|
MIDODRINE 2.5 MG ORAL TAB
|
Facility
OP
|
$4.56
|
|
|
Service Code
|
NDC 00904681761
|
| Hospital Charge Code |
10609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: Aetna Medicare |
$1.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Centivo All Commercial |
$2.33
|
| Rate for Payer: Cigna All Commercial |
$3.94
|
| Rate for Payer: CORVEL All Commercial |
$4.24
|
| Rate for Payer: Coventry All Commercial |
$4.02
|
| Rate for Payer: Encore All Commercial |
$4.20
|
| Rate for Payer: Frontpath All Commercial |
$4.20
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Humana Medicare |
$2.33
|
| Rate for Payer: Lucent All Commercial |
$2.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.11
|
| Rate for Payer: PHCS All Commercial |
$3.42
|
| Rate for Payer: PHP All Commercial |
$3.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.78
|
| Rate for Payer: Sagamore Health Network All Products |
$3.52
|
| Rate for Payer: Signature Care EPO |
$3.79
|
| Rate for Payer: Signature Care PPO |
$4.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.88
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
| Rate for Payer: United Healthcare Medicare |
$1.51
|
|
|
MIDODRINE 2.5 MG ORAL TAB
|
Facility
IP
|
$4.56
|
|
|
Service Code
|
NDC 00904681761
|
| Hospital Charge Code |
10609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.94
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cigna All Commercial |
$3.94
|
| Rate for Payer: CORVEL All Commercial |
$4.24
|
| Rate for Payer: Coventry All Commercial |
$4.02
|
| Rate for Payer: Encore All Commercial |
$4.20
|
| Rate for Payer: Frontpath All Commercial |
$4.20
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.11
|
| Rate for Payer: PHCS All Commercial |
$3.42
|
| Rate for Payer: PHP All Commercial |
$3.46
|
| Rate for Payer: Sagamore Health Network All Products |
$3.52
|
| Rate for Payer: Signature Care EPO |
$3.79
|
| Rate for Payer: Signature Care PPO |
$4.02
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
|
|
MIDODRINE 5 MG ORAL TAB
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.23
|
| Rate for Payer: Frontpath All Commercial |
$1.23
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.11
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
MIDODRINE 5 MG ORAL TAB
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Centivo All Commercial |
$0.68
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.23
|
| Rate for Payer: Frontpath All Commercial |
$1.23
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Humana Medicare |
$0.68
|
| Rate for Payer: Lucent All Commercial |
$0.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.11
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
MILRINONE 20 MG/100 ML IVPB
|
Facility
OP
|
$69.30
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$64.45 |
| Rate for Payer: Aetna Commercial |
$58.49
|
| Rate for Payer: Aetna Medicare |
$22.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.16
|
| Rate for Payer: Cash Price |
$42.97
|
| Rate for Payer: Centivo All Commercial |
$35.34
|
| Rate for Payer: Cigna All Commercial |
$59.81
|
| Rate for Payer: CORVEL All Commercial |
$64.45
|
| Rate for Payer: Coventry All Commercial |
$60.98
|
| Rate for Payer: Encore All Commercial |
$63.79
|
| Rate for Payer: Frontpath All Commercial |
$63.76
|
| Rate for Payer: Humana ChoiceCare |
$59.85
|
| Rate for Payer: Humana Medicare |
$35.34
|
| Rate for Payer: Lucent All Commercial |
$35.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.37
|
| Rate for Payer: PHCS All Commercial |
$51.98
|
| Rate for Payer: PHP All Commercial |
$52.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.03
|
| Rate for Payer: Sagamore Health Network All Products |
$53.50
|
| Rate for Payer: Signature Care EPO |
$57.52
|
| Rate for Payer: Signature Care PPO |
$60.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.90
|
| Rate for Payer: United Healthcare Commercial |
$54.61
|
| Rate for Payer: United Healthcare Medicare |
$22.87
|
|
|
MILRINONE 20 MG/100 ML IVPB
|
Facility
IP
|
$69.30
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$64.45 |
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Cash Price |
$42.97
|
| Rate for Payer: Cigna All Commercial |
$59.81
|
| Rate for Payer: CORVEL All Commercial |
$64.45
|
| Rate for Payer: Coventry All Commercial |
$60.98
|
| Rate for Payer: Encore All Commercial |
$63.79
|
| Rate for Payer: Frontpath All Commercial |
$63.76
|
| Rate for Payer: Humana ChoiceCare |
$59.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.37
|
| Rate for Payer: PHCS All Commercial |
$51.98
|
| Rate for Payer: PHP All Commercial |
$52.56
|
| Rate for Payer: Sagamore Health Network All Products |
$53.50
|
| Rate for Payer: Signature Care EPO |
$57.52
|
| Rate for Payer: Signature Care PPO |
$60.98
|
| Rate for Payer: United Healthcare Commercial |
$54.61
|
|
|
MINERAL OIL-HYDROPHIL PETROLAT TOP OINT
|
Facility
OP
|
$50.85
|
|
|
Service Code
|
NDC 61924018416
|
| Hospital Charge Code |
27996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$47.29 |
| Rate for Payer: Aetna Commercial |
$42.92
|
| Rate for Payer: Aetna Medicare |
$16.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.46
|
| Rate for Payer: Cash Price |
$31.53
|
| Rate for Payer: Centivo All Commercial |
$25.93
|
| Rate for Payer: Cigna All Commercial |
$43.88
|
| Rate for Payer: CORVEL All Commercial |
$47.29
|
| Rate for Payer: Coventry All Commercial |
$44.75
|
| Rate for Payer: Encore All Commercial |
$46.81
|
| Rate for Payer: Frontpath All Commercial |
$46.78
|
| Rate for Payer: Humana ChoiceCare |
$43.92
|
| Rate for Payer: Humana Medicare |
$25.93
|
| Rate for Payer: Lucent All Commercial |
$25.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.76
|
| Rate for Payer: PHCS All Commercial |
$38.14
|
| Rate for Payer: PHP All Commercial |
$38.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.83
|
| Rate for Payer: Sagamore Health Network All Products |
$39.25
|
| Rate for Payer: Signature Care EPO |
$42.20
|
| Rate for Payer: Signature Care PPO |
$44.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.22
|
| Rate for Payer: United Healthcare Commercial |
$40.07
|
| Rate for Payer: United Healthcare Medicare |
$16.78
|
|
|
MINERAL OIL-HYDROPHIL PETROLAT TOP OINT
|
Facility
IP
|
$50.85
|
|
|
Service Code
|
NDC 61924018416
|
| Hospital Charge Code |
27996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.14 |
| Max. Negotiated Rate |
$47.29 |
| Rate for Payer: Aetna Commercial |
$43.93
|
| Rate for Payer: Cash Price |
$31.53
|
| Rate for Payer: Cigna All Commercial |
$43.88
|
| Rate for Payer: CORVEL All Commercial |
$47.29
|
| Rate for Payer: Coventry All Commercial |
$44.75
|
| Rate for Payer: Encore All Commercial |
$46.81
|
| Rate for Payer: Frontpath All Commercial |
$46.78
|
| Rate for Payer: Humana ChoiceCare |
$43.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.76
|
| Rate for Payer: PHCS All Commercial |
$38.14
|
| Rate for Payer: PHP All Commercial |
$38.56
|
| Rate for Payer: Sagamore Health Network All Products |
$39.25
|
| Rate for Payer: Signature Care EPO |
$42.20
|
| Rate for Payer: Signature Care PPO |
$44.75
|
| Rate for Payer: United Healthcare Commercial |
$40.07
|
|
|
MINERAL OIL ORAL OIL
|
Facility
OP
|
$12.81
|
|
|
Service Code
|
NDC 48433020230
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: Aetna Medicare |
$4.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Centivo All Commercial |
$6.53
|
| Rate for Payer: Cigna All Commercial |
$11.06
|
| Rate for Payer: CORVEL All Commercial |
$11.91
|
| Rate for Payer: Coventry All Commercial |
$11.27
|
| Rate for Payer: Encore All Commercial |
$11.79
|
| Rate for Payer: Frontpath All Commercial |
$11.79
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Humana Medicare |
$6.53
|
| Rate for Payer: Lucent All Commercial |
$6.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.53
|
| Rate for Payer: PHCS All Commercial |
$9.61
|
| Rate for Payer: PHP All Commercial |
$9.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.00
|
| Rate for Payer: Sagamore Health Network All Products |
$9.89
|
| Rate for Payer: Signature Care EPO |
$10.63
|
| Rate for Payer: Signature Care PPO |
$11.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.89
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
| Rate for Payer: United Healthcare Medicare |
$4.23
|
|
|
MINERAL OIL ORAL OIL
|
Facility
IP
|
$12.81
|
|
|
Service Code
|
NDC 48433020230
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$11.07
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Cigna All Commercial |
$11.06
|
| Rate for Payer: CORVEL All Commercial |
$11.91
|
| Rate for Payer: Coventry All Commercial |
$11.27
|
| Rate for Payer: Encore All Commercial |
$11.79
|
| Rate for Payer: Frontpath All Commercial |
$11.79
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.53
|
| Rate for Payer: PHCS All Commercial |
$9.61
|
| Rate for Payer: PHP All Commercial |
$9.72
|
| Rate for Payer: Sagamore Health Network All Products |
$9.89
|
| Rate for Payer: Signature Care EPO |
$10.63
|
| Rate for Payer: Signature Care PPO |
$11.27
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
|
|
MIRABEGRON 25 MG ORAL TB24
|
Facility
IP
|
$101.87
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
158433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.40 |
| Max. Negotiated Rate |
$94.74 |
| Rate for Payer: Aetna Commercial |
$88.02
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Cigna All Commercial |
$87.91
|
| Rate for Payer: CORVEL All Commercial |
$94.74
|
| Rate for Payer: Coventry All Commercial |
$89.65
|
| Rate for Payer: Encore All Commercial |
$93.77
|
| Rate for Payer: Frontpath All Commercial |
$93.72
|
| Rate for Payer: Humana ChoiceCare |
$87.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.68
|
| Rate for Payer: PHCS All Commercial |
$76.40
|
| Rate for Payer: PHP All Commercial |
$77.26
|
| Rate for Payer: Sagamore Health Network All Products |
$78.64
|
| Rate for Payer: Signature Care EPO |
$84.55
|
| Rate for Payer: Signature Care PPO |
$89.65
|
| Rate for Payer: United Healthcare Commercial |
$80.27
|
|
|
MIRABEGRON 25 MG ORAL TB24
|
Facility
OP
|
$101.87
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
158433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$94.74 |
| Rate for Payer: Aetna Commercial |
$85.98
|
| Rate for Payer: Aetna Medicare |
$33.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$58.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.98
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Centivo All Commercial |
$51.95
|
| Rate for Payer: Cigna All Commercial |
$87.91
|
| Rate for Payer: CORVEL All Commercial |
$94.74
|
| Rate for Payer: Coventry All Commercial |
$89.65
|
| Rate for Payer: Encore All Commercial |
$93.77
|
| Rate for Payer: Frontpath All Commercial |
$93.72
|
| Rate for Payer: Humana ChoiceCare |
$87.99
|
| Rate for Payer: Humana Medicare |
$51.95
|
| Rate for Payer: Lucent All Commercial |
$51.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.68
|
| Rate for Payer: PHCS All Commercial |
$76.40
|
| Rate for Payer: PHP All Commercial |
$77.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.73
|
| Rate for Payer: Sagamore Health Network All Products |
$78.64
|
| Rate for Payer: Signature Care EPO |
$84.55
|
| Rate for Payer: Signature Care PPO |
$89.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.59
|
| Rate for Payer: United Healthcare Commercial |
$80.27
|
| Rate for Payer: United Healthcare Medicare |
$33.62
|
|
|
MIRABEGRON 50 MG ORAL TB24
|
Facility
IP
|
$101.87
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
158434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.40 |
| Max. Negotiated Rate |
$94.74 |
| Rate for Payer: Aetna Commercial |
$88.02
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Cigna All Commercial |
$87.91
|
| Rate for Payer: CORVEL All Commercial |
$94.74
|
| Rate for Payer: Coventry All Commercial |
$89.65
|
| Rate for Payer: Encore All Commercial |
$93.77
|
| Rate for Payer: Frontpath All Commercial |
$93.72
|
| Rate for Payer: Humana ChoiceCare |
$87.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.68
|
| Rate for Payer: PHCS All Commercial |
$76.40
|
| Rate for Payer: PHP All Commercial |
$77.26
|
| Rate for Payer: Sagamore Health Network All Products |
$78.64
|
| Rate for Payer: Signature Care EPO |
$84.55
|
| Rate for Payer: Signature Care PPO |
$89.65
|
| Rate for Payer: United Healthcare Commercial |
$80.27
|
|
|
MIRABEGRON 50 MG ORAL TB24
|
Facility
OP
|
$101.87
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
158434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$94.74 |
| Rate for Payer: Aetna Commercial |
$85.98
|
| Rate for Payer: Aetna Medicare |
$33.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$58.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.98
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Centivo All Commercial |
$51.95
|
| Rate for Payer: Cigna All Commercial |
$87.91
|
| Rate for Payer: CORVEL All Commercial |
$94.74
|
| Rate for Payer: Coventry All Commercial |
$89.65
|
| Rate for Payer: Encore All Commercial |
$93.77
|
| Rate for Payer: Frontpath All Commercial |
$93.72
|
| Rate for Payer: Humana ChoiceCare |
$87.99
|
| Rate for Payer: Humana Medicare |
$51.95
|
| Rate for Payer: Lucent All Commercial |
$51.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.68
|
| Rate for Payer: PHCS All Commercial |
$76.40
|
| Rate for Payer: PHP All Commercial |
$77.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.73
|
| Rate for Payer: Sagamore Health Network All Products |
$78.64
|
| Rate for Payer: Signature Care EPO |
$84.55
|
| Rate for Payer: Signature Care PPO |
$89.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.59
|
| Rate for Payer: United Healthcare Commercial |
$80.27
|
| Rate for Payer: United Healthcare Medicare |
$33.62
|
|
|
MIRIKIZUMAB-MRKZ 300 MG/15 ML (20 MG/ML) IV SOLN
|
Facility
IP
|
$35,255.06
|
|
|
Service Code
|
HCPCS J2267
|
| Hospital Charge Code |
203340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26,441.30 |
| Max. Negotiated Rate |
$32,787.21 |
| Rate for Payer: Aetna Commercial |
$30,460.37
|
| Rate for Payer: Cash Price |
$21,858.14
|
| Rate for Payer: Cigna All Commercial |
$30,425.12
|
| Rate for Payer: CORVEL All Commercial |
$32,787.21
|
| Rate for Payer: Coventry All Commercial |
$31,024.46
|
| Rate for Payer: Encore All Commercial |
$32,452.29
|
| Rate for Payer: Frontpath All Commercial |
$32,434.66
|
| Rate for Payer: Humana ChoiceCare |
$30,449.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31,729.56
|
| Rate for Payer: PHCS All Commercial |
$26,441.30
|
| Rate for Payer: PHP All Commercial |
$26,737.44
|
| Rate for Payer: Sagamore Health Network All Products |
$27,216.91
|
| Rate for Payer: Signature Care EPO |
$29,261.70
|
| Rate for Payer: Signature Care PPO |
$31,024.46
|
| Rate for Payer: United Healthcare Commercial |
$27,780.99
|
|
|
MIRIKIZUMAB-MRKZ 300 MG/15 ML (20 MG/ML) IV SOLN
|
Facility
OP
|
$35,255.06
|
|
|
Service Code
|
HCPCS J2267
|
| Hospital Charge Code |
203340
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,634.17 |
| Max. Negotiated Rate |
$32,787.21 |
| Rate for Payer: Aetna Commercial |
$29,755.27
|
| Rate for Payer: Aetna Medicare |
$11,634.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11,634.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20,246.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22,037.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13,379.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12,797.59
|
| Rate for Payer: Cash Price |
$21,858.14
|
| Rate for Payer: Centivo All Commercial |
$17,980.08
|
| Rate for Payer: Cigna All Commercial |
$30,425.12
|
| Rate for Payer: CORVEL All Commercial |
$32,787.21
|
| Rate for Payer: Coventry All Commercial |
$31,024.46
|
| Rate for Payer: Encore All Commercial |
$32,452.29
|
| Rate for Payer: Frontpath All Commercial |
$32,434.66
|
| Rate for Payer: Humana ChoiceCare |
$30,449.80
|
| Rate for Payer: Humana Medicare |
$17,980.08
|
| Rate for Payer: Lucent All Commercial |
$17,980.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31,729.56
|
| Rate for Payer: PHCS All Commercial |
$26,441.30
|
| Rate for Payer: PHP All Commercial |
$26,737.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13,749.47
|
| Rate for Payer: Sagamore Health Network All Products |
$27,216.91
|
| Rate for Payer: Signature Care EPO |
$29,261.70
|
| Rate for Payer: Signature Care PPO |
$31,024.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29,966.80
|
| Rate for Payer: United Healthcare Commercial |
$27,780.99
|
| Rate for Payer: United Healthcare Medicare |
$11,634.17
|
|
|
MIRTAZAPINE 15 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
MIRTAZAPINE 15 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
MISOPROSTOL 100 MCG ORAL TAB
|
Facility
OP
|
$4.31
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Aetna Medicare |
$1.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Centivo All Commercial |
$2.20
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Humana Medicare |
$2.20
|
| Rate for Payer: Lucent All Commercial |
$2.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
| Rate for Payer: United Healthcare Medicare |
$1.42
|
|
|
MISOPROSTOL 100 MCG ORAL TAB
|
Facility
IP
|
$4.31
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
|
|
MISOPROSTOL 200 MCG ORAL TAB
|
Facility
OP
|
$15.33
|
|
|
Service Code
|
NDC 60687074601
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Aetna Medicare |
$5.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.56
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Centivo All Commercial |
$7.82
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Humana Medicare |
$7.82
|
| Rate for Payer: Lucent All Commercial |
$7.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.03
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
| Rate for Payer: United Healthcare Medicare |
$5.06
|
|
|
MISOPROSTOL 200 MCG ORAL TAB
|
Facility
OP
|
$15.33
|
|
|
Service Code
|
NDC 60687074611
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Aetna Medicare |
$5.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.56
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Centivo All Commercial |
$7.82
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Humana Medicare |
$7.82
|
| Rate for Payer: Lucent All Commercial |
$7.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.03
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
| Rate for Payer: United Healthcare Medicare |
$5.06
|
|
|
MISOPROSTOL 200 MCG ORAL TAB
|
Facility
IP
|
$15.33
|
|
|
Service Code
|
NDC 60687074601
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$13.25
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
|
|
MISOPROSTOL 200 MCG ORAL TAB
|
Facility
IP
|
$15.33
|
|
|
Service Code
|
NDC 60687074611
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna Commercial |
$13.25
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Cigna All Commercial |
$13.23
|
| Rate for Payer: CORVEL All Commercial |
$14.26
|
| Rate for Payer: Coventry All Commercial |
$13.49
|
| Rate for Payer: Encore All Commercial |
$14.11
|
| Rate for Payer: Frontpath All Commercial |
$14.10
|
| Rate for Payer: Humana ChoiceCare |
$13.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.80
|
| Rate for Payer: PHCS All Commercial |
$11.50
|
| Rate for Payer: PHP All Commercial |
$11.63
|
| Rate for Payer: Sagamore Health Network All Products |
$11.83
|
| Rate for Payer: Signature Care EPO |
$12.72
|
| Rate for Payer: Signature Care PPO |
$13.49
|
| Rate for Payer: United Healthcare Commercial |
$12.08
|
|
|
MISOPROSTOL 25 MCG TABLET (QUARTER TAB)
|
Facility
IP
|
$1.05
|
|
|
Service Code
|
NDC 579625007
|
| Hospital Charge Code |
800064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Aetna Commercial |
$0.91
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna All Commercial |
$0.91
|
| Rate for Payer: CORVEL All Commercial |
$0.98
|
| Rate for Payer: Coventry All Commercial |
$0.92
|
| Rate for Payer: Encore All Commercial |
$0.97
|
| Rate for Payer: Frontpath All Commercial |
$0.97
|
| Rate for Payer: Humana ChoiceCare |
$0.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.95
|
| Rate for Payer: PHCS All Commercial |
$0.79
|
| Rate for Payer: PHP All Commercial |
$0.80
|
| Rate for Payer: Sagamore Health Network All Products |
$0.81
|
| Rate for Payer: Signature Care EPO |
$0.87
|
| Rate for Payer: Signature Care PPO |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$0.83
|
|
