|
VALSARTAN 40 MG ORAL TAB
|
Facility
|
IP
|
$5.74
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.96
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.34
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.28
|
| Rate for Payer: Humana ChoiceCare |
$4.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.17
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
|
|
VALSARTAN 40 MG ORAL TAB
|
Facility
|
OP
|
$5.74
|
|
|
Service Code
|
NDC 60687061221
|
| Hospital Charge Code |
33541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Centivo All Commercial |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.95
|
| Rate for Payer: CORVEL All Commercial |
$5.34
|
| Rate for Payer: Coventry All Commercial |
$5.05
|
| Rate for Payer: Encore All Commercial |
$5.28
|
| Rate for Payer: Frontpath All Commercial |
$5.28
|
| Rate for Payer: Humana ChoiceCare |
$4.96
|
| Rate for Payer: Humana Medicare |
$1.84
|
| Rate for Payer: Lucent All Commercial |
$3.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.17
|
| Rate for Payer: PHCS All Commercial |
$4.30
|
| Rate for Payer: PHP All Commercial |
$4.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4.43
|
| Rate for Payer: Signature Care EPO |
$4.76
|
| Rate for Payer: Signature Care PPO |
$5.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.88
|
| Rate for Payer: United Healthcare Commercial |
$4.52
|
| Rate for Payer: United Healthcare Medicare |
$1.84
|
|
|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
OP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Centivo All Commercial |
$1.87
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Humana Medicare |
$1.10
|
| Rate for Payer: Lucent All Commercial |
$1.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.92
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
|
|
VALSARTAN 80 MG ORAL TAB
|
Facility
|
IP
|
$3.44
|
|
|
Service Code
|
NDC 00378581377
|
| Hospital Charge Code |
31209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.97
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna All Commercial |
$2.97
|
| Rate for Payer: CORVEL All Commercial |
$3.20
|
| Rate for Payer: Coventry All Commercial |
$3.02
|
| Rate for Payer: Encore All Commercial |
$3.16
|
| Rate for Payer: Frontpath All Commercial |
$3.16
|
| Rate for Payer: Humana ChoiceCare |
$2.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.09
|
| Rate for Payer: PHCS All Commercial |
$2.58
|
| Rate for Payer: PHP All Commercial |
$2.61
|
| Rate for Payer: Sagamore Health Network All Products |
$2.65
|
| Rate for Payer: Signature Care EPO |
$2.85
|
| Rate for Payer: Signature Care PPO |
$3.02
|
| Rate for Payer: United Healthcare Commercial |
$2.71
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
IP
|
$29.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$27.34 |
| Rate for Payer: Aetna Commercial |
$25.40
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna All Commercial |
$25.37
|
| Rate for Payer: CORVEL All Commercial |
$27.34
|
| Rate for Payer: Coventry All Commercial |
$25.87
|
| Rate for Payer: Encore All Commercial |
$27.06
|
| Rate for Payer: Frontpath All Commercial |
$27.05
|
| Rate for Payer: Humana ChoiceCare |
$25.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.46
|
| Rate for Payer: PHCS All Commercial |
$22.05
|
| Rate for Payer: PHP All Commercial |
$22.30
|
| Rate for Payer: Sagamore Health Network All Products |
$22.70
|
| Rate for Payer: Signature Care EPO |
$24.40
|
| Rate for Payer: Signature Care PPO |
$25.87
|
| Rate for Payer: United Healthcare Commercial |
$23.17
|
|
|
VANCOMYCIN 1000 MG IV SOLR
|
Facility
|
OP
|
$29.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
8442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$27.34 |
| Rate for Payer: Aetna Commercial |
$24.81
|
| Rate for Payer: Aetna Medicare |
$9.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.35
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Centivo All Commercial |
$15.99
|
| Rate for Payer: Cigna All Commercial |
$25.37
|
| Rate for Payer: CORVEL All Commercial |
$27.34
|
| Rate for Payer: Coventry All Commercial |
$25.87
|
| Rate for Payer: Encore All Commercial |
$27.06
|
| Rate for Payer: Frontpath All Commercial |
$27.05
|
| Rate for Payer: Humana ChoiceCare |
$25.39
|
| Rate for Payer: Humana Medicare |
$9.41
|
| Rate for Payer: Lucent All Commercial |
$15.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.46
|
| Rate for Payer: PHCS All Commercial |
$22.05
|
| Rate for Payer: PHP All Commercial |
$22.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.47
|
| Rate for Payer: Sagamore Health Network All Products |
$22.70
|
| Rate for Payer: Signature Care EPO |
$24.40
|
| Rate for Payer: Signature Care PPO |
$25.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.99
|
| Rate for Payer: United Healthcare Commercial |
$23.17
|
| Rate for Payer: United Healthcare Medicare |
$9.41
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
OP
|
$158.29
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.07 |
| Max. Negotiated Rate |
$147.21 |
| Rate for Payer: Aetna Commercial |
$133.60
|
| Rate for Payer: Aetna Medicare |
$50.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$90.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.72
|
| Rate for Payer: Cash Price |
$98.14
|
| Rate for Payer: Centivo All Commercial |
$86.11
|
| Rate for Payer: Cigna All Commercial |
$136.60
|
| Rate for Payer: CORVEL All Commercial |
$147.21
|
| Rate for Payer: Coventry All Commercial |
$139.30
|
| Rate for Payer: Encore All Commercial |
$145.71
|
| Rate for Payer: Frontpath All Commercial |
$145.63
|
| Rate for Payer: Humana ChoiceCare |
$136.72
|
| Rate for Payer: Humana Medicare |
$50.65
|
| Rate for Payer: Lucent All Commercial |
$86.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.46
|
| Rate for Payer: PHCS All Commercial |
$118.72
|
| Rate for Payer: PHP All Commercial |
$120.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.73
|
| Rate for Payer: Sagamore Health Network All Products |
$122.20
|
| Rate for Payer: Signature Care EPO |
$131.38
|
| Rate for Payer: Signature Care PPO |
$139.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$134.55
|
| Rate for Payer: United Healthcare Commercial |
$124.73
|
| Rate for Payer: United Healthcare Medicare |
$50.65
|
|
|
VANCOMYCIN 1.25 G IV SOLR
|
Facility
|
IP
|
$158.29
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
187150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.72 |
| Max. Negotiated Rate |
$147.21 |
| Rate for Payer: Aetna Commercial |
$136.76
|
| Rate for Payer: Cash Price |
$98.14
|
| Rate for Payer: Cigna All Commercial |
$136.60
|
| Rate for Payer: CORVEL All Commercial |
$147.21
|
| Rate for Payer: Coventry All Commercial |
$139.30
|
| Rate for Payer: Encore All Commercial |
$145.71
|
| Rate for Payer: Frontpath All Commercial |
$145.63
|
| Rate for Payer: Humana ChoiceCare |
$136.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.46
|
| Rate for Payer: PHCS All Commercial |
$118.72
|
| Rate for Payer: PHP All Commercial |
$120.05
|
| Rate for Payer: Sagamore Health Network All Products |
$122.20
|
| Rate for Payer: Signature Care EPO |
$131.38
|
| Rate for Payer: Signature Care PPO |
$139.30
|
| Rate for Payer: United Healthcare Commercial |
$124.73
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
OP
|
$7.84
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna Commercial |
$6.62
|
| Rate for Payer: Aetna Medicare |
$2.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.76
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Centivo All Commercial |
$4.26
|
| Rate for Payer: Cigna All Commercial |
$6.77
|
| Rate for Payer: CORVEL All Commercial |
$7.29
|
| Rate for Payer: Coventry All Commercial |
$6.90
|
| Rate for Payer: Encore All Commercial |
$7.22
|
| Rate for Payer: Frontpath All Commercial |
$7.21
|
| Rate for Payer: Humana ChoiceCare |
$6.77
|
| Rate for Payer: Humana Medicare |
$2.51
|
| Rate for Payer: Lucent All Commercial |
$4.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.06
|
| Rate for Payer: PHCS All Commercial |
$5.88
|
| Rate for Payer: PHP All Commercial |
$5.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.06
|
| Rate for Payer: Sagamore Health Network All Products |
$6.05
|
| Rate for Payer: Signature Care EPO |
$6.51
|
| Rate for Payer: Signature Care PPO |
$6.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.66
|
| Rate for Payer: United Healthcare Commercial |
$6.18
|
| Rate for Payer: United Healthcare Medicare |
$2.51
|
|
|
VANCOMYCIN 125 MG ORAL CAP
|
Facility
|
IP
|
$7.84
|
|
|
Service Code
|
NDC 23155085878
|
| Hospital Charge Code |
11628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna Commercial |
$6.77
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna All Commercial |
$6.77
|
| Rate for Payer: CORVEL All Commercial |
$7.29
|
| Rate for Payer: Coventry All Commercial |
$6.90
|
| Rate for Payer: Encore All Commercial |
$7.22
|
| Rate for Payer: Frontpath All Commercial |
$7.21
|
| Rate for Payer: Humana ChoiceCare |
$6.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.06
|
| Rate for Payer: PHCS All Commercial |
$5.88
|
| Rate for Payer: PHP All Commercial |
$5.95
|
| Rate for Payer: Sagamore Health Network All Products |
$6.05
|
| Rate for Payer: Signature Care EPO |
$6.51
|
| Rate for Payer: Signature Care PPO |
$6.90
|
| Rate for Payer: United Healthcare Commercial |
$6.18
|
|
|
VANCOMYCIN 1.5 G IV SOLR
|
Facility
|
IP
|
$122.38
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
186918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.78 |
| Max. Negotiated Rate |
$113.81 |
| Rate for Payer: Aetna Commercial |
$105.73
|
| Rate for Payer: Cash Price |
$75.87
|
| Rate for Payer: Cigna All Commercial |
$105.61
|
| Rate for Payer: CORVEL All Commercial |
$113.81
|
| Rate for Payer: Coventry All Commercial |
$107.69
|
| Rate for Payer: Encore All Commercial |
$112.65
|
| Rate for Payer: Frontpath All Commercial |
$112.59
|
| Rate for Payer: Humana ChoiceCare |
$105.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.14
|
| Rate for Payer: PHCS All Commercial |
$91.78
|
| Rate for Payer: PHP All Commercial |
$92.81
|
| Rate for Payer: Sagamore Health Network All Products |
$94.48
|
| Rate for Payer: Signature Care EPO |
$101.57
|
| Rate for Payer: Signature Care PPO |
$107.69
|
| Rate for Payer: United Healthcare Commercial |
$96.43
|
|
|
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 |
$75.87
|
| 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 |
$152.38
|
| 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 |
$152.38
|
| 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 |
$174.15
|
| 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 |
$174.15
|
| 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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$517.55
|
| 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
|
|
|
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 |
$517.55
|
| 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
|
|
|
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 |
$34.10
|
| 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
|
|
|
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 |
$34.10
|
| 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
|
|
|
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 |
$539.06
|
| 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 |
$539.06
|
| Rate for Payer: Cash Price |
$539.06
|
| 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 |
$626.32
|
| 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
|
|
