|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG ORAL TAB
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
NDC 00904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.63
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.06
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$6.00
|
| Rate for Payer: Frontpath All Commercial |
$6.00
|
| Rate for Payer: Humana ChoiceCare |
$5.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.87
|
| Rate for Payer: PHCS All Commercial |
$4.89
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.41
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: United Healthcare Commercial |
$5.14
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG ORAL TAB
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
NDC 00904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.50
|
| Rate for Payer: Aetna Medicare |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.37
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Centivo All Commercial |
$3.32
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.06
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$6.00
|
| Rate for Payer: Frontpath All Commercial |
$6.00
|
| Rate for Payer: Humana ChoiceCare |
$5.63
|
| Rate for Payer: Humana Medicare |
$3.32
|
| Rate for Payer: Lucent All Commercial |
$3.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.87
|
| Rate for Payer: PHCS All Commercial |
$4.89
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.54
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.41
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.54
|
| Rate for Payer: United Healthcare Commercial |
$5.14
|
| Rate for Payer: United Healthcare Medicare |
$2.15
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP SPR CMCH
|
Facility
|
IP
|
$347.16
|
|
|
Service Code
|
NDC 10223020104
|
| Hospital Charge Code |
14010009328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.37 |
| Max. Negotiated Rate |
$322.86 |
| Rate for Payer: Aetna Commercial |
$299.95
|
| Rate for Payer: Cash Price |
$215.24
|
| Rate for Payer: Cigna All Commercial |
$299.60
|
| Rate for Payer: CORVEL All Commercial |
$322.86
|
| Rate for Payer: Coventry All Commercial |
$305.50
|
| Rate for Payer: Encore All Commercial |
$319.56
|
| Rate for Payer: Frontpath All Commercial |
$319.39
|
| Rate for Payer: Humana ChoiceCare |
$299.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.44
|
| Rate for Payer: PHCS All Commercial |
$260.37
|
| Rate for Payer: PHP All Commercial |
$263.29
|
| Rate for Payer: Sagamore Health Network All Products |
$268.01
|
| Rate for Payer: Signature Care EPO |
$288.14
|
| Rate for Payer: Signature Care PPO |
$305.50
|
| Rate for Payer: United Healthcare Commercial |
$273.56
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP SPR CMCH
|
Facility
|
OP
|
$347.16
|
|
|
Service Code
|
NDC 10223020104
|
| Hospital Charge Code |
14010009328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$322.86 |
| Rate for Payer: Aetna Commercial |
$293.00
|
| Rate for Payer: Aetna Medicare |
$114.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$114.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$199.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$217.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$131.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.02
|
| Rate for Payer: Cash Price |
$215.24
|
| Rate for Payer: Cash Price |
$215.24
|
| Rate for Payer: Centivo All Commercial |
$177.05
|
| Rate for Payer: Cigna All Commercial |
$299.60
|
| Rate for Payer: CORVEL All Commercial |
$322.86
|
| Rate for Payer: Coventry All Commercial |
$305.50
|
| Rate for Payer: Encore All Commercial |
$319.56
|
| Rate for Payer: Frontpath All Commercial |
$319.39
|
| Rate for Payer: Humana ChoiceCare |
$299.84
|
| Rate for Payer: Humana Medicare |
$177.05
|
| Rate for Payer: Lucent All Commercial |
$177.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.44
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$260.37
|
| Rate for Payer: PHP All Commercial |
$263.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$135.39
|
| Rate for Payer: Sagamore Health Network All Products |
$268.01
|
| Rate for Payer: Signature Care EPO |
$288.14
|
| Rate for Payer: Signature Care PPO |
$305.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$295.09
|
| Rate for Payer: United Healthcare Commercial |
$273.56
|
| Rate for Payer: United Healthcare Medicare |
$114.56
|
|
|
BUTORPHANOL 1 MG/ML INJ SOLN
|
Facility
|
OP
|
$41.70
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$38.78 |
| Rate for Payer: Aetna Commercial |
$35.19
|
| Rate for Payer: Aetna Medicare |
$13.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.14
|
| Rate for Payer: Cash Price |
$25.85
|
| Rate for Payer: Centivo All Commercial |
$21.27
|
| Rate for Payer: Cigna All Commercial |
$35.99
|
| Rate for Payer: CORVEL All Commercial |
$38.78
|
| Rate for Payer: Coventry All Commercial |
$36.70
|
| Rate for Payer: Encore All Commercial |
$38.38
|
| Rate for Payer: Frontpath All Commercial |
$38.36
|
| Rate for Payer: Humana ChoiceCare |
$36.02
|
| Rate for Payer: Humana Medicare |
$21.27
|
| Rate for Payer: Lucent All Commercial |
$21.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.53
|
| Rate for Payer: PHCS All Commercial |
$31.27
|
| Rate for Payer: PHP All Commercial |
$31.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.26
|
| Rate for Payer: Sagamore Health Network All Products |
$32.19
|
| Rate for Payer: Signature Care EPO |
$34.61
|
| Rate for Payer: Signature Care PPO |
$36.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.44
|
| Rate for Payer: United Healthcare Commercial |
$32.86
|
| Rate for Payer: United Healthcare Medicare |
$13.76
|
|
|
BUTORPHANOL 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$41.70
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.27 |
| Max. Negotiated Rate |
$38.78 |
| Rate for Payer: Aetna Commercial |
$36.03
|
| Rate for Payer: Cash Price |
$25.85
|
| Rate for Payer: Cigna All Commercial |
$35.99
|
| Rate for Payer: CORVEL All Commercial |
$38.78
|
| Rate for Payer: Coventry All Commercial |
$36.70
|
| Rate for Payer: Encore All Commercial |
$38.38
|
| Rate for Payer: Frontpath All Commercial |
$38.36
|
| Rate for Payer: Humana ChoiceCare |
$36.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.53
|
| Rate for Payer: PHCS All Commercial |
$31.27
|
| Rate for Payer: PHP All Commercial |
$31.62
|
| Rate for Payer: Sagamore Health Network All Products |
$32.19
|
| Rate for Payer: Signature Care EPO |
$34.61
|
| Rate for Payer: Signature Care PPO |
$36.70
|
| Rate for Payer: United Healthcare Commercial |
$32.86
|
|
|
CAFFEINE 200 MG ORAL TAB
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 70000040901
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: Aetna Medicare |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Centivo All Commercial |
$0.30
|
| Rate for Payer: Cigna All Commercial |
$0.51
|
| Rate for Payer: CORVEL All Commercial |
$0.55
|
| Rate for Payer: Coventry All Commercial |
$0.52
|
| Rate for Payer: Encore All Commercial |
$0.55
|
| Rate for Payer: Frontpath All Commercial |
$0.55
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Humana Medicare |
$0.30
|
| Rate for Payer: Lucent All Commercial |
$0.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.54
|
| Rate for Payer: PHCS All Commercial |
$0.45
|
| Rate for Payer: PHP All Commercial |
$0.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.23
|
| Rate for Payer: Sagamore Health Network All Products |
$0.46
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
|
|
CAFFEINE 200 MG ORAL TAB
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 70000040901
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna All Commercial |
$0.51
|
| Rate for Payer: CORVEL All Commercial |
$0.55
|
| Rate for Payer: Coventry All Commercial |
$0.52
|
| Rate for Payer: Encore All Commercial |
$0.55
|
| Rate for Payer: Frontpath All Commercial |
$0.55
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.54
|
| Rate for Payer: PHCS All Commercial |
$0.45
|
| Rate for Payer: PHP All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.46
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
|
|
CALCITONIN (SALMON) 200 UNITS/ML INJ SOLN
|
Facility
|
OP
|
$10,397.80
|
|
|
Service Code
|
HCPCS J0630
|
| Hospital Charge Code |
9347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,287.55 |
| Max. Negotiated Rate |
$9,669.95 |
| Rate for Payer: Aetna Commercial |
$8,775.74
|
| Rate for Payer: Aetna Medicare |
$3,431.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,431.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,971.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,499.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,287.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,945.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,774.40
|
| Rate for Payer: Cash Price |
$6,446.64
|
| Rate for Payer: Cash Price |
$6,446.64
|
| Rate for Payer: Centivo All Commercial |
$5,302.88
|
| Rate for Payer: Cigna All Commercial |
$8,973.30
|
| Rate for Payer: CORVEL All Commercial |
$9,669.95
|
| Rate for Payer: Coventry All Commercial |
$9,150.06
|
| Rate for Payer: Encore All Commercial |
$9,571.17
|
| Rate for Payer: Frontpath All Commercial |
$9,565.98
|
| Rate for Payer: Humana ChoiceCare |
$8,980.58
|
| Rate for Payer: Humana Medicare |
$5,302.88
|
| Rate for Payer: Lucent All Commercial |
$5,302.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,358.02
|
| Rate for Payer: Managed Health Services Medicaid |
$3,287.55
|
| Rate for Payer: MDWise Medicaid |
$3,287.55
|
| Rate for Payer: PHCS All Commercial |
$7,798.35
|
| Rate for Payer: PHP All Commercial |
$7,885.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,055.14
|
| Rate for Payer: Sagamore Health Network All Products |
$8,027.10
|
| Rate for Payer: Signature Care EPO |
$8,630.17
|
| Rate for Payer: Signature Care PPO |
$9,150.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,838.13
|
| Rate for Payer: United Healthcare Commercial |
$8,193.47
|
| Rate for Payer: United Healthcare Medicare |
$3,431.27
|
|
|
CALCITONIN (SALMON) 200 UNITS/ML INJ SOLN
|
Facility
|
IP
|
$10,397.80
|
|
|
Service Code
|
HCPCS J0630
|
| Hospital Charge Code |
9347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,798.35 |
| Max. Negotiated Rate |
$9,669.95 |
| Rate for Payer: Aetna Commercial |
$8,983.70
|
| Rate for Payer: Cash Price |
$6,446.64
|
| Rate for Payer: Cigna All Commercial |
$8,973.30
|
| Rate for Payer: CORVEL All Commercial |
$9,669.95
|
| Rate for Payer: Coventry All Commercial |
$9,150.06
|
| Rate for Payer: Encore All Commercial |
$9,571.17
|
| Rate for Payer: Frontpath All Commercial |
$9,565.98
|
| Rate for Payer: Humana ChoiceCare |
$8,980.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,358.02
|
| Rate for Payer: PHCS All Commercial |
$7,798.35
|
| Rate for Payer: PHP All Commercial |
$7,885.69
|
| Rate for Payer: Sagamore Health Network All Products |
$8,027.10
|
| Rate for Payer: Signature Care EPO |
$8,630.17
|
| Rate for Payer: Signature Care PPO |
$9,150.06
|
| Rate for Payer: United Healthcare Commercial |
$8,193.47
|
|
|
CALCITRIOL 0.25 MCG ORAL CAP
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
9350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Aetna Commercial |
$1.38
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.38
|
| Rate for Payer: CORVEL All Commercial |
$1.49
|
| Rate for Payer: Coventry All Commercial |
$1.41
|
| Rate for Payer: Encore All Commercial |
$1.48
|
| Rate for Payer: Frontpath All Commercial |
$1.47
|
| Rate for Payer: Humana ChoiceCare |
$1.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.44
|
| Rate for Payer: PHCS All Commercial |
$1.20
|
| Rate for Payer: PHP All Commercial |
$1.22
|
| Rate for Payer: Sagamore Health Network All Products |
$1.24
|
| Rate for Payer: Signature Care EPO |
$1.33
|
| Rate for Payer: Signature Care PPO |
$1.41
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
|
|
CALCITRIOL 0.25 MCG ORAL CAP
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
9350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Aetna Commercial |
$1.35
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Centivo All Commercial |
$0.82
|
| Rate for Payer: Cigna All Commercial |
$1.38
|
| Rate for Payer: CORVEL All Commercial |
$1.49
|
| Rate for Payer: Coventry All Commercial |
$1.41
|
| Rate for Payer: Encore All Commercial |
$1.48
|
| Rate for Payer: Frontpath All Commercial |
$1.47
|
| Rate for Payer: Humana ChoiceCare |
$1.38
|
| Rate for Payer: Humana Medicare |
$0.82
|
| Rate for Payer: Lucent All Commercial |
$0.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.44
|
| Rate for Payer: PHCS All Commercial |
$1.20
|
| Rate for Payer: PHP All Commercial |
$1.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1.24
|
| Rate for Payer: Signature Care EPO |
$1.33
|
| Rate for Payer: Signature Care PPO |
$1.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
CALCIUM CARBONATE 500 MG ORAL CHEW
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 48433010601
|
| Hospital Charge Code |
9385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Centivo All Commercial |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Humana Medicare |
$0.60
|
| Rate for Payer: Lucent All Commercial |
$0.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
|
|
CALCIUM CARBONATE 500 MG ORAL CHEW
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 48433010601
|
| Hospital Charge Code |
9385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$1.02
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
|
|
CALCIUM CARBONATE-VITAMIN D3 600 MG-5 MCG (200 UNIT) ORAL TAB
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 80681013800
|
| Hospital Charge Code |
9378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.14
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.14
|
| Rate for Payer: PHCS All Commercial |
$0.12
|
| Rate for Payer: PHP All Commercial |
$0.12
|
| Rate for Payer: Sagamore Health Network All Products |
$0.12
|
| Rate for Payer: Signature Care EPO |
$0.13
|
| Rate for Payer: Signature Care PPO |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
|
|
CALCIUM CARBONATE-VITAMIN D3 600 MG-5 MCG (200 UNIT) ORAL TAB
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 80681013800
|
| Hospital Charge Code |
9378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.13
|
| Rate for Payer: Aetna Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Centivo All Commercial |
$0.08
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.14
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Humana Medicare |
$0.08
|
| Rate for Payer: Lucent All Commercial |
$0.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.14
|
| Rate for Payer: PHCS All Commercial |
$0.12
|
| Rate for Payer: PHP All Commercial |
$0.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.06
|
| Rate for Payer: Sagamore Health Network All Products |
$0.12
|
| Rate for Payer: Signature Care EPO |
$0.13
|
| Rate for Payer: Signature Care PPO |
$0.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRG
|
Facility
|
OP
|
$63.63
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: Aetna Commercial |
$53.70
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.10
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Centivo All Commercial |
$32.45
|
| Rate for Payer: Cigna All Commercial |
$54.91
|
| Rate for Payer: CORVEL All Commercial |
$59.18
|
| Rate for Payer: Coventry All Commercial |
$55.99
|
| Rate for Payer: Encore All Commercial |
$58.57
|
| Rate for Payer: Frontpath All Commercial |
$58.54
|
| Rate for Payer: Humana ChoiceCare |
$54.96
|
| Rate for Payer: Humana Medicare |
$32.45
|
| Rate for Payer: Lucent All Commercial |
$32.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.27
|
| Rate for Payer: PHCS All Commercial |
$47.72
|
| Rate for Payer: PHP All Commercial |
$48.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.82
|
| Rate for Payer: Sagamore Health Network All Products |
$49.12
|
| Rate for Payer: Signature Care EPO |
$52.81
|
| Rate for Payer: Signature Care PPO |
$55.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$54.09
|
| Rate for Payer: United Healthcare Commercial |
$50.14
|
| Rate for Payer: United Healthcare Medicare |
$21.00
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRG
|
Facility
|
IP
|
$63.63
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.72 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: Aetna Commercial |
$54.98
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cigna All Commercial |
$54.91
|
| Rate for Payer: CORVEL All Commercial |
$59.18
|
| Rate for Payer: Coventry All Commercial |
$55.99
|
| Rate for Payer: Encore All Commercial |
$58.57
|
| Rate for Payer: Frontpath All Commercial |
$58.54
|
| Rate for Payer: Humana ChoiceCare |
$54.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.27
|
| Rate for Payer: PHCS All Commercial |
$47.72
|
| Rate for Payer: PHP All Commercial |
$48.26
|
| Rate for Payer: Sagamore Health Network All Products |
$49.12
|
| Rate for Payer: Signature Care EPO |
$52.81
|
| Rate for Payer: Signature Care PPO |
$55.99
|
| Rate for Payer: United Healthcare Commercial |
$50.14
|
|
|
CALCIUM GLUCONATE 100 MG/ML (10%) IV SOLN
|
Facility
|
OP
|
$74.34
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
1312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.53 |
| Max. Negotiated Rate |
$69.14 |
| Rate for Payer: Aetna Commercial |
$62.74
|
| Rate for Payer: Aetna Medicare |
$24.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$42.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.99
|
| Rate for Payer: Cash Price |
$46.09
|
| Rate for Payer: Centivo All Commercial |
$37.91
|
| Rate for Payer: Cigna All Commercial |
$64.16
|
| Rate for Payer: CORVEL All Commercial |
$69.14
|
| Rate for Payer: Coventry All Commercial |
$65.42
|
| Rate for Payer: Encore All Commercial |
$68.43
|
| Rate for Payer: Frontpath All Commercial |
$68.39
|
| Rate for Payer: Humana ChoiceCare |
$64.21
|
| Rate for Payer: Humana Medicare |
$37.91
|
| Rate for Payer: Lucent All Commercial |
$37.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.91
|
| Rate for Payer: PHCS All Commercial |
$55.76
|
| Rate for Payer: PHP All Commercial |
$56.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.99
|
| Rate for Payer: Sagamore Health Network All Products |
$57.39
|
| Rate for Payer: Signature Care EPO |
$61.70
|
| Rate for Payer: Signature Care PPO |
$65.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$63.19
|
| Rate for Payer: United Healthcare Commercial |
$58.58
|
| Rate for Payer: United Healthcare Medicare |
$24.53
|
|
|
CALCIUM GLUCONATE 100 MG/ML (10%) IV SOLN
|
Facility
|
IP
|
$74.34
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
1312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$69.14 |
| Rate for Payer: Aetna Commercial |
$64.23
|
| Rate for Payer: Cash Price |
$46.09
|
| Rate for Payer: Cigna All Commercial |
$64.16
|
| Rate for Payer: CORVEL All Commercial |
$69.14
|
| Rate for Payer: Coventry All Commercial |
$65.42
|
| Rate for Payer: Encore All Commercial |
$68.43
|
| Rate for Payer: Frontpath All Commercial |
$68.39
|
| Rate for Payer: Humana ChoiceCare |
$64.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.91
|
| Rate for Payer: PHCS All Commercial |
$55.76
|
| Rate for Payer: PHP All Commercial |
$56.38
|
| Rate for Payer: Sagamore Health Network All Products |
$57.39
|
| Rate for Payer: Signature Care EPO |
$61.70
|
| Rate for Payer: Signature Care PPO |
$65.42
|
| Rate for Payer: United Healthcare Commercial |
$58.58
|
|
|
CALCIUM POLYCARBOPHIL 625 MG ORAL TAB
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 00536430608
|
| Hospital Charge Code |
11046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna All Commercial |
$0.48
|
| Rate for Payer: CORVEL All Commercial |
$0.51
|
| Rate for Payer: Coventry All Commercial |
$0.49
|
| Rate for Payer: Encore All Commercial |
$0.51
|
| Rate for Payer: Frontpath All Commercial |
$0.51
|
| Rate for Payer: Humana ChoiceCare |
$0.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.50
|
| Rate for Payer: PHCS All Commercial |
$0.41
|
| Rate for Payer: PHP All Commercial |
$0.42
|
| Rate for Payer: Sagamore Health Network All Products |
$0.43
|
| Rate for Payer: Signature Care EPO |
$0.46
|
| Rate for Payer: Signature Care PPO |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
|
|
CALCIUM POLYCARBOPHIL 625 MG ORAL TAB
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 00536430608
|
| Hospital Charge Code |
11046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna Commercial |
$0.47
|
| Rate for Payer: Aetna Medicare |
$0.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Centivo All Commercial |
$0.28
|
| Rate for Payer: Cigna All Commercial |
$0.48
|
| Rate for Payer: CORVEL All Commercial |
$0.51
|
| Rate for Payer: Coventry All Commercial |
$0.49
|
| Rate for Payer: Encore All Commercial |
$0.51
|
| Rate for Payer: Frontpath All Commercial |
$0.51
|
| Rate for Payer: Humana ChoiceCare |
$0.48
|
| Rate for Payer: Humana Medicare |
$0.28
|
| Rate for Payer: Lucent All Commercial |
$0.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.50
|
| Rate for Payer: PHCS All Commercial |
$0.41
|
| Rate for Payer: PHP All Commercial |
$0.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.22
|
| Rate for Payer: Sagamore Health Network All Products |
$0.43
|
| Rate for Payer: Signature Care EPO |
$0.46
|
| Rate for Payer: Signature Care PPO |
$0.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.47
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
|
|
CAMPHOR-METHYL SALICYL-MENTHOL 4-30-10 % TOP CREA
|
Facility
|
OP
|
$31.52
|
|
|
Service Code
|
NDC 74300008193
|
| Hospital Charge Code |
103884
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$29.31 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Medicare |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.44
|
| Rate for Payer: Cash Price |
$19.54
|
| Rate for Payer: Centivo All Commercial |
$16.08
|
| Rate for Payer: Cigna All Commercial |
$27.20
|
| Rate for Payer: CORVEL All Commercial |
$29.31
|
| Rate for Payer: Coventry All Commercial |
$27.74
|
| Rate for Payer: Encore All Commercial |
$29.02
|
| Rate for Payer: Frontpath All Commercial |
$29.00
|
| Rate for Payer: Humana ChoiceCare |
$27.22
|
| Rate for Payer: Humana Medicare |
$16.08
|
| Rate for Payer: Lucent All Commercial |
$16.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.37
|
| Rate for Payer: PHCS All Commercial |
$23.64
|
| Rate for Payer: PHP All Commercial |
$23.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.29
|
| Rate for Payer: Sagamore Health Network All Products |
$24.33
|
| Rate for Payer: Signature Care EPO |
$26.16
|
| Rate for Payer: Signature Care PPO |
$27.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.79
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
|
|
CAMPHOR-METHYL SALICYL-MENTHOL 4-30-10 % TOP CREA
|
Facility
|
IP
|
$31.52
|
|
|
Service Code
|
NDC 74300008193
|
| Hospital Charge Code |
103884
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$29.31 |
| Rate for Payer: Aetna Commercial |
$27.23
|
| Rate for Payer: Cash Price |
$19.54
|
| Rate for Payer: Cigna All Commercial |
$27.20
|
| Rate for Payer: CORVEL All Commercial |
$29.31
|
| Rate for Payer: Coventry All Commercial |
$27.74
|
| Rate for Payer: Encore All Commercial |
$29.02
|
| Rate for Payer: Frontpath All Commercial |
$29.00
|
| Rate for Payer: Humana ChoiceCare |
$27.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.37
|
| Rate for Payer: PHCS All Commercial |
$23.64
|
| Rate for Payer: PHP All Commercial |
$23.91
|
| Rate for Payer: Sagamore Health Network All Products |
$24.33
|
| Rate for Payer: Signature Care EPO |
$26.16
|
| Rate for Payer: Signature Care PPO |
$27.74
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
|
|
CANTHARIDIN-PODOPHYLLIN-SALICYLIC ACID SOLUTION
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
NDC 05446097003
|
| Hospital Charge Code |
810084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$697.50 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cigna All Commercial |
$647.25
|
| Rate for Payer: CORVEL All Commercial |
$697.50
|
| Rate for Payer: Coventry All Commercial |
$660.00
|
| Rate for Payer: Encore All Commercial |
$690.38
|
| Rate for Payer: Frontpath All Commercial |
$690.00
|
| Rate for Payer: Humana ChoiceCare |
$647.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$675.00
|
| Rate for Payer: PHCS All Commercial |
$562.50
|
| Rate for Payer: PHP All Commercial |
$568.80
|
| Rate for Payer: Sagamore Health Network All Products |
$579.00
|
| Rate for Payer: Signature Care EPO |
$622.50
|
| Rate for Payer: Signature Care PPO |
$660.00
|
| Rate for Payer: United Healthcare Commercial |
$591.00
|
|
