
$205.15
|
| Rate for Payer: Cash Price |
$142.46
|
| Rate for Payer: Cigna All Commercial |
$204.91
|
| Rate for Payer: CORVEL All Commercial |
$220.82
|
| Rate for Payer: Coventry All Commercial |
$208.95
|
| Rate for Payer: Encore All Commercial |
$218.56
|
| Rate for Payer: Frontpath All Commercial |
$218.44
|
| Rate for Payer: Humana ChoiceCare |
$205.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.70
|
| Rate for Payer: PHCS All Commercial |
$178.08
|
| Rate for Payer: PHP All Commercial |
$180.07
|
| Rate for Payer: Sagamore Health Network All Products |
$183.30
|
| Rate for Payer: Signature Care EPO |
$197.08
|
| Rate for Payer: Signature Care PPO |
$208.95
|
| Rate for Payer: United Healthcare Commercial |
$187.10
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$755.25 |
| Max. Negotiated Rate |
$936.51 |
| Rate for Payer: Aetna Commercial |
$870.05
|
| Rate for Payer: Cash Price |
$604.20
|
| Rate for Payer: Cigna All Commercial |
$869.04
|
| Rate for Payer: CORVEL All Commercial |
$936.51
|
| Rate for Payer: Coventry All Commercial |
$886.16
|
| Rate for Payer: Encore All Commercial |
$926.94
|
| Rate for Payer: Frontpath All Commercial |
$926.44
|
| Rate for Payer: Humana ChoiceCare |
$869.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.30
|
| Rate for Payer: PHCS All Commercial |
$755.25
|
| Rate for Payer: PHP All Commercial |
$763.71
|
| Rate for Payer: Sagamore Health Network All Products |
$777.40
|
| Rate for Payer: Signature Care EPO |
$835.81
|
| Rate for Payer: Signature Care PPO |
$886.16
|
| Rate for Payer: United Healthcare Commercial |
$793.52
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$312.17 |
| Max. Negotiated Rate |
$936.51 |
| Rate for Payer: Aetna Commercial |
$849.91
|
| Rate for Payer: Aetna Medicare |
$322.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$312.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$578.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$629.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$370.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$354.46
|
| Rate for Payer: Cash Price |
$604.20
|
| Rate for Payer: Centivo All Commercial |
$547.81
|
| Rate for Payer: Cigna All Commercial |
$869.04
|
| Rate for Payer: CORVEL All Commercial |
$936.51
|
| Rate for Payer: Coventry All Commercial |
$886.16
|
| Rate for Payer: Encore All Commercial |
$926.94
|
| Rate for Payer: Frontpath All Commercial |
$926.44
|
| Rate for Payer: Humana ChoiceCare |
$869.75
|
| Rate for Payer: Humana Medicare |
$322.24
|
| Rate for Payer: Lucent All Commercial |
$547.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.30
|
| Rate for Payer: PHCS All Commercial |
$755.25
|
| Rate for Payer: PHP All Commercial |
$763.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$392.73
|
| Rate for Payer: Sagamore Health Network All Products |
$777.40
|
| Rate for Payer: Signature Care EPO |
$835.81
|
| Rate for Payer: Signature Care PPO |
$886.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$855.95
|
| Rate for Payer: United Healthcare Commercial |
$793.52
|
| Rate for Payer: United Healthcare Medicare |
$322.24
|
|
