|
ATORVASTATIN 10 MG ORAL TAB
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 00904629061
|
| Hospital Charge Code |
19176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna Commercial |
$1.04
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Centivo All Commercial |
$0.63
|
| Rate for Payer: Cigna All Commercial |
$1.06
|
| Rate for Payer: CORVEL All Commercial |
$1.15
|
| Rate for Payer: Coventry All Commercial |
$1.08
|
| Rate for Payer: Encore All Commercial |
$1.13
|
| Rate for Payer: Frontpath All Commercial |
$1.13
|
| Rate for Payer: Humana ChoiceCare |
$1.06
|
| Rate for Payer: Humana Medicare |
$0.63
|
| Rate for Payer: Lucent All Commercial |
$0.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.11
|
| Rate for Payer: PHCS All Commercial |
$0.92
|
| Rate for Payer: PHP All Commercial |
$0.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.48
|
| Rate for Payer: Sagamore Health Network All Products |
$0.95
|
| Rate for Payer: Signature Care EPO |
$1.02
|
| Rate for Payer: Signature Care PPO |
$1.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
|
|
ATORVASTATIN 40 MG ORAL TAB
|
Facility
OP
|
$1.65
|
|
|
Service Code
|
NDC 00904629261
|
| Hospital Charge Code |
19177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Centivo All Commercial |
$0.84
|
| Rate for Payer: Cigna All Commercial |
$1.42
|
| Rate for Payer: CORVEL All Commercial |
$1.53
|
| Rate for Payer: Coventry All Commercial |
$1.45
|
| Rate for Payer: Encore All Commercial |
$1.51
|
| Rate for Payer: Frontpath All Commercial |
$1.51
|
| Rate for Payer: Humana ChoiceCare |
$1.42
|
| Rate for Payer: Humana Medicare |
$0.84
|
| Rate for Payer: Lucent All Commercial |
$0.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.48
|
| Rate for Payer: PHCS All Commercial |
$1.23
|
| Rate for Payer: PHP All Commercial |
$1.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.64
|
| Rate for Payer: Sagamore Health Network All Products |
$1.27
|
| Rate for Payer: Signature Care EPO |
$1.37
|
| Rate for Payer: Signature Care PPO |
$1.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
|
|
ATORVASTATIN 40 MG ORAL TAB
|
Facility
IP
|
$1.65
|
|
|
Service Code
|
NDC 00904629261
|
| Hospital Charge Code |
19177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna Commercial |
$1.42
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.42
|
| Rate for Payer: CORVEL All Commercial |
$1.53
|
| Rate for Payer: Coventry All Commercial |
$1.45
|
| Rate for Payer: Encore All Commercial |
$1.51
|
| Rate for Payer: Frontpath All Commercial |
$1.51
|
| Rate for Payer: Humana ChoiceCare |
$1.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.48
|
| Rate for Payer: PHCS All Commercial |
$1.23
|
| Rate for Payer: PHP All Commercial |
$1.25
|
| Rate for Payer: Sagamore Health Network All Products |
$1.27
|
| Rate for Payer: Signature Care EPO |
$1.37
|
| Rate for Payer: Signature Care PPO |
$1.45
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
ATROPINE 0.1 MG/ML INJ SYRG
|
Facility
OP
|
$69.44
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
730
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.92 |
| Max. Negotiated Rate |
$64.58 |
| Rate for Payer: Aetna Commercial |
$58.61
|
| Rate for Payer: Aetna Medicare |
$22.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.21
|
| Rate for Payer: Cash Price |
$43.05
|
| Rate for Payer: Centivo All Commercial |
$35.41
|
| Rate for Payer: Cigna All Commercial |
$59.93
|
| Rate for Payer: CORVEL All Commercial |
$64.58
|
| Rate for Payer: Coventry All Commercial |
$61.11
|
| Rate for Payer: Encore All Commercial |
$63.92
|
| Rate for Payer: Frontpath All Commercial |
$63.88
|
| Rate for Payer: Humana ChoiceCare |
$59.98
|
| Rate for Payer: Humana Medicare |
$35.41
|
| Rate for Payer: Lucent All Commercial |
$35.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.50
|
| Rate for Payer: PHCS All Commercial |
$52.08
|
| Rate for Payer: PHP All Commercial |
$52.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.08
|
| Rate for Payer: Sagamore Health Network All Products |
$53.61
|
| Rate for Payer: Signature Care EPO |
$57.64
|
| Rate for Payer: Signature Care PPO |
$61.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.02
|
| Rate for Payer: United Healthcare Commercial |
$54.72
|
| Rate for Payer: United Healthcare Medicare |
$22.92
|
|
|
ATROPINE 0.1 MG/ML INJ SYRG
|
Facility
IP
|
$69.44
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$64.58 |
| Rate for Payer: Aetna Commercial |
$60.00
|
| Rate for Payer: Cash Price |
$43.05
|
| Rate for Payer: Cigna All Commercial |
$59.93
|
| Rate for Payer: CORVEL All Commercial |
$64.58
|
| Rate for Payer: Coventry All Commercial |
$61.11
|
| Rate for Payer: Encore All Commercial |
$63.92
|
| Rate for Payer: Frontpath All Commercial |
$63.88
|
| Rate for Payer: Humana ChoiceCare |
$59.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.50
|
| Rate for Payer: PHCS All Commercial |
$52.08
|
| Rate for Payer: PHP All Commercial |
$52.66
|
| Rate for Payer: Sagamore Health Network All Products |
$53.61
|
| Rate for Payer: Signature Care EPO |
$57.64
|
| Rate for Payer: Signature Care PPO |
$61.11
|
| Rate for Payer: United Healthcare Commercial |
$54.72
|
|
|
ATROPINE 0.4 MG/ML IV SOLN
|
Facility
IP
|
$31.49
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
193431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.61 |
| Max. Negotiated Rate |
$29.28 |
| Rate for Payer: Aetna Commercial |
$27.20
|
| Rate for Payer: Cash Price |
$19.52
|
| Rate for Payer: Cigna All Commercial |
$27.17
|
| Rate for Payer: CORVEL All Commercial |
$29.28
|
| Rate for Payer: Coventry All Commercial |
$27.71
|
| Rate for Payer: Encore All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$28.97
|
| Rate for Payer: Humana ChoiceCare |
$27.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.34
|
| Rate for Payer: PHCS All Commercial |
$23.61
|
| Rate for Payer: PHP All Commercial |
$23.88
|
| Rate for Payer: Sagamore Health Network All Products |
$24.31
|
| Rate for Payer: Signature Care EPO |
$26.13
|
| Rate for Payer: Signature Care PPO |
$27.71
|
| Rate for Payer: United Healthcare Commercial |
$24.81
|
|
|
ATROPINE 0.4 MG/ML IV SOLN
|
Facility
OP
|
$31.49
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
193431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$29.28 |
| Rate for Payer: Aetna Commercial |
$26.57
|
| Rate for Payer: Aetna Medicare |
$10.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$19.52
|
| Rate for Payer: Centivo All Commercial |
$16.06
|
| Rate for Payer: Cigna All Commercial |
$27.17
|
| Rate for Payer: CORVEL All Commercial |
$29.28
|
| Rate for Payer: Coventry All Commercial |
$27.71
|
| Rate for Payer: Encore All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$28.97
|
| Rate for Payer: Humana ChoiceCare |
$27.19
|
| Rate for Payer: Humana Medicare |
$16.06
|
| Rate for Payer: Lucent All Commercial |
$16.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.34
|
| Rate for Payer: PHCS All Commercial |
$23.61
|
| Rate for Payer: PHP All Commercial |
$23.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.28
|
| Rate for Payer: Sagamore Health Network All Products |
$24.31
|
| Rate for Payer: Signature Care EPO |
$26.13
|
| Rate for Payer: Signature Care PPO |
$27.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.76
|
| Rate for Payer: United Healthcare Commercial |
$24.81
|
| Rate for Payer: United Healthcare Medicare |
$10.39
|
|
|
ATROPINE 1 % OPHT DROP
|
Facility
OP
|
$341.46
|
|
|
Service Code
|
NDC 60219174903
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$317.56 |
| Rate for Payer: Aetna Commercial |
$288.19
|
| Rate for Payer: Aetna Medicare |
$112.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$112.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$196.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$129.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$123.95
|
| Rate for Payer: Cash Price |
$211.71
|
| Rate for Payer: Cash Price |
$211.71
|
| Rate for Payer: Centivo All Commercial |
$174.14
|
| Rate for Payer: Cigna All Commercial |
$294.68
|
| Rate for Payer: CORVEL All Commercial |
$317.56
|
| Rate for Payer: Coventry All Commercial |
$300.48
|
| Rate for Payer: Encore All Commercial |
$314.31
|
| Rate for Payer: Frontpath All Commercial |
$314.14
|
| Rate for Payer: Humana ChoiceCare |
$294.92
|
| Rate for Payer: Humana Medicare |
$174.14
|
| Rate for Payer: Lucent All Commercial |
$174.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.31
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$256.10
|
| Rate for Payer: PHP All Commercial |
$258.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.17
|
| Rate for Payer: Sagamore Health Network All Products |
$263.61
|
| Rate for Payer: Signature Care EPO |
$283.41
|
| Rate for Payer: Signature Care PPO |
$300.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.24
|
| Rate for Payer: United Healthcare Commercial |
$269.07
|
| Rate for Payer: United Healthcare Medicare |
$112.68
|
|
|
ATROPINE 1 % OPHT DROP
|
Facility
IP
|
$341.46
|
|
|
Service Code
|
NDC 60219174903
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$256.10 |
| Max. Negotiated Rate |
$317.56 |
| Rate for Payer: Aetna Commercial |
$295.02
|
| Rate for Payer: Cash Price |
$211.71
|
| Rate for Payer: Cigna All Commercial |
$294.68
|
| Rate for Payer: CORVEL All Commercial |
$317.56
|
| Rate for Payer: Coventry All Commercial |
$300.48
|
| Rate for Payer: Encore All Commercial |
$314.31
|
| Rate for Payer: Frontpath All Commercial |
$314.14
|
| Rate for Payer: Humana ChoiceCare |
$294.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.31
|
| Rate for Payer: PHCS All Commercial |
$256.10
|
| Rate for Payer: PHP All Commercial |
$258.96
|
| Rate for Payer: Sagamore Health Network All Products |
$263.61
|
| Rate for Payer: Signature Care EPO |
$283.41
|
| Rate for Payer: Signature Care PPO |
$300.48
|
| Rate for Payer: United Healthcare Commercial |
$269.07
|
|
|
Avulsion of nail plate, partial or complete, simple; single
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 11730
|
| Hospital Charge Code |
CPT-11730
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.87 |
| Max. Negotiated Rate |
$285.87 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$285.87
|
| Rate for Payer: Managed Health Services Medicaid |
$285.87
|
| Rate for Payer: MDWise Medicaid |
$285.87
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSR
|
Facility
IP
|
$74.76
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.07 |
| Max. Negotiated Rate |
$69.53 |
| Rate for Payer: Aetna Commercial |
$64.59
|
| Rate for Payer: Cash Price |
$46.35
|
| Rate for Payer: Cigna All Commercial |
$64.52
|
| Rate for Payer: CORVEL All Commercial |
$69.53
|
| Rate for Payer: Coventry All Commercial |
$65.79
|
| Rate for Payer: Encore All Commercial |
$68.82
|
| Rate for Payer: Frontpath All Commercial |
$68.78
|
| Rate for Payer: Humana ChoiceCare |
$64.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.28
|
| Rate for Payer: PHCS All Commercial |
$56.07
|
| Rate for Payer: PHP All Commercial |
$56.70
|
| Rate for Payer: Sagamore Health Network All Products |
$57.71
|
| Rate for Payer: Signature Care EPO |
$62.05
|
| Rate for Payer: Signature Care PPO |
$65.79
|
| Rate for Payer: United Healthcare Commercial |
$58.91
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSR
|
Facility
OP
|
$74.76
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.67 |
| Max. Negotiated Rate |
$69.53 |
| Rate for Payer: Aetna Commercial |
$63.10
|
| Rate for Payer: Aetna Medicare |
$24.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$42.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.14
|
| Rate for Payer: Cash Price |
$46.35
|
| Rate for Payer: Centivo All Commercial |
$38.13
|
| Rate for Payer: Cigna All Commercial |
$64.52
|
| Rate for Payer: CORVEL All Commercial |
$69.53
|
| Rate for Payer: Coventry All Commercial |
$65.79
|
| Rate for Payer: Encore All Commercial |
$68.82
|
| Rate for Payer: Frontpath All Commercial |
$68.78
|
| Rate for Payer: Humana ChoiceCare |
$64.57
|
| Rate for Payer: Humana Medicare |
$38.13
|
| Rate for Payer: Lucent All Commercial |
$38.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.28
|
| Rate for Payer: PHCS All Commercial |
$56.07
|
| Rate for Payer: PHP All Commercial |
$56.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.16
|
| Rate for Payer: Sagamore Health Network All Products |
$57.71
|
| Rate for Payer: Signature Care EPO |
$62.05
|
| Rate for Payer: Signature Care PPO |
$65.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$63.55
|
| Rate for Payer: United Healthcare Commercial |
$58.91
|
| Rate for Payer: United Healthcare Medicare |
$24.67
|
|
|
AZITHROMYCIN 200 MG/5 ML SUSP 30 ML ED PACK (CAMERON)
|
Facility
OP
|
$80.64
|
|
|
Service Code
|
NDC 42806151
|
| Hospital Charge Code |
1401000800177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$68.06
|
| Rate for Payer: Aetna Medicare |
$26.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$46.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.27
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Centivo All Commercial |
$41.13
|
| Rate for Payer: Cigna All Commercial |
$69.59
|
| Rate for Payer: CORVEL All Commercial |
$75.00
|
| Rate for Payer: Coventry All Commercial |
$70.96
|
| Rate for Payer: Encore All Commercial |
$74.23
|
| Rate for Payer: Frontpath All Commercial |
$74.19
|
| Rate for Payer: Humana ChoiceCare |
$69.65
|
| Rate for Payer: Humana Medicare |
$41.13
|
| Rate for Payer: Lucent All Commercial |
$41.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.58
|
| Rate for Payer: PHCS All Commercial |
$60.48
|
| Rate for Payer: PHP All Commercial |
$61.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.45
|
| Rate for Payer: Sagamore Health Network All Products |
$62.25
|
| Rate for Payer: Signature Care EPO |
$66.93
|
| Rate for Payer: Signature Care PPO |
$70.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$68.54
|
| Rate for Payer: United Healthcare Commercial |
$63.54
|
| Rate for Payer: United Healthcare Medicare |
$26.61
|
|
|
AZITHROMYCIN 200 MG/5 ML SUSP 30 ML ED PACK (CAMERON)
|
Facility
IP
|
$80.64
|
|
|
Service Code
|
NDC 42806151
|
| Hospital Charge Code |
1401000800177
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$60.48 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$69.67
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna All Commercial |
$69.59
|
| Rate for Payer: CORVEL All Commercial |
$75.00
|
| Rate for Payer: Coventry All Commercial |
$70.96
|
| Rate for Payer: Encore All Commercial |
$74.23
|
| Rate for Payer: Frontpath All Commercial |
$74.19
|
| Rate for Payer: Humana ChoiceCare |
$69.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.58
|
| Rate for Payer: PHCS All Commercial |
$60.48
|
| Rate for Payer: PHP All Commercial |
$61.16
|
| Rate for Payer: Sagamore Health Network All Products |
$62.25
|
| Rate for Payer: Signature Care EPO |
$66.93
|
| Rate for Payer: Signature Care PPO |
$70.96
|
| Rate for Payer: United Healthcare Commercial |
$63.54
|
|
|
AZITHROMYCIN 250 MG ORAL TAB
|
Facility
OP
|
$5.48
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna Commercial |
$4.63
|
| Rate for Payer: Aetna Medicare |
$1.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Centivo All Commercial |
$2.80
|
| Rate for Payer: Cigna All Commercial |
$4.73
|
| Rate for Payer: CORVEL All Commercial |
$5.10
|
| Rate for Payer: Coventry All Commercial |
$4.82
|
| Rate for Payer: Encore All Commercial |
$5.05
|
| Rate for Payer: Frontpath All Commercial |
$5.04
|
| Rate for Payer: Humana ChoiceCare |
$4.73
|
| Rate for Payer: Humana Medicare |
$2.80
|
| Rate for Payer: Lucent All Commercial |
$2.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.93
|
| Rate for Payer: PHCS All Commercial |
$4.11
|
| Rate for Payer: PHP All Commercial |
$4.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.14
|
| Rate for Payer: Sagamore Health Network All Products |
$4.23
|
| Rate for Payer: Signature Care EPO |
$4.55
|
| Rate for Payer: Signature Care PPO |
$4.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.66
|
| Rate for Payer: United Healthcare Commercial |
$4.32
|
| Rate for Payer: United Healthcare Medicare |
$1.81
|
|
|
AZITHROMYCIN 250 MG ORAL TAB
|
Facility
IP
|
$5.48
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna Commercial |
$4.74
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cigna All Commercial |
$4.73
|
| Rate for Payer: CORVEL All Commercial |
$5.10
|
| Rate for Payer: Coventry All Commercial |
$4.82
|
| Rate for Payer: Encore All Commercial |
$5.05
|
| Rate for Payer: Frontpath All Commercial |
$5.04
|
| Rate for Payer: Humana ChoiceCare |
$4.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.93
|
| Rate for Payer: PHCS All Commercial |
$4.11
|
| Rate for Payer: PHP All Commercial |
$4.16
|
| Rate for Payer: Sagamore Health Network All Products |
$4.23
|
| Rate for Payer: Signature Care EPO |
$4.55
|
| Rate for Payer: Signature Care PPO |
$4.82
|
| Rate for Payer: United Healthcare Commercial |
$4.32
|
|
|
AZITHROMYCIN 500 MG IV SOLR
|
Facility
IP
|
$19.42
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
21063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$18.06 |
| Rate for Payer: Aetna Commercial |
$16.78
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna All Commercial |
$16.76
|
| Rate for Payer: CORVEL All Commercial |
$18.06
|
| Rate for Payer: Coventry All Commercial |
$17.09
|
| Rate for Payer: Encore All Commercial |
$17.87
|
| Rate for Payer: Frontpath All Commercial |
$17.86
|
| Rate for Payer: Humana ChoiceCare |
$16.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.48
|
| Rate for Payer: PHCS All Commercial |
$14.56
|
| Rate for Payer: PHP All Commercial |
$14.73
|
| Rate for Payer: Sagamore Health Network All Products |
$14.99
|
| Rate for Payer: Signature Care EPO |
$16.12
|
| Rate for Payer: Signature Care PPO |
$17.09
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
|
|
AZITHROMYCIN 500 MG IV SOLR
|
Facility
OP
|
$19.42
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
21063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$18.06 |
| Rate for Payer: Aetna Commercial |
$16.39
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.05
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Centivo All Commercial |
$9.90
|
| Rate for Payer: Cigna All Commercial |
$16.76
|
| Rate for Payer: CORVEL All Commercial |
$18.06
|
| Rate for Payer: Coventry All Commercial |
$17.09
|
| Rate for Payer: Encore All Commercial |
$17.87
|
| Rate for Payer: Frontpath All Commercial |
$17.86
|
| Rate for Payer: Humana ChoiceCare |
$16.77
|
| Rate for Payer: Humana Medicare |
$9.90
|
| Rate for Payer: Lucent All Commercial |
$9.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.48
|
| Rate for Payer: PHCS All Commercial |
$14.56
|
| Rate for Payer: PHP All Commercial |
$14.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.57
|
| Rate for Payer: Sagamore Health Network All Products |
$14.99
|
| Rate for Payer: Signature Care EPO |
$16.12
|
| Rate for Payer: Signature Care PPO |
$17.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.51
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
| Rate for Payer: United Healthcare Medicare |
$6.41
|
|
|
AZTREONAM 1 G INJ SOLR
|
Facility
IP
|
$195.38
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.54 |
| Max. Negotiated Rate |
$181.71 |
| Rate for Payer: Aetna Commercial |
$168.81
|
| Rate for Payer: Cash Price |
$121.14
|
| Rate for Payer: Cigna All Commercial |
$168.62
|
| Rate for Payer: CORVEL All Commercial |
$181.71
|
| Rate for Payer: Coventry All Commercial |
$171.94
|
| Rate for Payer: Encore All Commercial |
$179.85
|
| Rate for Payer: Frontpath All Commercial |
$179.75
|
| Rate for Payer: Humana ChoiceCare |
$168.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.85
|
| Rate for Payer: PHCS All Commercial |
$146.54
|
| Rate for Payer: PHP All Commercial |
$148.18
|
| Rate for Payer: Sagamore Health Network All Products |
$150.84
|
| Rate for Payer: Signature Care EPO |
$162.17
|
| Rate for Payer: Signature Care PPO |
$171.94
|
| Rate for Payer: United Healthcare Commercial |
$153.96
|
|
|
AZTREONAM 1 G INJ SOLR
|
Facility
OP
|
$195.38
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.48 |
| Max. Negotiated Rate |
$181.71 |
| Rate for Payer: Aetna Commercial |
$164.90
|
| Rate for Payer: Aetna Medicare |
$64.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$112.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$122.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$74.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$70.92
|
| Rate for Payer: Cash Price |
$121.14
|
| Rate for Payer: Centivo All Commercial |
$99.65
|
| Rate for Payer: Cigna All Commercial |
$168.62
|
| Rate for Payer: CORVEL All Commercial |
$181.71
|
| Rate for Payer: Coventry All Commercial |
$171.94
|
| Rate for Payer: Encore All Commercial |
$179.85
|
| Rate for Payer: Frontpath All Commercial |
$179.75
|
| Rate for Payer: Humana ChoiceCare |
$168.75
|
| Rate for Payer: Humana Medicare |
$99.65
|
| Rate for Payer: Lucent All Commercial |
$99.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.85
|
| Rate for Payer: PHCS All Commercial |
$146.54
|
| Rate for Payer: PHP All Commercial |
$148.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.20
|
| Rate for Payer: Sagamore Health Network All Products |
$150.84
|
| Rate for Payer: Signature Care EPO |
$162.17
|
| Rate for Payer: Signature Care PPO |
$171.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$166.08
|
| Rate for Payer: United Healthcare Commercial |
$153.96
|
| Rate for Payer: United Healthcare Medicare |
$64.48
|
|
|
BACITRACIN 500 UNIT/GRAM TOP OINT
|
Facility
IP
|
$12.39
|
|
|
Service Code
|
NDC 00536125628
|
| Hospital Charge Code |
850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cigna All Commercial |
$10.69
|
| Rate for Payer: CORVEL All Commercial |
$11.52
|
| Rate for Payer: Coventry All Commercial |
$10.90
|
| Rate for Payer: Encore All Commercial |
$11.40
|
| Rate for Payer: Frontpath All Commercial |
$11.40
|
| Rate for Payer: Humana ChoiceCare |
$10.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.15
|
| Rate for Payer: PHCS All Commercial |
$9.29
|
| Rate for Payer: PHP All Commercial |
$9.40
|
| Rate for Payer: Sagamore Health Network All Products |
$9.57
|
| Rate for Payer: Signature Care EPO |
$10.28
|
| Rate for Payer: Signature Care PPO |
$10.90
|
| Rate for Payer: United Healthcare Commercial |
$9.76
|
|
|
BACITRACIN 500 UNIT/GRAM TOP OINT
|
Facility
OP
|
$12.39
|
|
|
Service Code
|
NDC 00536125628
|
| Hospital Charge Code |
850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$10.46
|
| Rate for Payer: Aetna Medicare |
$4.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Centivo All Commercial |
$6.32
|
| Rate for Payer: Cigna All Commercial |
$10.69
|
| Rate for Payer: CORVEL All Commercial |
$11.52
|
| Rate for Payer: Coventry All Commercial |
$10.90
|
| Rate for Payer: Encore All Commercial |
$11.40
|
| Rate for Payer: Frontpath All Commercial |
$11.40
|
| Rate for Payer: Humana ChoiceCare |
$10.70
|
| Rate for Payer: Humana Medicare |
$6.32
|
| Rate for Payer: Lucent All Commercial |
$6.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.15
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$9.29
|
| Rate for Payer: PHP All Commercial |
$9.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.83
|
| Rate for Payer: Sagamore Health Network All Products |
$9.57
|
| Rate for Payer: Signature Care EPO |
$10.28
|
| Rate for Payer: Signature Care PPO |
$10.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.53
|
| Rate for Payer: United Healthcare Commercial |
$9.76
|
| Rate for Payer: United Healthcare Medicare |
$4.09
|
|
|
BACITRACIN 500 UNIT/GRAM TOP PACK
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
115118
|
|
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
|
|
|
BACITRACIN 500 UNIT/GRAM TOP PACK
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802006000
|
| Hospital Charge Code |
115118
|
|
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
|
|
|
BACITRACIN 500 UNIT/GRAM TOP PACK
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802006000
|
| Hospital Charge Code |
115118
|
|
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
|
|
