|
VANCOMYCIN 1.5 G IV SOLR
|
Facility
|
OP
|
$122.38
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
186918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.94 |
| Max. Negotiated Rate |
$113.81 |
| Rate for Payer: Aetna Commercial |
$103.29
|
| Rate for Payer: Aetna Medicare |
$39.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$70.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$76.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$45.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$43.08
|
| Rate for Payer: Cash Price |
$73.43
|
| Rate for Payer: Centivo All Commercial |
$66.57
|
| 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: Humana Medicare |
$39.16
|
| Rate for Payer: Lucent All Commercial |
$66.57
|
| 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: Plain Church Group Ministry All Commercial |
$47.73
|
| 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: Three Rivers Preferred All Commercial |
$104.02
|
| Rate for Payer: United Healthcare Commercial |
$96.43
|
| Rate for Payer: United Healthcare Medicare |
$39.16
|
|
|
VANCOMYCIN 1.75 G IV SOLR
|
Facility
|
OP
|
$245.78
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
205716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.19 |
| Max. Negotiated Rate |
$228.57 |
| Rate for Payer: Aetna Commercial |
$207.44
|
| Rate for Payer: Aetna Medicare |
$78.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$76.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$141.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$153.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.51
|
| Rate for Payer: Cash Price |
$147.47
|
| Rate for Payer: Centivo All Commercial |
$133.70
|
| Rate for Payer: Cigna All Commercial |
$212.11
|
| Rate for Payer: CORVEL All Commercial |
$228.57
|
| Rate for Payer: Coventry All Commercial |
$216.28
|
| Rate for Payer: Encore All Commercial |
$226.24
|
| Rate for Payer: Frontpath All Commercial |
$226.11
|
| Rate for Payer: Humana ChoiceCare |
$212.28
|
| Rate for Payer: Humana Medicare |
$78.65
|
| Rate for Payer: Lucent All Commercial |
$133.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.20
|
| Rate for Payer: PHCS All Commercial |
$184.33
|
| Rate for Payer: PHP All Commercial |
$186.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$95.85
|
| Rate for Payer: Sagamore Health Network All Products |
$189.74
|
| Rate for Payer: Signature Care EPO |
$203.99
|
| Rate for Payer: Signature Care PPO |
$216.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$208.91
|
| Rate for Payer: United Healthcare Commercial |
$193.67
|
| Rate for Payer: United Healthcare Medicare |
$78.65
|
|
|
VANCOMYCIN 1.75 G IV SOLR
|
Facility
|
IP
|
$245.78
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
205716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.33 |
| Max. Negotiated Rate |
$228.57 |
| Rate for Payer: Aetna Commercial |
$212.35
|
| Rate for Payer: Cash Price |
$147.47
|
| Rate for Payer: Cigna All Commercial |
$212.11
|
| Rate for Payer: CORVEL All Commercial |
$228.57
|
| Rate for Payer: Coventry All Commercial |
$216.28
|
| Rate for Payer: Encore All Commercial |
$226.24
|
| Rate for Payer: Frontpath All Commercial |
$226.11
|
| Rate for Payer: Humana ChoiceCare |
$212.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.20
|
| Rate for Payer: PHCS All Commercial |
$184.33
|
| Rate for Payer: PHP All Commercial |
$186.40
|
| Rate for Payer: Sagamore Health Network All Products |
$189.74
|
| Rate for Payer: Signature Care EPO |
$203.99
|
| Rate for Payer: Signature Care PPO |
$216.28
|
| Rate for Payer: United Healthcare Commercial |
$193.67
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
OP
|
$280.89
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.08 |
| Max. Negotiated Rate |
$261.23 |
| Rate for Payer: Aetna Commercial |
$237.07
|
| Rate for Payer: Aetna Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$161.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$98.87
|
| Rate for Payer: Cash Price |
$168.53
|
| Rate for Payer: Centivo All Commercial |
$152.80
|
| Rate for Payer: Cigna All Commercial |
$242.41
|
| Rate for Payer: CORVEL All Commercial |
$261.23
|
| Rate for Payer: Coventry All Commercial |
$247.18
|
| Rate for Payer: Encore All Commercial |
$258.56
|
| Rate for Payer: Frontpath All Commercial |
$258.42
|
| Rate for Payer: Humana ChoiceCare |
$242.60
|
| Rate for Payer: Humana Medicare |
$89.88
|
| Rate for Payer: Lucent All Commercial |
$152.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.80
|
| Rate for Payer: PHCS All Commercial |
$210.67
|
| Rate for Payer: PHP All Commercial |
$213.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.55
|
| Rate for Payer: Sagamore Health Network All Products |
$216.85
|
| Rate for Payer: Signature Care EPO |
$233.14
|
| Rate for Payer: Signature Care PPO |
$247.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$238.76
|
| Rate for Payer: United Healthcare Commercial |
$221.34
|
| Rate for Payer: United Healthcare Medicare |
$89.88
|
|
|
VANCOMYCIN 2 G IV SOLR
|
Facility
|
IP
|
$280.89
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
205717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.67 |
| Max. Negotiated Rate |
$261.23 |
| Rate for Payer: Aetna Commercial |
$242.69
|
| Rate for Payer: Cash Price |
$168.53
|
| Rate for Payer: Cigna All Commercial |
$242.41
|
| Rate for Payer: CORVEL All Commercial |
$261.23
|
| Rate for Payer: Coventry All Commercial |
$247.18
|
| Rate for Payer: Encore All Commercial |
$258.56
|
| Rate for Payer: Frontpath All Commercial |
$258.42
|
| Rate for Payer: Humana ChoiceCare |
$242.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.80
|
| Rate for Payer: PHCS All Commercial |
$210.67
|
| Rate for Payer: PHP All Commercial |
$213.03
|
| Rate for Payer: Sagamore Health Network All Products |
$216.85
|
| Rate for Payer: Signature Care EPO |
$233.14
|
| Rate for Payer: Signature Care PPO |
$247.18
|
| Rate for Payer: United Healthcare Commercial |
$221.34
|
|
|
VANCOMYCIN 500 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
VANCOMYCIN 500 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8443
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
VANCOMYCIN 50 MG/ML ORAL SOLR
|
Facility
|
IP
|
$834.75
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
11630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$626.06 |
| Max. Negotiated Rate |
$776.32 |
| Rate for Payer: Aetna Commercial |
$721.22
|
| Rate for Payer: Cash Price |
$500.85
|
| Rate for Payer: Cigna All Commercial |
$720.39
|
| Rate for Payer: CORVEL All Commercial |
$776.32
|
| Rate for Payer: Coventry All Commercial |
$734.58
|
| Rate for Payer: Encore All Commercial |
$768.39
|
| Rate for Payer: Frontpath All Commercial |
$767.97
|
| Rate for Payer: Humana ChoiceCare |
$720.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$751.27
|
| Rate for Payer: PHCS All Commercial |
$626.06
|
| Rate for Payer: PHP All Commercial |
$633.07
|
| Rate for Payer: Sagamore Health Network All Products |
$644.43
|
| Rate for Payer: Signature Care EPO |
$692.84
|
| Rate for Payer: Signature Care PPO |
$734.58
|
| Rate for Payer: United Healthcare Commercial |
$657.78
|
|
|
VANCOMYCIN 50 MG/ML ORAL SOLR
|
Facility
|
OP
|
$834.75
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
11630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.77 |
| Max. Negotiated Rate |
$776.32 |
| Rate for Payer: Aetna Commercial |
$704.53
|
| Rate for Payer: Aetna Medicare |
$267.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$258.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$479.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$521.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$307.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$293.83
|
| Rate for Payer: Cash Price |
$500.85
|
| Rate for Payer: Centivo All Commercial |
$454.10
|
| Rate for Payer: Cigna All Commercial |
$720.39
|
| Rate for Payer: CORVEL All Commercial |
$776.32
|
| Rate for Payer: Coventry All Commercial |
$734.58
|
| Rate for Payer: Encore All Commercial |
$768.39
|
| Rate for Payer: Frontpath All Commercial |
$767.97
|
| Rate for Payer: Humana ChoiceCare |
$720.97
|
| Rate for Payer: Humana Medicare |
$267.12
|
| Rate for Payer: Lucent All Commercial |
$454.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$751.27
|
| Rate for Payer: PHCS All Commercial |
$626.06
|
| Rate for Payer: PHP All Commercial |
$633.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$325.55
|
| Rate for Payer: Sagamore Health Network All Products |
$644.43
|
| Rate for Payer: Signature Care EPO |
$692.84
|
| Rate for Payer: Signature Care PPO |
$734.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$709.54
|
| Rate for Payer: United Healthcare Commercial |
$657.78
|
| Rate for Payer: United Healthcare Medicare |
$267.12
|
|
|
VARENICLINE TARTRATE 0.5 MG ORAL TAB
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
NDC 00069046856
|
| Hospital Charge Code |
76444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$51.15 |
| Rate for Payer: Aetna Commercial |
$46.42
|
| Rate for Payer: Aetna Medicare |
$17.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$31.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$34.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.36
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Centivo All Commercial |
$29.92
|
| Rate for Payer: Cigna All Commercial |
$47.46
|
| Rate for Payer: CORVEL All Commercial |
$51.15
|
| Rate for Payer: Coventry All Commercial |
$48.40
|
| Rate for Payer: Encore All Commercial |
$50.63
|
| Rate for Payer: Frontpath All Commercial |
$50.60
|
| Rate for Payer: Humana ChoiceCare |
$47.50
|
| Rate for Payer: Humana Medicare |
$17.60
|
| Rate for Payer: Lucent All Commercial |
$29.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.50
|
| Rate for Payer: PHCS All Commercial |
$41.25
|
| Rate for Payer: PHP All Commercial |
$41.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.45
|
| Rate for Payer: Sagamore Health Network All Products |
$42.46
|
| Rate for Payer: Signature Care EPO |
$45.65
|
| Rate for Payer: Signature Care PPO |
$48.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.75
|
| Rate for Payer: United Healthcare Commercial |
$43.34
|
| Rate for Payer: United Healthcare Medicare |
$17.60
|
|
|
VARENICLINE TARTRATE 0.5 MG ORAL TAB
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 00069046856
|
| Hospital Charge Code |
76444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.25 |
| Max. Negotiated Rate |
$51.15 |
| Rate for Payer: Aetna Commercial |
$47.52
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna All Commercial |
$47.46
|
| Rate for Payer: CORVEL All Commercial |
$51.15
|
| Rate for Payer: Coventry All Commercial |
$48.40
|
| Rate for Payer: Encore All Commercial |
$50.63
|
| Rate for Payer: Frontpath All Commercial |
$50.60
|
| Rate for Payer: Humana ChoiceCare |
$47.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.50
|
| Rate for Payer: PHCS All Commercial |
$41.25
|
| Rate for Payer: PHP All Commercial |
$41.71
|
| Rate for Payer: Sagamore Health Network All Products |
$42.46
|
| Rate for Payer: Signature Care EPO |
$45.65
|
| Rate for Payer: Signature Care PPO |
$48.40
|
| Rate for Payer: United Healthcare Commercial |
$43.34
|
|
|
VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SUBQ SUSR
|
Facility
|
IP
|
$869.45
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
14757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$652.08 |
| Max. Negotiated Rate |
$808.58 |
| Rate for Payer: Aetna Commercial |
$751.20
|
| Rate for Payer: Cash Price |
$521.67
|
| Rate for Payer: Cigna All Commercial |
$750.33
|
| Rate for Payer: CORVEL All Commercial |
$808.58
|
| Rate for Payer: Coventry All Commercial |
$765.11
|
| Rate for Payer: Encore All Commercial |
$800.32
|
| Rate for Payer: Frontpath All Commercial |
$799.89
|
| Rate for Payer: Humana ChoiceCare |
$750.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$782.50
|
| Rate for Payer: PHCS All Commercial |
$652.08
|
| Rate for Payer: PHP All Commercial |
$659.39
|
| Rate for Payer: Sagamore Health Network All Products |
$671.21
|
| Rate for Payer: Signature Care EPO |
$721.64
|
| Rate for Payer: Signature Care PPO |
$765.11
|
| Rate for Payer: United Healthcare Commercial |
$685.12
|
|
|
VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SUBQ SUSR
|
Facility
|
OP
|
$869.45
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
14757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.36 |
| Max. Negotiated Rate |
$808.58 |
| Rate for Payer: Aetna Commercial |
$733.81
|
| Rate for Payer: Aetna Medicare |
$278.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$191.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$269.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$499.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$543.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$191.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$319.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$306.04
|
| Rate for Payer: Cash Price |
$521.67
|
| Rate for Payer: Cash Price |
$521.67
|
| Rate for Payer: Centivo All Commercial |
$472.98
|
| Rate for Payer: Cigna All Commercial |
$750.33
|
| Rate for Payer: CORVEL All Commercial |
$808.58
|
| Rate for Payer: Coventry All Commercial |
$765.11
|
| Rate for Payer: Encore All Commercial |
$800.32
|
| Rate for Payer: Frontpath All Commercial |
$799.89
|
| Rate for Payer: Humana ChoiceCare |
$750.94
|
| Rate for Payer: Humana Medicare |
$278.22
|
| Rate for Payer: Lucent All Commercial |
$472.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$782.50
|
| Rate for Payer: Managed Health Services Medicaid |
$191.36
|
| Rate for Payer: MDWise Medicaid |
$191.36
|
| Rate for Payer: PHCS All Commercial |
$652.08
|
| Rate for Payer: PHP All Commercial |
$659.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$339.08
|
| Rate for Payer: Sagamore Health Network All Products |
$671.21
|
| Rate for Payer: Signature Care EPO |
$721.64
|
| Rate for Payer: Signature Care PPO |
$765.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$739.03
|
| Rate for Payer: United Healthcare Commercial |
$685.12
|
| Rate for Payer: United Healthcare Medicare |
$278.22
|
|
|
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR
|
Facility
|
IP
|
$1,010.20
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
182723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$757.65 |
| Max. Negotiated Rate |
$939.48 |
| Rate for Payer: Aetna Commercial |
$872.81
|
| Rate for Payer: Cash Price |
$606.12
|
| Rate for Payer: Cigna All Commercial |
$871.80
|
| Rate for Payer: CORVEL All Commercial |
$939.48
|
| Rate for Payer: Coventry All Commercial |
$888.97
|
| Rate for Payer: Encore All Commercial |
$929.88
|
| Rate for Payer: Frontpath All Commercial |
$929.38
|
| Rate for Payer: Humana ChoiceCare |
$872.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$909.18
|
| Rate for Payer: PHCS All Commercial |
$757.65
|
| Rate for Payer: PHP All Commercial |
$766.13
|
| Rate for Payer: Sagamore Health Network All Products |
$779.87
|
| Rate for Payer: Signature Care EPO |
$838.46
|
| Rate for Payer: Signature Care PPO |
$888.97
|
| Rate for Payer: United Healthcare Commercial |
$796.03
|
|
|
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR
|
Facility
|
OP
|
$1,010.20
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
182723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.28 |
| Max. Negotiated Rate |
$939.48 |
| Rate for Payer: Aetna Commercial |
$852.60
|
| Rate for Payer: Aetna Medicare |
$323.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$226.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$313.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$580.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$631.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$226.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$371.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$355.59
|
| Rate for Payer: Cash Price |
$606.12
|
| Rate for Payer: Cash Price |
$606.12
|
| Rate for Payer: Centivo All Commercial |
$549.55
|
| Rate for Payer: Cigna All Commercial |
$871.80
|
| Rate for Payer: CORVEL All Commercial |
$939.48
|
| Rate for Payer: Coventry All Commercial |
$888.97
|
| Rate for Payer: Encore All Commercial |
$929.88
|
| Rate for Payer: Frontpath All Commercial |
$929.38
|
| Rate for Payer: Humana ChoiceCare |
$872.51
|
| Rate for Payer: Humana Medicare |
$323.26
|
| Rate for Payer: Lucent All Commercial |
$549.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$909.18
|
| Rate for Payer: Managed Health Services Medicaid |
$226.28
|
| Rate for Payer: MDWise Medicaid |
$226.28
|
| Rate for Payer: PHCS All Commercial |
$757.65
|
| Rate for Payer: PHP All Commercial |
$766.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$393.98
|
| Rate for Payer: Sagamore Health Network All Products |
$779.87
|
| Rate for Payer: Signature Care EPO |
$838.46
|
| Rate for Payer: Signature Care PPO |
$888.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$858.67
|
| Rate for Payer: United Healthcare Commercial |
$796.03
|
| Rate for Payer: United Healthcare Medicare |
$323.26
|
|
|
VASOPRESSIN 20 UNITS/ML IV SOLN
|
Facility
|
IP
|
$73.55
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
170714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Aetna Commercial |
$63.55
|
| Rate for Payer: Cash Price |
$44.13
|
| Rate for Payer: Cigna All Commercial |
$63.47
|
| Rate for Payer: CORVEL All Commercial |
$68.40
|
| Rate for Payer: Coventry All Commercial |
$64.72
|
| Rate for Payer: Encore All Commercial |
$67.70
|
| Rate for Payer: Frontpath All Commercial |
$67.67
|
| Rate for Payer: Humana ChoiceCare |
$63.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.19
|
| Rate for Payer: PHCS All Commercial |
$55.16
|
| Rate for Payer: PHP All Commercial |
$55.78
|
| Rate for Payer: Sagamore Health Network All Products |
$56.78
|
| Rate for Payer: Signature Care EPO |
$61.05
|
| Rate for Payer: Signature Care PPO |
$64.72
|
| Rate for Payer: United Healthcare Commercial |
$57.96
|
|
|
VASOPRESSIN 20 UNITS/ML IV SOLN
|
Facility
|
OP
|
$73.55
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
170714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Aetna Commercial |
$62.08
|
| Rate for Payer: Aetna Medicare |
$23.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$42.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.89
|
| Rate for Payer: Cash Price |
$44.13
|
| Rate for Payer: Cash Price |
$44.13
|
| Rate for Payer: Centivo All Commercial |
$40.01
|
| Rate for Payer: Cigna All Commercial |
$63.47
|
| Rate for Payer: CORVEL All Commercial |
$68.40
|
| Rate for Payer: Coventry All Commercial |
$64.72
|
| Rate for Payer: Encore All Commercial |
$67.70
|
| Rate for Payer: Frontpath All Commercial |
$67.67
|
| Rate for Payer: Humana ChoiceCare |
$63.52
|
| Rate for Payer: Humana Medicare |
$23.54
|
| Rate for Payer: Lucent All Commercial |
$40.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.19
|
| Rate for Payer: Managed Health Services Medicaid |
$1.05
|
| Rate for Payer: MDWise Medicaid |
$1.05
|
| Rate for Payer: PHCS All Commercial |
$55.16
|
| Rate for Payer: PHP All Commercial |
$55.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.68
|
| Rate for Payer: Sagamore Health Network All Products |
$56.78
|
| Rate for Payer: Signature Care EPO |
$61.05
|
| Rate for Payer: Signature Care PPO |
$64.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.52
|
| Rate for Payer: United Healthcare Commercial |
$57.96
|
| Rate for Payer: United Healthcare Medicare |
$23.54
|
|
|
VECURONIUM BROMIDE 10 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
VECURONIUM BROMIDE 10 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
OP
|
$32,759.69
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
168378
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$30,466.51 |
| Rate for Payer: Aetna Commercial |
$27,649.17
|
| Rate for Payer: Aetna Medicare |
$10,483.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$32.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10,155.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18,813.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20,478.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$32.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12,055.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11,531.41
|
| Rate for Payer: Cash Price |
$19,655.81
|
| Rate for Payer: Cash Price |
$19,655.81
|
| Rate for Payer: Centivo All Commercial |
$17,821.27
|
| Rate for Payer: Cigna All Commercial |
$28,271.61
|
| Rate for Payer: CORVEL All Commercial |
$30,466.51
|
| Rate for Payer: Coventry All Commercial |
$28,828.52
|
| Rate for Payer: Encore All Commercial |
$30,155.29
|
| Rate for Payer: Frontpath All Commercial |
$30,138.91
|
| Rate for Payer: Humana ChoiceCare |
$28,294.54
|
| Rate for Payer: Humana Medicare |
$10,483.10
|
| Rate for Payer: Lucent All Commercial |
$17,821.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29,483.72
|
| Rate for Payer: Managed Health Services Medicaid |
$32.76
|
| Rate for Payer: MDWise Medicaid |
$32.76
|
| Rate for Payer: PHCS All Commercial |
$24,569.76
|
| Rate for Payer: PHP All Commercial |
$24,844.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12,776.28
|
| Rate for Payer: Sagamore Health Network All Products |
$25,290.48
|
| Rate for Payer: Signature Care EPO |
$27,190.54
|
| Rate for Payer: Signature Care PPO |
$28,828.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27,845.73
|
| Rate for Payer: United Healthcare Commercial |
$25,814.63
|
| Rate for Payer: United Healthcare Medicare |
$10,483.10
|
|
|
VEDOLIZUMAB 300 MG IV SOLR
|
Facility
|
IP
|
$32,759.69
|
|
|
Service Code
|
HCPCS J3380
|
| Hospital Charge Code |
168378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24,569.76 |
| Max. Negotiated Rate |
$30,466.51 |
| Rate for Payer: Aetna Commercial |
$28,304.37
|
| Rate for Payer: Cash Price |
$19,655.81
|
| Rate for Payer: Cigna All Commercial |
$28,271.61
|
| Rate for Payer: CORVEL All Commercial |
$30,466.51
|
| Rate for Payer: Coventry All Commercial |
$28,828.52
|
| Rate for Payer: Encore All Commercial |
$30,155.29
|
| Rate for Payer: Frontpath All Commercial |
$30,138.91
|
| Rate for Payer: Humana ChoiceCare |
$28,294.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29,483.72
|
| Rate for Payer: PHCS All Commercial |
$24,569.76
|
| Rate for Payer: PHP All Commercial |
$24,844.95
|
| Rate for Payer: Sagamore Health Network All Products |
$25,290.48
|
| Rate for Payer: Signature Care EPO |
$27,190.54
|
| Rate for Payer: Signature Care PPO |
$28,828.52
|
| Rate for Payer: United Healthcare Commercial |
$25,814.63
|
|
|
VENLAFAXINE 150 MG ORAL CP24
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862069730
|
| Hospital Charge Code |
27859
|
|
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
|
|
|
VENLAFAXINE 150 MG ORAL CP24
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862069730
|
| Hospital Charge Code |
27859
|
|
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
|
|
|
VENLAFAXINE 25 MG ORAL TAB
|
Facility
|
IP
|
$2.09
|
|
|
Service Code
|
NDC 68382001801
|
| Hospital Charge Code |
12203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna All Commercial |
$1.80
|
| Rate for Payer: CORVEL All Commercial |
$1.94
|
| Rate for Payer: Coventry All Commercial |
$1.84
|
| Rate for Payer: Encore All Commercial |
$1.92
|
| Rate for Payer: Frontpath All Commercial |
$1.92
|
| Rate for Payer: Humana ChoiceCare |
$1.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.88
|
| Rate for Payer: PHCS All Commercial |
$1.56
|
| Rate for Payer: PHP All Commercial |
$1.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.61
|
| Rate for Payer: Signature Care EPO |
$1.73
|
| Rate for Payer: Signature Care PPO |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
|
|
VENLAFAXINE 25 MG ORAL TAB
|
Facility
|
OP
|
$2.09
|
|
|
Service Code
|
NDC 68382001801
|
| Hospital Charge Code |
12203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: Aetna Medicare |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Centivo All Commercial |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.80
|
| Rate for Payer: CORVEL All Commercial |
$1.94
|
| Rate for Payer: Coventry All Commercial |
$1.84
|
| Rate for Payer: Encore All Commercial |
$1.92
|
| Rate for Payer: Frontpath All Commercial |
$1.92
|
| Rate for Payer: Humana ChoiceCare |
$1.80
|
| Rate for Payer: Humana Medicare |
$0.67
|
| Rate for Payer: Lucent All Commercial |
$1.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.88
|
| Rate for Payer: PHCS All Commercial |
$1.56
|
| Rate for Payer: PHP All Commercial |
$1.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.81
|
| Rate for Payer: Sagamore Health Network All Products |
$1.61
|
| Rate for Payer: Signature Care EPO |
$1.73
|
| Rate for Payer: Signature Care PPO |
$1.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.77
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$0.67
|
|
