|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$54.25
|
|
|
Service Code
|
NDC 00990613922
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna Commercial |
$45.79
|
| Rate for Payer: Aetna Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$31.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.69
|
| Rate for Payer: Cash Price |
$33.64
|
| Rate for Payer: Cash Price |
$33.64
|
| Rate for Payer: Centivo All Commercial |
$27.67
|
| Rate for Payer: Cigna All Commercial |
$46.82
|
| Rate for Payer: CORVEL All Commercial |
$50.45
|
| Rate for Payer: Coventry All Commercial |
$47.74
|
| Rate for Payer: Encore All Commercial |
$49.94
|
| Rate for Payer: Frontpath All Commercial |
$49.91
|
| Rate for Payer: Humana ChoiceCare |
$46.86
|
| Rate for Payer: Humana Medicare |
$27.67
|
| Rate for Payer: Lucent All Commercial |
$27.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.82
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$40.69
|
| Rate for Payer: PHP All Commercial |
$41.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.16
|
| Rate for Payer: Sagamore Health Network All Products |
$41.88
|
| Rate for Payer: Signature Care EPO |
$45.03
|
| Rate for Payer: Signature Care PPO |
$47.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.11
|
| Rate for Payer: United Healthcare Commercial |
$42.75
|
| Rate for Payer: United Healthcare Medicare |
$17.90
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 00990797308
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338000405
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00338000404
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.70
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Centivo All Commercial |
$17.85
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$17.85
|
| Rate for Payer: Lucent All Commercial |
$17.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$54.25
|
|
|
Service Code
|
NDC 00990613922
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna Commercial |
$46.87
|
| Rate for Payer: Cash Price |
$33.64
|
| Rate for Payer: Cigna All Commercial |
$46.82
|
| Rate for Payer: CORVEL All Commercial |
$50.45
|
| Rate for Payer: Coventry All Commercial |
$47.74
|
| Rate for Payer: Encore All Commercial |
$49.94
|
| Rate for Payer: Frontpath All Commercial |
$49.91
|
| Rate for Payer: Humana ChoiceCare |
$46.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.82
|
| Rate for Payer: PHCS All Commercial |
$40.69
|
| Rate for Payer: PHP All Commercial |
$41.14
|
| Rate for Payer: Sagamore Health Network All Products |
$41.88
|
| Rate for Payer: Signature Care EPO |
$45.03
|
| Rate for Payer: Signature Care PPO |
$47.74
|
| Rate for Payer: United Healthcare Commercial |
$42.75
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.79
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Centivo All Commercial |
$24.99
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana Medicare |
$24.99
|
| Rate for Payer: Lucent All Commercial |
$24.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Medicare |
$16.17
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 00990797308
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$88.62
|
| Rate for Payer: Aetna Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.12
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Centivo All Commercial |
$53.55
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Humana Medicare |
$53.55
|
| Rate for Payer: Lucent All Commercial |
$53.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.95
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
| Rate for Payer: United Healthcare Medicare |
$34.65
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338000405
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT
|
Facility
|
OP
|
$72.45
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
119525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.91 |
| Max. Negotiated Rate |
$67.38 |
| Rate for Payer: Aetna Commercial |
$61.15
|
| Rate for Payer: Aetna Medicare |
$23.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$41.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.30
|
| Rate for Payer: Cash Price |
$44.92
|
| Rate for Payer: Centivo All Commercial |
$36.95
|
| Rate for Payer: Cigna All Commercial |
$62.52
|
| Rate for Payer: CORVEL All Commercial |
$67.38
|
| Rate for Payer: Coventry All Commercial |
$63.75
|
| Rate for Payer: Encore All Commercial |
$66.69
|
| Rate for Payer: Frontpath All Commercial |
$66.65
|
| Rate for Payer: Humana ChoiceCare |
$62.57
|
| Rate for Payer: Humana Medicare |
$36.95
|
| Rate for Payer: Lucent All Commercial |
$36.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.20
|
| Rate for Payer: PHCS All Commercial |
$54.34
|
| Rate for Payer: PHP All Commercial |
$54.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.25
|
| Rate for Payer: Sagamore Health Network All Products |
$55.93
|
| Rate for Payer: Signature Care EPO |
$60.13
|
| Rate for Payer: Signature Care PPO |
$63.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$57.09
|
| Rate for Payer: United Healthcare Medicare |
$23.91
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT
|
Facility
|
IP
|
$72.45
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
119525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$67.38 |
| Rate for Payer: Aetna Commercial |
$62.59
|
| Rate for Payer: Cash Price |
$44.92
|
| Rate for Payer: Cigna All Commercial |
$62.52
|
| Rate for Payer: CORVEL All Commercial |
$67.38
|
| Rate for Payer: Coventry All Commercial |
$63.75
|
| Rate for Payer: Encore All Commercial |
$66.69
|
| Rate for Payer: Frontpath All Commercial |
$66.65
|
| Rate for Payer: Humana ChoiceCare |
$62.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.20
|
| Rate for Payer: PHCS All Commercial |
$54.34
|
| Rate for Payer: PHP All Commercial |
$54.94
|
| Rate for Payer: Sagamore Health Network All Products |
$55.93
|
| Rate for Payer: Signature Care EPO |
$60.13
|
| Rate for Payer: Signature Care PPO |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$57.09
|
|
|
WHITE PETROLATUM-MINERAL OIL 83-15 % OPHT OINT
|
Facility
|
OP
|
$39.84
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
119339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna Medicare |
$13.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.46
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Centivo All Commercial |
$20.32
|
| Rate for Payer: Cigna All Commercial |
$34.38
|
| Rate for Payer: CORVEL All Commercial |
$37.05
|
| Rate for Payer: Coventry All Commercial |
$35.06
|
| Rate for Payer: Encore All Commercial |
$36.67
|
| Rate for Payer: Frontpath All Commercial |
$36.65
|
| Rate for Payer: Humana ChoiceCare |
$34.41
|
| Rate for Payer: Humana Medicare |
$20.32
|
| Rate for Payer: Lucent All Commercial |
$20.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$29.88
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.54
|
| Rate for Payer: Sagamore Health Network All Products |
$30.75
|
| Rate for Payer: Signature Care EPO |
$33.06
|
| Rate for Payer: Signature Care PPO |
$35.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.86
|
| Rate for Payer: United Healthcare Commercial |
$31.39
|
| Rate for Payer: United Healthcare Medicare |
$13.15
|
|
|
WHITE PETROLATUM-MINERAL OIL 83-15 % OPHT OINT
|
Facility
|
IP
|
$39.84
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
119339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.88 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Aetna Commercial |
$34.42
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cigna All Commercial |
$34.38
|
| Rate for Payer: CORVEL All Commercial |
$37.05
|
| Rate for Payer: Coventry All Commercial |
$35.06
|
| Rate for Payer: Encore All Commercial |
$36.67
|
| Rate for Payer: Frontpath All Commercial |
$36.65
|
| Rate for Payer: Humana ChoiceCare |
$34.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: PHCS All Commercial |
$29.88
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| Rate for Payer: Sagamore Health Network All Products |
$30.75
|
| Rate for Payer: Signature Care EPO |
$33.06
|
| Rate for Payer: Signature Care PPO |
$35.06
|
| Rate for Payer: United Healthcare Commercial |
$31.39
|
|
|
WHITE PETROLATUM TOP GEL
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Centivo All Commercial |
$2.53
|
| Rate for Payer: Cigna All Commercial |
$4.29
|
| Rate for Payer: CORVEL All Commercial |
$4.62
|
| Rate for Payer: Coventry All Commercial |
$4.37
|
| Rate for Payer: Encore All Commercial |
$4.57
|
| Rate for Payer: Frontpath All Commercial |
$4.57
|
| Rate for Payer: Humana ChoiceCare |
$4.29
|
| Rate for Payer: Humana Medicare |
$2.53
|
| Rate for Payer: Lucent All Commercial |
$2.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.47
|
| Rate for Payer: PHCS All Commercial |
$3.73
|
| Rate for Payer: PHP All Commercial |
$3.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.94
|
| Rate for Payer: Sagamore Health Network All Products |
$3.84
|
| Rate for Payer: Signature Care EPO |
$4.13
|
| Rate for Payer: Signature Care PPO |
$4.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.22
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
| Rate for Payer: United Healthcare Medicare |
$1.64
|
|
|
WHITE PETROLATUM TOP GEL
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$4.29
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cigna All Commercial |
$4.29
|
| Rate for Payer: CORVEL All Commercial |
$4.62
|
| Rate for Payer: Coventry All Commercial |
$4.37
|
| Rate for Payer: Encore All Commercial |
$4.57
|
| Rate for Payer: Frontpath All Commercial |
$4.57
|
| Rate for Payer: Humana ChoiceCare |
$4.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.47
|
| Rate for Payer: PHCS All Commercial |
$3.73
|
| Rate for Payer: PHP All Commercial |
$3.77
|
| Rate for Payer: Sagamore Health Network All Products |
$3.84
|
| Rate for Payer: Signature Care EPO |
$4.13
|
| Rate for Payer: Signature Care PPO |
$4.37
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
|
|
WHITE PETROLATUM TOP OIPK
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 84521000686
|
| Hospital Charge Code |
158550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Aetna Medicare |
$0.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Centivo All Commercial |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.60
|
| Rate for Payer: CORVEL All Commercial |
$1.73
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.71
|
| Rate for Payer: Frontpath All Commercial |
$1.71
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Humana Medicare |
$0.95
|
| Rate for Payer: Lucent All Commercial |
$0.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.67
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.72
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.54
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
|
|
WHITE PETROLATUM TOP OIPK
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 84521000686
|
| Hospital Charge Code |
158550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna All Commercial |
$1.60
|
| Rate for Payer: CORVEL All Commercial |
$1.73
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.71
|
| Rate for Payer: Frontpath All Commercial |
$1.71
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.67
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.41
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.54
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
|
|
ZALEPLON 10 MG ORAL CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 29300013201
|
| Hospital Charge Code |
25998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
ZALEPLON 10 MG ORAL CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 29300013201
|
| Hospital Charge Code |
25998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
ZANAMIVIR 5 MG/ACTUATION INHL DSDV
|
Facility
|
IP
|
$335.76
|
|
|
Service Code
|
NDC 00173068101
|
| Hospital Charge Code |
28245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.82 |
| Max. Negotiated Rate |
$312.26 |
| Rate for Payer: Aetna Commercial |
$290.10
|
| Rate for Payer: Cash Price |
$208.17
|
| Rate for Payer: Cigna All Commercial |
$289.76
|
| Rate for Payer: CORVEL All Commercial |
$312.26
|
| Rate for Payer: Coventry All Commercial |
$295.47
|
| Rate for Payer: Encore All Commercial |
$309.07
|
| Rate for Payer: Frontpath All Commercial |
$308.90
|
| Rate for Payer: Humana ChoiceCare |
$290.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$302.18
|
| Rate for Payer: PHCS All Commercial |
$251.82
|
| Rate for Payer: PHP All Commercial |
$254.64
|
| Rate for Payer: Sagamore Health Network All Products |
$259.21
|
| Rate for Payer: Signature Care EPO |
$278.68
|
| Rate for Payer: Signature Care PPO |
$295.47
|
| Rate for Payer: United Healthcare Commercial |
$264.58
|
|
|
ZANAMIVIR 5 MG/ACTUATION INHL DSDV
|
Facility
|
OP
|
$335.76
|
|
|
Service Code
|
NDC 00173068101
|
| Hospital Charge Code |
28245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.80 |
| Max. Negotiated Rate |
$312.26 |
| Rate for Payer: Aetna Commercial |
$283.38
|
| Rate for Payer: Aetna Medicare |
$110.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$110.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$192.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$209.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$127.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$121.88
|
| Rate for Payer: Cash Price |
$208.17
|
| Rate for Payer: Centivo All Commercial |
$171.24
|
| Rate for Payer: Cigna All Commercial |
$289.76
|
| Rate for Payer: CORVEL All Commercial |
$312.26
|
| Rate for Payer: Coventry All Commercial |
$295.47
|
| Rate for Payer: Encore All Commercial |
$309.07
|
| Rate for Payer: Frontpath All Commercial |
$308.90
|
| Rate for Payer: Humana ChoiceCare |
$290.00
|
| Rate for Payer: Humana Medicare |
$171.24
|
| Rate for Payer: Lucent All Commercial |
$171.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$302.18
|
| Rate for Payer: PHCS All Commercial |
$251.82
|
| Rate for Payer: PHP All Commercial |
$254.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$130.95
|
| Rate for Payer: Sagamore Health Network All Products |
$259.21
|
| Rate for Payer: Signature Care EPO |
$278.68
|
| Rate for Payer: Signature Care PPO |
$295.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$285.40
|
| Rate for Payer: United Healthcare Commercial |
$264.58
|
| Rate for Payer: United Healthcare Medicare |
$110.80
|
|
|
ZIDOVUDINE 10 MG/ML IV SOLN
|
Facility
|
OP
|
$199.22
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Aetna Commercial |
$168.14
|
| Rate for Payer: Aetna Medicare |
$65.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$65.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$114.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$124.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$75.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$72.32
|
| Rate for Payer: Cash Price |
$123.52
|
| Rate for Payer: Centivo All Commercial |
$101.60
|
| Rate for Payer: Cigna All Commercial |
$171.93
|
| Rate for Payer: CORVEL All Commercial |
$185.27
|
| Rate for Payer: Coventry All Commercial |
$175.31
|
| Rate for Payer: Encore All Commercial |
$183.38
|
| Rate for Payer: Frontpath All Commercial |
$183.28
|
| Rate for Payer: Humana ChoiceCare |
$172.07
|
| Rate for Payer: Humana Medicare |
$101.60
|
| Rate for Payer: Lucent All Commercial |
$101.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.30
|
| Rate for Payer: PHCS All Commercial |
$149.42
|
| Rate for Payer: PHP All Commercial |
$151.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$77.70
|
| Rate for Payer: Sagamore Health Network All Products |
$153.80
|
| Rate for Payer: Signature Care EPO |
$165.35
|
| Rate for Payer: Signature Care PPO |
$175.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$169.34
|
| Rate for Payer: United Healthcare Commercial |
$156.99
|
| Rate for Payer: United Healthcare Medicare |
$65.74
|
|
|
ZIDOVUDINE 10 MG/ML IV SOLN
|
Facility
|
IP
|
$199.22
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.42 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Aetna Commercial |
$172.13
|
| Rate for Payer: Cash Price |
$123.52
|
| Rate for Payer: Cigna All Commercial |
$171.93
|
| Rate for Payer: CORVEL All Commercial |
$185.27
|
| Rate for Payer: Coventry All Commercial |
$175.31
|
| Rate for Payer: Encore All Commercial |
$183.38
|
| Rate for Payer: Frontpath All Commercial |
$183.28
|
| Rate for Payer: Humana ChoiceCare |
$172.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.30
|
| Rate for Payer: PHCS All Commercial |
$149.42
|
| Rate for Payer: PHP All Commercial |
$151.09
|
| Rate for Payer: Sagamore Health Network All Products |
$153.80
|
| Rate for Payer: Signature Care EPO |
$165.35
|
| Rate for Payer: Signature Care PPO |
$175.31
|
| Rate for Payer: United Healthcare Commercial |
$156.99
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRP
|
Facility
|
IP
|
$330.96
|
|
|
Service Code
|
NDC 65862004824
|
| Hospital Charge Code |
11693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.22 |
| Max. Negotiated Rate |
$307.79 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna All Commercial |
$285.62
|
| Rate for Payer: CORVEL All Commercial |
$307.79
|
| Rate for Payer: Coventry All Commercial |
$291.24
|
| Rate for Payer: Encore All Commercial |
$304.65
|
| Rate for Payer: Frontpath All Commercial |
$304.48
|
| Rate for Payer: Humana ChoiceCare |
$285.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.86
|
| Rate for Payer: PHCS All Commercial |
$248.22
|
| Rate for Payer: PHP All Commercial |
$251.00
|
| Rate for Payer: Sagamore Health Network All Products |
$255.50
|
| Rate for Payer: Signature Care EPO |
$274.70
|
| Rate for Payer: Signature Care PPO |
$291.24
|
| Rate for Payer: United Healthcare Commercial |
$260.80
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRP
|
Facility
|
OP
|
$330.96
|
|
|
Service Code
|
NDC 65862004824
|
| Hospital Charge Code |
11693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.22 |
| Max. Negotiated Rate |
$307.79 |
| Rate for Payer: Aetna Commercial |
$279.33
|
| Rate for Payer: Aetna Medicare |
$109.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$109.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$190.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.14
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Centivo All Commercial |
$168.79
|
| Rate for Payer: Cigna All Commercial |
$285.62
|
| Rate for Payer: CORVEL All Commercial |
$307.79
|
| Rate for Payer: Coventry All Commercial |
$291.24
|
| Rate for Payer: Encore All Commercial |
$304.65
|
| Rate for Payer: Frontpath All Commercial |
$304.48
|
| Rate for Payer: Humana ChoiceCare |
$285.85
|
| Rate for Payer: Humana Medicare |
$168.79
|
| Rate for Payer: Lucent All Commercial |
$168.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.86
|
| Rate for Payer: PHCS All Commercial |
$248.22
|
| Rate for Payer: PHP All Commercial |
$251.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$129.07
|
| Rate for Payer: Sagamore Health Network All Products |
$255.50
|
| Rate for Payer: Signature Care EPO |
$274.70
|
| Rate for Payer: Signature Care PPO |
$291.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$281.32
|
| Rate for Payer: United Healthcare Commercial |
$260.80
|
| Rate for Payer: United Healthcare Medicare |
$109.22
|
|
