|
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| 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 |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| 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 |
$1.28
|
|
|
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
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 |
$2.40
|
| 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
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MM MWSH
|
Facility
|
IP
|
$19.87
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.90 |
| Max. Negotiated Rate |
$18.48 |
| Rate for Payer: Aetna Commercial |
$17.16
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cigna All Commercial |
$17.14
|
| Rate for Payer: CORVEL All Commercial |
$18.48
|
| Rate for Payer: Coventry All Commercial |
$17.48
|
| Rate for Payer: Encore All Commercial |
$18.29
|
| Rate for Payer: Frontpath All Commercial |
$18.28
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.88
|
| Rate for Payer: PHCS All Commercial |
$14.90
|
| Rate for Payer: PHP All Commercial |
$15.07
|
| Rate for Payer: Sagamore Health Network All Products |
$15.34
|
| Rate for Payer: Signature Care EPO |
$16.49
|
| Rate for Payer: Signature Care PPO |
$17.48
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MM MWSH
|
Facility
|
OP
|
$19.87
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$18.48 |
| Rate for Payer: Aetna Commercial |
$16.77
|
| Rate for Payer: Aetna Medicare |
$6.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.99
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Centivo All Commercial |
$10.81
|
| Rate for Payer: Cigna All Commercial |
$17.14
|
| Rate for Payer: CORVEL All Commercial |
$18.48
|
| Rate for Payer: Coventry All Commercial |
$17.48
|
| Rate for Payer: Encore All Commercial |
$18.29
|
| Rate for Payer: Frontpath All Commercial |
$18.28
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Humana Medicare |
$6.36
|
| Rate for Payer: Lucent All Commercial |
$10.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.88
|
| Rate for Payer: PHCS All Commercial |
$14.90
|
| Rate for Payer: PHP All Commercial |
$15.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.75
|
| Rate for Payer: Sagamore Health Network All Products |
$15.34
|
| Rate for Payer: Signature Care EPO |
$16.49
|
| Rate for Payer: Signature Care PPO |
$17.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.89
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
| Rate for Payer: United Healthcare Medicare |
$6.36
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
OP
|
$159.46
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.43 |
| Max. Negotiated Rate |
$148.30 |
| Rate for Payer: Aetna Commercial |
$134.58
|
| Rate for Payer: Aetna Medicare |
$51.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$91.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$99.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$56.13
|
| Rate for Payer: Cash Price |
$95.68
|
| Rate for Payer: Centivo All Commercial |
$86.75
|
| Rate for Payer: Cigna All Commercial |
$137.61
|
| Rate for Payer: CORVEL All Commercial |
$148.30
|
| Rate for Payer: Coventry All Commercial |
$140.32
|
| Rate for Payer: Encore All Commercial |
$146.78
|
| Rate for Payer: Frontpath All Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$137.73
|
| Rate for Payer: Humana Medicare |
$51.03
|
| Rate for Payer: Lucent All Commercial |
$86.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.51
|
| Rate for Payer: PHCS All Commercial |
$119.59
|
| Rate for Payer: PHP All Commercial |
$120.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.19
|
| Rate for Payer: Sagamore Health Network All Products |
$123.10
|
| Rate for Payer: Signature Care EPO |
$132.35
|
| Rate for Payer: Signature Care PPO |
$140.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$135.54
|
| Rate for Payer: United Healthcare Commercial |
$125.65
|
| Rate for Payer: United Healthcare Medicare |
$51.03
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
IP
|
$159.46
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.59 |
| Max. Negotiated Rate |
$148.30 |
| Rate for Payer: Aetna Commercial |
$137.77
|
| Rate for Payer: Cash Price |
$95.68
|
| Rate for Payer: Cigna All Commercial |
$137.61
|
| Rate for Payer: CORVEL All Commercial |
$148.30
|
| Rate for Payer: Coventry All Commercial |
$140.32
|
| Rate for Payer: Encore All Commercial |
$146.78
|
| Rate for Payer: Frontpath All Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$137.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.51
|
| Rate for Payer: PHCS All Commercial |
$119.59
|
| Rate for Payer: PHP All Commercial |
$120.93
|
| Rate for Payer: Sagamore Health Network All Products |
$123.10
|
| Rate for Payer: Signature Care EPO |
$132.35
|
| Rate for Payer: Signature Care PPO |
$140.32
|
| Rate for Payer: United Healthcare Commercial |
$125.65
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJ SOLN
|
Facility
|
OP
|
$146.86
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.53 |
| Max. Negotiated Rate |
$136.58 |
| Rate for Payer: Aetna Commercial |
$123.95
|
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$84.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.69
|
| Rate for Payer: Cash Price |
$88.12
|
| Rate for Payer: Centivo All Commercial |
$79.89
|
| Rate for Payer: Cigna All Commercial |
$126.74
|
| Rate for Payer: CORVEL All Commercial |
$136.58
|
| Rate for Payer: Coventry All Commercial |
$129.24
|
| Rate for Payer: Encore All Commercial |
$135.18
|
| Rate for Payer: Frontpath All Commercial |
$135.11
|
| Rate for Payer: Humana ChoiceCare |
$126.84
|
| Rate for Payer: Humana Medicare |
$47.00
|
| Rate for Payer: Lucent All Commercial |
$79.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.17
|
| Rate for Payer: PHCS All Commercial |
$110.14
|
| Rate for Payer: PHP All Commercial |
$111.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.28
|
| Rate for Payer: Sagamore Health Network All Products |
$113.38
|
| Rate for Payer: Signature Care EPO |
$121.89
|
| Rate for Payer: Signature Care PPO |
$129.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.83
|
| Rate for Payer: United Healthcare Commercial |
$115.73
|
| Rate for Payer: United Healthcare Medicare |
$47.00
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJ SOLN
|
Facility
|
IP
|
$146.86
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.14 |
| Max. Negotiated Rate |
$136.58 |
| Rate for Payer: Aetna Commercial |
$126.89
|
| Rate for Payer: Cash Price |
$88.12
|
| Rate for Payer: Cigna All Commercial |
$126.74
|
| Rate for Payer: CORVEL All Commercial |
$136.58
|
| Rate for Payer: Coventry All Commercial |
$129.24
|
| Rate for Payer: Encore All Commercial |
$135.18
|
| Rate for Payer: Frontpath All Commercial |
$135.11
|
| Rate for Payer: Humana ChoiceCare |
$126.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.17
|
| Rate for Payer: PHCS All Commercial |
$110.14
|
| Rate for Payer: PHP All Commercial |
$111.38
|
| Rate for Payer: Sagamore Health Network All Products |
$113.38
|
| Rate for Payer: Signature Care EPO |
$121.89
|
| Rate for Payer: Signature Care PPO |
$129.24
|
| Rate for Payer: United Healthcare Commercial |
$115.73
|
|
|
CHLORPROMAZINE 25 MG/ML INJ SOLN
|
Facility
|
IP
|
$180.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.08 |
| Max. Negotiated Rate |
$167.50 |
| Rate for Payer: Aetna Commercial |
$155.61
|
| Rate for Payer: Cash Price |
$108.06
|
| Rate for Payer: Cigna All Commercial |
$155.43
|
| Rate for Payer: CORVEL All Commercial |
$167.50
|
| Rate for Payer: Coventry All Commercial |
$158.49
|
| Rate for Payer: Encore All Commercial |
$165.78
|
| Rate for Payer: Frontpath All Commercial |
$165.69
|
| Rate for Payer: Humana ChoiceCare |
$155.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$162.09
|
| Rate for Payer: PHCS All Commercial |
$135.08
|
| Rate for Payer: PHP All Commercial |
$136.59
|
| Rate for Payer: Sagamore Health Network All Products |
$139.04
|
| Rate for Payer: Signature Care EPO |
$149.49
|
| Rate for Payer: Signature Care PPO |
$158.49
|
| Rate for Payer: United Healthcare Commercial |
$141.92
|
|
|
CHLORPROMAZINE 25 MG/ML INJ SOLN
|
Facility
|
OP
|
$180.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$167.50 |
| Rate for Payer: Aetna Commercial |
$152.01
|
| Rate for Payer: Aetna Medicare |
$57.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$55.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$103.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$112.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$66.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$63.40
|
| Rate for Payer: Cash Price |
$108.06
|
| Rate for Payer: Centivo All Commercial |
$97.98
|
| Rate for Payer: Cigna All Commercial |
$155.43
|
| Rate for Payer: CORVEL All Commercial |
$167.50
|
| Rate for Payer: Coventry All Commercial |
$158.49
|
| Rate for Payer: Encore All Commercial |
$165.78
|
| Rate for Payer: Frontpath All Commercial |
$165.69
|
| Rate for Payer: Humana ChoiceCare |
$155.55
|
| Rate for Payer: Humana Medicare |
$57.63
|
| Rate for Payer: Lucent All Commercial |
$97.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$162.09
|
| Rate for Payer: PHCS All Commercial |
$135.08
|
| Rate for Payer: PHP All Commercial |
$136.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$70.24
|
| Rate for Payer: Sagamore Health Network All Products |
$139.04
|
| Rate for Payer: Signature Care EPO |
$149.49
|
| Rate for Payer: Signature Care PPO |
$158.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$153.09
|
| Rate for Payer: United Healthcare Commercial |
$141.92
|
| Rate for Payer: United Healthcare Medicare |
$57.63
|
|
|
CHLORPROMAZINE 25 MG ORAL TAB
|
Facility
|
OP
|
$14.28
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: Aetna Medicare |
$4.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.03
|
| Rate for Payer: Cash Price |
$8.57
|
| Rate for Payer: Centivo All Commercial |
$7.77
|
| Rate for Payer: Cigna All Commercial |
$12.32
|
| Rate for Payer: CORVEL All Commercial |
$13.28
|
| Rate for Payer: Coventry All Commercial |
$12.57
|
| Rate for Payer: Encore All Commercial |
$13.14
|
| Rate for Payer: Frontpath All Commercial |
$13.14
|
| Rate for Payer: Humana ChoiceCare |
$12.33
|
| Rate for Payer: Humana Medicare |
$4.57
|
| Rate for Payer: Lucent All Commercial |
$7.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.85
|
| Rate for Payer: PHCS All Commercial |
$10.71
|
| Rate for Payer: PHP All Commercial |
$10.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.57
|
| Rate for Payer: Sagamore Health Network All Products |
$11.02
|
| Rate for Payer: Signature Care EPO |
$11.85
|
| Rate for Payer: Signature Care PPO |
$12.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.14
|
| Rate for Payer: United Healthcare Commercial |
$11.25
|
| Rate for Payer: United Healthcare Medicare |
$4.57
|
|
|
CHLORPROMAZINE 25 MG ORAL TAB
|
Facility
|
IP
|
$14.28
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna Commercial |
$12.34
|
| Rate for Payer: Cash Price |
$8.57
|
| Rate for Payer: Cigna All Commercial |
$12.32
|
| Rate for Payer: CORVEL All Commercial |
$13.28
|
| Rate for Payer: Coventry All Commercial |
$12.57
|
| Rate for Payer: Encore All Commercial |
$13.14
|
| Rate for Payer: Frontpath All Commercial |
$13.14
|
| Rate for Payer: Humana ChoiceCare |
$12.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.85
|
| Rate for Payer: PHCS All Commercial |
$10.71
|
| Rate for Payer: PHP All Commercial |
$10.83
|
| Rate for Payer: Sagamore Health Network All Products |
$11.02
|
| Rate for Payer: Signature Care EPO |
$11.85
|
| Rate for Payer: Signature Care PPO |
$12.57
|
| Rate for Payer: United Healthcare Commercial |
$11.25
|
|
|
CHLORZOXAZONE 500 MG ORAL TAB
|
Facility
|
IP
|
$1.90
|
|
|
Service Code
|
NDC 00591252001
|
| Hospital Charge Code |
1664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cigna All Commercial |
$1.64
|
| Rate for Payer: CORVEL All Commercial |
$1.76
|
| Rate for Payer: Coventry All Commercial |
$1.67
|
| Rate for Payer: Encore All Commercial |
$1.75
|
| Rate for Payer: Frontpath All Commercial |
$1.75
|
| Rate for Payer: Humana ChoiceCare |
$1.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.71
|
| Rate for Payer: PHCS All Commercial |
$1.42
|
| Rate for Payer: PHP All Commercial |
$1.44
|
| Rate for Payer: Sagamore Health Network All Products |
$1.46
|
| Rate for Payer: Signature Care EPO |
$1.57
|
| Rate for Payer: Signature Care PPO |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$1.49
|
|
|
CHLORZOXAZONE 500 MG ORAL TAB
|
Facility
|
OP
|
$1.90
|
|
|
Service Code
|
NDC 00591252001
|
| Hospital Charge Code |
1664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna Commercial |
$1.60
|
| Rate for Payer: Aetna Medicare |
$0.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.19
|
| 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 |
$1.14
|
| Rate for Payer: Centivo All Commercial |
$1.03
|
| Rate for Payer: Cigna All Commercial |
$1.64
|
| Rate for Payer: CORVEL All Commercial |
$1.76
|
| Rate for Payer: Coventry All Commercial |
$1.67
|
| Rate for Payer: Encore All Commercial |
$1.75
|
| Rate for Payer: Frontpath All Commercial |
$1.75
|
| Rate for Payer: Humana ChoiceCare |
$1.64
|
| Rate for Payer: Humana Medicare |
$0.61
|
| Rate for Payer: Lucent All Commercial |
$1.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.71
|
| Rate for Payer: PHCS All Commercial |
$1.42
|
| Rate for Payer: PHP All Commercial |
$1.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.74
|
| Rate for Payer: Sagamore Health Network All Products |
$1.46
|
| Rate for Payer: Signature Care EPO |
$1.57
|
| Rate for Payer: Signature Care PPO |
$1.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$1.49
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1000 UNITS ORAL TAB
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna All Commercial |
$0.30
|
| Rate for Payer: CORVEL All Commercial |
$0.32
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.32
|
| Rate for Payer: Frontpath All Commercial |
$0.32
|
| Rate for Payer: Humana ChoiceCare |
$0.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.31
|
| Rate for Payer: PHCS All Commercial |
$0.26
|
| Rate for Payer: PHP All Commercial |
$0.26
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1000 UNITS ORAL TAB
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.29
|
| Rate for Payer: Aetna Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Centivo All Commercial |
$0.19
|
| Rate for Payer: Cigna All Commercial |
$0.30
|
| Rate for Payer: CORVEL All Commercial |
$0.32
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.32
|
| Rate for Payer: Frontpath All Commercial |
$0.32
|
| Rate for Payer: Humana ChoiceCare |
$0.30
|
| Rate for Payer: Humana Medicare |
$0.11
|
| Rate for Payer: Lucent All Commercial |
$0.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.31
|
| Rate for Payer: PHCS All Commercial |
$0.26
|
| Rate for Payer: PHP All Commercial |
$0.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.13
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) ORAL CAP
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 75834002012
|
| Hospital Charge Code |
88945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.22
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) ORAL CAP
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 75834002012
|
| Hospital Charge Code |
88945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Aetna Medicare |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.13
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Centivo All Commercial |
$3.29
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Humana Medicare |
$1.93
|
| Rate for Payer: Lucent All Commercial |
$3.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.36
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.13
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
| Rate for Payer: United Healthcare Medicare |
$1.93
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 400 UNITS ORAL TAB
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
112022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.00
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Centivo All Commercial |
$0.65
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.09
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Humana Medicare |
$0.38
|
| Rate for Payer: Lucent All Commercial |
$0.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.07
|
| Rate for Payer: PHCS All Commercial |
$0.89
|
| Rate for Payer: PHP All Commercial |
$0.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 400 UNITS ORAL TAB
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
112022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.09
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.07
|
| Rate for Payer: PHCS All Commercial |
$0.89
|
| Rate for Payer: PHP All Commercial |
$0.90
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
|
|
CHOLESTYRAMINE 4 G ORAL PWPK
|
Facility
|
OP
|
$20.25
|
|
|
Service Code
|
NDC 00245003642
|
| Hospital Charge Code |
209027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$18.83 |
| Rate for Payer: Aetna Commercial |
$17.09
|
| Rate for Payer: Aetna Medicare |
$6.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.13
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Centivo All Commercial |
$11.02
|
| Rate for Payer: Cigna All Commercial |
$17.48
|
| Rate for Payer: CORVEL All Commercial |
$18.83
|
| Rate for Payer: Coventry All Commercial |
$17.82
|
| Rate for Payer: Encore All Commercial |
$18.64
|
| Rate for Payer: Frontpath All Commercial |
$18.63
|
| Rate for Payer: Humana ChoiceCare |
$17.49
|
| Rate for Payer: Humana Medicare |
$6.48
|
| Rate for Payer: Lucent All Commercial |
$11.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.23
|
| Rate for Payer: PHCS All Commercial |
$15.19
|
| Rate for Payer: PHP All Commercial |
$15.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.90
|
| Rate for Payer: Sagamore Health Network All Products |
$15.63
|
| Rate for Payer: Signature Care EPO |
$16.81
|
| Rate for Payer: Signature Care PPO |
$17.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.21
|
| Rate for Payer: United Healthcare Commercial |
$15.96
|
| Rate for Payer: United Healthcare Medicare |
$6.48
|
|
|
CHOLESTYRAMINE 4 G ORAL PWPK
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 00245003642
|
| Hospital Charge Code |
209027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$18.83 |
| Rate for Payer: Aetna Commercial |
$17.50
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cigna All Commercial |
$17.48
|
| Rate for Payer: CORVEL All Commercial |
$18.83
|
| Rate for Payer: Coventry All Commercial |
$17.82
|
| Rate for Payer: Encore All Commercial |
$18.64
|
| Rate for Payer: Frontpath All Commercial |
$18.63
|
| Rate for Payer: Humana ChoiceCare |
$17.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.23
|
| Rate for Payer: PHCS All Commercial |
$15.19
|
| Rate for Payer: PHP All Commercial |
$15.36
|
| Rate for Payer: Sagamore Health Network All Products |
$15.63
|
| Rate for Payer: Signature Care EPO |
$16.81
|
| Rate for Payer: Signature Care PPO |
$17.82
|
| Rate for Payer: United Healthcare Commercial |
$15.96
|
|
|
CHONDROITIN SULF-SOD HYALURON 4-3 % (40-30 MG/ML) IO SYRG
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 080651893
|
| Hospital Charge Code |
28923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
CHORIOGONADOTROPIN ALFA,HUMREC 250 MCG/0.5 ML SUBQ SYRG
|
Facility
|
OP
|
$1,180.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
37111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$365.95 |
| Max. Negotiated Rate |
$1,097.87 |
| Rate for Payer: Aetna Commercial |
$996.34
|
| Rate for Payer: Aetna Medicare |
$377.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$365.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$677.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$737.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$434.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$415.54
|
| Rate for Payer: Cash Price |
$708.30
|
| Rate for Payer: Centivo All Commercial |
$642.19
|
| Rate for Payer: Cigna All Commercial |
$1,018.77
|
| Rate for Payer: CORVEL All Commercial |
$1,097.87
|
| Rate for Payer: Coventry All Commercial |
$1,038.84
|
| Rate for Payer: Encore All Commercial |
$1,086.65
|
| Rate for Payer: Frontpath All Commercial |
$1,086.06
|
| Rate for Payer: Humana ChoiceCare |
$1,019.60
|
| Rate for Payer: Humana Medicare |
$377.76
|
| Rate for Payer: Lucent All Commercial |
$642.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,062.45
|
| Rate for Payer: PHCS All Commercial |
$885.38
|
| Rate for Payer: PHP All Commercial |
$895.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$460.39
|
| Rate for Payer: Sagamore Health Network All Products |
$911.35
|
| Rate for Payer: Signature Care EPO |
$979.82
|
| Rate for Payer: Signature Care PPO |
$1,038.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,003.42
|
| Rate for Payer: United Healthcare Commercial |
$930.23
|
| Rate for Payer: United Healthcare Medicare |
$377.76
|
|
|
CHORIOGONADOTROPIN ALFA,HUMREC 250 MCG/0.5 ML SUBQ SYRG
|
Facility
|
IP
|
$1,180.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
37111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$885.38 |
| Max. Negotiated Rate |
$1,097.87 |
| Rate for Payer: Aetna Commercial |
$1,019.95
|
| Rate for Payer: Cash Price |
$708.30
|
| Rate for Payer: Cigna All Commercial |
$1,018.77
|
| Rate for Payer: CORVEL All Commercial |
$1,097.87
|
| Rate for Payer: Coventry All Commercial |
$1,038.84
|
| Rate for Payer: Encore All Commercial |
$1,086.65
|
| Rate for Payer: Frontpath All Commercial |
$1,086.06
|
| Rate for Payer: Humana ChoiceCare |
$1,019.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,062.45
|
| Rate for Payer: PHCS All Commercial |
$885.38
|
| Rate for Payer: PHP All Commercial |
$895.29
|
| Rate for Payer: Sagamore Health Network All Products |
$911.35
|
| Rate for Payer: Signature Care EPO |
$979.82
|
| Rate for Payer: Signature Care PPO |
$1,038.84
|
| Rate for Payer: United Healthcare Commercial |
$930.23
|
|
