|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
|
IP
|
$72.25
|
|
|
Service Code
|
NDC 492810752
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.19 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: Aetna Commercial |
$62.43
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: Cigna All Commercial |
$62.36
|
| Rate for Payer: CORVEL All Commercial |
$67.20
|
| Rate for Payer: Coventry All Commercial |
$63.58
|
| Rate for Payer: Encore All Commercial |
$66.51
|
| Rate for Payer: Frontpath All Commercial |
$66.47
|
| Rate for Payer: Humana ChoiceCare |
$62.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.03
|
| Rate for Payer: PHCS All Commercial |
$54.19
|
| Rate for Payer: PHP All Commercial |
$54.80
|
| Rate for Payer: Sagamore Health Network All Products |
$55.78
|
| Rate for Payer: Signature Care EPO |
$59.97
|
| Rate for Payer: Signature Care PPO |
$63.58
|
| Rate for Payer: United Healthcare Commercial |
$56.94
|
|
|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
|
OP
|
$516.10
|
|
|
Service Code
|
NDC 49281075221
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$479.97 |
| Rate for Payer: Aetna Commercial |
$435.59
|
| Rate for Payer: Aetna Medicare |
$165.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$159.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$296.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$322.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$189.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$181.67
|
| Rate for Payer: Cash Price |
$309.66
|
| Rate for Payer: Cash Price |
$309.66
|
| Rate for Payer: Centivo All Commercial |
$280.76
|
| Rate for Payer: Cigna All Commercial |
$445.39
|
| Rate for Payer: CORVEL All Commercial |
$479.97
|
| Rate for Payer: Coventry All Commercial |
$454.17
|
| Rate for Payer: Encore All Commercial |
$475.07
|
| Rate for Payer: Frontpath All Commercial |
$474.81
|
| Rate for Payer: Humana ChoiceCare |
$445.76
|
| Rate for Payer: Humana Medicare |
$165.15
|
| Rate for Payer: Lucent All Commercial |
$280.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$464.49
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$387.07
|
| Rate for Payer: PHP All Commercial |
$391.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$201.28
|
| Rate for Payer: Sagamore Health Network All Products |
$398.43
|
| Rate for Payer: Signature Care EPO |
$428.36
|
| Rate for Payer: Signature Care PPO |
$454.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$438.69
|
| Rate for Payer: United Healthcare Commercial |
$406.69
|
| Rate for Payer: United Healthcare Medicare |
$165.15
|
|
|
URSODIOL 300 MG ORAL CAP
|
Facility
|
OP
|
$13.85
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Aetna Commercial |
$11.69
|
| Rate for Payer: Aetna Medicare |
$4.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.87
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Centivo All Commercial |
$7.53
|
| Rate for Payer: Cigna All Commercial |
$11.95
|
| Rate for Payer: CORVEL All Commercial |
$12.88
|
| Rate for Payer: Coventry All Commercial |
$12.18
|
| Rate for Payer: Encore All Commercial |
$12.75
|
| Rate for Payer: Frontpath All Commercial |
$12.74
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Humana Medicare |
$4.43
|
| Rate for Payer: Lucent All Commercial |
$7.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.46
|
| Rate for Payer: PHCS All Commercial |
$10.38
|
| Rate for Payer: PHP All Commercial |
$10.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.40
|
| Rate for Payer: Sagamore Health Network All Products |
$10.69
|
| Rate for Payer: Signature Care EPO |
$11.49
|
| Rate for Payer: Signature Care PPO |
$12.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.77
|
| Rate for Payer: United Healthcare Commercial |
$10.91
|
| Rate for Payer: United Healthcare Medicare |
$4.43
|
|
|
URSODIOL 300 MG ORAL CAP
|
Facility
|
IP
|
$13.85
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Aetna Commercial |
$11.96
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Cigna All Commercial |
$11.95
|
| Rate for Payer: CORVEL All Commercial |
$12.88
|
| Rate for Payer: Coventry All Commercial |
$12.18
|
| Rate for Payer: Encore All Commercial |
$12.75
|
| Rate for Payer: Frontpath All Commercial |
$12.74
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.46
|
| Rate for Payer: PHCS All Commercial |
$10.38
|
| Rate for Payer: PHP All Commercial |
$10.50
|
| Rate for Payer: Sagamore Health Network All Products |
$10.69
|
| Rate for Payer: Signature Care EPO |
$11.49
|
| Rate for Payer: Signature Care PPO |
$12.18
|
| Rate for Payer: United Healthcare Commercial |
$10.91
|
|
|
USTEKINUMAB 130 MG/26 ML IV SOLN
|
Facility
|
IP
|
$7,418.78
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
179041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,564.08 |
| Max. Negotiated Rate |
$6,899.46 |
| Rate for Payer: Aetna Commercial |
$6,409.82
|
| Rate for Payer: Cash Price |
$4,451.27
|
| Rate for Payer: Cigna All Commercial |
$6,402.40
|
| Rate for Payer: CORVEL All Commercial |
$6,899.46
|
| Rate for Payer: Coventry All Commercial |
$6,528.52
|
| Rate for Payer: Encore All Commercial |
$6,828.98
|
| Rate for Payer: Frontpath All Commercial |
$6,825.27
|
| Rate for Payer: Humana ChoiceCare |
$6,407.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,676.90
|
| Rate for Payer: PHCS All Commercial |
$5,564.08
|
| Rate for Payer: PHP All Commercial |
$5,626.40
|
| Rate for Payer: Sagamore Health Network All Products |
$5,727.29
|
| Rate for Payer: Signature Care EPO |
$6,157.58
|
| Rate for Payer: Signature Care PPO |
$6,528.52
|
| Rate for Payer: United Healthcare Commercial |
$5,845.99
|
|
|
USTEKINUMAB 130 MG/26 ML IV SOLN
|
Facility
|
OP
|
$7,418.78
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
179041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.54 |
| Max. Negotiated Rate |
$6,899.46 |
| Rate for Payer: Aetna Commercial |
$6,261.45
|
| Rate for Payer: Aetna Medicare |
$2,374.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,299.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,260.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,637.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,730.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,611.41
|
| Rate for Payer: Cash Price |
$4,451.27
|
| Rate for Payer: Cash Price |
$4,451.27
|
| Rate for Payer: Centivo All Commercial |
$4,035.81
|
| Rate for Payer: Cigna All Commercial |
$6,402.40
|
| Rate for Payer: CORVEL All Commercial |
$6,899.46
|
| Rate for Payer: Coventry All Commercial |
$6,528.52
|
| Rate for Payer: Encore All Commercial |
$6,828.98
|
| Rate for Payer: Frontpath All Commercial |
$6,825.27
|
| Rate for Payer: Humana ChoiceCare |
$6,407.60
|
| Rate for Payer: Humana Medicare |
$2,374.01
|
| Rate for Payer: Lucent All Commercial |
$4,035.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,676.90
|
| Rate for Payer: Managed Health Services Medicaid |
$14.54
|
| Rate for Payer: MDWise Medicaid |
$14.54
|
| Rate for Payer: PHCS All Commercial |
$5,564.08
|
| Rate for Payer: PHP All Commercial |
$5,626.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,893.32
|
| Rate for Payer: Sagamore Health Network All Products |
$5,727.29
|
| Rate for Payer: Signature Care EPO |
$6,157.58
|
| Rate for Payer: Signature Care PPO |
$6,528.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,305.96
|
| Rate for Payer: United Healthcare Commercial |
$5,845.99
|
| Rate for Payer: United Healthcare Medicare |
$2,374.01
|
|
|
USTEKINUMAB 90 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$99,479.35
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
108054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74,609.51 |
| Max. Negotiated Rate |
$92,515.79 |
| Rate for Payer: Aetna Commercial |
$85,950.15
|
| Rate for Payer: Cash Price |
$59,687.61
|
| Rate for Payer: Cigna All Commercial |
$85,850.67
|
| Rate for Payer: CORVEL All Commercial |
$92,515.79
|
| Rate for Payer: Coventry All Commercial |
$87,541.82
|
| Rate for Payer: Encore All Commercial |
$91,570.74
|
| Rate for Payer: Frontpath All Commercial |
$91,521.00
|
| Rate for Payer: Humana ChoiceCare |
$85,920.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89,531.41
|
| Rate for Payer: PHCS All Commercial |
$74,609.51
|
| Rate for Payer: PHP All Commercial |
$75,445.14
|
| Rate for Payer: Sagamore Health Network All Products |
$76,798.05
|
| Rate for Payer: Signature Care EPO |
$82,567.86
|
| Rate for Payer: Signature Care PPO |
$87,541.82
|
| Rate for Payer: United Healthcare Commercial |
$78,389.72
|
|
|
USTEKINUMAB 90 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$99,479.35
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.03 |
| Max. Negotiated Rate |
$92,515.79 |
| Rate for Payer: Aetna Commercial |
$83,960.57
|
| Rate for Payer: Aetna Medicare |
$31,833.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$85.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30,838.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$57,130.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62,184.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$85.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36,608.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35,016.73
|
| Rate for Payer: Cash Price |
$59,687.61
|
| Rate for Payer: Cash Price |
$59,687.61
|
| Rate for Payer: Centivo All Commercial |
$54,116.76
|
| Rate for Payer: Cigna All Commercial |
$85,850.67
|
| Rate for Payer: CORVEL All Commercial |
$92,515.79
|
| Rate for Payer: Coventry All Commercial |
$87,541.82
|
| Rate for Payer: Encore All Commercial |
$91,570.74
|
| Rate for Payer: Frontpath All Commercial |
$91,521.00
|
| Rate for Payer: Humana ChoiceCare |
$85,920.31
|
| Rate for Payer: Humana Medicare |
$31,833.39
|
| Rate for Payer: Lucent All Commercial |
$54,116.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89,531.41
|
| Rate for Payer: Managed Health Services Medicaid |
$85.03
|
| Rate for Payer: MDWise Medicaid |
$85.03
|
| Rate for Payer: PHCS All Commercial |
$74,609.51
|
| Rate for Payer: PHP All Commercial |
$75,445.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38,796.94
|
| Rate for Payer: Sagamore Health Network All Products |
$76,798.05
|
| Rate for Payer: Signature Care EPO |
$82,567.86
|
| Rate for Payer: Signature Care PPO |
$87,541.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$84,557.44
|
| Rate for Payer: United Healthcare Commercial |
$78,389.72
|
| Rate for Payer: United Healthcare Medicare |
$31,833.39
|
|
|
VALACYCLOVIR 500 MG ORAL TAB
|
Facility
|
IP
|
$9.52
|
|
|
Service Code
|
NDC 50268078815
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: Aetna Commercial |
$8.23
|
| Rate for Payer: Cash Price |
$5.71
|
| Rate for Payer: Cigna All Commercial |
$8.22
|
| Rate for Payer: CORVEL All Commercial |
$8.85
|
| Rate for Payer: Coventry All Commercial |
$8.38
|
| Rate for Payer: Encore All Commercial |
$8.76
|
| Rate for Payer: Frontpath All Commercial |
$8.76
|
| Rate for Payer: Humana ChoiceCare |
$8.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.57
|
| Rate for Payer: PHCS All Commercial |
$7.14
|
| Rate for Payer: PHP All Commercial |
$7.22
|
| Rate for Payer: Sagamore Health Network All Products |
$7.35
|
| Rate for Payer: Signature Care EPO |
$7.90
|
| Rate for Payer: Signature Care PPO |
$8.38
|
| Rate for Payer: United Healthcare Commercial |
$7.50
|
|
|
VALACYCLOVIR 500 MG ORAL TAB
|
Facility
|
OP
|
$9.52
|
|
|
Service Code
|
NDC 50268078815
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: Aetna Medicare |
$3.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.35
|
| Rate for Payer: Cash Price |
$5.71
|
| Rate for Payer: Centivo All Commercial |
$5.18
|
| Rate for Payer: Cigna All Commercial |
$8.22
|
| Rate for Payer: CORVEL All Commercial |
$8.85
|
| Rate for Payer: Coventry All Commercial |
$8.38
|
| Rate for Payer: Encore All Commercial |
$8.76
|
| Rate for Payer: Frontpath All Commercial |
$8.76
|
| Rate for Payer: Humana ChoiceCare |
$8.22
|
| Rate for Payer: Humana Medicare |
$3.05
|
| Rate for Payer: Lucent All Commercial |
$5.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.57
|
| Rate for Payer: PHCS All Commercial |
$7.14
|
| Rate for Payer: PHP All Commercial |
$7.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.71
|
| Rate for Payer: Sagamore Health Network All Products |
$7.35
|
| Rate for Payer: Signature Care EPO |
$7.90
|
| Rate for Payer: Signature Care PPO |
$8.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.09
|
| Rate for Payer: United Healthcare Commercial |
$7.50
|
| Rate for Payer: United Healthcare Medicare |
$3.05
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN
|
Facility
|
OP
|
$46.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.54 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Aetna Commercial |
$39.58
|
| Rate for Payer: Aetna Medicare |
$15.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$26.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.51
|
| Rate for Payer: Cash Price |
$28.14
|
| Rate for Payer: Centivo All Commercial |
$25.51
|
| Rate for Payer: Cigna All Commercial |
$40.47
|
| Rate for Payer: CORVEL All Commercial |
$43.62
|
| Rate for Payer: Coventry All Commercial |
$41.27
|
| Rate for Payer: Encore All Commercial |
$43.17
|
| Rate for Payer: Frontpath All Commercial |
$43.15
|
| Rate for Payer: Humana ChoiceCare |
$40.51
|
| Rate for Payer: Humana Medicare |
$15.01
|
| Rate for Payer: Lucent All Commercial |
$25.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.21
|
| Rate for Payer: PHCS All Commercial |
$35.17
|
| Rate for Payer: PHP All Commercial |
$35.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.29
|
| Rate for Payer: Sagamore Health Network All Products |
$36.21
|
| Rate for Payer: Signature Care EPO |
$38.93
|
| Rate for Payer: Signature Care PPO |
$41.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39.87
|
| Rate for Payer: United Healthcare Commercial |
$36.96
|
| Rate for Payer: United Healthcare Medicare |
$15.01
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN
|
Facility
|
IP
|
$46.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.17 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Aetna Commercial |
$40.52
|
| Rate for Payer: Cash Price |
$28.14
|
| Rate for Payer: Cigna All Commercial |
$40.47
|
| Rate for Payer: CORVEL All Commercial |
$43.62
|
| Rate for Payer: Coventry All Commercial |
$41.27
|
| Rate for Payer: Encore All Commercial |
$43.17
|
| Rate for Payer: Frontpath All Commercial |
$43.15
|
| Rate for Payer: Humana ChoiceCare |
$40.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.21
|
| Rate for Payer: PHCS All Commercial |
$35.17
|
| Rate for Payer: PHP All Commercial |
$35.57
|
| Rate for Payer: Sagamore Health Network All Products |
$36.21
|
| Rate for Payer: Signature Care EPO |
$38.93
|
| Rate for Payer: Signature Care PPO |
$41.27
|
| Rate for Payer: United Healthcare Commercial |
$36.96
|
|
|
VALSARTAN 320 MG ORAL TAB
|
Facility
|
OP
|
$5.73
|
|
|
Service Code
|
NDC 00378581577
|
| Hospital Charge Code |
31211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Centivo All Commercial |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Humana Medicare |
$1.83
|
| Rate for Payer: Lucent All Commercial |
$3.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.87
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.83
|
|
|
VALSARTAN 320 MG ORAL TAB
|
Facility
|
IP
|
$5.73
|
|
|
Service Code
|
NDC 00378581577
|
| Hospital Charge Code |
31211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.33
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.27
|
| Rate for Payer: Humana ChoiceCare |
$4.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.16
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
VALSARTAN 40 MG ORAL TAB
|
Facility
|
IP
|
$5.74
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.96
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.34
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.28
|
| Rate for Payer: Humana ChoiceCare |
$4.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.17
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
VALSARTAN 40 MG ORAL TAB
|
Facility
|
OP
|
$5.74
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Centivo All Commercial |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.34
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.28
|
| Rate for Payer: Humana ChoiceCare |
$4.96
|
| Rate for Payer: Humana Medicare |
$1.84
|
| Rate for Payer: Lucent All Commercial |
$3.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.17
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.88
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.84
|
|
|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
OP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Centivo All Commercial |
$1.87
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Humana Medicare |
$1.10
|
| Rate for Payer: Lucent All Commercial |
$1.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.92
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
|
|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
IP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.97
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
OP
|
$29.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$27.34 |
| Rate for Payer: Aetna Commercial |
$24.81
|
| Rate for Payer: Aetna Medicare |
$9.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.35
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Centivo All Commercial |
$15.99
|
| Rate for Payer: Cigna All Commercial |
$25.37
|
| Rate for Payer: CORVEL All Commercial |
$27.34
|
| Rate for Payer: Coventry All Commercial |
$25.87
|
| Rate for Payer: Encore All Commercial |
$27.06
|
| Rate for Payer: Frontpath All Commercial |
$27.05
|
| Rate for Payer: Humana ChoiceCare |
$25.39
|
| Rate for Payer: Humana Medicare |
$9.41
|
| Rate for Payer: Lucent All Commercial |
$15.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.46
|
| Rate for Payer: PHCS All Commercial |
$22.05
|
| Rate for Payer: PHP All Commercial |
$22.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.47
|
| Rate for Payer: Sagamore Health Network All Products |
$22.70
|
| Rate for Payer: Signature Care EPO |
$24.40
|
| Rate for Payer: Signature Care PPO |
$25.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.99
|
| Rate for Payer: United Healthcare Commercial |
$23.17
|
| Rate for Payer: United Healthcare Medicare |
$9.41
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
IP
|
$29.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$27.34 |
| Rate for Payer: Aetna Commercial |
$25.40
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cigna All Commercial |
$25.37
|
| Rate for Payer: CORVEL All Commercial |
$27.34
|
| Rate for Payer: Coventry All Commercial |
$25.87
|
| Rate for Payer: Encore All Commercial |
$27.06
|
| Rate for Payer: Frontpath All Commercial |
$27.05
|
| Rate for Payer: Humana ChoiceCare |
$25.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.46
|
| Rate for Payer: PHCS All Commercial |
$22.05
|
| Rate for Payer: PHP All Commercial |
$22.30
|
| Rate for Payer: Sagamore Health Network All Products |
$22.70
|
| Rate for Payer: Signature Care EPO |
$24.40
|
| Rate for Payer: Signature Care PPO |
$25.87
|
| Rate for Payer: United Healthcare Commercial |
$23.17
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
OP
|
$158.29
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.07 |
| Max. Negotiated Rate |
$147.21 |
| Rate for Payer: Aetna Commercial |
$133.60
|
| Rate for Payer: Aetna Medicare |
$50.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$90.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.72
|
| Rate for Payer: Cash Price |
$94.97
|
| Rate for Payer: Centivo All Commercial |
$86.11
|
| Rate for Payer: Cigna All Commercial |
$136.60
|
| Rate for Payer: CORVEL All Commercial |
$147.21
|
| Rate for Payer: Coventry All Commercial |
$139.30
|
| Rate for Payer: Encore All Commercial |
$145.71
|
| Rate for Payer: Frontpath All Commercial |
$145.63
|
| Rate for Payer: Humana ChoiceCare |
$136.72
|
| Rate for Payer: Humana Medicare |
$50.65
|
| Rate for Payer: Lucent All Commercial |
$86.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.46
|
| Rate for Payer: PHCS All Commercial |
$118.72
|
| Rate for Payer: PHP All Commercial |
$120.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.73
|
| Rate for Payer: Sagamore Health Network All Products |
$122.20
|
| Rate for Payer: Signature Care EPO |
$131.38
|
| Rate for Payer: Signature Care PPO |
$139.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$134.55
|
| Rate for Payer: United Healthcare Commercial |
$124.73
|
| Rate for Payer: United Healthcare Medicare |
$50.65
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
IP
|
$158.29
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.72 |
| Max. Negotiated Rate |
$147.21 |
| Rate for Payer: Aetna Commercial |
$136.76
|
| Rate for Payer: Cash Price |
$94.97
|
| Rate for Payer: Cigna All Commercial |
$136.60
|
| Rate for Payer: CORVEL All Commercial |
$147.21
|
| Rate for Payer: Coventry All Commercial |
$139.30
|
| Rate for Payer: Encore All Commercial |
$145.71
|
| Rate for Payer: Frontpath All Commercial |
$145.63
|
| Rate for Payer: Humana ChoiceCare |
$136.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.46
|
| Rate for Payer: PHCS All Commercial |
$118.72
|
| Rate for Payer: PHP All Commercial |
$120.05
|
| Rate for Payer: Sagamore Health Network All Products |
$122.20
|
| Rate for Payer: Signature Care EPO |
$131.38
|
| Rate for Payer: Signature Care PPO |
$139.30
|
| Rate for Payer: United Healthcare Commercial |
$124.73
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
OP
|
$7.84
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna Commercial |
$6.62
|
| Rate for Payer: Aetna Medicare |
$2.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.76
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Centivo All Commercial |
$4.26
|
| Rate for Payer: Cigna All Commercial |
$6.77
|
| Rate for Payer: CORVEL All Commercial |
$7.29
|
| Rate for Payer: Coventry All Commercial |
$6.90
|
| Rate for Payer: Encore All Commercial |
$7.22
|
| Rate for Payer: Frontpath All Commercial |
$7.21
|
| Rate for Payer: Humana ChoiceCare |
$6.77
|
| Rate for Payer: Humana Medicare |
$2.51
|
| Rate for Payer: Lucent All Commercial |
$4.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.06
|
| Rate for Payer: PHCS All Commercial |
$5.88
|
| Rate for Payer: PHP All Commercial |
$5.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.06
|
| Rate for Payer: Sagamore Health Network All Products |
$6.05
|
| Rate for Payer: Signature Care EPO |
$6.51
|
| Rate for Payer: Signature Care PPO |
$6.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.66
|
| Rate for Payer: United Healthcare Commercial |
$6.18
|
| Rate for Payer: United Healthcare Medicare |
$2.51
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
IP
|
$7.84
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna Commercial |
$6.77
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna All Commercial |
$6.77
|
| Rate for Payer: CORVEL All Commercial |
$7.29
|
| Rate for Payer: Coventry All Commercial |
$6.90
|
| Rate for Payer: Encore All Commercial |
$7.22
|
| Rate for Payer: Frontpath All Commercial |
$7.21
|
| Rate for Payer: Humana ChoiceCare |
$6.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.06
|
| Rate for Payer: PHCS All Commercial |
$5.88
|
| Rate for Payer: PHP All Commercial |
$5.95
|
| Rate for Payer: Sagamore Health Network All Products |
$6.05
|
| Rate for Payer: Signature Care EPO |
$6.51
|
| Rate for Payer: Signature Care PPO |
$6.90
|
| Rate for Payer: United Healthcare Commercial |
$6.18
|
|
|
VANCOMYCIN 1.5 G IV SOLR
|
Facility
|
IP
|
$122.38
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
186918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.78 |
| Max. Negotiated Rate |
$113.81 |
| Rate for Payer: Aetna Commercial |
$105.73
|
| Rate for Payer: Cash Price |
$73.43
|
| Rate for Payer: Cigna All Commercial |
$105.61
|
| Rate for Payer: CORVEL All Commercial |
$113.81
|
| Rate for Payer: Coventry All Commercial |
$107.69
|
| Rate for Payer: Encore All Commercial |
$112.65
|
| Rate for Payer: Frontpath All Commercial |
$112.59
|
| Rate for Payer: Humana ChoiceCare |
$105.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.14
|
| Rate for Payer: PHCS All Commercial |
$91.78
|
| Rate for Payer: PHP All Commercial |
$92.81
|
| Rate for Payer: Sagamore Health Network All Products |
$94.48
|
| Rate for Payer: Signature Care EPO |
$101.57
|
| Rate for Payer: Signature Care PPO |
$107.69
|
| Rate for Payer: United Healthcare Commercial |
$96.43
|
|
