|
CLOPIDOGREL 75 MG ORAL TAB
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.35
|
| Rate for Payer: Encore All Commercial |
$1.41
|
| Rate for Payer: Frontpath All Commercial |
$1.41
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.38
|
| Rate for Payer: PHCS All Commercial |
$1.15
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
CLOPIDOGREL 75 MG ORAL TAB
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.35
|
| Rate for Payer: Encore All Commercial |
$1.41
|
| Rate for Payer: Frontpath All Commercial |
$1.41
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.38
|
| Rate for Payer: PHCS All Commercial |
$1.15
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
CLORAZEPATE DIPOTASSIUM 7.5 MG ORAL TAB
|
Facility
|
OP
|
$6.93
|
|
|
Service Code
|
NDC 60505475501
|
| Hospital Charge Code |
1760
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: Aetna Medicare |
$2.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.44
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Centivo All Commercial |
$3.77
|
| Rate for Payer: Cigna All Commercial |
$5.98
|
| Rate for Payer: CORVEL All Commercial |
$6.44
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.38
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Humana Medicare |
$2.22
|
| Rate for Payer: Lucent All Commercial |
$3.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.70
|
| Rate for Payer: Sagamore Health Network All Products |
$5.35
|
| Rate for Payer: Signature Care EPO |
$5.75
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.89
|
| Rate for Payer: United Healthcare Commercial |
$5.46
|
| Rate for Payer: United Healthcare Medicare |
$2.22
|
|
|
CLORAZEPATE DIPOTASSIUM 7.5 MG ORAL TAB
|
Facility
|
IP
|
$6.93
|
|
|
Service Code
|
NDC 60505475501
|
| Hospital Charge Code |
1760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$5.99
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Cigna All Commercial |
$5.98
|
| Rate for Payer: CORVEL All Commercial |
$6.44
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.38
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Sagamore Health Network All Products |
$5.35
|
| Rate for Payer: Signature Care EPO |
$5.75
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: United Healthcare Commercial |
$5.46
|
|
|
CLOTRIMAZOLE 10 MG MM TROC
|
Facility
|
OP
|
$19.43
|
|
|
Service Code
|
NDC 00054814622
|
| Hospital Charge Code |
9644
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$18.07 |
| Rate for Payer: Aetna Commercial |
$16.40
|
| Rate for Payer: Aetna Medicare |
$6.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: Centivo All Commercial |
$10.57
|
| Rate for Payer: Cigna All Commercial |
$16.77
|
| Rate for Payer: CORVEL All Commercial |
$18.07
|
| Rate for Payer: Coventry All Commercial |
$17.10
|
| Rate for Payer: Encore All Commercial |
$17.89
|
| Rate for Payer: Frontpath All Commercial |
$17.88
|
| Rate for Payer: Humana ChoiceCare |
$16.78
|
| Rate for Payer: Humana Medicare |
$6.22
|
| Rate for Payer: Lucent All Commercial |
$10.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.49
|
| Rate for Payer: PHCS All Commercial |
$14.57
|
| Rate for Payer: PHP All Commercial |
$14.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.58
|
| Rate for Payer: Sagamore Health Network All Products |
$15.00
|
| Rate for Payer: Signature Care EPO |
$16.13
|
| Rate for Payer: Signature Care PPO |
$17.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.52
|
| Rate for Payer: United Healthcare Commercial |
$15.31
|
| Rate for Payer: United Healthcare Medicare |
$6.22
|
|
|
CLOTRIMAZOLE 10 MG MM TROC
|
Facility
|
IP
|
$19.43
|
|
|
Service Code
|
NDC 00054814622
|
| Hospital Charge Code |
9644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$18.07 |
| Rate for Payer: Aetna Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: Cigna All Commercial |
$16.77
|
| Rate for Payer: CORVEL All Commercial |
$18.07
|
| Rate for Payer: Coventry All Commercial |
$17.10
|
| Rate for Payer: Encore All Commercial |
$17.89
|
| Rate for Payer: Frontpath All Commercial |
$17.88
|
| Rate for Payer: Humana ChoiceCare |
$16.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.49
|
| Rate for Payer: PHCS All Commercial |
$14.57
|
| Rate for Payer: PHP All Commercial |
$14.74
|
| Rate for Payer: Sagamore Health Network All Products |
$15.00
|
| Rate for Payer: Signature Care EPO |
$16.13
|
| Rate for Payer: Signature Care PPO |
$17.10
|
| Rate for Payer: United Healthcare Commercial |
$15.31
|
|
|
CLOTRIMAZOLE 1 % TOP CREA
|
Facility
|
OP
|
$14.91
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.58
|
| Rate for Payer: Aetna Medicare |
$4.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.25
|
| Rate for Payer: Cash Price |
$8.95
|
| Rate for Payer: Centivo All Commercial |
$8.11
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Humana Medicare |
$4.77
|
| Rate for Payer: Lucent All Commercial |
$8.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.81
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
| Rate for Payer: United Healthcare Medicare |
$4.77
|
|
|
CLOTRIMAZOLE 1 % TOP CREA
|
Facility
|
IP
|
$14.91
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Cash Price |
$8.95
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CREA
|
Facility
|
OP
|
$25.31
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$23.53 |
| Rate for Payer: Aetna Commercial |
$21.36
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.91
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Centivo All Commercial |
$13.77
|
| Rate for Payer: Cigna All Commercial |
$21.84
|
| Rate for Payer: CORVEL All Commercial |
$23.53
|
| Rate for Payer: Coventry All Commercial |
$22.27
|
| Rate for Payer: Encore All Commercial |
$23.29
|
| Rate for Payer: Frontpath All Commercial |
$23.28
|
| Rate for Payer: Humana ChoiceCare |
$21.86
|
| Rate for Payer: Humana Medicare |
$8.10
|
| Rate for Payer: Lucent All Commercial |
$13.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.77
|
| Rate for Payer: PHCS All Commercial |
$18.98
|
| Rate for Payer: PHP All Commercial |
$19.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.87
|
| Rate for Payer: Sagamore Health Network All Products |
$19.54
|
| Rate for Payer: Signature Care EPO |
$21.00
|
| Rate for Payer: Signature Care PPO |
$22.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.51
|
| Rate for Payer: United Healthcare Commercial |
$19.94
|
| Rate for Payer: United Healthcare Medicare |
$8.10
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CREA
|
Facility
|
IP
|
$25.31
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$23.53 |
| Rate for Payer: Aetna Commercial |
$21.86
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna All Commercial |
$21.84
|
| Rate for Payer: CORVEL All Commercial |
$23.53
|
| Rate for Payer: Coventry All Commercial |
$22.27
|
| Rate for Payer: Encore All Commercial |
$23.29
|
| Rate for Payer: Frontpath All Commercial |
$23.28
|
| Rate for Payer: Humana ChoiceCare |
$21.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.77
|
| Rate for Payer: PHCS All Commercial |
$18.98
|
| Rate for Payer: PHP All Commercial |
$19.19
|
| Rate for Payer: Sagamore Health Network All Products |
$19.54
|
| Rate for Payer: Signature Care EPO |
$21.00
|
| Rate for Payer: Signature Care PPO |
$22.27
|
| Rate for Payer: United Healthcare Commercial |
$19.94
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
IP
|
$33.60
|
|
|
Service Code
|
NDC 00121155010
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$29.03
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Cigna All Commercial |
$29.00
|
| Rate for Payer: CORVEL All Commercial |
$31.25
|
| Rate for Payer: Coventry All Commercial |
$29.57
|
| Rate for Payer: Encore All Commercial |
$30.93
|
| Rate for Payer: Frontpath All Commercial |
$30.91
|
| Rate for Payer: Humana ChoiceCare |
$29.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.24
|
| Rate for Payer: PHCS All Commercial |
$25.20
|
| Rate for Payer: PHP All Commercial |
$25.48
|
| Rate for Payer: Sagamore Health Network All Products |
$25.94
|
| Rate for Payer: Signature Care EPO |
$27.89
|
| Rate for Payer: Signature Care PPO |
$29.57
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
IP
|
$33.60
|
|
|
Service Code
|
NDC 00121155040
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$29.03
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Cigna All Commercial |
$29.00
|
| Rate for Payer: CORVEL All Commercial |
$31.25
|
| Rate for Payer: Coventry All Commercial |
$29.57
|
| Rate for Payer: Encore All Commercial |
$30.93
|
| Rate for Payer: Frontpath All Commercial |
$30.91
|
| Rate for Payer: Humana ChoiceCare |
$29.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.24
|
| Rate for Payer: PHCS All Commercial |
$25.20
|
| Rate for Payer: PHP All Commercial |
$25.48
|
| Rate for Payer: Sagamore Health Network All Products |
$25.94
|
| Rate for Payer: Signature Care EPO |
$27.89
|
| Rate for Payer: Signature Care PPO |
$29.57
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
NDC 00121155040
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.42 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.36
|
| Rate for Payer: Aetna Medicare |
$10.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.83
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Centivo All Commercial |
$18.28
|
| Rate for Payer: Cigna All Commercial |
$29.00
|
| Rate for Payer: CORVEL All Commercial |
$31.25
|
| Rate for Payer: Coventry All Commercial |
$29.57
|
| Rate for Payer: Encore All Commercial |
$30.93
|
| Rate for Payer: Frontpath All Commercial |
$30.91
|
| Rate for Payer: Humana ChoiceCare |
$29.02
|
| Rate for Payer: Humana Medicare |
$10.75
|
| Rate for Payer: Lucent All Commercial |
$18.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.24
|
| Rate for Payer: PHCS All Commercial |
$25.20
|
| Rate for Payer: PHP All Commercial |
$25.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.10
|
| Rate for Payer: Sagamore Health Network All Products |
$25.94
|
| Rate for Payer: Signature Care EPO |
$27.89
|
| Rate for Payer: Signature Care PPO |
$29.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.56
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
| Rate for Payer: United Healthcare Medicare |
$10.75
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
NDC 00121155010
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.42 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.36
|
| Rate for Payer: Aetna Medicare |
$10.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.83
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Centivo All Commercial |
$18.28
|
| Rate for Payer: Cigna All Commercial |
$29.00
|
| Rate for Payer: CORVEL All Commercial |
$31.25
|
| Rate for Payer: Coventry All Commercial |
$29.57
|
| Rate for Payer: Encore All Commercial |
$30.93
|
| Rate for Payer: Frontpath All Commercial |
$30.91
|
| Rate for Payer: Humana ChoiceCare |
$29.02
|
| Rate for Payer: Humana Medicare |
$10.75
|
| Rate for Payer: Lucent All Commercial |
$18.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.24
|
| Rate for Payer: PHCS All Commercial |
$25.20
|
| Rate for Payer: PHP All Commercial |
$25.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.10
|
| Rate for Payer: Sagamore Health Network All Products |
$25.94
|
| Rate for Payer: Signature Care EPO |
$27.89
|
| Rate for Payer: Signature Care PPO |
$29.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.56
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
| Rate for Payer: United Healthcare Medicare |
$10.75
|
|
|
COENZYME Q10 50 MG ORAL CAP
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 00904561646
|
| Hospital Charge Code |
35228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Centivo All Commercial |
$0.73
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.23
|
| Rate for Payer: Frontpath All Commercial |
$1.23
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Humana Medicare |
$0.43
|
| Rate for Payer: Lucent All Commercial |
$0.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.11
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
COENZYME Q10 50 MG ORAL CAP
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 00904561646
|
| Hospital Charge Code |
35228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.23
|
| Rate for Payer: Frontpath All Commercial |
$1.23
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.11
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
COLCHICINE 0.6 MG ORAL TAB
|
Facility
|
OP
|
$19.64
|
|
|
Service Code
|
NDC 00904712004
|
| Hospital Charge Code |
1821
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$18.26 |
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Medicare |
$6.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.91
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Centivo All Commercial |
$10.68
|
| Rate for Payer: Cigna All Commercial |
$16.95
|
| Rate for Payer: CORVEL All Commercial |
$18.26
|
| Rate for Payer: Coventry All Commercial |
$17.28
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.96
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Lucent All Commercial |
$10.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.73
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.66
|
| Rate for Payer: Sagamore Health Network All Products |
$15.16
|
| Rate for Payer: Signature Care EPO |
$16.30
|
| Rate for Payer: Signature Care PPO |
$17.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.69
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$6.28
|
|
|
COLCHICINE 0.6 MG ORAL TAB
|
Facility
|
IP
|
$19.64
|
|
|
Service Code
|
NDC 00904712004
|
| Hospital Charge Code |
1821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$18.26 |
| Rate for Payer: Aetna Commercial |
$16.96
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna All Commercial |
$16.95
|
| Rate for Payer: CORVEL All Commercial |
$18.26
|
| Rate for Payer: Coventry All Commercial |
$17.28
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.73
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Sagamore Health Network All Products |
$15.16
|
| Rate for Payer: Signature Care EPO |
$16.30
|
| Rate for Payer: Signature Care PPO |
$17.28
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
|
|
COLESEVELAM 625 MG ORAL TAB
|
Facility
|
OP
|
$24.35
|
|
|
Service Code
|
NDC 60687038525
|
| Hospital Charge Code |
28372
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial |
$20.55
|
| Rate for Payer: Aetna Medicare |
$7.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.57
|
| Rate for Payer: Cash Price |
$14.61
|
| Rate for Payer: Centivo All Commercial |
$13.25
|
| Rate for Payer: Cigna All Commercial |
$21.02
|
| Rate for Payer: CORVEL All Commercial |
$22.65
|
| Rate for Payer: Coventry All Commercial |
$21.43
|
| Rate for Payer: Encore All Commercial |
$22.42
|
| Rate for Payer: Frontpath All Commercial |
$22.40
|
| Rate for Payer: Humana ChoiceCare |
$21.03
|
| Rate for Payer: Humana Medicare |
$7.79
|
| Rate for Payer: Lucent All Commercial |
$13.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.92
|
| Rate for Payer: PHCS All Commercial |
$18.26
|
| Rate for Payer: PHP All Commercial |
$18.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.50
|
| Rate for Payer: Sagamore Health Network All Products |
$18.80
|
| Rate for Payer: Signature Care EPO |
$20.21
|
| Rate for Payer: Signature Care PPO |
$21.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$19.19
|
| Rate for Payer: United Healthcare Medicare |
$7.79
|
|
|
COLESEVELAM 625 MG ORAL TAB
|
Facility
|
IP
|
$24.35
|
|
|
Service Code
|
NDC 60687038525
|
| Hospital Charge Code |
28372
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.26 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Cash Price |
$14.61
|
| Rate for Payer: Cigna All Commercial |
$21.02
|
| Rate for Payer: CORVEL All Commercial |
$22.65
|
| Rate for Payer: Coventry All Commercial |
$21.43
|
| Rate for Payer: Encore All Commercial |
$22.42
|
| Rate for Payer: Frontpath All Commercial |
$22.40
|
| Rate for Payer: Humana ChoiceCare |
$21.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.92
|
| Rate for Payer: PHCS All Commercial |
$18.26
|
| Rate for Payer: PHP All Commercial |
$18.47
|
| Rate for Payer: Sagamore Health Network All Products |
$18.80
|
| Rate for Payer: Signature Care EPO |
$20.21
|
| Rate for Payer: Signature Care PPO |
$21.43
|
| Rate for Payer: United Healthcare Commercial |
$19.19
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 0.9 MG INJ SOLR
|
Facility
|
OP
|
$24,878.07
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
101010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.93 |
| Max. Negotiated Rate |
$23,136.61 |
| Rate for Payer: Aetna Commercial |
$20,997.09
|
| Rate for Payer: Aetna Medicare |
$7,960.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$82.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7,712.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14,287.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15,551.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$82.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9,155.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8,757.08
|
| Rate for Payer: Cash Price |
$14,926.84
|
| Rate for Payer: Cash Price |
$14,926.84
|
| Rate for Payer: Centivo All Commercial |
$13,533.67
|
| Rate for Payer: Cigna All Commercial |
$21,469.77
|
| Rate for Payer: CORVEL All Commercial |
$23,136.61
|
| Rate for Payer: Coventry All Commercial |
$21,892.70
|
| Rate for Payer: Encore All Commercial |
$22,900.26
|
| Rate for Payer: Frontpath All Commercial |
$22,887.82
|
| Rate for Payer: Humana ChoiceCare |
$21,487.19
|
| Rate for Payer: Humana Medicare |
$7,960.98
|
| Rate for Payer: Lucent All Commercial |
$13,533.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22,390.26
|
| Rate for Payer: Managed Health Services Medicaid |
$82.93
|
| Rate for Payer: MDWise Medicaid |
$82.93
|
| Rate for Payer: PHCS All Commercial |
$18,658.55
|
| Rate for Payer: PHP All Commercial |
$18,867.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9,702.45
|
| Rate for Payer: Sagamore Health Network All Products |
$19,205.87
|
| Rate for Payer: Signature Care EPO |
$20,648.80
|
| Rate for Payer: Signature Care PPO |
$21,892.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21,146.36
|
| Rate for Payer: United Healthcare Commercial |
$19,603.92
|
| Rate for Payer: United Healthcare Medicare |
$7,960.98
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 0.9 MG INJ SOLR
|
Facility
|
IP
|
$24,878.07
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
101010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18,658.55 |
| Max. Negotiated Rate |
$23,136.61 |
| Rate for Payer: Aetna Commercial |
$21,494.65
|
| Rate for Payer: Cash Price |
$14,926.84
|
| Rate for Payer: Cigna All Commercial |
$21,469.77
|
| Rate for Payer: CORVEL All Commercial |
$23,136.61
|
| Rate for Payer: Coventry All Commercial |
$21,892.70
|
| Rate for Payer: Encore All Commercial |
$22,900.26
|
| Rate for Payer: Frontpath All Commercial |
$22,887.82
|
| Rate for Payer: Humana ChoiceCare |
$21,487.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22,390.26
|
| Rate for Payer: PHCS All Commercial |
$18,658.55
|
| Rate for Payer: PHP All Commercial |
$18,867.53
|
| Rate for Payer: Sagamore Health Network All Products |
$19,205.87
|
| Rate for Payer: Signature Care EPO |
$20,648.80
|
| Rate for Payer: Signature Care PPO |
$21,892.70
|
| Rate for Payer: United Healthcare Commercial |
$19,603.92
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 250 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$1,190.52
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
9682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,107.18 |
| Rate for Payer: Aetna Commercial |
$1,004.80
|
| Rate for Payer: Aetna Medicare |
$380.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$369.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$683.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$744.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$438.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$419.06
|
| Rate for Payer: Cash Price |
$714.31
|
| Rate for Payer: Cash Price |
$714.31
|
| Rate for Payer: Centivo All Commercial |
$647.64
|
| Rate for Payer: Cigna All Commercial |
$1,027.42
|
| Rate for Payer: CORVEL All Commercial |
$1,107.18
|
| Rate for Payer: Coventry All Commercial |
$1,047.66
|
| Rate for Payer: Encore All Commercial |
$1,095.87
|
| Rate for Payer: Frontpath All Commercial |
$1,095.28
|
| Rate for Payer: Humana ChoiceCare |
$1,028.25
|
| Rate for Payer: Humana Medicare |
$380.97
|
| Rate for Payer: Lucent All Commercial |
$647.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,071.47
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$892.89
|
| Rate for Payer: PHP All Commercial |
$902.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$464.30
|
| Rate for Payer: Sagamore Health Network All Products |
$919.08
|
| Rate for Payer: Signature Care EPO |
$988.13
|
| Rate for Payer: Signature Care PPO |
$1,047.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,011.94
|
| Rate for Payer: United Healthcare Commercial |
$938.13
|
| Rate for Payer: United Healthcare Medicare |
$380.97
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 250 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$1,190.52
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
9682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$892.89 |
| Max. Negotiated Rate |
$1,107.18 |
| Rate for Payer: Aetna Commercial |
$1,028.61
|
| Rate for Payer: Cash Price |
$714.31
|
| Rate for Payer: Cigna All Commercial |
$1,027.42
|
| Rate for Payer: CORVEL All Commercial |
$1,107.18
|
| Rate for Payer: Coventry All Commercial |
$1,047.66
|
| Rate for Payer: Encore All Commercial |
$1,095.87
|
| Rate for Payer: Frontpath All Commercial |
$1,095.28
|
| Rate for Payer: Humana ChoiceCare |
$1,028.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,071.47
|
| Rate for Payer: PHCS All Commercial |
$892.89
|
| Rate for Payer: PHP All Commercial |
$902.89
|
| Rate for Payer: Sagamore Health Network All Products |
$919.08
|
| Rate for Payer: Signature Care EPO |
$988.13
|
| Rate for Payer: Signature Care PPO |
$1,047.66
|
| Rate for Payer: United Healthcare Commercial |
$938.13
|
|
|
CONJUGATED ESTROGENS 0.625 MG ORAL TAB
|
Facility
|
IP
|
$46.40
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$43.15 |
| Rate for Payer: Aetna Commercial |
$40.09
|
| Rate for Payer: Cash Price |
$27.84
|
| Rate for Payer: Cigna All Commercial |
$40.05
|
| Rate for Payer: CORVEL All Commercial |
$43.15
|
| Rate for Payer: Coventry All Commercial |
$40.83
|
| Rate for Payer: Encore All Commercial |
$42.71
|
| Rate for Payer: Frontpath All Commercial |
$42.69
|
| Rate for Payer: Humana ChoiceCare |
$40.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.76
|
| Rate for Payer: PHCS All Commercial |
$34.80
|
| Rate for Payer: PHP All Commercial |
$35.19
|
| Rate for Payer: Sagamore Health Network All Products |
$35.82
|
| Rate for Payer: Signature Care EPO |
$38.51
|
| Rate for Payer: Signature Care PPO |
$40.83
|
| Rate for Payer: United Healthcare Commercial |
$36.57
|
|
