|
ASPIRIN 300 MG RECT SUPP
|
Facility
|
OP
|
$10.30
|
|
|
Service Code
|
NDC 00574703412
|
| Hospital Charge Code |
693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.69
|
| Rate for Payer: Aetna Medicare |
$3.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.62
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Centivo All Commercial |
$5.60
|
| Rate for Payer: Cigna All Commercial |
$8.89
|
| Rate for Payer: CORVEL All Commercial |
$9.58
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.48
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Humana Medicare |
$3.30
|
| Rate for Payer: Lucent All Commercial |
$5.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.27
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.02
|
| Rate for Payer: Sagamore Health Network All Products |
$7.95
|
| Rate for Payer: Signature Care EPO |
$8.55
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
| Rate for Payer: United Healthcare Medicare |
$3.30
|
|
|
ASPIRIN 300 MG RECT SUPP
|
Facility
|
IP
|
$10.30
|
|
|
Service Code
|
NDC 00574703412
|
| Hospital Charge Code |
693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.90
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna All Commercial |
$8.89
|
| Rate for Payer: CORVEL All Commercial |
$9.58
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.48
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.27
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.81
|
| Rate for Payer: Sagamore Health Network All Products |
$7.95
|
| Rate for Payer: Signature Care EPO |
$8.55
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
|
|
ASPIRIN 325 MG ORAL TBEC
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 00536123201
|
| Hospital Charge Code |
685
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Aetna Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Centivo All Commercial |
$0.08
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.13
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Humana Medicare |
$0.05
|
| Rate for Payer: Lucent All Commercial |
$0.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.13
|
| Rate for Payer: PHCS All Commercial |
$0.11
|
| Rate for Payer: PHP All Commercial |
$0.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.06
|
| Rate for Payer: Sagamore Health Network All Products |
$0.11
|
| Rate for Payer: Signature Care EPO |
$0.12
|
| Rate for Payer: Signature Care PPO |
$0.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
|
|
ASPIRIN 325 MG ORAL TBEC
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 00536123201
|
| Hospital Charge Code |
685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.13
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.13
|
| Rate for Payer: PHCS All Commercial |
$0.11
|
| Rate for Payer: PHP All Commercial |
$0.11
|
| Rate for Payer: Sagamore Health Network All Products |
$0.11
|
| Rate for Payer: Signature Care EPO |
$0.12
|
| Rate for Payer: Signature Care PPO |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
|
|
ASPIRIN 81 MG ORAL CHEW
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 66553000201
|
| Hospital Charge Code |
679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna All Commercial |
$0.74
|
| Rate for Payer: CORVEL All Commercial |
$0.80
|
| Rate for Payer: Coventry All Commercial |
$0.76
|
| Rate for Payer: Encore All Commercial |
$0.79
|
| Rate for Payer: Frontpath All Commercial |
$0.79
|
| Rate for Payer: Humana ChoiceCare |
$0.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.77
|
| Rate for Payer: PHCS All Commercial |
$0.65
|
| Rate for Payer: PHP All Commercial |
$0.65
|
| Rate for Payer: Sagamore Health Network All Products |
$0.66
|
| Rate for Payer: Signature Care EPO |
$0.71
|
| Rate for Payer: Signature Care PPO |
$0.76
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
|
|
ASPIRIN 81 MG ORAL CHEW
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 66553000201
|
| Hospital Charge Code |
679
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna Commercial |
$0.73
|
| Rate for Payer: Aetna Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Centivo All Commercial |
$0.47
|
| Rate for Payer: Cigna All Commercial |
$0.74
|
| Rate for Payer: CORVEL All Commercial |
$0.80
|
| Rate for Payer: Coventry All Commercial |
$0.76
|
| Rate for Payer: Encore All Commercial |
$0.79
|
| Rate for Payer: Frontpath All Commercial |
$0.79
|
| Rate for Payer: Humana ChoiceCare |
$0.74
|
| Rate for Payer: Humana Medicare |
$0.28
|
| Rate for Payer: Lucent All Commercial |
$0.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.77
|
| Rate for Payer: PHCS All Commercial |
$0.65
|
| Rate for Payer: PHP All Commercial |
$0.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.34
|
| Rate for Payer: Sagamore Health Network All Products |
$0.66
|
| Rate for Payer: Signature Care EPO |
$0.71
|
| Rate for Payer: Signature Care PPO |
$0.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.73
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
|
|
ASPIRIN 81 MG ORAL TBEC
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 00536123441
|
| Hospital Charge Code |
688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.11
|
| Rate for Payer: Aetna Medicare |
$0.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Centivo All Commercial |
$0.07
|
| Rate for Payer: Cigna All Commercial |
$0.11
|
| Rate for Payer: CORVEL All Commercial |
$0.12
|
| Rate for Payer: Coventry All Commercial |
$0.12
|
| Rate for Payer: Encore All Commercial |
$0.12
|
| Rate for Payer: Frontpath All Commercial |
$0.12
|
| Rate for Payer: Humana ChoiceCare |
$0.11
|
| Rate for Payer: Humana Medicare |
$0.04
|
| Rate for Payer: Lucent All Commercial |
$0.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.12
|
| Rate for Payer: PHCS All Commercial |
$0.10
|
| Rate for Payer: PHP All Commercial |
$0.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.05
|
| Rate for Payer: Sagamore Health Network All Products |
$0.10
|
| Rate for Payer: Signature Care EPO |
$0.11
|
| Rate for Payer: Signature Care PPO |
$0.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
|
|
ASPIRIN 81 MG ORAL TBEC
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 00536123441
|
| Hospital Charge Code |
688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna All Commercial |
$0.11
|
| Rate for Payer: CORVEL All Commercial |
$0.12
|
| Rate for Payer: Coventry All Commercial |
$0.12
|
| Rate for Payer: Encore All Commercial |
$0.12
|
| Rate for Payer: Frontpath All Commercial |
$0.12
|
| Rate for Payer: Humana ChoiceCare |
$0.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.12
|
| Rate for Payer: PHCS All Commercial |
$0.10
|
| Rate for Payer: PHP All Commercial |
$0.10
|
| Rate for Payer: Sagamore Health Network All Products |
$0.10
|
| Rate for Payer: Signature Care EPO |
$0.11
|
| Rate for Payer: Signature Care PPO |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
|
|
ATENOLOL 25 MG ORAL TAB
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 51079075920
|
| Hospital Charge Code |
717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.20
|
| Rate for Payer: CORVEL All Commercial |
$1.29
|
| Rate for Payer: Coventry All Commercial |
$1.22
|
| Rate for Payer: Encore All Commercial |
$1.28
|
| Rate for Payer: Frontpath All Commercial |
$1.28
|
| Rate for Payer: Humana ChoiceCare |
$1.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.25
|
| Rate for Payer: PHCS All Commercial |
$1.04
|
| Rate for Payer: PHP All Commercial |
$1.05
|
| Rate for Payer: Sagamore Health Network All Products |
$1.07
|
| Rate for Payer: Signature Care EPO |
$1.15
|
| Rate for Payer: Signature Care PPO |
$1.22
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
|
|
ATENOLOL 25 MG ORAL TAB
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 51079075920
|
| Hospital Charge Code |
717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.17
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.87
|
| 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 |
$0.75
|
| Rate for Payer: Cigna All Commercial |
$1.20
|
| Rate for Payer: CORVEL All Commercial |
$1.29
|
| Rate for Payer: Coventry All Commercial |
$1.22
|
| Rate for Payer: Encore All Commercial |
$1.28
|
| Rate for Payer: Frontpath All Commercial |
$1.28
|
| Rate for Payer: Humana ChoiceCare |
$1.20
|
| Rate for Payer: Humana Medicare |
$0.44
|
| Rate for Payer: Lucent All Commercial |
$0.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.25
|
| Rate for Payer: PHCS All Commercial |
$1.04
|
| Rate for Payer: PHP All Commercial |
$1.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.54
|
| Rate for Payer: Sagamore Health Network All Products |
$1.07
|
| Rate for Payer: Signature Care EPO |
$1.15
|
| Rate for Payer: Signature Care PPO |
$1.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
ATENOLOL 50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00093075210
|
| Hospital Charge Code |
718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
ATENOLOL 50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00093075210
|
| Hospital Charge Code |
718
|
|
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 |
$0.60
|
| 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
|
|
|
ATORVASTATIN 10 MG ORAL TAB
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 00904629061
|
| Hospital Charge Code |
19176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna Commercial |
$1.06
|
| Rate for Payer: Aetna Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Centivo All Commercial |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$1.09
|
| Rate for Payer: CORVEL All Commercial |
$1.17
|
| Rate for Payer: Coventry All Commercial |
$1.11
|
| Rate for Payer: Encore All Commercial |
$1.16
|
| Rate for Payer: Frontpath All Commercial |
$1.16
|
| Rate for Payer: Humana ChoiceCare |
$1.09
|
| Rate for Payer: Humana Medicare |
$0.40
|
| Rate for Payer: Lucent All Commercial |
$0.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.13
|
| Rate for Payer: PHCS All Commercial |
$0.95
|
| Rate for Payer: PHP All Commercial |
$0.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.49
|
| Rate for Payer: Sagamore Health Network All Products |
$0.97
|
| Rate for Payer: Signature Care EPO |
$1.05
|
| Rate for Payer: Signature Care PPO |
$1.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$0.99
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
|
|
ATORVASTATIN 10 MG ORAL TAB
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 00904629061
|
| Hospital Charge Code |
19176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna All Commercial |
$1.09
|
| Rate for Payer: CORVEL All Commercial |
$1.17
|
| Rate for Payer: Coventry All Commercial |
$1.11
|
| Rate for Payer: Encore All Commercial |
$1.16
|
| Rate for Payer: Frontpath All Commercial |
$1.16
|
| Rate for Payer: Humana ChoiceCare |
$1.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.13
|
| Rate for Payer: PHCS All Commercial |
$0.95
|
| Rate for Payer: PHP All Commercial |
$0.96
|
| Rate for Payer: Sagamore Health Network All Products |
$0.97
|
| Rate for Payer: Signature Care EPO |
$1.05
|
| Rate for Payer: Signature Care PPO |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$0.99
|
|
|
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 |
$0.99
|
| 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
|
|
|
ATORVASTATIN 40 MG ORAL TAB
|
Facility
|
OP
|
$1.65
|
|
|
Service Code
|
NDC 00904629261
|
| Hospital Charge Code |
19177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Centivo All Commercial |
$0.89
|
| 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 |
$0.53
|
| Rate for Payer: Lucent All Commercial |
$0.89
|
| 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 |
$0.53
|
|
|
ATROPINE 0.1 MG/ML INJ SYRG
|
Facility
|
OP
|
$68.67
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
730
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$57.96
|
| Rate for Payer: Aetna Medicare |
$21.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$39.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.17
|
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: Centivo All Commercial |
$37.36
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Humana Medicare |
$21.97
|
| Rate for Payer: Lucent All Commercial |
$37.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.78
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.37
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
| Rate for Payer: United Healthcare Medicare |
$21.97
|
|
|
ATROPINE 0.1 MG/ML INJ SYRG
|
Facility
|
IP
|
$68.67
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: Cigna All Commercial |
$59.26
|
| Rate for Payer: CORVEL All Commercial |
$63.86
|
| Rate for Payer: Coventry All Commercial |
$60.43
|
| Rate for Payer: Encore All Commercial |
$63.21
|
| Rate for Payer: Frontpath All Commercial |
$63.18
|
| Rate for Payer: Humana ChoiceCare |
$59.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.80
|
| Rate for Payer: PHCS All Commercial |
$51.50
|
| Rate for Payer: PHP All Commercial |
$52.08
|
| Rate for Payer: Sagamore Health Network All Products |
$53.01
|
| Rate for Payer: Signature Care EPO |
$57.00
|
| Rate for Payer: Signature Care PPO |
$60.43
|
| Rate for Payer: United Healthcare Commercial |
$54.11
|
|
|
ATROPINE 0.4 MG/ML IV SOLN
|
Facility
|
OP
|
$31.12
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
193431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$28.94 |
| Rate for Payer: Aetna Commercial |
$26.27
|
| Rate for Payer: Aetna Medicare |
$9.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.95
|
| Rate for Payer: Cash Price |
$18.67
|
| Rate for Payer: Centivo All Commercial |
$16.93
|
| Rate for Payer: Cigna All Commercial |
$26.86
|
| Rate for Payer: CORVEL All Commercial |
$28.94
|
| Rate for Payer: Coventry All Commercial |
$27.39
|
| Rate for Payer: Encore All Commercial |
$28.65
|
| Rate for Payer: Frontpath All Commercial |
$28.63
|
| Rate for Payer: Humana ChoiceCare |
$26.88
|
| Rate for Payer: Humana Medicare |
$9.96
|
| Rate for Payer: Lucent All Commercial |
$16.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.01
|
| Rate for Payer: PHCS All Commercial |
$23.34
|
| Rate for Payer: PHP All Commercial |
$23.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.14
|
| Rate for Payer: Sagamore Health Network All Products |
$24.03
|
| Rate for Payer: Signature Care EPO |
$25.83
|
| Rate for Payer: Signature Care PPO |
$27.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.45
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Medicare |
$9.96
|
|
|
ATROPINE 0.4 MG/ML IV SOLN
|
Facility
|
IP
|
$31.12
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
193431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.34 |
| Max. Negotiated Rate |
$28.94 |
| Rate for Payer: Aetna Commercial |
$26.89
|
| Rate for Payer: Cash Price |
$18.67
|
| Rate for Payer: Cigna All Commercial |
$26.86
|
| Rate for Payer: CORVEL All Commercial |
$28.94
|
| Rate for Payer: Coventry All Commercial |
$27.39
|
| Rate for Payer: Encore All Commercial |
$28.65
|
| Rate for Payer: Frontpath All Commercial |
$28.63
|
| Rate for Payer: Humana ChoiceCare |
$26.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.01
|
| Rate for Payer: PHCS All Commercial |
$23.34
|
| Rate for Payer: PHP All Commercial |
$23.60
|
| Rate for Payer: Sagamore Health Network All Products |
$24.03
|
| Rate for Payer: Signature Care EPO |
$25.83
|
| Rate for Payer: Signature Care PPO |
$27.39
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
|
|
ATROPINE 1 % OPHT DROP
|
Facility
|
IP
|
$287.21
|
|
|
Service Code
|
NDC 60219174903
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.41 |
| Max. Negotiated Rate |
$267.11 |
| Rate for Payer: Aetna Commercial |
$248.15
|
| Rate for Payer: Cash Price |
$172.33
|
| Rate for Payer: Cigna All Commercial |
$247.86
|
| Rate for Payer: CORVEL All Commercial |
$267.11
|
| Rate for Payer: Coventry All Commercial |
$252.74
|
| Rate for Payer: Encore All Commercial |
$264.38
|
| Rate for Payer: Frontpath All Commercial |
$264.23
|
| Rate for Payer: Humana ChoiceCare |
$248.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.49
|
| Rate for Payer: PHCS All Commercial |
$215.41
|
| Rate for Payer: PHP All Commercial |
$217.82
|
| Rate for Payer: Sagamore Health Network All Products |
$221.73
|
| Rate for Payer: Signature Care EPO |
$238.38
|
| Rate for Payer: Signature Care PPO |
$252.74
|
| Rate for Payer: United Healthcare Commercial |
$226.32
|
|
|
ATROPINE 1 % OPHT DROP
|
Facility
|
OP
|
$287.21
|
|
|
Service Code
|
NDC 60219174903
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$267.11 |
| Rate for Payer: Aetna Commercial |
$242.41
|
| Rate for Payer: Aetna Medicare |
$91.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$89.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$164.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$179.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$105.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.10
|
| Rate for Payer: Cash Price |
$172.33
|
| Rate for Payer: Cash Price |
$172.33
|
| Rate for Payer: Centivo All Commercial |
$156.24
|
| Rate for Payer: Cigna All Commercial |
$247.86
|
| Rate for Payer: CORVEL All Commercial |
$267.11
|
| Rate for Payer: Coventry All Commercial |
$252.74
|
| Rate for Payer: Encore All Commercial |
$264.38
|
| Rate for Payer: Frontpath All Commercial |
$264.23
|
| Rate for Payer: Humana ChoiceCare |
$248.06
|
| Rate for Payer: Humana Medicare |
$91.91
|
| Rate for Payer: Lucent All Commercial |
$156.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.49
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$215.41
|
| Rate for Payer: PHP All Commercial |
$217.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.01
|
| Rate for Payer: Sagamore Health Network All Products |
$221.73
|
| Rate for Payer: Signature Care EPO |
$238.38
|
| Rate for Payer: Signature Care PPO |
$252.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$244.13
|
| Rate for Payer: United Healthcare Commercial |
$226.32
|
| Rate for Payer: United Healthcare Medicare |
$91.91
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSR
|
Facility
|
OP
|
$73.92
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.92 |
| Max. Negotiated Rate |
$68.75 |
| Rate for Payer: Aetna Commercial |
$62.39
|
| Rate for Payer: Aetna Medicare |
$23.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$42.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.02
|
| Rate for Payer: Cash Price |
$44.35
|
| Rate for Payer: Centivo All Commercial |
$40.21
|
| Rate for Payer: Cigna All Commercial |
$63.79
|
| Rate for Payer: CORVEL All Commercial |
$68.75
|
| Rate for Payer: Coventry All Commercial |
$65.05
|
| Rate for Payer: Encore All Commercial |
$68.04
|
| Rate for Payer: Frontpath All Commercial |
$68.01
|
| Rate for Payer: Humana ChoiceCare |
$63.84
|
| Rate for Payer: Humana Medicare |
$23.65
|
| Rate for Payer: Lucent All Commercial |
$40.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.53
|
| Rate for Payer: PHCS All Commercial |
$55.44
|
| Rate for Payer: PHP All Commercial |
$56.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.83
|
| Rate for Payer: Sagamore Health Network All Products |
$57.07
|
| Rate for Payer: Signature Care EPO |
$61.35
|
| Rate for Payer: Signature Care PPO |
$65.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.83
|
| Rate for Payer: United Healthcare Commercial |
$58.25
|
| Rate for Payer: United Healthcare Medicare |
$23.65
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSR
|
Facility
|
IP
|
$73.92
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.44 |
| Max. Negotiated Rate |
$68.75 |
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Cash Price |
$44.35
|
| Rate for Payer: Cigna All Commercial |
$63.79
|
| Rate for Payer: CORVEL All Commercial |
$68.75
|
| Rate for Payer: Coventry All Commercial |
$65.05
|
| Rate for Payer: Encore All Commercial |
$68.04
|
| Rate for Payer: Frontpath All Commercial |
$68.01
|
| Rate for Payer: Humana ChoiceCare |
$63.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.53
|
| Rate for Payer: PHCS All Commercial |
$55.44
|
| Rate for Payer: PHP All Commercial |
$56.06
|
| Rate for Payer: Sagamore Health Network All Products |
$57.07
|
| Rate for Payer: Signature Care EPO |
$61.35
|
| Rate for Payer: Signature Care PPO |
$65.05
|
| Rate for Payer: United Healthcare Commercial |
$58.25
|
|
|
AZITHROMYCIN 250 MG ORAL TAB
|
Facility
|
OP
|
$5.80
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: Aetna Medicare |
$1.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.04
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Centivo All Commercial |
$3.16
|
| Rate for Payer: Cigna All Commercial |
$5.01
|
| Rate for Payer: CORVEL All Commercial |
$5.40
|
| Rate for Payer: Coventry All Commercial |
$5.11
|
| Rate for Payer: Encore All Commercial |
$5.34
|
| Rate for Payer: Frontpath All Commercial |
$5.34
|
| Rate for Payer: Humana ChoiceCare |
$5.01
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Lucent All Commercial |
$3.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.22
|
| Rate for Payer: PHCS All Commercial |
$4.35
|
| Rate for Payer: PHP All Commercial |
$4.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.26
|
| Rate for Payer: Sagamore Health Network All Products |
$4.48
|
| Rate for Payer: Signature Care EPO |
$4.82
|
| Rate for Payer: Signature Care PPO |
$5.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.93
|
| Rate for Payer: United Healthcare Commercial |
$4.57
|
| Rate for Payer: United Healthcare Medicare |
$1.86
|
|
