|
GLIPIZIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Centivo All Commercial |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.23
|
| Rate for Payer: CORVEL All Commercial |
$1.32
|
| Rate for Payer: Coventry All Commercial |
$1.25
|
| Rate for Payer: Encore All Commercial |
$1.31
|
| Rate for Payer: Frontpath All Commercial |
$1.31
|
| Rate for Payer: Humana ChoiceCare |
$1.23
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: Lucent All Commercial |
$0.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.28
|
| Rate for Payer: PHCS All Commercial |
$1.07
|
| Rate for Payer: PHP All Commercial |
$1.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.55
|
| Rate for Payer: Sagamore Health Network All Products |
$1.10
|
| Rate for Payer: Signature Care EPO |
$1.18
|
| Rate for Payer: Signature Care PPO |
$1.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
|
|
GLIPIZIDE 5 MG ORAL TR24
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 59762054101
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
|
|
GLIPIZIDE 5 MG ORAL TR24
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 59762054101
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Centivo All Commercial |
$0.59
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Humana Medicare |
$0.35
|
| Rate for Payer: Lucent All Commercial |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
|
|
GLUCAGON 1 MG INJ SOLR
|
Facility
|
IP
|
$1,119.96
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
111859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$839.97 |
| Max. Negotiated Rate |
$1,041.56 |
| Rate for Payer: Aetna Commercial |
$967.65
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Cigna All Commercial |
$966.53
|
| Rate for Payer: CORVEL All Commercial |
$1,041.56
|
| Rate for Payer: Coventry All Commercial |
$985.56
|
| Rate for Payer: Encore All Commercial |
$1,030.92
|
| Rate for Payer: Frontpath All Commercial |
$1,030.36
|
| Rate for Payer: Humana ChoiceCare |
$967.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,007.96
|
| Rate for Payer: PHCS All Commercial |
$839.97
|
| Rate for Payer: PHP All Commercial |
$849.38
|
| Rate for Payer: Sagamore Health Network All Products |
$864.61
|
| Rate for Payer: Signature Care EPO |
$929.57
|
| Rate for Payer: Signature Care PPO |
$985.56
|
| Rate for Payer: United Healthcare Commercial |
$882.53
|
|
|
GLUCAGON 1 MG INJ SOLR
|
Facility
|
OP
|
$1,119.96
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
111859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$1,041.56 |
| Rate for Payer: Aetna Commercial |
$945.25
|
| Rate for Payer: Aetna Medicare |
$358.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$294.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$347.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$643.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$700.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$294.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$412.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$394.23
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Centivo All Commercial |
$609.26
|
| Rate for Payer: Cigna All Commercial |
$966.53
|
| Rate for Payer: CORVEL All Commercial |
$1,041.56
|
| Rate for Payer: Coventry All Commercial |
$985.56
|
| Rate for Payer: Encore All Commercial |
$1,030.92
|
| Rate for Payer: Frontpath All Commercial |
$1,030.36
|
| Rate for Payer: Humana ChoiceCare |
$967.31
|
| Rate for Payer: Humana Medicare |
$358.39
|
| Rate for Payer: Lucent All Commercial |
$609.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,007.96
|
| Rate for Payer: Managed Health Services Medicaid |
$294.00
|
| Rate for Payer: MDWise Medicaid |
$294.00
|
| Rate for Payer: PHCS All Commercial |
$839.97
|
| Rate for Payer: PHP All Commercial |
$849.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$436.78
|
| Rate for Payer: Sagamore Health Network All Products |
$864.61
|
| Rate for Payer: Signature Care EPO |
$929.57
|
| Rate for Payer: Signature Care PPO |
$985.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$951.97
|
| Rate for Payer: United Healthcare Commercial |
$882.53
|
| Rate for Payer: United Healthcare Medicare |
$358.39
|
|
|
GLUCAGON 1 MG/ML INJ SOLR
|
Facility
|
IP
|
$502.70
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
121354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$377.02 |
| Max. Negotiated Rate |
$467.51 |
| Rate for Payer: Aetna Commercial |
$434.33
|
| Rate for Payer: Cash Price |
$301.62
|
| Rate for Payer: Cigna All Commercial |
$433.83
|
| Rate for Payer: CORVEL All Commercial |
$467.51
|
| Rate for Payer: Coventry All Commercial |
$442.38
|
| Rate for Payer: Encore All Commercial |
$462.74
|
| Rate for Payer: Frontpath All Commercial |
$462.48
|
| Rate for Payer: Humana ChoiceCare |
$434.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$452.43
|
| Rate for Payer: PHCS All Commercial |
$377.02
|
| Rate for Payer: PHP All Commercial |
$381.25
|
| Rate for Payer: Sagamore Health Network All Products |
$388.08
|
| Rate for Payer: Signature Care EPO |
$417.24
|
| Rate for Payer: Signature Care PPO |
$442.38
|
| Rate for Payer: United Healthcare Commercial |
$396.13
|
|
|
GLUCAGON 1 MG/ML INJ SOLR
|
Facility
|
OP
|
$502.70
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.84 |
| Max. Negotiated Rate |
$467.51 |
| Rate for Payer: Aetna Commercial |
$424.28
|
| Rate for Payer: Aetna Medicare |
$160.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$294.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$155.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$288.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$314.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$294.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$184.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$176.95
|
| Rate for Payer: Cash Price |
$301.62
|
| Rate for Payer: Cash Price |
$301.62
|
| Rate for Payer: Centivo All Commercial |
$273.47
|
| Rate for Payer: Cigna All Commercial |
$433.83
|
| Rate for Payer: CORVEL All Commercial |
$467.51
|
| Rate for Payer: Coventry All Commercial |
$442.38
|
| Rate for Payer: Encore All Commercial |
$462.74
|
| Rate for Payer: Frontpath All Commercial |
$462.48
|
| Rate for Payer: Humana ChoiceCare |
$434.18
|
| Rate for Payer: Humana Medicare |
$160.86
|
| Rate for Payer: Lucent All Commercial |
$273.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$452.43
|
| Rate for Payer: Managed Health Services Medicaid |
$294.00
|
| Rate for Payer: MDWise Medicaid |
$294.00
|
| Rate for Payer: PHCS All Commercial |
$377.02
|
| Rate for Payer: PHP All Commercial |
$381.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$196.05
|
| Rate for Payer: Sagamore Health Network All Products |
$388.08
|
| Rate for Payer: Signature Care EPO |
$417.24
|
| Rate for Payer: Signature Care PPO |
$442.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$427.30
|
| Rate for Payer: United Healthcare Commercial |
$396.13
|
| Rate for Payer: United Healthcare Medicare |
$160.86
|
|
|
GLUCAGON 1 MG/ML INJ SOLR S.O. (CAMERON)
|
Facility
|
IP
|
$1,119.96
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
140121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$839.97 |
| Max. Negotiated Rate |
$1,041.56 |
| Rate for Payer: Aetna Commercial |
$967.65
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Cigna All Commercial |
$966.53
|
| Rate for Payer: CORVEL All Commercial |
$1,041.56
|
| Rate for Payer: Coventry All Commercial |
$985.56
|
| Rate for Payer: Encore All Commercial |
$1,030.92
|
| Rate for Payer: Frontpath All Commercial |
$1,030.36
|
| Rate for Payer: Humana ChoiceCare |
$967.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,007.96
|
| Rate for Payer: PHCS All Commercial |
$839.97
|
| Rate for Payer: PHP All Commercial |
$849.38
|
| Rate for Payer: Sagamore Health Network All Products |
$864.61
|
| Rate for Payer: Signature Care EPO |
$929.57
|
| Rate for Payer: Signature Care PPO |
$985.56
|
| Rate for Payer: United Healthcare Commercial |
$882.53
|
|
|
GLUCAGON 1 MG/ML INJ SOLR S.O. (CAMERON)
|
Facility
|
OP
|
$1,119.96
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
140121354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,041.56 |
| Rate for Payer: Aetna Commercial |
$945.25
|
| Rate for Payer: Aetna Medicare |
$358.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$347.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$643.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$700.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$412.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$394.23
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Cash Price |
$671.98
|
| Rate for Payer: Centivo All Commercial |
$609.26
|
| Rate for Payer: Cigna All Commercial |
$966.53
|
| Rate for Payer: CORVEL All Commercial |
$1,041.56
|
| Rate for Payer: Coventry All Commercial |
$985.56
|
| Rate for Payer: Encore All Commercial |
$1,030.92
|
| Rate for Payer: Frontpath All Commercial |
$1,030.36
|
| Rate for Payer: Humana ChoiceCare |
$967.31
|
| Rate for Payer: Humana Medicare |
$358.39
|
| Rate for Payer: Lucent All Commercial |
$609.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,007.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$839.97
|
| Rate for Payer: PHP All Commercial |
$849.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$436.78
|
| Rate for Payer: Sagamore Health Network All Products |
$864.61
|
| Rate for Payer: Signature Care EPO |
$929.57
|
| Rate for Payer: Signature Care PPO |
$985.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$951.97
|
| Rate for Payer: United Healthcare Commercial |
$882.53
|
| Rate for Payer: United Healthcare Medicare |
$358.39
|
|
|
GLYBURIDE 1.25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 23155005601
|
| Hospital Charge Code |
10125
|
|
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 |
$0.60
|
| 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
|
|
|
GLYBURIDE 1.25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 23155005601
|
| Hospital Charge Code |
10125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
GLYBURIDE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 23155005801
|
| Hospital Charge Code |
3489
|
|
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 |
$0.60
|
| 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
|
|
|
GLYBURIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 23155005801
|
| Hospital Charge Code |
3489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
GLYCERIN (ADULT) RECT SUPP
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 58980041012
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Centivo All Commercial |
$0.59
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Humana Medicare |
$0.35
|
| Rate for Payer: Lucent All Commercial |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
|
|
GLYCERIN (ADULT) RECT SUPP
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 58980041012
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
|
|
GLYCERIN (CHILD) RECT SUPP
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: Aetna Medicare |
$0.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Centivo All Commercial |
$0.32
|
| 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 |
$0.54
|
| Rate for Payer: Frontpath All Commercial |
$0.54
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Humana Medicare |
$0.19
|
| Rate for Payer: Lucent All Commercial |
$0.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.53
|
| Rate for Payer: PHCS All Commercial |
$0.44
|
| 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 |
$0.45
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.50
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
|
|
GLYCERIN (CHILD) RECT SUPP
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$0.35
|
| 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 |
$0.54
|
| Rate for Payer: Frontpath All Commercial |
$0.54
|
| Rate for Payer: Humana ChoiceCare |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.53
|
| Rate for Payer: PHCS All Commercial |
$0.44
|
| Rate for Payer: PHP All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.45
|
| Rate for Payer: Signature Care EPO |
$0.49
|
| Rate for Payer: Signature Care PPO |
$0.52
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECT SOLN
|
Facility
|
IP
|
$5.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
120948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.49
|
| Rate for Payer: Coventry All Commercial |
$5.20
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: PHCS All Commercial |
$4.43
|
| Rate for Payer: PHP All Commercial |
$4.48
|
| Rate for Payer: Sagamore Health Network All Products |
$4.56
|
| Rate for Payer: Signature Care EPO |
$4.90
|
| Rate for Payer: Signature Care PPO |
$5.20
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECT SOLN
|
Facility
|
OP
|
$5.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
120948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$4.99
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Centivo All Commercial |
$3.21
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.49
|
| Rate for Payer: Coventry All Commercial |
$5.20
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Lucent All Commercial |
$3.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$4.43
|
| Rate for Payer: PHP All Commercial |
$4.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.30
|
| Rate for Payer: Sagamore Health Network All Products |
$4.56
|
| Rate for Payer: Signature Care EPO |
$4.90
|
| Rate for Payer: Signature Care PPO |
$5.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.02
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
| Rate for Payer: United Healthcare Medicare |
$1.89
|
|
|
GLYCERIN-WITCH HAZEL 12.5-50 % TOP PADM
|
Facility
|
OP
|
$22.96
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
117736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.12 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$19.38
|
| Rate for Payer: Aetna Medicare |
$7.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.08
|
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: Centivo All Commercial |
$12.49
|
| Rate for Payer: Cigna All Commercial |
$19.81
|
| Rate for Payer: CORVEL All Commercial |
$21.35
|
| Rate for Payer: Coventry All Commercial |
$20.20
|
| Rate for Payer: Encore All Commercial |
$21.13
|
| Rate for Payer: Frontpath All Commercial |
$21.12
|
| Rate for Payer: Humana ChoiceCare |
$19.83
|
| Rate for Payer: Humana Medicare |
$7.35
|
| Rate for Payer: Lucent All Commercial |
$12.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.66
|
| Rate for Payer: PHCS All Commercial |
$17.22
|
| Rate for Payer: PHP All Commercial |
$17.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.95
|
| Rate for Payer: Sagamore Health Network All Products |
$17.73
|
| Rate for Payer: Signature Care EPO |
$19.06
|
| Rate for Payer: Signature Care PPO |
$20.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19.52
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Medicare |
$7.35
|
|
|
GLYCERIN-WITCH HAZEL 12.5-50 % TOP PADM
|
Facility
|
IP
|
$22.96
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
117736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.22 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: Cigna All Commercial |
$19.81
|
| Rate for Payer: CORVEL All Commercial |
$21.35
|
| Rate for Payer: Coventry All Commercial |
$20.20
|
| Rate for Payer: Encore All Commercial |
$21.13
|
| Rate for Payer: Frontpath All Commercial |
$21.12
|
| Rate for Payer: Humana ChoiceCare |
$19.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.66
|
| Rate for Payer: PHCS All Commercial |
$17.22
|
| Rate for Payer: PHP All Commercial |
$17.41
|
| Rate for Payer: Sagamore Health Network All Products |
$17.73
|
| Rate for Payer: Signature Care EPO |
$19.06
|
| Rate for Payer: Signature Care PPO |
$20.20
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
|
|
GLYCINE UROLOGIC SOLUTION 1.5 % IR SOLN
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
NDC 00990797408
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$127.01
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
|
|
GLYCINE UROLOGIC SOLUTION 1.5 % IR SOLN
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
NDC 00990797408
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$124.07
|
| Rate for Payer: Aetna Medicare |
$47.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$84.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.74
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Centivo All Commercial |
$79.97
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Humana Medicare |
$47.04
|
| Rate for Payer: Lucent All Commercial |
$79.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.33
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.95
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
| Rate for Payer: United Healthcare Medicare |
$47.04
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| 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: 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: 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: United Healthcare Commercial |
$14.18
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
