|
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
|
|
|
CAPSAICIN 0.025 % TOP CREA
|
Facility
|
IP
|
$26.88
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
1350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.22
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna All Commercial |
$23.20
|
| Rate for Payer: CORVEL All Commercial |
$25.00
|
| Rate for Payer: Coventry All Commercial |
$23.65
|
| Rate for Payer: Encore All Commercial |
$24.74
|
| Rate for Payer: Frontpath All Commercial |
$24.73
|
| Rate for Payer: Humana ChoiceCare |
$23.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.19
|
| Rate for Payer: PHCS All Commercial |
$20.16
|
| Rate for Payer: PHP All Commercial |
$20.39
|
| Rate for Payer: Sagamore Health Network All Products |
$20.75
|
| Rate for Payer: Signature Care EPO |
$22.31
|
| Rate for Payer: Signature Care PPO |
$23.65
|
| Rate for Payer: United Healthcare Commercial |
$21.18
|
|
|
CAPSAICIN 0.025 % TOP CREA
|
Facility
|
OP
|
$26.88
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
1350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$22.69
|
| Rate for Payer: Aetna Medicare |
$8.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.76
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Centivo All Commercial |
$13.71
|
| Rate for Payer: Cigna All Commercial |
$23.20
|
| Rate for Payer: CORVEL All Commercial |
$25.00
|
| Rate for Payer: Coventry All Commercial |
$23.65
|
| Rate for Payer: Encore All Commercial |
$24.74
|
| Rate for Payer: Frontpath All Commercial |
$24.73
|
| Rate for Payer: Humana ChoiceCare |
$23.22
|
| Rate for Payer: Humana Medicare |
$13.71
|
| Rate for Payer: Lucent All Commercial |
$13.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.19
|
| Rate for Payer: PHCS All Commercial |
$20.16
|
| Rate for Payer: PHP All Commercial |
$20.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.48
|
| Rate for Payer: Sagamore Health Network All Products |
$20.75
|
| Rate for Payer: Signature Care EPO |
$22.31
|
| Rate for Payer: Signature Care PPO |
$23.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.85
|
| Rate for Payer: United Healthcare Commercial |
$21.18
|
| Rate for Payer: United Healthcare Medicare |
$8.87
|
|
|
CAPTOPRIL 12.5 MG ORAL TAB
|
Facility
|
OP
|
$6.66
|
|
|
Service Code
|
NDC 00904710561
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$6.20 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Medicare |
$2.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.42
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Centivo All Commercial |
$3.40
|
| Rate for Payer: Cigna All Commercial |
$5.75
|
| Rate for Payer: CORVEL All Commercial |
$6.20
|
| Rate for Payer: Coventry All Commercial |
$5.86
|
| Rate for Payer: Encore All Commercial |
$6.13
|
| Rate for Payer: Frontpath All Commercial |
$6.13
|
| Rate for Payer: Humana ChoiceCare |
$5.76
|
| Rate for Payer: Humana Medicare |
$3.40
|
| Rate for Payer: Lucent All Commercial |
$3.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.00
|
| Rate for Payer: PHCS All Commercial |
$5.00
|
| Rate for Payer: PHP All Commercial |
$5.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.60
|
| Rate for Payer: Sagamore Health Network All Products |
$5.14
|
| Rate for Payer: Signature Care EPO |
$5.53
|
| Rate for Payer: Signature Care PPO |
$5.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.66
|
| Rate for Payer: United Healthcare Commercial |
$5.25
|
| Rate for Payer: United Healthcare Medicare |
$2.20
|
|
|
CAPTOPRIL 12.5 MG ORAL TAB
|
Facility
|
IP
|
$6.66
|
|
|
Service Code
|
NDC 00904710561
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$6.20 |
| Rate for Payer: Aetna Commercial |
$5.76
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cigna All Commercial |
$5.75
|
| Rate for Payer: CORVEL All Commercial |
$6.20
|
| Rate for Payer: Coventry All Commercial |
$5.86
|
| Rate for Payer: Encore All Commercial |
$6.13
|
| Rate for Payer: Frontpath All Commercial |
$6.13
|
| Rate for Payer: Humana ChoiceCare |
$5.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.00
|
| Rate for Payer: PHCS All Commercial |
$5.00
|
| Rate for Payer: PHP All Commercial |
$5.05
|
| Rate for Payer: Sagamore Health Network All Products |
$5.14
|
| Rate for Payer: Signature Care EPO |
$5.53
|
| Rate for Payer: Signature Care PPO |
$5.86
|
| Rate for Payer: United Healthcare Commercial |
$5.25
|
|
|
CARBACHOL 0.01 % IO SOLN
|
Facility
|
IP
|
$296.66
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$222.49 |
| Max. Negotiated Rate |
$275.89 |
| Rate for Payer: Aetna Commercial |
$256.31
|
| Rate for Payer: Cash Price |
$183.93
|
| Rate for Payer: Cigna All Commercial |
$256.01
|
| Rate for Payer: CORVEL All Commercial |
$275.89
|
| Rate for Payer: Coventry All Commercial |
$261.06
|
| Rate for Payer: Encore All Commercial |
$273.07
|
| Rate for Payer: Frontpath All Commercial |
$272.92
|
| Rate for Payer: Humana ChoiceCare |
$256.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$266.99
|
| Rate for Payer: PHCS All Commercial |
$222.49
|
| Rate for Payer: PHP All Commercial |
$224.98
|
| Rate for Payer: Sagamore Health Network All Products |
$229.02
|
| Rate for Payer: Signature Care EPO |
$246.23
|
| Rate for Payer: Signature Care PPO |
$261.06
|
| Rate for Payer: United Healthcare Commercial |
$233.77
|
|
|
CARBACHOL 0.01 % IO SOLN
|
Facility
|
OP
|
$296.66
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$275.89 |
| Rate for Payer: Aetna Commercial |
$250.38
|
| Rate for Payer: Aetna Medicare |
$97.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$170.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$185.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$112.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$107.69
|
| Rate for Payer: Cash Price |
$183.93
|
| Rate for Payer: Cash Price |
$183.93
|
| Rate for Payer: Centivo All Commercial |
$151.30
|
| Rate for Payer: Cigna All Commercial |
$256.01
|
| Rate for Payer: CORVEL All Commercial |
$275.89
|
| Rate for Payer: Coventry All Commercial |
$261.06
|
| Rate for Payer: Encore All Commercial |
$273.07
|
| Rate for Payer: Frontpath All Commercial |
$272.92
|
| Rate for Payer: Humana ChoiceCare |
$256.22
|
| Rate for Payer: Humana Medicare |
$151.30
|
| Rate for Payer: Lucent All Commercial |
$151.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$266.99
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$222.49
|
| Rate for Payer: PHP All Commercial |
$224.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$115.70
|
| Rate for Payer: Sagamore Health Network All Products |
$229.02
|
| Rate for Payer: Signature Care EPO |
$246.23
|
| Rate for Payer: Signature Care PPO |
$261.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$252.16
|
| Rate for Payer: United Healthcare Commercial |
$233.77
|
| Rate for Payer: United Healthcare Medicare |
$97.90
|
|
|
CARBAMAZEPINE 200 MG ORAL TAB
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna Commercial |
$2.54
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cigna All Commercial |
$2.54
|
| Rate for Payer: CORVEL All Commercial |
$2.73
|
| Rate for Payer: Coventry All Commercial |
$2.59
|
| Rate for Payer: Encore All Commercial |
$2.71
|
| Rate for Payer: Frontpath All Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$2.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.65
|
| Rate for Payer: PHCS All Commercial |
$2.20
|
| Rate for Payer: PHP All Commercial |
$2.23
|
| Rate for Payer: Sagamore Health Network All Products |
$2.27
|
| Rate for Payer: Signature Care EPO |
$2.44
|
| Rate for Payer: Signature Care PPO |
$2.59
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
|
|
CARBAMAZEPINE 200 MG ORAL TAB
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna Commercial |
$2.48
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Centivo All Commercial |
$1.50
|
| Rate for Payer: Cigna All Commercial |
$2.54
|
| Rate for Payer: CORVEL All Commercial |
$2.73
|
| Rate for Payer: Coventry All Commercial |
$2.59
|
| Rate for Payer: Encore All Commercial |
$2.71
|
| Rate for Payer: Frontpath All Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$2.54
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Lucent All Commercial |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.65
|
| Rate for Payer: PHCS All Commercial |
$2.20
|
| Rate for Payer: PHP All Commercial |
$2.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2.27
|
| Rate for Payer: Signature Care EPO |
$2.44
|
| Rate for Payer: Signature Care PPO |
$2.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.50
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$0.97
|
|
|
CARBAMAZEPINE 200 MG ORAL TB12
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
NDC 68084056121
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.18 |
| Max. Negotiated Rate |
$26.27 |
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: Cigna All Commercial |
$24.38
|
| Rate for Payer: CORVEL All Commercial |
$26.27
|
| Rate for Payer: Coventry All Commercial |
$24.86
|
| Rate for Payer: Encore All Commercial |
$26.00
|
| Rate for Payer: Frontpath All Commercial |
$25.99
|
| Rate for Payer: Humana ChoiceCare |
$24.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.42
|
| Rate for Payer: PHCS All Commercial |
$21.18
|
| Rate for Payer: PHP All Commercial |
$21.42
|
| Rate for Payer: Sagamore Health Network All Products |
$21.81
|
| Rate for Payer: Signature Care EPO |
$23.44
|
| Rate for Payer: Signature Care PPO |
$24.86
|
| Rate for Payer: United Healthcare Commercial |
$22.26
|
|
|
CARBAMAZEPINE 200 MG ORAL TB12
|
Facility
|
OP
|
$28.25
|
|
|
Service Code
|
NDC 68084056121
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$26.27 |
| Rate for Payer: Aetna Commercial |
$23.84
|
| Rate for Payer: Aetna Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.25
|
| Rate for Payer: Cash Price |
$17.51
|
| Rate for Payer: Centivo All Commercial |
$14.40
|
| Rate for Payer: Cigna All Commercial |
$24.38
|
| Rate for Payer: CORVEL All Commercial |
$26.27
|
| Rate for Payer: Coventry All Commercial |
$24.86
|
| Rate for Payer: Encore All Commercial |
$26.00
|
| Rate for Payer: Frontpath All Commercial |
$25.99
|
| Rate for Payer: Humana ChoiceCare |
$24.40
|
| Rate for Payer: Humana Medicare |
$14.40
|
| Rate for Payer: Lucent All Commercial |
$14.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.42
|
| Rate for Payer: PHCS All Commercial |
$21.18
|
| Rate for Payer: PHP All Commercial |
$21.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.02
|
| Rate for Payer: Sagamore Health Network All Products |
$21.81
|
| Rate for Payer: Signature Care EPO |
$23.44
|
| Rate for Payer: Signature Care PPO |
$24.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.01
|
| Rate for Payer: United Healthcare Commercial |
$22.26
|
| Rate for Payer: United Healthcare Medicare |
$9.32
|
|
|
CARBAMIDE PEROXIDE 6.5 % OTIC DROP
|
Facility
|
IP
|
$12.29
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.21 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Aetna Commercial |
$10.61
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cigna All Commercial |
$10.60
|
| Rate for Payer: CORVEL All Commercial |
$11.43
|
| Rate for Payer: Coventry All Commercial |
$10.81
|
| Rate for Payer: Encore All Commercial |
$11.31
|
| Rate for Payer: Frontpath All Commercial |
$11.30
|
| Rate for Payer: Humana ChoiceCare |
$10.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.06
|
| Rate for Payer: PHCS All Commercial |
$9.21
|
| Rate for Payer: PHP All Commercial |
$9.32
|
| Rate for Payer: Sagamore Health Network All Products |
$9.48
|
| Rate for Payer: Signature Care EPO |
$10.20
|
| Rate for Payer: Signature Care PPO |
$10.81
|
| Rate for Payer: United Healthcare Commercial |
$9.68
|
|
|
CARBAMIDE PEROXIDE 6.5 % OTIC DROP
|
Facility
|
OP
|
$12.29
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Aetna Commercial |
$10.37
|
| Rate for Payer: Aetna Medicare |
$4.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.46
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Centivo All Commercial |
$6.27
|
| Rate for Payer: Cigna All Commercial |
$10.60
|
| Rate for Payer: CORVEL All Commercial |
$11.43
|
| Rate for Payer: Coventry All Commercial |
$10.81
|
| Rate for Payer: Encore All Commercial |
$11.31
|
| Rate for Payer: Frontpath All Commercial |
$11.30
|
| Rate for Payer: Humana ChoiceCare |
$10.61
|
| Rate for Payer: Humana Medicare |
$6.27
|
| Rate for Payer: Lucent All Commercial |
$6.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.06
|
| Rate for Payer: PHCS All Commercial |
$9.21
|
| Rate for Payer: PHP All Commercial |
$9.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.79
|
| Rate for Payer: Sagamore Health Network All Products |
$9.48
|
| Rate for Payer: Signature Care EPO |
$10.20
|
| Rate for Payer: Signature Care PPO |
$10.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.44
|
| Rate for Payer: United Healthcare Commercial |
$9.68
|
| Rate for Payer: United Healthcare Medicare |
$4.05
|
|
|
CARBIDOPA-LEVODOPA 10-100 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
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
|
|
|
CARBIDOPA-LEVODOPA 10-100 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
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
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TAB
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.04 |
| 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 |
$0.64
|
| 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 |
$0.69
|
| Rate for Payer: Centivo All Commercial |
$0.57
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.03
|
| Rate for Payer: Frontpath All Commercial |
$1.03
|
| 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 |
$0.84
|
| 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 |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.93
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TAB
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.03
|
| Rate for Payer: Frontpath All Commercial |
$1.03
|
| Rate for Payer: Humana ChoiceCare |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.01
|
| Rate for Payer: PHCS All Commercial |
$0.84
|
| Rate for Payer: PHP All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.93
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TBER
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079097820
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.68
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Centivo All Commercial |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.86
|
| Rate for Payer: Coventry All Commercial |
$1.76
|
| Rate for Payer: Encore All Commercial |
$1.84
|
| Rate for Payer: Frontpath All Commercial |
$1.84
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Humana Medicare |
$1.02
|
| Rate for Payer: Lucent All Commercial |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.80
|
| Rate for Payer: PHCS All Commercial |
$1.50
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1.54
|
| Rate for Payer: Signature Care EPO |
$1.66
|
| Rate for Payer: Signature Care PPO |
$1.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.70
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TBER
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.68
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Centivo All Commercial |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.86
|
| Rate for Payer: Coventry All Commercial |
$1.76
|
| Rate for Payer: Encore All Commercial |
$1.84
|
| Rate for Payer: Frontpath All Commercial |
$1.84
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Humana Medicare |
$1.02
|
| Rate for Payer: Lucent All Commercial |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.80
|
| Rate for Payer: PHCS All Commercial |
$1.50
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1.54
|
| Rate for Payer: Signature Care EPO |
$1.66
|
| Rate for Payer: Signature Care PPO |
$1.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.70
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TBER
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.72
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.86
|
| Rate for Payer: Coventry All Commercial |
$1.76
|
| Rate for Payer: Encore All Commercial |
$1.84
|
| Rate for Payer: Frontpath All Commercial |
$1.84
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.80
|
| Rate for Payer: PHCS All Commercial |
$1.50
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.54
|
| Rate for Payer: Signature Care EPO |
$1.66
|
| Rate for Payer: Signature Care PPO |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
|
|
CARBIDOPA-LEVODOPA 25-100 MG ORAL TBER
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079097820
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.72
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.86
|
| Rate for Payer: Coventry All Commercial |
$1.76
|
| Rate for Payer: Encore All Commercial |
$1.84
|
| Rate for Payer: Frontpath All Commercial |
$1.84
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.80
|
| Rate for Payer: PHCS All Commercial |
$1.50
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.54
|
| Rate for Payer: Signature Care EPO |
$1.66
|
| Rate for Payer: Signature Care PPO |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
|
|
CARBIDOPA-LEVODOPA 25-250 MG ORAL TAB
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna All Commercial |
$1.73
|
| Rate for Payer: CORVEL All Commercial |
$1.87
|
| Rate for Payer: Coventry All Commercial |
$1.77
|
| Rate for Payer: Encore All Commercial |
$1.85
|
| Rate for Payer: Frontpath All Commercial |
$1.85
|
| Rate for Payer: Humana ChoiceCare |
$1.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.81
|
| Rate for Payer: PHCS All Commercial |
$1.51
|
| Rate for Payer: PHP All Commercial |
$1.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.55
|
| Rate for Payer: Signature Care EPO |
$1.67
|
| Rate for Payer: Signature Care PPO |
$1.77
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
|
|
CARBIDOPA-LEVODOPA 25-250 MG ORAL TAB
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687083611
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna All Commercial |
$1.73
|
| Rate for Payer: CORVEL All Commercial |
$1.87
|
| Rate for Payer: Coventry All Commercial |
$1.77
|
| Rate for Payer: Encore All Commercial |
$1.85
|
| Rate for Payer: Frontpath All Commercial |
$1.85
|
| Rate for Payer: Humana ChoiceCare |
$1.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.81
|
| Rate for Payer: PHCS All Commercial |
$1.51
|
| Rate for Payer: PHP All Commercial |
$1.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.55
|
| Rate for Payer: Signature Care EPO |
$1.67
|
| Rate for Payer: Signature Care PPO |
$1.77
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
|
|
CARBIDOPA-LEVODOPA 25-250 MG ORAL TAB
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687083611
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.70
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Centivo All Commercial |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.73
|
| Rate for Payer: CORVEL All Commercial |
$1.87
|
| Rate for Payer: Coventry All Commercial |
$1.77
|
| Rate for Payer: Encore All Commercial |
$1.85
|
| Rate for Payer: Frontpath All Commercial |
$1.85
|
| Rate for Payer: Humana ChoiceCare |
$1.74
|
| Rate for Payer: Humana Medicare |
$1.02
|
| Rate for Payer: Lucent All Commercial |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.81
|
| Rate for Payer: PHCS All Commercial |
$1.51
|
| Rate for Payer: PHP All Commercial |
$1.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1.55
|
| Rate for Payer: Signature Care EPO |
$1.67
|
| Rate for Payer: Signature Care PPO |
$1.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.71
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
|
CARBIDOPA-LEVODOPA 25-250 MG ORAL TAB
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.70
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Centivo All Commercial |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.73
|
| Rate for Payer: CORVEL All Commercial |
$1.87
|
| Rate for Payer: Coventry All Commercial |
$1.77
|
| Rate for Payer: Encore All Commercial |
$1.85
|
| Rate for Payer: Frontpath All Commercial |
$1.85
|
| Rate for Payer: Humana ChoiceCare |
$1.74
|
| Rate for Payer: Humana Medicare |
$1.02
|
| Rate for Payer: Lucent All Commercial |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.81
|
| Rate for Payer: PHCS All Commercial |
$1.51
|
| Rate for Payer: PHP All Commercial |
$1.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1.55
|
| Rate for Payer: Signature Care EPO |
$1.67
|
| Rate for Payer: Signature Care PPO |
$1.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.71
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
