|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
OP
|
$33.26
|
|
|
Service Code
|
NDC 12496120203
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Aetna Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.07
|
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Centivo All Commercial |
$16.96
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Humana Medicare |
$16.96
|
| Rate for Payer: Lucent All Commercial |
$16.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.97
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
| Rate for Payer: United Healthcare Medicare |
$10.98
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
OP
|
$33.26
|
|
|
Service Code
|
NDC 12496120201
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Aetna Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.07
|
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Centivo All Commercial |
$16.96
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Humana Medicare |
$16.96
|
| Rate for Payer: Lucent All Commercial |
$16.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.97
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
| Rate for Payer: United Healthcare Medicare |
$10.98
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
IP
|
$33.26
|
|
|
Service Code
|
NDC 12496120203
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.95 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.74
|
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
IP
|
$33.26
|
|
|
Service Code
|
NDC 12496120201
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.95 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.74
|
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
|
|
BUPRENORPHINE-NALOXONE 8-2 MG SL FILM
|
Facility
|
OP
|
$59.63
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
106177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.68 |
| Max. Negotiated Rate |
$55.45 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna Medicare |
$19.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$34.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.64
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Centivo All Commercial |
$30.41
|
| Rate for Payer: Cigna All Commercial |
$51.46
|
| Rate for Payer: CORVEL All Commercial |
$55.45
|
| Rate for Payer: Coventry All Commercial |
$52.47
|
| Rate for Payer: Encore All Commercial |
$54.89
|
| Rate for Payer: Frontpath All Commercial |
$54.86
|
| Rate for Payer: Humana ChoiceCare |
$51.50
|
| Rate for Payer: Humana Medicare |
$30.41
|
| Rate for Payer: Lucent All Commercial |
$30.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.66
|
| Rate for Payer: PHCS All Commercial |
$44.72
|
| Rate for Payer: PHP All Commercial |
$45.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.25
|
| Rate for Payer: Sagamore Health Network All Products |
$46.03
|
| Rate for Payer: Signature Care EPO |
$49.49
|
| Rate for Payer: Signature Care PPO |
$52.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.68
|
| Rate for Payer: United Healthcare Commercial |
$46.99
|
| Rate for Payer: United Healthcare Medicare |
$19.68
|
|
|
BUPRENORPHINE-NALOXONE 8-2 MG SL FILM
|
Facility
|
IP
|
$59.63
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
106177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.72 |
| Max. Negotiated Rate |
$55.45 |
| Rate for Payer: Aetna Commercial |
$51.52
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cigna All Commercial |
$51.46
|
| Rate for Payer: CORVEL All Commercial |
$55.45
|
| Rate for Payer: Coventry All Commercial |
$52.47
|
| Rate for Payer: Encore All Commercial |
$54.89
|
| Rate for Payer: Frontpath All Commercial |
$54.86
|
| Rate for Payer: Humana ChoiceCare |
$51.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.66
|
| Rate for Payer: PHCS All Commercial |
$44.72
|
| Rate for Payer: PHP All Commercial |
$45.22
|
| Rate for Payer: Sagamore Health Network All Products |
$46.03
|
| Rate for Payer: Signature Care EPO |
$49.49
|
| Rate for Payer: Signature Care PPO |
$52.47
|
| Rate for Payer: United Healthcare Commercial |
$46.99
|
|
|
BUPROPION HCL 100 MG ORAL SR12
|
Facility
|
OP
|
$5.43
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
18385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna Commercial |
$4.58
|
| Rate for Payer: Aetna Medicare |
$1.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Centivo All Commercial |
$2.77
|
| Rate for Payer: Cigna All Commercial |
$4.69
|
| Rate for Payer: CORVEL All Commercial |
$5.05
|
| Rate for Payer: Coventry All Commercial |
$4.78
|
| Rate for Payer: Encore All Commercial |
$5.00
|
| Rate for Payer: Frontpath All Commercial |
$5.00
|
| Rate for Payer: Humana ChoiceCare |
$4.69
|
| Rate for Payer: Humana Medicare |
$2.77
|
| Rate for Payer: Lucent All Commercial |
$2.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.89
|
| Rate for Payer: PHCS All Commercial |
$4.07
|
| Rate for Payer: PHP All Commercial |
$4.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.12
|
| Rate for Payer: Sagamore Health Network All Products |
$4.19
|
| Rate for Payer: Signature Care EPO |
$4.51
|
| Rate for Payer: Signature Care PPO |
$4.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.62
|
| Rate for Payer: United Healthcare Commercial |
$4.28
|
| Rate for Payer: United Healthcare Medicare |
$1.79
|
|
|
BUPROPION HCL 100 MG ORAL SR12
|
Facility
|
IP
|
$5.43
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
18385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna Commercial |
$4.69
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cigna All Commercial |
$4.69
|
| Rate for Payer: CORVEL All Commercial |
$5.05
|
| Rate for Payer: Coventry All Commercial |
$4.78
|
| Rate for Payer: Encore All Commercial |
$5.00
|
| Rate for Payer: Frontpath All Commercial |
$5.00
|
| Rate for Payer: Humana ChoiceCare |
$4.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.89
|
| Rate for Payer: PHCS All Commercial |
$4.07
|
| Rate for Payer: PHP All Commercial |
$4.12
|
| Rate for Payer: Sagamore Health Network All Products |
$4.19
|
| Rate for Payer: Signature Care EPO |
$4.51
|
| Rate for Payer: Signature Care PPO |
$4.78
|
| Rate for Payer: United Healthcare Commercial |
$4.28
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
IP
|
$7.21
|
|
|
Service Code
|
NDC 50268014311
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.23
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.49
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
OP
|
$7.21
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.09
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Centivo All Commercial |
$3.68
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Humana Medicare |
$3.68
|
| Rate for Payer: Lucent All Commercial |
$3.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.49
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.81
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.13
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
| Rate for Payer: United Healthcare Medicare |
$2.38
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
IP
|
$7.21
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.23
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.49
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
OP
|
$7.21
|
|
|
Service Code
|
NDC 50268014311
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.09
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Centivo All Commercial |
$3.68
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.71
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.64
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.23
|
| Rate for Payer: Humana Medicare |
$3.68
|
| Rate for Payer: Lucent All Commercial |
$3.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.49
|
| Rate for Payer: PHCS All Commercial |
$5.41
|
| Rate for Payer: PHP All Commercial |
$5.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.81
|
| Rate for Payer: Sagamore Health Network All Products |
$5.57
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.13
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
| Rate for Payer: United Healthcare Medicare |
$2.38
|
|
|
BUPROPION HCL 150 MG ORAL SR12
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 43598075260
|
| Hospital Charge Code |
18386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| Rate for Payer: Humana Medicare |
$0.90
|
| Rate for Payer: Lucent All Commercial |
$0.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.58
|
| Rate for Payer: PHCS All Commercial |
$1.32
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.49
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
BUPROPION HCL 150 MG ORAL SR12
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 43598075260
|
| Hospital Charge Code |
18386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.58
|
| Rate for Payer: PHCS All Commercial |
$1.32
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68180031906
|
| Hospital Charge Code |
36775
|
|
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 |
$0.62
|
| 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
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
IP
|
$17.73
|
|
|
Service Code
|
NDC 50268014013
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Aetna Commercial |
$15.32
|
| Rate for Payer: Cash Price |
$10.99
|
| Rate for Payer: Cigna All Commercial |
$15.30
|
| Rate for Payer: CORVEL All Commercial |
$16.49
|
| Rate for Payer: Coventry All Commercial |
$15.60
|
| Rate for Payer: Encore All Commercial |
$16.32
|
| Rate for Payer: Frontpath All Commercial |
$16.31
|
| Rate for Payer: Humana ChoiceCare |
$15.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.96
|
| Rate for Payer: PHCS All Commercial |
$13.30
|
| Rate for Payer: PHP All Commercial |
$13.45
|
| Rate for Payer: Sagamore Health Network All Products |
$13.69
|
| Rate for Payer: Signature Care EPO |
$14.72
|
| Rate for Payer: Signature Care PPO |
$15.60
|
| Rate for Payer: United Healthcare Commercial |
$13.97
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
OP
|
$17.73
|
|
|
Service Code
|
NDC 50268014013
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Aetna Commercial |
$14.96
|
| Rate for Payer: Aetna Medicare |
$5.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.44
|
| Rate for Payer: Cash Price |
$10.99
|
| Rate for Payer: Centivo All Commercial |
$9.04
|
| Rate for Payer: Cigna All Commercial |
$15.30
|
| Rate for Payer: CORVEL All Commercial |
$16.49
|
| Rate for Payer: Coventry All Commercial |
$15.60
|
| Rate for Payer: Encore All Commercial |
$16.32
|
| Rate for Payer: Frontpath All Commercial |
$16.31
|
| Rate for Payer: Humana ChoiceCare |
$15.31
|
| Rate for Payer: Humana Medicare |
$9.04
|
| Rate for Payer: Lucent All Commercial |
$9.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.96
|
| Rate for Payer: PHCS All Commercial |
$13.30
|
| Rate for Payer: PHP All Commercial |
$13.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.92
|
| Rate for Payer: Sagamore Health Network All Products |
$13.69
|
| Rate for Payer: Signature Care EPO |
$14.72
|
| Rate for Payer: Signature Care PPO |
$15.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.07
|
| Rate for Payer: United Healthcare Commercial |
$13.97
|
| Rate for Payer: United Healthcare Medicare |
$5.85
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68180031906
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
BUSPIRONE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 51079098620
|
| Hospital Charge Code |
9323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Centivo All Commercial |
$0.57
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.97
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.01
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.44
|
| Rate for Payer: Sagamore Health Network All Products |
$0.87
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
|
|
BUSPIRONE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 51079098620
|
| Hospital Charge Code |
9323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.05
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.04
|
| Rate for Payer: Frontpath All Commercial |
$1.04
|
| Rate for Payer: Humana ChoiceCare |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.01
|
| Rate for Payer: PHCS All Commercial |
$0.85
|
| Rate for Payer: PHP All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$0.87
|
| Rate for Payer: Signature Care EPO |
$0.94
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$0.89
|
|
|
BUSPIRONE 15 MG ORAL TAB
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
NDC 50268013515
|
| Hospital Charge Code |
17464
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.84
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.89
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.02
|
| Rate for Payer: Humana ChoiceCare |
$2.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.49
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| Rate for Payer: Signature Care PPO |
$2.89
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
|
|
BUSPIRONE 15 MG ORAL TAB
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
NDC 50268013515
|
| Hospital Charge Code |
17464
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: Aetna Medicare |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Centivo All Commercial |
$1.67
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.89
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.02
|
| Rate for Payer: Humana ChoiceCare |
$2.84
|
| Rate for Payer: Humana Medicare |
$1.67
|
| Rate for Payer: Lucent All Commercial |
$1.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| Rate for Payer: Signature Care PPO |
$2.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.79
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-300-40 MG ORAL CAP
|
Facility
|
IP
|
$5.93
|
|
|
Service Code
|
NDC 70010004401
|
| Hospital Charge Code |
104993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$5.51 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Cash Price |
$3.68
|
| Rate for Payer: Cigna All Commercial |
$5.12
|
| Rate for Payer: CORVEL All Commercial |
$5.51
|
| Rate for Payer: Coventry All Commercial |
$5.22
|
| Rate for Payer: Encore All Commercial |
$5.46
|
| Rate for Payer: Frontpath All Commercial |
$5.45
|
| Rate for Payer: Humana ChoiceCare |
$5.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.34
|
| Rate for Payer: PHCS All Commercial |
$4.45
|
| Rate for Payer: PHP All Commercial |
$4.50
|
| Rate for Payer: Sagamore Health Network All Products |
$4.58
|
| Rate for Payer: Signature Care EPO |
$4.92
|
| Rate for Payer: Signature Care PPO |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$4.67
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-300-40 MG ORAL CAP
|
Facility
|
OP
|
$5.93
|
|
|
Service Code
|
NDC 70010004401
|
| Hospital Charge Code |
104993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$5.51 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Aetna Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.15
|
| Rate for Payer: Cash Price |
$3.68
|
| Rate for Payer: Centivo All Commercial |
$3.02
|
| Rate for Payer: Cigna All Commercial |
$5.12
|
| Rate for Payer: CORVEL All Commercial |
$5.51
|
| Rate for Payer: Coventry All Commercial |
$5.22
|
| Rate for Payer: Encore All Commercial |
$5.46
|
| Rate for Payer: Frontpath All Commercial |
$5.45
|
| Rate for Payer: Humana ChoiceCare |
$5.12
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Lucent All Commercial |
$3.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.34
|
| Rate for Payer: PHCS All Commercial |
$4.45
|
| Rate for Payer: PHP All Commercial |
$4.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.31
|
| Rate for Payer: Sagamore Health Network All Products |
$4.58
|
| Rate for Payer: Signature Care EPO |
$4.92
|
| Rate for Payer: Signature Care PPO |
$5.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.04
|
| Rate for Payer: United Healthcare Commercial |
$4.67
|
| Rate for Payer: United Healthcare Medicare |
$1.96
|
|
