|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
|
IP
|
$69.13
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.84 |
| Max. Negotiated Rate |
$64.29 |
| Rate for Payer: Aetna Commercial |
$59.72
|
| Rate for Payer: Cash Price |
$42.86
|
| Rate for Payer: Cigna All Commercial |
$59.65
|
| Rate for Payer: CORVEL All Commercial |
$64.29
|
| Rate for Payer: Coventry All Commercial |
$60.83
|
| Rate for Payer: Encore All Commercial |
$63.63
|
| Rate for Payer: Frontpath All Commercial |
$63.59
|
| Rate for Payer: Humana ChoiceCare |
$59.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.21
|
| Rate for Payer: PHCS All Commercial |
$51.84
|
| Rate for Payer: PHP All Commercial |
$52.42
|
| Rate for Payer: Sagamore Health Network All Products |
$53.36
|
| Rate for Payer: Signature Care EPO |
$57.37
|
| Rate for Payer: Signature Care PPO |
$60.83
|
| Rate for Payer: United Healthcare Commercial |
$54.47
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
|
OP
|
$69.13
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$64.29 |
| Rate for Payer: Aetna Commercial |
$58.34
|
| Rate for Payer: Aetna Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$39.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.33
|
| Rate for Payer: Cash Price |
$42.86
|
| Rate for Payer: Cash Price |
$42.86
|
| Rate for Payer: Centivo All Commercial |
$37.60
|
| Rate for Payer: Cigna All Commercial |
$59.65
|
| Rate for Payer: CORVEL All Commercial |
$64.29
|
| Rate for Payer: Coventry All Commercial |
$60.83
|
| Rate for Payer: Encore All Commercial |
$63.63
|
| Rate for Payer: Frontpath All Commercial |
$63.59
|
| Rate for Payer: Humana ChoiceCare |
$59.70
|
| Rate for Payer: Humana Medicare |
$22.12
|
| Rate for Payer: Lucent All Commercial |
$37.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.21
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$51.84
|
| Rate for Payer: PHP All Commercial |
$52.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.96
|
| Rate for Payer: Sagamore Health Network All Products |
$53.36
|
| Rate for Payer: Signature Care EPO |
$57.37
|
| Rate for Payer: Signature Care PPO |
$60.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.76
|
| Rate for Payer: United Healthcare Commercial |
$54.47
|
| Rate for Payer: United Healthcare Medicare |
$22.12
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT
|
Facility
|
IP
|
$540.41
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$405.31 |
| Max. Negotiated Rate |
$502.58 |
| Rate for Payer: Aetna Commercial |
$466.91
|
| Rate for Payer: Cash Price |
$335.05
|
| Rate for Payer: Cigna All Commercial |
$466.37
|
| Rate for Payer: CORVEL All Commercial |
$502.58
|
| Rate for Payer: Coventry All Commercial |
$475.56
|
| Rate for Payer: Encore All Commercial |
$497.45
|
| Rate for Payer: Frontpath All Commercial |
$497.18
|
| Rate for Payer: Humana ChoiceCare |
$466.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.37
|
| Rate for Payer: PHCS All Commercial |
$405.31
|
| Rate for Payer: PHP All Commercial |
$409.85
|
| Rate for Payer: Sagamore Health Network All Products |
$417.20
|
| Rate for Payer: Signature Care EPO |
$448.54
|
| Rate for Payer: Signature Care PPO |
$475.56
|
| Rate for Payer: United Healthcare Commercial |
$425.84
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT
|
Facility
|
OP
|
$540.41
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$502.58 |
| Rate for Payer: Aetna Commercial |
$456.11
|
| Rate for Payer: Aetna Medicare |
$172.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$167.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$310.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$337.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$198.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$190.22
|
| Rate for Payer: Cash Price |
$335.05
|
| Rate for Payer: Cash Price |
$335.05
|
| Rate for Payer: Centivo All Commercial |
$293.98
|
| Rate for Payer: Cigna All Commercial |
$466.37
|
| Rate for Payer: CORVEL All Commercial |
$502.58
|
| Rate for Payer: Coventry All Commercial |
$475.56
|
| Rate for Payer: Encore All Commercial |
$497.45
|
| Rate for Payer: Frontpath All Commercial |
$497.18
|
| Rate for Payer: Humana ChoiceCare |
$466.75
|
| Rate for Payer: Humana Medicare |
$172.93
|
| Rate for Payer: Lucent All Commercial |
$293.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.37
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$405.31
|
| Rate for Payer: PHP All Commercial |
$409.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$210.76
|
| Rate for Payer: Sagamore Health Network All Products |
$417.20
|
| Rate for Payer: Signature Care EPO |
$448.54
|
| Rate for Payer: Signature Care PPO |
$475.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$459.35
|
| Rate for Payer: United Healthcare Commercial |
$425.84
|
| Rate for Payer: United Healthcare Medicare |
$172.93
|
|
|
TOBRAMYCIN SULFATE 1.2 G INJ SOLR
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.65 |
| Max. Negotiated Rate |
$292.95 |
| Rate for Payer: Aetna Commercial |
$265.86
|
| Rate for Payer: Aetna Medicare |
$100.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$180.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$196.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.88
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Centivo All Commercial |
$171.36
|
| Rate for Payer: Cigna All Commercial |
$271.85
|
| Rate for Payer: CORVEL All Commercial |
$292.95
|
| Rate for Payer: Coventry All Commercial |
$277.20
|
| Rate for Payer: Encore All Commercial |
$289.96
|
| Rate for Payer: Frontpath All Commercial |
$289.80
|
| Rate for Payer: Humana ChoiceCare |
$272.07
|
| Rate for Payer: Humana Medicare |
$100.80
|
| Rate for Payer: Lucent All Commercial |
$171.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.50
|
| Rate for Payer: PHCS All Commercial |
$236.25
|
| Rate for Payer: PHP All Commercial |
$238.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.85
|
| Rate for Payer: Sagamore Health Network All Products |
$243.18
|
| Rate for Payer: Signature Care EPO |
$261.45
|
| Rate for Payer: Signature Care PPO |
$277.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$267.75
|
| Rate for Payer: United Healthcare Commercial |
$248.22
|
| Rate for Payer: United Healthcare Medicare |
$100.80
|
|
|
TOBRAMYCIN SULFATE 1.2 G INJ SOLR
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$292.95 |
| Rate for Payer: Aetna Commercial |
$272.16
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna All Commercial |
$271.85
|
| Rate for Payer: CORVEL All Commercial |
$292.95
|
| Rate for Payer: Coventry All Commercial |
$277.20
|
| Rate for Payer: Encore All Commercial |
$289.96
|
| Rate for Payer: Frontpath All Commercial |
$289.80
|
| Rate for Payer: Humana ChoiceCare |
$272.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.50
|
| Rate for Payer: PHCS All Commercial |
$236.25
|
| Rate for Payer: PHP All Commercial |
$238.90
|
| Rate for Payer: Sagamore Health Network All Products |
$243.18
|
| Rate for Payer: Signature Care EPO |
$261.45
|
| Rate for Payer: Signature Care PPO |
$277.20
|
| Rate for Payer: United Healthcare Commercial |
$248.22
|
|
|
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
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 |
$11.16
|
| 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
|
|
|
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
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 |
$11.16
|
| 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
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLN
|
Facility
|
IP
|
$4,531.49
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,398.61 |
| Max. Negotiated Rate |
$4,214.28 |
| Rate for Payer: Aetna Commercial |
$3,915.20
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Cigna All Commercial |
$3,910.67
|
| Rate for Payer: CORVEL All Commercial |
$4,214.28
|
| Rate for Payer: Coventry All Commercial |
$3,987.71
|
| Rate for Payer: Encore All Commercial |
$4,171.23
|
| Rate for Payer: Frontpath All Commercial |
$4,168.97
|
| Rate for Payer: Humana ChoiceCare |
$3,913.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,078.34
|
| Rate for Payer: PHCS All Commercial |
$3,398.61
|
| Rate for Payer: PHP All Commercial |
$3,436.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3,498.31
|
| Rate for Payer: Signature Care EPO |
$3,761.13
|
| Rate for Payer: Signature Care PPO |
$3,987.71
|
| Rate for Payer: United Healthcare Commercial |
$3,570.81
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLN
|
Facility
|
OP
|
$4,531.49
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$4,214.28 |
| Rate for Payer: Aetna Commercial |
$3,824.57
|
| Rate for Payer: Aetna Medicare |
$1,450.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$6.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,404.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,602.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,832.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$6.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,667.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,595.08
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Cash Price |
$2,809.52
|
| Rate for Payer: Centivo All Commercial |
$2,465.13
|
| Rate for Payer: Cigna All Commercial |
$3,910.67
|
| Rate for Payer: CORVEL All Commercial |
$4,214.28
|
| Rate for Payer: Coventry All Commercial |
$3,987.71
|
| Rate for Payer: Encore All Commercial |
$4,171.23
|
| Rate for Payer: Frontpath All Commercial |
$4,168.97
|
| Rate for Payer: Humana ChoiceCare |
$3,913.84
|
| Rate for Payer: Humana Medicare |
$1,450.08
|
| Rate for Payer: Lucent All Commercial |
$2,465.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,078.34
|
| Rate for Payer: Managed Health Services Medicaid |
$6.97
|
| Rate for Payer: MDWise Medicaid |
$6.97
|
| Rate for Payer: PHCS All Commercial |
$3,398.61
|
| Rate for Payer: PHP All Commercial |
$3,436.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,767.28
|
| Rate for Payer: Sagamore Health Network All Products |
$3,498.31
|
| Rate for Payer: Signature Care EPO |
$3,761.13
|
| Rate for Payer: Signature Care PPO |
$3,987.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,851.76
|
| Rate for Payer: United Healthcare Commercial |
$3,570.81
|
| Rate for Payer: United Healthcare Medicare |
$1,450.08
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN
|
Facility
|
IP
|
$2,071.52
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,553.64 |
| Max. Negotiated Rate |
$1,926.51 |
| Rate for Payer: Aetna Commercial |
$1,789.79
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Cigna All Commercial |
$1,787.72
|
| Rate for Payer: CORVEL All Commercial |
$1,926.51
|
| Rate for Payer: Coventry All Commercial |
$1,822.94
|
| Rate for Payer: Encore All Commercial |
$1,906.83
|
| Rate for Payer: Frontpath All Commercial |
$1,905.80
|
| Rate for Payer: Humana ChoiceCare |
$1,789.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,864.37
|
| Rate for Payer: PHCS All Commercial |
$1,553.64
|
| Rate for Payer: PHP All Commercial |
$1,571.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1,599.21
|
| Rate for Payer: Signature Care EPO |
$1,719.36
|
| Rate for Payer: Signature Care PPO |
$1,822.94
|
| Rate for Payer: United Healthcare Commercial |
$1,632.36
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN
|
Facility
|
OP
|
$2,071.52
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
108061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$1,926.51 |
| Rate for Payer: Aetna Commercial |
$1,748.36
|
| Rate for Payer: Aetna Medicare |
$662.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$6.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$642.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,189.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,294.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$6.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$762.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$729.18
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Cash Price |
$1,284.34
|
| Rate for Payer: Centivo All Commercial |
$1,126.91
|
| Rate for Payer: Cigna All Commercial |
$1,787.72
|
| Rate for Payer: CORVEL All Commercial |
$1,926.51
|
| Rate for Payer: Coventry All Commercial |
$1,822.94
|
| Rate for Payer: Encore All Commercial |
$1,906.83
|
| Rate for Payer: Frontpath All Commercial |
$1,905.80
|
| Rate for Payer: Humana ChoiceCare |
$1,789.17
|
| Rate for Payer: Humana Medicare |
$662.89
|
| Rate for Payer: Lucent All Commercial |
$1,126.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,864.37
|
| Rate for Payer: Managed Health Services Medicaid |
$6.97
|
| Rate for Payer: MDWise Medicaid |
$6.97
|
| Rate for Payer: PHCS All Commercial |
$1,553.64
|
| Rate for Payer: PHP All Commercial |
$1,571.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$807.89
|
| Rate for Payer: Sagamore Health Network All Products |
$1,599.21
|
| Rate for Payer: Signature Care EPO |
$1,719.36
|
| Rate for Payer: Signature Care PPO |
$1,822.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,760.79
|
| Rate for Payer: United Healthcare Commercial |
$1,632.36
|
| Rate for Payer: United Healthcare Medicare |
$662.89
|
|
|
TOLTERODINE 2 MG ORAL CP24
|
Facility
|
OP
|
$37.37
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
29434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.59 |
| Max. Negotiated Rate |
$34.76 |
| Rate for Payer: Aetna Commercial |
$31.54
|
| Rate for Payer: Aetna Medicare |
$11.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.16
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Centivo All Commercial |
$20.33
|
| Rate for Payer: Cigna All Commercial |
$32.25
|
| Rate for Payer: CORVEL All Commercial |
$34.76
|
| Rate for Payer: Coventry All Commercial |
$32.89
|
| Rate for Payer: Encore All Commercial |
$34.40
|
| Rate for Payer: Frontpath All Commercial |
$34.38
|
| Rate for Payer: Humana ChoiceCare |
$32.28
|
| Rate for Payer: Humana Medicare |
$11.96
|
| Rate for Payer: Lucent All Commercial |
$20.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.64
|
| Rate for Payer: PHCS All Commercial |
$28.03
|
| Rate for Payer: PHP All Commercial |
$28.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.58
|
| Rate for Payer: Sagamore Health Network All Products |
$28.85
|
| Rate for Payer: Signature Care EPO |
$31.02
|
| Rate for Payer: Signature Care PPO |
$32.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.77
|
| Rate for Payer: United Healthcare Commercial |
$29.45
|
| Rate for Payer: United Healthcare Medicare |
$11.96
|
|
|
TOLTERODINE 2 MG ORAL CP24
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
29434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$34.76 |
| Rate for Payer: Aetna Commercial |
$32.29
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cigna All Commercial |
$32.25
|
| Rate for Payer: CORVEL All Commercial |
$34.76
|
| Rate for Payer: Coventry All Commercial |
$32.89
|
| Rate for Payer: Encore All Commercial |
$34.40
|
| Rate for Payer: Frontpath All Commercial |
$34.38
|
| Rate for Payer: Humana ChoiceCare |
$32.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.64
|
| Rate for Payer: PHCS All Commercial |
$28.03
|
| Rate for Payer: PHP All Commercial |
$28.34
|
| Rate for Payer: Sagamore Health Network All Products |
$28.85
|
| Rate for Payer: Signature Care EPO |
$31.02
|
| Rate for Payer: Signature Care PPO |
$32.89
|
| Rate for Payer: United Healthcare Commercial |
$29.45
|
|
|
TOLTERODINE 2 MG ORAL TAB
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 16571012706
|
| Hospital Charge Code |
22783
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.42
|
| Rate for Payer: CORVEL All Commercial |
$2.61
|
| Rate for Payer: Coventry All Commercial |
$2.47
|
| Rate for Payer: Encore All Commercial |
$2.58
|
| Rate for Payer: Frontpath All Commercial |
$2.58
|
| Rate for Payer: Humana ChoiceCare |
$2.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.53
|
| Rate for Payer: PHCS All Commercial |
$2.11
|
| Rate for Payer: PHP All Commercial |
$2.13
|
| Rate for Payer: Sagamore Health Network All Products |
$2.17
|
| Rate for Payer: Signature Care EPO |
$2.33
|
| Rate for Payer: Signature Care PPO |
$2.47
|
| Rate for Payer: United Healthcare Commercial |
$2.21
|
|
|
TOLTERODINE 2 MG ORAL TAB
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 16571012706
|
| Hospital Charge Code |
22783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Aetna Commercial |
$2.37
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.99
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Centivo All Commercial |
$1.53
|
| Rate for Payer: Cigna All Commercial |
$2.42
|
| Rate for Payer: CORVEL All Commercial |
$2.61
|
| Rate for Payer: Coventry All Commercial |
$2.47
|
| Rate for Payer: Encore All Commercial |
$2.58
|
| Rate for Payer: Frontpath All Commercial |
$2.58
|
| Rate for Payer: Humana ChoiceCare |
$2.42
|
| Rate for Payer: Humana Medicare |
$0.90
|
| Rate for Payer: Lucent All Commercial |
$1.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.53
|
| Rate for Payer: PHCS All Commercial |
$2.11
|
| Rate for Payer: PHP All Commercial |
$2.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.09
|
| Rate for Payer: Sagamore Health Network All Products |
$2.17
|
| Rate for Payer: Signature Care EPO |
$2.33
|
| Rate for Payer: Signature Care PPO |
$2.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.39
|
| Rate for Payer: United Healthcare Commercial |
$2.21
|
| Rate for Payer: United Healthcare Medicare |
$0.90
|
|
|
TOLVAPTAN 15 MG ORAL TAB
|
Facility
|
OP
|
$359.99
|
|
|
Service Code
|
NDC 31722086803
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$334.79 |
| Rate for Payer: Aetna Commercial |
$303.83
|
| Rate for Payer: Aetna Medicare |
$115.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$111.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$206.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$225.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.72
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Centivo All Commercial |
$195.84
|
| Rate for Payer: Cigna All Commercial |
$310.67
|
| Rate for Payer: CORVEL All Commercial |
$334.79
|
| Rate for Payer: Coventry All Commercial |
$316.79
|
| Rate for Payer: Encore All Commercial |
$331.37
|
| Rate for Payer: Frontpath All Commercial |
$331.19
|
| Rate for Payer: Humana ChoiceCare |
$310.93
|
| Rate for Payer: Humana Medicare |
$115.20
|
| Rate for Payer: Lucent All Commercial |
$195.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.99
|
| Rate for Payer: PHCS All Commercial |
$270.00
|
| Rate for Payer: PHP All Commercial |
$273.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$140.40
|
| Rate for Payer: Sagamore Health Network All Products |
$277.92
|
| Rate for Payer: Signature Care EPO |
$298.80
|
| Rate for Payer: Signature Care PPO |
$316.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.99
|
| Rate for Payer: United Healthcare Commercial |
$283.68
|
| Rate for Payer: United Healthcare Medicare |
$115.20
|
|
|
TOLVAPTAN 15 MG ORAL TAB
|
Facility
|
IP
|
$359.99
|
|
|
Service Code
|
NDC 31722086803
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$270.00 |
| Max. Negotiated Rate |
$334.79 |
| Rate for Payer: Aetna Commercial |
$311.03
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Cigna All Commercial |
$310.67
|
| Rate for Payer: CORVEL All Commercial |
$334.79
|
| Rate for Payer: Coventry All Commercial |
$316.79
|
| Rate for Payer: Encore All Commercial |
$331.37
|
| Rate for Payer: Frontpath All Commercial |
$331.19
|
| Rate for Payer: Humana ChoiceCare |
$310.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.99
|
| Rate for Payer: PHCS All Commercial |
$270.00
|
| Rate for Payer: PHP All Commercial |
$273.02
|
| Rate for Payer: Sagamore Health Network All Products |
$277.92
|
| Rate for Payer: Signature Care EPO |
$298.80
|
| Rate for Payer: Signature Care PPO |
$316.79
|
| Rate for Payer: United Healthcare Commercial |
$283.68
|
|
|
TOPIRAMATE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna All Commercial |
$1.10
|
| Rate for Payer: CORVEL All Commercial |
$1.18
|
| Rate for Payer: Coventry All Commercial |
$1.12
|
| Rate for Payer: Encore All Commercial |
$1.17
|
| Rate for Payer: Frontpath All Commercial |
$1.17
|
| Rate for Payer: Humana ChoiceCare |
$1.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.15
|
| Rate for Payer: PHCS All Commercial |
$0.96
|
| Rate for Payer: PHP All Commercial |
$0.97
|
| Rate for Payer: Sagamore Health Network All Products |
$0.98
|
| Rate for Payer: Signature Care EPO |
$1.06
|
| Rate for Payer: Signature Care PPO |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.00
|
|
|
TOPIRAMATE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Centivo All Commercial |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$1.10
|
| Rate for Payer: CORVEL All Commercial |
$1.18
|
| Rate for Payer: Coventry All Commercial |
$1.12
|
| Rate for Payer: Encore All Commercial |
$1.17
|
| Rate for Payer: Frontpath All Commercial |
$1.17
|
| Rate for Payer: Humana ChoiceCare |
$1.10
|
| Rate for Payer: Humana Medicare |
$0.41
|
| Rate for Payer: Lucent All Commercial |
$0.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.15
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$0.96
|
| Rate for Payer: PHP All Commercial |
$0.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.50
|
| Rate for Payer: Sagamore Health Network All Products |
$0.98
|
| Rate for Payer: Signature Care EPO |
$1.06
|
| Rate for Payer: Signature Care PPO |
$1.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
|
|
TORSEMIDE 20 MG ORAL TAB
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$2.00
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna All Commercial |
$2.00
|
| Rate for Payer: CORVEL All Commercial |
$2.15
|
| Rate for Payer: Coventry All Commercial |
$2.04
|
| Rate for Payer: Encore All Commercial |
$2.13
|
| Rate for Payer: Frontpath All Commercial |
$2.13
|
| Rate for Payer: Humana ChoiceCare |
$2.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.09
|
| Rate for Payer: PHCS All Commercial |
$1.74
|
| Rate for Payer: PHP All Commercial |
$1.76
|
| Rate for Payer: Sagamore Health Network All Products |
$1.79
|
| Rate for Payer: Signature Care EPO |
$1.92
|
| Rate for Payer: Signature Care PPO |
$2.04
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
|
|
TORSEMIDE 20 MG ORAL TAB
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$1.96
|
| Rate for Payer: Aetna Medicare |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Centivo All Commercial |
$1.26
|
| Rate for Payer: Cigna All Commercial |
$2.00
|
| Rate for Payer: CORVEL All Commercial |
$2.15
|
| Rate for Payer: Coventry All Commercial |
$2.04
|
| Rate for Payer: Encore All Commercial |
$2.13
|
| Rate for Payer: Frontpath All Commercial |
$2.13
|
| Rate for Payer: Humana ChoiceCare |
$2.00
|
| Rate for Payer: Humana Medicare |
$0.74
|
| Rate for Payer: Lucent All Commercial |
$1.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.09
|
| Rate for Payer: PHCS All Commercial |
$1.74
|
| Rate for Payer: PHP All Commercial |
$1.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.90
|
| Rate for Payer: Sagamore Health Network All Products |
$1.79
|
| Rate for Payer: Signature Care EPO |
$1.92
|
| Rate for Payer: Signature Care PPO |
$2.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.97
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
|
|
TRAMADOL 50 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687079501
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
TRAMADOL 50 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687079511
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
TRAMADOL 50 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687079501
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
