|
TRIPTORELIN PAMOATE 22.5 MG IM SUSR
|
Facility
|
OP
|
$17,989.58
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
121160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$959.44 |
| Max. Negotiated Rate |
$16,730.31 |
| Rate for Payer: Aetna Commercial |
$15,183.21
|
| Rate for Payer: Aetna Medicare |
$5,756.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$959.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,576.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10,331.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11,245.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$959.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,620.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,332.33
|
| Rate for Payer: Cash Price |
$11,153.54
|
| Rate for Payer: Cash Price |
$11,153.54
|
| Rate for Payer: Centivo All Commercial |
$9,786.33
|
| Rate for Payer: Cigna All Commercial |
$15,525.01
|
| Rate for Payer: CORVEL All Commercial |
$16,730.31
|
| Rate for Payer: Coventry All Commercial |
$15,830.83
|
| Rate for Payer: Encore All Commercial |
$16,559.41
|
| Rate for Payer: Frontpath All Commercial |
$16,550.41
|
| Rate for Payer: Humana ChoiceCare |
$15,537.60
|
| Rate for Payer: Humana Medicare |
$5,756.67
|
| Rate for Payer: Lucent All Commercial |
$9,786.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16,190.62
|
| Rate for Payer: Managed Health Services Medicaid |
$959.44
|
| Rate for Payer: MDWise Medicaid |
$959.44
|
| Rate for Payer: PHCS All Commercial |
$13,492.18
|
| Rate for Payer: PHP All Commercial |
$13,643.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,015.94
|
| Rate for Payer: Sagamore Health Network All Products |
$13,887.96
|
| Rate for Payer: Signature Care EPO |
$14,931.35
|
| Rate for Payer: Signature Care PPO |
$15,830.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15,291.14
|
| Rate for Payer: United Healthcare Commercial |
$14,175.79
|
| Rate for Payer: United Healthcare Medicare |
$5,756.67
|
|
|
TROP-CYCLO-PHENYL-KETORO-OFLOX-XYLO 0.06-0.06-0.14-0.03-0.02-1.5 % OPHT DRPS (CAMERON)
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
NDC 9999999882
|
| Hospital Charge Code |
198927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$192.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$186.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$344.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$375.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$220.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$211.20
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Centivo All Commercial |
$326.40
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Humana Medicare |
$192.00
|
| Rate for Payer: Lucent All Commercial |
$326.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.00
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$510.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
| Rate for Payer: United Healthcare Medicare |
$192.00
|
|
|
TROP-CYCLO-PHENYL-KETORO-OFLOX-XYLO 0.06-0.06-0.14-0.03-0.02-1.5 % OPHT DRPS (CAMERON)
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
NDC 9999999882
|
| Hospital Charge Code |
198927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$518.40
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
|
IP
|
$69.93
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.45 |
| Max. Negotiated Rate |
$65.03 |
| Rate for Payer: Aetna Commercial |
$60.42
|
| Rate for Payer: Cash Price |
$43.36
|
| Rate for Payer: Cigna All Commercial |
$60.35
|
| Rate for Payer: CORVEL All Commercial |
$65.03
|
| Rate for Payer: Coventry All Commercial |
$61.54
|
| Rate for Payer: Encore All Commercial |
$64.37
|
| Rate for Payer: Frontpath All Commercial |
$64.34
|
| Rate for Payer: Humana ChoiceCare |
$60.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.94
|
| Rate for Payer: PHCS All Commercial |
$52.45
|
| Rate for Payer: PHP All Commercial |
$53.03
|
| Rate for Payer: Sagamore Health Network All Products |
$53.99
|
| Rate for Payer: Signature Care EPO |
$58.04
|
| Rate for Payer: Signature Care PPO |
$61.54
|
| Rate for Payer: United Healthcare Commercial |
$55.10
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
|
OP
|
$69.93
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$65.03 |
| Rate for Payer: Aetna Commercial |
$59.02
|
| Rate for Payer: Aetna Medicare |
$22.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$40.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.62
|
| Rate for Payer: Cash Price |
$43.36
|
| Rate for Payer: Cash Price |
$43.36
|
| Rate for Payer: Centivo All Commercial |
$38.04
|
| Rate for Payer: Cigna All Commercial |
$60.35
|
| Rate for Payer: CORVEL All Commercial |
$65.03
|
| Rate for Payer: Coventry All Commercial |
$61.54
|
| Rate for Payer: Encore All Commercial |
$64.37
|
| Rate for Payer: Frontpath All Commercial |
$64.34
|
| Rate for Payer: Humana ChoiceCare |
$60.40
|
| Rate for Payer: Humana Medicare |
$22.38
|
| Rate for Payer: Lucent All Commercial |
$38.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.94
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$52.45
|
| Rate for Payer: PHP All Commercial |
$53.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.27
|
| Rate for Payer: Sagamore Health Network All Products |
$53.99
|
| Rate for Payer: Signature Care EPO |
$58.04
|
| Rate for Payer: Signature Care PPO |
$61.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.44
|
| Rate for Payer: United Healthcare Commercial |
$55.10
|
| Rate for Payer: United Healthcare Medicare |
$22.38
|
|
|
TRYPAN BLUE 0.06 % IO SYRG
|
Facility
|
OP
|
$320.40
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$297.97 |
| Rate for Payer: Aetna Commercial |
$270.42
|
| Rate for Payer: Aetna Medicare |
$102.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$99.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$184.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$200.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$117.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$112.78
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Centivo All Commercial |
$174.30
|
| Rate for Payer: Cigna All Commercial |
$276.51
|
| Rate for Payer: CORVEL All Commercial |
$297.97
|
| Rate for Payer: Coventry All Commercial |
$281.95
|
| Rate for Payer: Encore All Commercial |
$294.93
|
| Rate for Payer: Frontpath All Commercial |
$294.77
|
| Rate for Payer: Humana ChoiceCare |
$276.73
|
| Rate for Payer: Humana Medicare |
$102.53
|
| Rate for Payer: Lucent All Commercial |
$174.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.36
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$240.30
|
| Rate for Payer: PHP All Commercial |
$242.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.96
|
| Rate for Payer: Sagamore Health Network All Products |
$247.35
|
| Rate for Payer: Signature Care EPO |
$265.93
|
| Rate for Payer: Signature Care PPO |
$281.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$272.34
|
| Rate for Payer: United Healthcare Commercial |
$252.48
|
| Rate for Payer: United Healthcare Medicare |
$102.53
|
|
|
TRYPAN BLUE 0.06 % IO SYRG
|
Facility
|
IP
|
$320.40
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$240.30 |
| Max. Negotiated Rate |
$297.97 |
| Rate for Payer: Aetna Commercial |
$276.83
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Cigna All Commercial |
$276.51
|
| Rate for Payer: CORVEL All Commercial |
$297.97
|
| Rate for Payer: Coventry All Commercial |
$281.95
|
| Rate for Payer: Encore All Commercial |
$294.93
|
| Rate for Payer: Frontpath All Commercial |
$294.77
|
| Rate for Payer: Humana ChoiceCare |
$276.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.36
|
| Rate for Payer: PHCS All Commercial |
$240.30
|
| Rate for Payer: PHP All Commercial |
$242.99
|
| Rate for Payer: Sagamore Health Network All Products |
$247.35
|
| Rate for Payer: Signature Care EPO |
$265.93
|
| Rate for Payer: Signature Care PPO |
$281.95
|
| Rate for Payer: United Healthcare Commercial |
$252.48
|
|
|
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 |
$319.98
|
| Rate for Payer: Cash Price |
$319.98
|
| 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
|
|
|
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 |
$44.80
|
| 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
|
$72.25
|
|
|
Service Code
|
NDC 492810752
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: Aetna Commercial |
$60.98
|
| Rate for Payer: Aetna Medicare |
$23.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$41.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.17
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.43
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Centivo All Commercial |
$39.31
|
| 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: Humana Medicare |
$23.12
|
| Rate for Payer: Lucent All Commercial |
$39.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.03
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$54.19
|
| Rate for Payer: PHP All Commercial |
$54.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.18
|
| 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: Three Rivers Preferred All Commercial |
$61.42
|
| Rate for Payer: United Healthcare Commercial |
$56.94
|
| Rate for Payer: United Healthcare Medicare |
$23.12
|
|
|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
|
IP
|
$516.10
|
|
|
Service Code
|
NDC 49281075221
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$387.07 |
| Max. Negotiated Rate |
$479.97 |
| Rate for Payer: Aetna Commercial |
$445.91
|
| Rate for Payer: Cash Price |
$319.98
|
| 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: Lutheran Preferred All Commercial |
$464.49
|
| Rate for Payer: PHCS All Commercial |
$387.07
|
| Rate for Payer: PHP All Commercial |
$391.41
|
| 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: United Healthcare Commercial |
$406.69
|
|
|
UNLISTED PROCEDURE, FOOT OR TOES
|
Facility
|
OP
|
$488.57
|
|
|
Service Code
|
CPT 28899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.57 |
| Max. Negotiated Rate |
$488.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$488.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$488.57
|
| Rate for Payer: Managed Health Services Medicaid |
$488.57
|
| Rate for Payer: MDWise Medicaid |
$488.57
|
|
|
UNLISTED PROCEDURE, VASCULAR SURGERY
|
Facility
|
OP
|
$488.57
|
|
|
Service Code
|
CPT 37799
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.57 |
| Max. Negotiated Rate |
$488.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$488.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$488.57
|
| Rate for Payer: Managed Health Services Medicaid |
$488.57
|
| Rate for Payer: MDWise Medicaid |
$488.57
|
|
|
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 |
$8.58
|
| 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 |
$8.58
|
| 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
|
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 |
$4,599.64
|
| Rate for Payer: Cash Price |
$4,599.64
|
| 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 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 |
$4,599.64
|
| 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 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 |
$61,677.19
|
| 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 |
$61,677.19
|
| Rate for Payer: Cash Price |
$61,677.19
|
| 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
|
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 |
$5.90
|
| 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
|
|
|
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 |
$5.90
|
| 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
|
|
|
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 |
$29.08
|
| 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 |
$29.08
|
| 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 |
$3.55
|
| 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 |
$3.55
|
| 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
|
|
