|
AZITHROMYCIN 250 MG ORAL TAB
|
Facility
|
IP
|
$5.80
|
|
|
Service Code
|
HCPCS Q0144
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna Commercial |
$5.01
|
| Rate for Payer: Cash Price |
$3.48
|
| 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: 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: 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: United Healthcare Commercial |
$4.57
|
|
|
AZITHROMYCIN 500 MG IV SOLR
|
Facility
|
OP
|
$19.19
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
21063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$17.85 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Medicare |
$6.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.76
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Centivo All Commercial |
$10.44
|
| Rate for Payer: Cigna All Commercial |
$16.56
|
| Rate for Payer: CORVEL All Commercial |
$17.85
|
| Rate for Payer: Coventry All Commercial |
$16.89
|
| Rate for Payer: Encore All Commercial |
$17.67
|
| Rate for Payer: Frontpath All Commercial |
$17.66
|
| Rate for Payer: Humana ChoiceCare |
$16.58
|
| Rate for Payer: Humana Medicare |
$6.14
|
| Rate for Payer: Lucent All Commercial |
$10.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.27
|
| Rate for Payer: PHCS All Commercial |
$14.40
|
| Rate for Payer: PHP All Commercial |
$14.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.49
|
| Rate for Payer: Sagamore Health Network All Products |
$14.82
|
| Rate for Payer: Signature Care EPO |
$15.93
|
| Rate for Payer: Signature Care PPO |
$16.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.31
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$6.14
|
|
|
AZITHROMYCIN 500 MG IV SOLR
|
Facility
|
IP
|
$19.19
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
21063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$17.85 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cigna All Commercial |
$16.56
|
| Rate for Payer: CORVEL All Commercial |
$17.85
|
| Rate for Payer: Coventry All Commercial |
$16.89
|
| Rate for Payer: Encore All Commercial |
$17.67
|
| Rate for Payer: Frontpath All Commercial |
$17.66
|
| Rate for Payer: Humana ChoiceCare |
$16.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.27
|
| Rate for Payer: PHCS All Commercial |
$14.40
|
| Rate for Payer: PHP All Commercial |
$14.56
|
| Rate for Payer: Sagamore Health Network All Products |
$14.82
|
| Rate for Payer: Signature Care EPO |
$15.93
|
| Rate for Payer: Signature Care PPO |
$16.89
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
|
|
AZTREONAM 1 G INJ SOLR
|
Facility
|
OP
|
$195.07
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$181.41 |
| Rate for Payer: Aetna Commercial |
$164.64
|
| Rate for Payer: Aetna Medicare |
$62.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$112.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$121.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.66
|
| Rate for Payer: Cash Price |
$117.04
|
| Rate for Payer: Centivo All Commercial |
$106.12
|
| Rate for Payer: Cigna All Commercial |
$168.34
|
| Rate for Payer: CORVEL All Commercial |
$181.41
|
| Rate for Payer: Coventry All Commercial |
$171.66
|
| Rate for Payer: Encore All Commercial |
$179.56
|
| Rate for Payer: Frontpath All Commercial |
$179.46
|
| Rate for Payer: Humana ChoiceCare |
$168.48
|
| Rate for Payer: Humana Medicare |
$62.42
|
| Rate for Payer: Lucent All Commercial |
$106.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.56
|
| Rate for Payer: PHCS All Commercial |
$146.30
|
| Rate for Payer: PHP All Commercial |
$147.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.08
|
| Rate for Payer: Sagamore Health Network All Products |
$150.59
|
| Rate for Payer: Signature Care EPO |
$161.91
|
| Rate for Payer: Signature Care PPO |
$171.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$165.81
|
| Rate for Payer: United Healthcare Commercial |
$153.71
|
| Rate for Payer: United Healthcare Medicare |
$62.42
|
|
|
AZTREONAM 1 G INJ SOLR
|
Facility
|
IP
|
$195.07
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.30 |
| Max. Negotiated Rate |
$181.41 |
| Rate for Payer: Aetna Commercial |
$168.54
|
| Rate for Payer: Cash Price |
$117.04
|
| Rate for Payer: Cigna All Commercial |
$168.34
|
| Rate for Payer: CORVEL All Commercial |
$181.41
|
| Rate for Payer: Coventry All Commercial |
$171.66
|
| Rate for Payer: Encore All Commercial |
$179.56
|
| Rate for Payer: Frontpath All Commercial |
$179.46
|
| Rate for Payer: Humana ChoiceCare |
$168.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.56
|
| Rate for Payer: PHCS All Commercial |
$146.30
|
| Rate for Payer: PHP All Commercial |
$147.94
|
| Rate for Payer: Sagamore Health Network All Products |
$150.59
|
| Rate for Payer: Signature Care EPO |
$161.91
|
| Rate for Payer: Signature Care PPO |
$171.66
|
| Rate for Payer: United Healthcare Commercial |
$153.71
|
|
|
BACITRACIN 500 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 00536125628
|
| Hospital Charge Code |
850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: PHCS All Commercial |
$9.77
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
|
|
BACITRACIN 500 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 00536125628
|
| Hospital Charge Code |
850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$10.99
|
| Rate for Payer: Aetna Medicare |
$4.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.58
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Centivo All Commercial |
$7.08
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Humana Medicare |
$4.17
|
| Rate for Payer: Lucent All Commercial |
$7.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$9.77
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.08
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
| Rate for Payer: United Healthcare Medicare |
$4.17
|
|
|
BACITRACIN 500 UNIT/GRAM TOP PACK
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
115118
|
|
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
|
|
|
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 |
$0.31 |
| 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
|
|
|
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 |
$0.60
|
| 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
|
|
|
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 |
$0.60
|
| 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
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$110.08
|
|
|
Service Code
|
NDC 16784011761
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$102.37 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: Aetna Medicare |
$35.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$63.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$68.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.75
|
| Rate for Payer: Cash Price |
$66.05
|
| Rate for Payer: Cash Price |
$66.05
|
| Rate for Payer: Centivo All Commercial |
$59.88
|
| Rate for Payer: Cigna All Commercial |
$94.99
|
| Rate for Payer: CORVEL All Commercial |
$102.37
|
| Rate for Payer: Coventry All Commercial |
$96.87
|
| Rate for Payer: Encore All Commercial |
$101.32
|
| Rate for Payer: Frontpath All Commercial |
$101.27
|
| Rate for Payer: Humana ChoiceCare |
$95.07
|
| Rate for Payer: Humana Medicare |
$35.22
|
| Rate for Payer: Lucent All Commercial |
$59.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.07
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$82.56
|
| Rate for Payer: PHP All Commercial |
$83.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.93
|
| Rate for Payer: Sagamore Health Network All Products |
$84.98
|
| Rate for Payer: Signature Care EPO |
$91.36
|
| Rate for Payer: Signature Care PPO |
$96.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$93.56
|
| Rate for Payer: United Healthcare Commercial |
$86.74
|
| Rate for Payer: United Healthcare Medicare |
$35.22
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$110.08
|
|
|
Service Code
|
NDC 16784011761
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$102.37 |
| Rate for Payer: Aetna Commercial |
$95.10
|
| Rate for Payer: Cash Price |
$66.05
|
| Rate for Payer: Cigna All Commercial |
$94.99
|
| Rate for Payer: CORVEL All Commercial |
$102.37
|
| Rate for Payer: Coventry All Commercial |
$96.87
|
| Rate for Payer: Encore All Commercial |
$101.32
|
| Rate for Payer: Frontpath All Commercial |
$101.27
|
| Rate for Payer: Humana ChoiceCare |
$95.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$99.07
|
| Rate for Payer: PHCS All Commercial |
$82.56
|
| Rate for Payer: PHP All Commercial |
$83.48
|
| Rate for Payer: Sagamore Health Network All Products |
$84.98
|
| Rate for Payer: Signature Care EPO |
$91.36
|
| Rate for Payer: Signature Care PPO |
$96.87
|
| Rate for Payer: United Healthcare Commercial |
$86.74
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OIPK
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 00904702367
|
| Hospital Charge Code |
115117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$0.60
|
| Rate for Payer: Aetna Medicare |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Centivo All Commercial |
$0.39
|
| Rate for Payer: Cigna All Commercial |
$0.62
|
| Rate for Payer: CORVEL All Commercial |
$0.66
|
| Rate for Payer: Coventry All Commercial |
$0.63
|
| Rate for Payer: Encore All Commercial |
$0.66
|
| Rate for Payer: Frontpath All Commercial |
$0.66
|
| Rate for Payer: Humana ChoiceCare |
$0.62
|
| Rate for Payer: Humana Medicare |
$0.23
|
| Rate for Payer: Lucent All Commercial |
$0.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$0.54
|
| Rate for Payer: PHP All Commercial |
$0.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.28
|
| Rate for Payer: Sagamore Health Network All Products |
$0.55
|
| Rate for Payer: Signature Care EPO |
$0.59
|
| Rate for Payer: Signature Care PPO |
$0.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOP OIPK
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 00904702367
|
| Hospital Charge Code |
115117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna All Commercial |
$0.62
|
| Rate for Payer: CORVEL All Commercial |
$0.66
|
| Rate for Payer: Coventry All Commercial |
$0.63
|
| Rate for Payer: Encore All Commercial |
$0.66
|
| Rate for Payer: Frontpath All Commercial |
$0.66
|
| Rate for Payer: Humana ChoiceCare |
$0.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.64
|
| Rate for Payer: PHCS All Commercial |
$0.54
|
| Rate for Payer: PHP All Commercial |
$0.54
|
| Rate for Payer: Sagamore Health Network All Products |
$0.55
|
| Rate for Payer: Signature Care EPO |
$0.59
|
| Rate for Payer: Signature Care PPO |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
|
|
BACLOFEN 10 MG ORAL TAB
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna All Commercial |
$1.78
|
| Rate for Payer: CORVEL All Commercial |
$1.91
|
| Rate for Payer: Coventry All Commercial |
$1.81
|
| Rate for Payer: Encore All Commercial |
$1.89
|
| Rate for Payer: Frontpath All Commercial |
$1.89
|
| Rate for Payer: Humana ChoiceCare |
$1.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.85
|
| Rate for Payer: PHCS All Commercial |
$1.54
|
| Rate for Payer: PHP All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$1.59
|
| Rate for Payer: Signature Care EPO |
$1.71
|
| Rate for Payer: Signature Care PPO |
$1.81
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
|
|
BACLOFEN 10 MG ORAL TAB
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.74
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Centivo All Commercial |
$1.12
|
| Rate for Payer: Cigna All Commercial |
$1.78
|
| Rate for Payer: CORVEL All Commercial |
$1.91
|
| Rate for Payer: Coventry All Commercial |
$1.81
|
| Rate for Payer: Encore All Commercial |
$1.89
|
| Rate for Payer: Frontpath All Commercial |
$1.89
|
| Rate for Payer: Humana ChoiceCare |
$1.78
|
| Rate for Payer: Humana Medicare |
$0.66
|
| Rate for Payer: Lucent All Commercial |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.85
|
| Rate for Payer: PHCS All Commercial |
$1.54
|
| Rate for Payer: PHP All Commercial |
$1.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.80
|
| Rate for Payer: Sagamore Health Network All Products |
$1.59
|
| Rate for Payer: Signature Care EPO |
$1.71
|
| Rate for Payer: Signature Care PPO |
$1.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.75
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
|
BALANCED SALT SOLN NO.1 IRRIG. IO SOLN
|
Facility
|
OP
|
$547.50
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$509.18 |
| Rate for Payer: Aetna Commercial |
$462.09
|
| Rate for Payer: Aetna Medicare |
$175.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$169.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$314.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$342.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$201.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$192.72
|
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: Centivo All Commercial |
$297.84
|
| Rate for Payer: Cigna All Commercial |
$472.49
|
| Rate for Payer: CORVEL All Commercial |
$509.18
|
| Rate for Payer: Coventry All Commercial |
$481.80
|
| Rate for Payer: Encore All Commercial |
$503.97
|
| Rate for Payer: Frontpath All Commercial |
$503.70
|
| Rate for Payer: Humana ChoiceCare |
$472.88
|
| Rate for Payer: Humana Medicare |
$175.20
|
| Rate for Payer: Lucent All Commercial |
$297.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$492.75
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$410.62
|
| Rate for Payer: PHP All Commercial |
$415.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$213.53
|
| Rate for Payer: Sagamore Health Network All Products |
$422.67
|
| Rate for Payer: Signature Care EPO |
$454.43
|
| Rate for Payer: Signature Care PPO |
$481.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$465.38
|
| Rate for Payer: United Healthcare Commercial |
$431.43
|
| Rate for Payer: United Healthcare Medicare |
$175.20
|
|
|
BALANCED SALT SOLN NO.1 IRRIG. IO SOLN
|
Facility
|
IP
|
$547.50
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$410.62 |
| Max. Negotiated Rate |
$509.18 |
| Rate for Payer: Aetna Commercial |
$473.04
|
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: Cigna All Commercial |
$472.49
|
| Rate for Payer: CORVEL All Commercial |
$509.18
|
| Rate for Payer: Coventry All Commercial |
$481.80
|
| Rate for Payer: Encore All Commercial |
$503.97
|
| Rate for Payer: Frontpath All Commercial |
$503.70
|
| Rate for Payer: Humana ChoiceCare |
$472.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$492.75
|
| Rate for Payer: PHCS All Commercial |
$410.62
|
| Rate for Payer: PHP All Commercial |
$415.22
|
| Rate for Payer: Sagamore Health Network All Products |
$422.67
|
| Rate for Payer: Signature Care EPO |
$454.43
|
| Rate for Payer: Signature Care PPO |
$481.80
|
| Rate for Payer: United Healthcare Commercial |
$431.43
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$242.23
|
| Rate for Payer: Aetna Medicare |
$91.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$164.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$179.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$105.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.02
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Centivo All Commercial |
$156.13
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Humana Medicare |
$91.84
|
| Rate for Payer: Lucent All Commercial |
$156.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$111.93
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$243.95
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
| Rate for Payer: United Healthcare Medicare |
$91.84
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.25 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$247.97
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
|
OP
|
$83.06
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$77.24 |
| Rate for Payer: Aetna Commercial |
$70.10
|
| Rate for Payer: Aetna Medicare |
$26.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.24
|
| Rate for Payer: Cash Price |
$49.83
|
| Rate for Payer: Cash Price |
$49.83
|
| Rate for Payer: Centivo All Commercial |
$45.18
|
| Rate for Payer: Cigna All Commercial |
$71.68
|
| Rate for Payer: CORVEL All Commercial |
$77.24
|
| Rate for Payer: Coventry All Commercial |
$73.09
|
| Rate for Payer: Encore All Commercial |
$76.45
|
| Rate for Payer: Frontpath All Commercial |
$76.41
|
| Rate for Payer: Humana ChoiceCare |
$71.73
|
| Rate for Payer: Humana Medicare |
$26.58
|
| Rate for Payer: Lucent All Commercial |
$45.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.75
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$62.29
|
| Rate for Payer: PHP All Commercial |
$62.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.39
|
| Rate for Payer: Sagamore Health Network All Products |
$64.12
|
| Rate for Payer: Signature Care EPO |
$68.94
|
| Rate for Payer: Signature Care PPO |
$73.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.60
|
| Rate for Payer: United Healthcare Commercial |
$65.45
|
| Rate for Payer: United Healthcare Medicare |
$26.58
|
|
|
BALANCED SALT SOLN NO.2 IRRIG. IO SOLN
|
Facility
|
IP
|
$83.06
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.29 |
| Max. Negotiated Rate |
$77.24 |
| Rate for Payer: Aetna Commercial |
$71.76
|
| Rate for Payer: Cash Price |
$49.83
|
| Rate for Payer: Cigna All Commercial |
$71.68
|
| Rate for Payer: CORVEL All Commercial |
$77.24
|
| Rate for Payer: Coventry All Commercial |
$73.09
|
| Rate for Payer: Encore All Commercial |
$76.45
|
| Rate for Payer: Frontpath All Commercial |
$76.41
|
| Rate for Payer: Humana ChoiceCare |
$71.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.75
|
| Rate for Payer: PHCS All Commercial |
$62.29
|
| Rate for Payer: PHP All Commercial |
$62.99
|
| Rate for Payer: Sagamore Health Network All Products |
$64.12
|
| Rate for Payer: Signature Care EPO |
$68.94
|
| Rate for Payer: Signature Care PPO |
$73.09
|
| Rate for Payer: United Healthcare Commercial |
$65.45
|
|
|
BARICITINIB (EUA) 2 MG ORAL TAB (CMCH)
|
Facility
|
IP
|
$531.55
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
1.40118E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$398.66 |
| Max. Negotiated Rate |
$494.34 |
| Rate for Payer: Aetna Commercial |
$459.26
|
| Rate for Payer: Cash Price |
$318.93
|
| Rate for Payer: Cigna All Commercial |
$458.72
|
| Rate for Payer: CORVEL All Commercial |
$494.34
|
| Rate for Payer: Coventry All Commercial |
$467.76
|
| Rate for Payer: Encore All Commercial |
$489.29
|
| Rate for Payer: Frontpath All Commercial |
$489.02
|
| Rate for Payer: Humana ChoiceCare |
$459.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.39
|
| Rate for Payer: PHCS All Commercial |
$398.66
|
| Rate for Payer: PHP All Commercial |
$403.12
|
| Rate for Payer: Sagamore Health Network All Products |
$410.35
|
| Rate for Payer: Signature Care EPO |
$441.18
|
| Rate for Payer: Signature Care PPO |
$467.76
|
| Rate for Payer: United Healthcare Commercial |
$418.86
|
|
|
BARICITINIB (EUA) 2 MG ORAL TAB (CMCH)
|
Facility
|
OP
|
$531.55
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
1.40118E+11
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.78 |
| Max. Negotiated Rate |
$494.34 |
| Rate for Payer: Aetna Commercial |
$448.62
|
| Rate for Payer: Aetna Medicare |
$170.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$164.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$305.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$332.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$195.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$187.10
|
| Rate for Payer: Cash Price |
$318.93
|
| Rate for Payer: Centivo All Commercial |
$289.16
|
| Rate for Payer: Cigna All Commercial |
$458.72
|
| Rate for Payer: CORVEL All Commercial |
$494.34
|
| Rate for Payer: Coventry All Commercial |
$467.76
|
| Rate for Payer: Encore All Commercial |
$489.29
|
| Rate for Payer: Frontpath All Commercial |
$489.02
|
| Rate for Payer: Humana ChoiceCare |
$459.10
|
| Rate for Payer: Humana Medicare |
$170.09
|
| Rate for Payer: Lucent All Commercial |
$289.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.39
|
| Rate for Payer: PHCS All Commercial |
$398.66
|
| Rate for Payer: PHP All Commercial |
$403.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$207.30
|
| Rate for Payer: Sagamore Health Network All Products |
$410.35
|
| Rate for Payer: Signature Care EPO |
$441.18
|
| Rate for Payer: Signature Care PPO |
$467.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$451.81
|
| Rate for Payer: United Healthcare Commercial |
$418.86
|
| Rate for Payer: United Healthcare Medicare |
$170.09
|
|
