|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
IP
|
$141.54
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.16 |
| Max. Negotiated Rate |
$131.63 |
| Rate for Payer: Aetna Commercial |
$122.29
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Cigna All Commercial |
$122.15
|
| Rate for Payer: CORVEL All Commercial |
$131.63
|
| Rate for Payer: Coventry All Commercial |
$124.56
|
| Rate for Payer: Encore All Commercial |
$130.29
|
| Rate for Payer: Frontpath All Commercial |
$130.22
|
| Rate for Payer: Humana ChoiceCare |
$122.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$127.39
|
| Rate for Payer: PHCS All Commercial |
$106.16
|
| Rate for Payer: PHP All Commercial |
$107.34
|
| Rate for Payer: Sagamore Health Network All Products |
$109.27
|
| Rate for Payer: Signature Care EPO |
$117.48
|
| Rate for Payer: Signature Care PPO |
$124.56
|
| Rate for Payer: United Healthcare Commercial |
$111.53
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
OP
|
$141.54
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.71 |
| Max. Negotiated Rate |
$131.63 |
| Rate for Payer: Aetna Commercial |
$119.46
|
| Rate for Payer: Aetna Medicare |
$46.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$81.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$53.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.38
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Centivo All Commercial |
$72.19
|
| Rate for Payer: Cigna All Commercial |
$122.15
|
| Rate for Payer: CORVEL All Commercial |
$131.63
|
| Rate for Payer: Coventry All Commercial |
$124.56
|
| Rate for Payer: Encore All Commercial |
$130.29
|
| Rate for Payer: Frontpath All Commercial |
$130.22
|
| Rate for Payer: Humana ChoiceCare |
$122.25
|
| Rate for Payer: Humana Medicare |
$72.19
|
| Rate for Payer: Lucent All Commercial |
$72.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$127.39
|
| Rate for Payer: PHCS All Commercial |
$106.16
|
| Rate for Payer: PHP All Commercial |
$107.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.20
|
| Rate for Payer: Sagamore Health Network All Products |
$109.27
|
| Rate for Payer: Signature Care EPO |
$117.48
|
| Rate for Payer: Signature Care PPO |
$124.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$120.31
|
| Rate for Payer: United Healthcare Commercial |
$111.53
|
| Rate for Payer: United Healthcare Medicare |
$46.71
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJ SOLN
|
Facility
|
IP
|
$148.54
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.40 |
| Max. Negotiated Rate |
$138.14 |
| Rate for Payer: Aetna Commercial |
$128.34
|
| Rate for Payer: Cash Price |
$92.09
|
| Rate for Payer: Cigna All Commercial |
$128.19
|
| Rate for Payer: CORVEL All Commercial |
$138.14
|
| Rate for Payer: Coventry All Commercial |
$130.72
|
| Rate for Payer: Encore All Commercial |
$136.73
|
| Rate for Payer: Frontpath All Commercial |
$136.66
|
| Rate for Payer: Humana ChoiceCare |
$128.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.69
|
| Rate for Payer: PHCS All Commercial |
$111.40
|
| Rate for Payer: PHP All Commercial |
$112.65
|
| Rate for Payer: Sagamore Health Network All Products |
$114.67
|
| Rate for Payer: Signature Care EPO |
$123.29
|
| Rate for Payer: Signature Care PPO |
$130.72
|
| Rate for Payer: United Healthcare Commercial |
$117.05
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJ SOLN
|
Facility
|
OP
|
$148.54
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.02 |
| Max. Negotiated Rate |
$138.14 |
| Rate for Payer: Aetna Commercial |
$125.37
|
| Rate for Payer: Aetna Medicare |
$49.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$85.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$92.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$56.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.92
|
| Rate for Payer: Cash Price |
$92.09
|
| Rate for Payer: Centivo All Commercial |
$75.76
|
| Rate for Payer: Cigna All Commercial |
$128.19
|
| Rate for Payer: CORVEL All Commercial |
$138.14
|
| Rate for Payer: Coventry All Commercial |
$130.72
|
| Rate for Payer: Encore All Commercial |
$136.73
|
| Rate for Payer: Frontpath All Commercial |
$136.66
|
| Rate for Payer: Humana ChoiceCare |
$128.29
|
| Rate for Payer: Humana Medicare |
$75.76
|
| Rate for Payer: Lucent All Commercial |
$75.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.69
|
| Rate for Payer: PHCS All Commercial |
$111.40
|
| Rate for Payer: PHP All Commercial |
$112.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.93
|
| Rate for Payer: Sagamore Health Network All Products |
$114.67
|
| Rate for Payer: Signature Care EPO |
$123.29
|
| Rate for Payer: Signature Care PPO |
$130.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$126.26
|
| Rate for Payer: United Healthcare Commercial |
$117.05
|
| Rate for Payer: United Healthcare Medicare |
$49.02
|
|
|
CHLORPROMAZINE 100 MG ORAL TAB
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1654
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$12.09 |
| Rate for Payer: Aetna Commercial |
$10.97
|
| Rate for Payer: Aetna Medicare |
$4.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.72
|
| Rate for Payer: Cash Price |
$8.06
|
| Rate for Payer: Centivo All Commercial |
$6.63
|
| Rate for Payer: Cigna All Commercial |
$11.22
|
| Rate for Payer: CORVEL All Commercial |
$12.09
|
| Rate for Payer: Coventry All Commercial |
$11.44
|
| Rate for Payer: Encore All Commercial |
$11.97
|
| Rate for Payer: Frontpath All Commercial |
$11.96
|
| Rate for Payer: Humana ChoiceCare |
$11.23
|
| Rate for Payer: Humana Medicare |
$6.63
|
| Rate for Payer: Lucent All Commercial |
$6.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.70
|
| Rate for Payer: PHCS All Commercial |
$9.75
|
| Rate for Payer: PHP All Commercial |
$9.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.07
|
| Rate for Payer: Sagamore Health Network All Products |
$10.04
|
| Rate for Payer: Signature Care EPO |
$10.79
|
| Rate for Payer: Signature Care PPO |
$11.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.05
|
| Rate for Payer: United Healthcare Commercial |
$10.24
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
|
|
CHLORPROMAZINE 100 MG ORAL TAB
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$12.09 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Cash Price |
$8.06
|
| Rate for Payer: Cigna All Commercial |
$11.22
|
| Rate for Payer: CORVEL All Commercial |
$12.09
|
| Rate for Payer: Coventry All Commercial |
$11.44
|
| Rate for Payer: Encore All Commercial |
$11.97
|
| Rate for Payer: Frontpath All Commercial |
$11.96
|
| Rate for Payer: Humana ChoiceCare |
$11.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.70
|
| Rate for Payer: PHCS All Commercial |
$9.75
|
| Rate for Payer: PHP All Commercial |
$9.86
|
| Rate for Payer: Sagamore Health Network All Products |
$10.04
|
| Rate for Payer: Signature Care EPO |
$10.79
|
| Rate for Payer: Signature Care PPO |
$11.44
|
| Rate for Payer: United Healthcare Commercial |
$10.24
|
|
|
CHLORPROMAZINE 25 MG/ML INJ SOLN
|
Facility
|
OP
|
$182.22
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$169.46 |
| Rate for Payer: Aetna Commercial |
$153.79
|
| Rate for Payer: Aetna Medicare |
$60.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$104.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$113.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$69.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$66.14
|
| Rate for Payer: Cash Price |
$112.97
|
| Rate for Payer: Centivo All Commercial |
$92.93
|
| Rate for Payer: Cigna All Commercial |
$157.25
|
| Rate for Payer: CORVEL All Commercial |
$169.46
|
| Rate for Payer: Coventry All Commercial |
$160.35
|
| Rate for Payer: Encore All Commercial |
$167.73
|
| Rate for Payer: Frontpath All Commercial |
$167.64
|
| Rate for Payer: Humana ChoiceCare |
$157.38
|
| Rate for Payer: Humana Medicare |
$92.93
|
| Rate for Payer: Lucent All Commercial |
$92.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$164.00
|
| Rate for Payer: PHCS All Commercial |
$136.66
|
| Rate for Payer: PHP All Commercial |
$138.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$71.06
|
| Rate for Payer: Sagamore Health Network All Products |
$140.67
|
| Rate for Payer: Signature Care EPO |
$151.24
|
| Rate for Payer: Signature Care PPO |
$160.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$154.88
|
| Rate for Payer: United Healthcare Commercial |
$143.59
|
| Rate for Payer: United Healthcare Medicare |
$60.13
|
|
|
CHLORPROMAZINE 25 MG/ML INJ SOLN
|
Facility
|
IP
|
$182.22
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.66 |
| Max. Negotiated Rate |
$169.46 |
| Rate for Payer: Aetna Commercial |
$157.44
|
| Rate for Payer: Cash Price |
$112.97
|
| Rate for Payer: Cigna All Commercial |
$157.25
|
| Rate for Payer: CORVEL All Commercial |
$169.46
|
| Rate for Payer: Coventry All Commercial |
$160.35
|
| Rate for Payer: Encore All Commercial |
$167.73
|
| Rate for Payer: Frontpath All Commercial |
$167.64
|
| Rate for Payer: Humana ChoiceCare |
$157.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$164.00
|
| Rate for Payer: PHCS All Commercial |
$136.66
|
| Rate for Payer: PHP All Commercial |
$138.19
|
| Rate for Payer: Sagamore Health Network All Products |
$140.67
|
| Rate for Payer: Signature Care EPO |
$151.24
|
| Rate for Payer: Signature Care PPO |
$160.35
|
| Rate for Payer: United Healthcare Commercial |
$143.59
|
|
|
CHLORPROMAZINE 25 MG ORAL TAB
|
Facility
|
OP
|
$18.05
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.96 |
| Max. Negotiated Rate |
$16.78 |
| Rate for Payer: Aetna Commercial |
$15.23
|
| Rate for Payer: Aetna Medicare |
$5.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.55
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: Centivo All Commercial |
$9.20
|
| Rate for Payer: Cigna All Commercial |
$15.57
|
| Rate for Payer: CORVEL All Commercial |
$16.78
|
| Rate for Payer: Coventry All Commercial |
$15.88
|
| Rate for Payer: Encore All Commercial |
$16.61
|
| Rate for Payer: Frontpath All Commercial |
$16.60
|
| Rate for Payer: Humana ChoiceCare |
$15.59
|
| Rate for Payer: Humana Medicare |
$9.20
|
| Rate for Payer: Lucent All Commercial |
$9.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.24
|
| Rate for Payer: PHCS All Commercial |
$13.53
|
| Rate for Payer: PHP All Commercial |
$13.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.04
|
| Rate for Payer: Sagamore Health Network All Products |
$13.93
|
| Rate for Payer: Signature Care EPO |
$14.98
|
| Rate for Payer: Signature Care PPO |
$15.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.34
|
| Rate for Payer: United Healthcare Commercial |
$14.22
|
| Rate for Payer: United Healthcare Medicare |
$5.96
|
|
|
CHLORPROMAZINE 25 MG ORAL TAB
|
Facility
|
IP
|
$18.05
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$16.78 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: Cigna All Commercial |
$15.57
|
| Rate for Payer: CORVEL All Commercial |
$16.78
|
| Rate for Payer: Coventry All Commercial |
$15.88
|
| Rate for Payer: Encore All Commercial |
$16.61
|
| Rate for Payer: Frontpath All Commercial |
$16.60
|
| Rate for Payer: Humana ChoiceCare |
$15.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.24
|
| Rate for Payer: PHCS All Commercial |
$13.53
|
| Rate for Payer: PHP All Commercial |
$13.69
|
| Rate for Payer: Sagamore Health Network All Products |
$13.93
|
| Rate for Payer: Signature Care EPO |
$14.98
|
| Rate for Payer: Signature Care PPO |
$15.88
|
| Rate for Payer: United Healthcare Commercial |
$14.22
|
|
|
CHLORZOXAZONE 500 MG ORAL TAB
|
Facility
|
IP
|
$1.90
|
|
|
Service Code
|
NDC 00591252001
|
| Hospital Charge Code |
1664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna All Commercial |
$1.64
|
| Rate for Payer: CORVEL All Commercial |
$1.76
|
| Rate for Payer: Coventry All Commercial |
$1.67
|
| Rate for Payer: Encore All Commercial |
$1.75
|
| Rate for Payer: Frontpath All Commercial |
$1.75
|
| Rate for Payer: Humana ChoiceCare |
$1.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.71
|
| Rate for Payer: PHCS All Commercial |
$1.42
|
| Rate for Payer: PHP All Commercial |
$1.44
|
| Rate for Payer: Sagamore Health Network All Products |
$1.46
|
| Rate for Payer: Signature Care EPO |
$1.57
|
| Rate for Payer: Signature Care PPO |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$1.49
|
|
|
CHLORZOXAZONE 500 MG ORAL TAB
|
Facility
|
OP
|
$1.90
|
|
|
Service Code
|
NDC 00591252001
|
| Hospital Charge Code |
1664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna Commercial |
$1.60
|
| Rate for Payer: Aetna Medicare |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Centivo All Commercial |
$0.97
|
| Rate for Payer: Cigna All Commercial |
$1.64
|
| Rate for Payer: CORVEL All Commercial |
$1.76
|
| Rate for Payer: Coventry All Commercial |
$1.67
|
| Rate for Payer: Encore All Commercial |
$1.75
|
| Rate for Payer: Frontpath All Commercial |
$1.75
|
| Rate for Payer: Humana ChoiceCare |
$1.64
|
| Rate for Payer: Humana Medicare |
$0.97
|
| Rate for Payer: Lucent All Commercial |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.71
|
| Rate for Payer: PHCS All Commercial |
$1.42
|
| Rate for Payer: PHP All Commercial |
$1.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.74
|
| Rate for Payer: Sagamore Health Network All Products |
$1.46
|
| Rate for Payer: Signature Care EPO |
$1.57
|
| Rate for Payer: Signature Care PPO |
$1.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$1.49
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1000 UNITS ORAL TAB
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna All Commercial |
$0.30
|
| Rate for Payer: CORVEL All Commercial |
$0.32
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.32
|
| Rate for Payer: Frontpath All Commercial |
$0.32
|
| Rate for Payer: Humana ChoiceCare |
$0.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.31
|
| Rate for Payer: PHCS All Commercial |
$0.26
|
| Rate for Payer: PHP All Commercial |
$0.26
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1000 UNITS ORAL TAB
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.29
|
| Rate for Payer: Aetna Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Centivo All Commercial |
$0.17
|
| Rate for Payer: Cigna All Commercial |
$0.30
|
| Rate for Payer: CORVEL All Commercial |
$0.32
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.32
|
| Rate for Payer: Frontpath All Commercial |
$0.32
|
| Rate for Payer: Humana ChoiceCare |
$0.30
|
| Rate for Payer: Humana Medicare |
$0.17
|
| Rate for Payer: Lucent All Commercial |
$0.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.31
|
| Rate for Payer: PHCS All Commercial |
$0.26
|
| Rate for Payer: PHP All Commercial |
$0.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.13
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) ORAL CAP
|
Facility
|
IP
|
$5.64
|
|
|
Service Code
|
NDC 75834002012
|
| Hospital Charge Code |
88945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Aetna Commercial |
$4.87
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cigna All Commercial |
$4.87
|
| Rate for Payer: CORVEL All Commercial |
$5.25
|
| Rate for Payer: Coventry All Commercial |
$4.96
|
| Rate for Payer: Encore All Commercial |
$5.19
|
| Rate for Payer: Frontpath All Commercial |
$5.19
|
| Rate for Payer: Humana ChoiceCare |
$4.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.08
|
| Rate for Payer: PHCS All Commercial |
$4.23
|
| Rate for Payer: PHP All Commercial |
$4.28
|
| Rate for Payer: Sagamore Health Network All Products |
$4.36
|
| Rate for Payer: Signature Care EPO |
$4.68
|
| Rate for Payer: Signature Care PPO |
$4.96
|
| Rate for Payer: United Healthcare Commercial |
$4.45
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) ORAL CAP
|
Facility
|
OP
|
$5.64
|
|
|
Service Code
|
NDC 75834002012
|
| Hospital Charge Code |
88945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Aetna Commercial |
$4.76
|
| Rate for Payer: Aetna Medicare |
$1.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.05
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Centivo All Commercial |
$2.88
|
| Rate for Payer: Cigna All Commercial |
$4.87
|
| Rate for Payer: CORVEL All Commercial |
$5.25
|
| Rate for Payer: Coventry All Commercial |
$4.96
|
| Rate for Payer: Encore All Commercial |
$5.19
|
| Rate for Payer: Frontpath All Commercial |
$5.19
|
| Rate for Payer: Humana ChoiceCare |
$4.87
|
| Rate for Payer: Humana Medicare |
$2.88
|
| Rate for Payer: Lucent All Commercial |
$2.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.08
|
| Rate for Payer: PHCS All Commercial |
$4.23
|
| Rate for Payer: PHP All Commercial |
$4.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.20
|
| Rate for Payer: Sagamore Health Network All Products |
$4.36
|
| Rate for Payer: Signature Care EPO |
$4.68
|
| Rate for Payer: Signature Care PPO |
$4.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.80
|
| Rate for Payer: United Healthcare Commercial |
$4.45
|
| Rate for Payer: United Healthcare Medicare |
$1.86
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 400 UNITS ORAL TAB
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
112022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$0.96
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.98
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 400 UNITS ORAL TAB
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
112022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| 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 |
$0.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Centivo All Commercial |
$0.57
|
| Rate for Payer: Cigna All Commercial |
$0.96
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.98
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.98
|
| 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
|
|
|
CHOLESTYRAMINE-ASPARTAME 4 G ORAL PWPK
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 00245003642
|
| Hospital Charge Code |
115289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$18.83 |
| Rate for Payer: Aetna Commercial |
$17.50
|
| Rate for Payer: Cash Price |
$12.56
|
| Rate for Payer: Cigna All Commercial |
$17.48
|
| Rate for Payer: CORVEL All Commercial |
$18.83
|
| Rate for Payer: Coventry All Commercial |
$17.82
|
| Rate for Payer: Encore All Commercial |
$18.64
|
| Rate for Payer: Frontpath All Commercial |
$18.63
|
| Rate for Payer: Humana ChoiceCare |
$17.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.23
|
| Rate for Payer: PHCS All Commercial |
$15.19
|
| Rate for Payer: PHP All Commercial |
$15.36
|
| Rate for Payer: Sagamore Health Network All Products |
$15.63
|
| Rate for Payer: Signature Care EPO |
$16.81
|
| Rate for Payer: Signature Care PPO |
$17.82
|
| Rate for Payer: United Healthcare Commercial |
$15.96
|
|
|
CHOLESTYRAMINE-ASPARTAME 4 G ORAL PWPK
|
Facility
|
OP
|
$20.25
|
|
|
Service Code
|
NDC 00245003642
|
| Hospital Charge Code |
115289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$18.83 |
| Rate for Payer: Aetna Commercial |
$17.09
|
| Rate for Payer: Aetna Medicare |
$6.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.35
|
| Rate for Payer: Cash Price |
$12.56
|
| Rate for Payer: Centivo All Commercial |
$10.33
|
| Rate for Payer: Cigna All Commercial |
$17.48
|
| Rate for Payer: CORVEL All Commercial |
$18.83
|
| Rate for Payer: Coventry All Commercial |
$17.82
|
| Rate for Payer: Encore All Commercial |
$18.64
|
| Rate for Payer: Frontpath All Commercial |
$18.63
|
| Rate for Payer: Humana ChoiceCare |
$17.49
|
| Rate for Payer: Humana Medicare |
$10.33
|
| Rate for Payer: Lucent All Commercial |
$10.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.23
|
| Rate for Payer: PHCS All Commercial |
$15.19
|
| Rate for Payer: PHP All Commercial |
$15.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.90
|
| Rate for Payer: Sagamore Health Network All Products |
$15.63
|
| Rate for Payer: Signature Care EPO |
$16.81
|
| Rate for Payer: Signature Care PPO |
$17.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.21
|
| Rate for Payer: United Healthcare Commercial |
$15.96
|
| Rate for Payer: United Healthcare Medicare |
$6.68
|
|
|
CHORIOGONADOTROPIN ALFA,HUMREC 250 MCG/0.5 ML SUBQ SYRG
|
Facility
|
OP
|
$1,111.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
37111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$366.65 |
| Max. Negotiated Rate |
$1,033.28 |
| Rate for Payer: Aetna Commercial |
$937.73
|
| Rate for Payer: Aetna Medicare |
$366.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$366.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$638.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$694.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$421.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$403.31
|
| Rate for Payer: Cash Price |
$688.85
|
| Rate for Payer: Centivo All Commercial |
$566.64
|
| Rate for Payer: Cigna All Commercial |
$958.84
|
| Rate for Payer: CORVEL All Commercial |
$1,033.28
|
| Rate for Payer: Coventry All Commercial |
$977.72
|
| Rate for Payer: Encore All Commercial |
$1,022.72
|
| Rate for Payer: Frontpath All Commercial |
$1,022.17
|
| Rate for Payer: Humana ChoiceCare |
$959.61
|
| Rate for Payer: Humana Medicare |
$566.64
|
| Rate for Payer: Lucent All Commercial |
$566.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$999.94
|
| Rate for Payer: PHCS All Commercial |
$833.29
|
| Rate for Payer: PHP All Commercial |
$842.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$433.31
|
| Rate for Payer: Sagamore Health Network All Products |
$857.73
|
| Rate for Payer: Signature Care EPO |
$922.17
|
| Rate for Payer: Signature Care PPO |
$977.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$944.39
|
| Rate for Payer: United Healthcare Commercial |
$875.51
|
| Rate for Payer: United Healthcare Medicare |
$366.65
|
|
|
CHORIOGONADOTROPIN ALFA,HUMREC 250 MCG/0.5 ML SUBQ SYRG
|
Facility
|
IP
|
$1,111.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
37111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$833.29 |
| Max. Negotiated Rate |
$1,033.28 |
| Rate for Payer: Aetna Commercial |
$959.95
|
| Rate for Payer: Cash Price |
$688.85
|
| Rate for Payer: Cigna All Commercial |
$958.84
|
| Rate for Payer: CORVEL All Commercial |
$1,033.28
|
| Rate for Payer: Coventry All Commercial |
$977.72
|
| Rate for Payer: Encore All Commercial |
$1,022.72
|
| Rate for Payer: Frontpath All Commercial |
$1,022.17
|
| Rate for Payer: Humana ChoiceCare |
$959.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$999.94
|
| Rate for Payer: PHCS All Commercial |
$833.29
|
| Rate for Payer: PHP All Commercial |
$842.62
|
| Rate for Payer: Sagamore Health Network All Products |
$857.73
|
| Rate for Payer: Signature Care EPO |
$922.17
|
| Rate for Payer: Signature Care PPO |
$977.72
|
| Rate for Payer: United Healthcare Commercial |
$875.51
|
|
|
CHORIONIC GONADOTROPIN, HUMAN 10000 UNITS IM SOLR
|
Facility
|
IP
|
$242.59
|
|
|
Service Code
|
HCPCS J0725
|
| Hospital Charge Code |
1676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.95 |
| Max. Negotiated Rate |
$225.61 |
| Rate for Payer: Aetna Commercial |
$209.60
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cigna All Commercial |
$209.36
|
| Rate for Payer: CORVEL All Commercial |
$225.61
|
| Rate for Payer: Coventry All Commercial |
$213.48
|
| Rate for Payer: Encore All Commercial |
$223.31
|
| Rate for Payer: Frontpath All Commercial |
$223.19
|
| Rate for Payer: Humana ChoiceCare |
$209.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.33
|
| Rate for Payer: PHCS All Commercial |
$181.95
|
| Rate for Payer: PHP All Commercial |
$183.98
|
| Rate for Payer: Sagamore Health Network All Products |
$187.28
|
| Rate for Payer: Signature Care EPO |
$201.35
|
| Rate for Payer: Signature Care PPO |
$213.48
|
| Rate for Payer: United Healthcare Commercial |
$191.16
|
|
|
CHORIONIC GONADOTROPIN, HUMAN 10000 UNITS IM SOLR
|
Facility
|
OP
|
$242.59
|
|
|
Service Code
|
HCPCS J0725
|
| Hospital Charge Code |
1676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$225.61 |
| Rate for Payer: Aetna Commercial |
$204.75
|
| Rate for Payer: Aetna Medicare |
$80.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$80.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$139.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$151.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$92.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$88.06
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Centivo All Commercial |
$123.72
|
| Rate for Payer: Cigna All Commercial |
$209.36
|
| Rate for Payer: CORVEL All Commercial |
$225.61
|
| Rate for Payer: Coventry All Commercial |
$213.48
|
| Rate for Payer: Encore All Commercial |
$223.31
|
| Rate for Payer: Frontpath All Commercial |
$223.19
|
| Rate for Payer: Humana ChoiceCare |
$209.53
|
| Rate for Payer: Humana Medicare |
$123.72
|
| Rate for Payer: Lucent All Commercial |
$123.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.33
|
| Rate for Payer: PHCS All Commercial |
$181.95
|
| Rate for Payer: PHP All Commercial |
$183.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$94.61
|
| Rate for Payer: Sagamore Health Network All Products |
$187.28
|
| Rate for Payer: Signature Care EPO |
$201.35
|
| Rate for Payer: Signature Care PPO |
$213.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$206.20
|
| Rate for Payer: United Healthcare Commercial |
$191.16
|
| Rate for Payer: United Healthcare Medicare |
$80.06
|
|
|
CHORIONIC GONADOTROPIN, HUMAN 5000 UNITS IM SOLR
|
Facility
|
OP
|
$338.67
|
|
|
Service Code
|
HCPCS J0725
|
| Hospital Charge Code |
1677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.76 |
| Max. Negotiated Rate |
$314.96 |
| Rate for Payer: Aetna Commercial |
$285.84
|
| Rate for Payer: Aetna Medicare |
$111.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$111.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$194.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$211.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$128.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$122.94
|
| Rate for Payer: Cash Price |
$209.97
|
| Rate for Payer: Centivo All Commercial |
$172.72
|
| Rate for Payer: Cigna All Commercial |
$292.27
|
| Rate for Payer: CORVEL All Commercial |
$314.96
|
| Rate for Payer: Coventry All Commercial |
$298.03
|
| Rate for Payer: Encore All Commercial |
$311.74
|
| Rate for Payer: Frontpath All Commercial |
$311.57
|
| Rate for Payer: Humana ChoiceCare |
$292.51
|
| Rate for Payer: Humana Medicare |
$172.72
|
| Rate for Payer: Lucent All Commercial |
$172.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$304.80
|
| Rate for Payer: PHCS All Commercial |
$254.00
|
| Rate for Payer: PHP All Commercial |
$256.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$132.08
|
| Rate for Payer: Sagamore Health Network All Products |
$261.45
|
| Rate for Payer: Signature Care EPO |
$281.09
|
| Rate for Payer: Signature Care PPO |
$298.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$287.87
|
| Rate for Payer: United Healthcare Commercial |
$266.87
|
| Rate for Payer: United Healthcare Medicare |
$111.76
|
|
