|
CLORAZEPATE DIPOTASSIUM 7.5 MG ORAL TAB
|
Facility
|
OP
|
$8.67
|
|
|
Service Code
|
NDC 00378004001
|
| Hospital Charge Code |
1760
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$8.07 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Aetna Medicare |
$2.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.15
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Centivo All Commercial |
$4.42
|
| Rate for Payer: Cigna All Commercial |
$7.48
|
| Rate for Payer: CORVEL All Commercial |
$8.07
|
| Rate for Payer: Coventry All Commercial |
$7.63
|
| Rate for Payer: Encore All Commercial |
$7.98
|
| Rate for Payer: Frontpath All Commercial |
$7.98
|
| Rate for Payer: Humana ChoiceCare |
$7.49
|
| Rate for Payer: Humana Medicare |
$4.42
|
| Rate for Payer: Lucent All Commercial |
$4.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.81
|
| Rate for Payer: PHCS All Commercial |
$6.50
|
| Rate for Payer: PHP All Commercial |
$6.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.38
|
| Rate for Payer: Sagamore Health Network All Products |
$6.70
|
| Rate for Payer: Signature Care EPO |
$7.20
|
| Rate for Payer: Signature Care PPO |
$7.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.37
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
| Rate for Payer: United Healthcare Medicare |
$2.86
|
|
|
CLORAZEPATE DIPOTASSIUM 7.5 MG ORAL TAB
|
Facility
|
IP
|
$8.67
|
|
|
Service Code
|
NDC 00378004001
|
| Hospital Charge Code |
1760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$8.07 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna All Commercial |
$7.48
|
| Rate for Payer: CORVEL All Commercial |
$8.07
|
| Rate for Payer: Coventry All Commercial |
$7.63
|
| Rate for Payer: Encore All Commercial |
$7.98
|
| Rate for Payer: Frontpath All Commercial |
$7.98
|
| Rate for Payer: Humana ChoiceCare |
$7.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.81
|
| Rate for Payer: PHCS All Commercial |
$6.50
|
| Rate for Payer: PHP All Commercial |
$6.58
|
| Rate for Payer: Sagamore Health Network All Products |
$6.70
|
| Rate for Payer: Signature Care EPO |
$7.20
|
| Rate for Payer: Signature Care PPO |
$7.63
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
|
|
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 25605
|
| Hospital Charge Code |
CPT-25605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 27266
|
| Hospital Charge Code |
CPT-27266
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
Closed treatment of radial head or neck fracture; with manipulation
|
Facility
|
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 24655
|
| Hospital Charge Code |
CPT-24655
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
CLOTRIMAZOLE 10 MG MM TROC
|
Facility
|
OP
|
$24.05
|
|
|
Service Code
|
NDC 00054814622
|
| Hospital Charge Code |
9644
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$20.29
|
| Rate for Payer: Aetna Medicare |
$7.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.73
|
| Rate for Payer: Cash Price |
$14.91
|
| Rate for Payer: Centivo All Commercial |
$12.26
|
| Rate for Payer: Cigna All Commercial |
$20.75
|
| Rate for Payer: CORVEL All Commercial |
$22.36
|
| Rate for Payer: Coventry All Commercial |
$21.16
|
| Rate for Payer: Encore All Commercial |
$22.13
|
| Rate for Payer: Frontpath All Commercial |
$22.12
|
| Rate for Payer: Humana ChoiceCare |
$20.77
|
| Rate for Payer: Humana Medicare |
$12.26
|
| Rate for Payer: Lucent All Commercial |
$12.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.64
|
| Rate for Payer: PHCS All Commercial |
$18.03
|
| Rate for Payer: PHP All Commercial |
$18.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.38
|
| Rate for Payer: Sagamore Health Network All Products |
$18.56
|
| Rate for Payer: Signature Care EPO |
$19.96
|
| Rate for Payer: Signature Care PPO |
$21.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.44
|
| Rate for Payer: United Healthcare Commercial |
$18.95
|
| Rate for Payer: United Healthcare Medicare |
$7.93
|
|
|
CLOTRIMAZOLE 10 MG MM TROC
|
Facility
|
IP
|
$24.05
|
|
|
Service Code
|
NDC 00054814622
|
| Hospital Charge Code |
9644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$20.77
|
| Rate for Payer: Cash Price |
$14.91
|
| Rate for Payer: Cigna All Commercial |
$20.75
|
| Rate for Payer: CORVEL All Commercial |
$22.36
|
| Rate for Payer: Coventry All Commercial |
$21.16
|
| Rate for Payer: Encore All Commercial |
$22.13
|
| Rate for Payer: Frontpath All Commercial |
$22.12
|
| Rate for Payer: Humana ChoiceCare |
$20.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.64
|
| Rate for Payer: PHCS All Commercial |
$18.03
|
| Rate for Payer: PHP All Commercial |
$18.24
|
| Rate for Payer: Sagamore Health Network All Products |
$18.56
|
| Rate for Payer: Signature Care EPO |
$19.96
|
| Rate for Payer: Signature Care PPO |
$21.16
|
| Rate for Payer: United Healthcare Commercial |
$18.95
|
|
|
CLOTRIMAZOLE 1 % TOP CREA
|
Facility
|
OP
|
$14.70
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna Commercial |
$12.41
|
| Rate for Payer: Aetna Medicare |
$4.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.34
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Centivo All Commercial |
$7.50
|
| Rate for Payer: Cigna All Commercial |
$12.69
|
| Rate for Payer: CORVEL All Commercial |
$13.67
|
| Rate for Payer: Coventry All Commercial |
$12.94
|
| Rate for Payer: Encore All Commercial |
$13.53
|
| Rate for Payer: Frontpath All Commercial |
$13.52
|
| Rate for Payer: Humana ChoiceCare |
$12.70
|
| Rate for Payer: Humana Medicare |
$7.50
|
| Rate for Payer: Lucent All Commercial |
$7.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.23
|
| Rate for Payer: PHCS All Commercial |
$11.02
|
| Rate for Payer: PHP All Commercial |
$11.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.73
|
| Rate for Payer: Sagamore Health Network All Products |
$11.35
|
| Rate for Payer: Signature Care EPO |
$12.20
|
| Rate for Payer: Signature Care PPO |
$12.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.50
|
| Rate for Payer: United Healthcare Commercial |
$11.58
|
| Rate for Payer: United Healthcare Medicare |
$4.85
|
|
|
CLOTRIMAZOLE 1 % TOP CREA
|
Facility
|
IP
|
$14.70
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.02 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cigna All Commercial |
$12.69
|
| Rate for Payer: CORVEL All Commercial |
$13.67
|
| Rate for Payer: Coventry All Commercial |
$12.94
|
| Rate for Payer: Encore All Commercial |
$13.53
|
| Rate for Payer: Frontpath All Commercial |
$13.52
|
| Rate for Payer: Humana ChoiceCare |
$12.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.23
|
| Rate for Payer: PHCS All Commercial |
$11.02
|
| Rate for Payer: PHP All Commercial |
$11.15
|
| Rate for Payer: Sagamore Health Network All Products |
$11.35
|
| Rate for Payer: Signature Care EPO |
$12.20
|
| Rate for Payer: Signature Care PPO |
$12.94
|
| Rate for Payer: United Healthcare Commercial |
$11.58
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CREA
|
Facility
|
IP
|
$25.52
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$23.73 |
| Rate for Payer: Aetna Commercial |
$22.04
|
| Rate for Payer: Cash Price |
$15.82
|
| Rate for Payer: Cigna All Commercial |
$22.02
|
| Rate for Payer: CORVEL All Commercial |
$23.73
|
| Rate for Payer: Coventry All Commercial |
$22.45
|
| Rate for Payer: Encore All Commercial |
$23.49
|
| Rate for Payer: Frontpath All Commercial |
$23.47
|
| Rate for Payer: Humana ChoiceCare |
$22.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.96
|
| Rate for Payer: PHCS All Commercial |
$19.14
|
| Rate for Payer: PHP All Commercial |
$19.35
|
| Rate for Payer: Sagamore Health Network All Products |
$19.70
|
| Rate for Payer: Signature Care EPO |
$21.18
|
| Rate for Payer: Signature Care PPO |
$22.45
|
| Rate for Payer: United Healthcare Commercial |
$20.11
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CREA
|
Facility
|
OP
|
$25.52
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$23.73 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Medicare |
$8.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.26
|
| Rate for Payer: Cash Price |
$15.82
|
| Rate for Payer: Centivo All Commercial |
$13.01
|
| Rate for Payer: Cigna All Commercial |
$22.02
|
| Rate for Payer: CORVEL All Commercial |
$23.73
|
| Rate for Payer: Coventry All Commercial |
$22.45
|
| Rate for Payer: Encore All Commercial |
$23.49
|
| Rate for Payer: Frontpath All Commercial |
$23.47
|
| Rate for Payer: Humana ChoiceCare |
$22.04
|
| Rate for Payer: Humana Medicare |
$13.01
|
| Rate for Payer: Lucent All Commercial |
$13.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.96
|
| Rate for Payer: PHCS All Commercial |
$19.14
|
| Rate for Payer: PHP All Commercial |
$19.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.95
|
| Rate for Payer: Sagamore Health Network All Products |
$19.70
|
| Rate for Payer: Signature Care EPO |
$21.18
|
| Rate for Payer: Signature Care PPO |
$22.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.69
|
| Rate for Payer: United Healthcare Commercial |
$20.11
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
IP
|
$4.48
|
|
|
Service Code
|
NDC 00121155000
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna All Commercial |
$3.87
|
| Rate for Payer: CORVEL All Commercial |
$4.17
|
| Rate for Payer: Coventry All Commercial |
$3.94
|
| Rate for Payer: Encore All Commercial |
$4.12
|
| Rate for Payer: Frontpath All Commercial |
$4.12
|
| Rate for Payer: Humana ChoiceCare |
$3.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.03
|
| Rate for Payer: PHCS All Commercial |
$3.36
|
| Rate for Payer: PHP All Commercial |
$3.40
|
| Rate for Payer: Sagamore Health Network All Products |
$3.46
|
| Rate for Payer: Signature Care EPO |
$3.72
|
| Rate for Payer: Signature Care PPO |
$3.94
|
| Rate for Payer: United Healthcare Commercial |
$3.53
|
|
|
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD
|
Facility
|
OP
|
$4.48
|
|
|
Service Code
|
NDC 00121155000
|
| Hospital Charge Code |
78003
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Aetna Medicare |
$1.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Centivo All Commercial |
$2.28
|
| Rate for Payer: Cigna All Commercial |
$3.87
|
| Rate for Payer: CORVEL All Commercial |
$4.17
|
| Rate for Payer: Coventry All Commercial |
$3.94
|
| Rate for Payer: Encore All Commercial |
$4.12
|
| Rate for Payer: Frontpath All Commercial |
$4.12
|
| Rate for Payer: Humana ChoiceCare |
$3.87
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Lucent All Commercial |
$2.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.03
|
| Rate for Payer: PHCS All Commercial |
$3.36
|
| Rate for Payer: PHP All Commercial |
$3.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.75
|
| Rate for Payer: Sagamore Health Network All Products |
$3.46
|
| Rate for Payer: Signature Care EPO |
$3.72
|
| Rate for Payer: Signature Care PPO |
$3.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.81
|
| Rate for Payer: United Healthcare Commercial |
$3.53
|
| Rate for Payer: United Healthcare Medicare |
$1.48
|
|
|
COENZYME Q10 50 MG ORAL CAP
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 00904561646
|
| Hospital Charge Code |
35228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.14
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cigna All Commercial |
$1.14
|
| Rate for Payer: CORVEL All Commercial |
$1.23
|
| Rate for Payer: Coventry All Commercial |
$1.16
|
| Rate for Payer: Encore All Commercial |
$1.22
|
| Rate for Payer: Frontpath All Commercial |
$1.22
|
| Rate for Payer: Humana ChoiceCare |
$1.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.19
|
| Rate for Payer: PHCS All Commercial |
$0.99
|
| Rate for Payer: PHP All Commercial |
$1.00
|
| Rate for Payer: Sagamore Health Network All Products |
$1.02
|
| Rate for Payer: Signature Care EPO |
$1.10
|
| Rate for Payer: Signature Care PPO |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
COENZYME Q10 50 MG ORAL CAP
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 00904561646
|
| Hospital Charge Code |
35228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Centivo All Commercial |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$1.14
|
| Rate for Payer: CORVEL All Commercial |
$1.23
|
| Rate for Payer: Coventry All Commercial |
$1.16
|
| Rate for Payer: Encore All Commercial |
$1.22
|
| Rate for Payer: Frontpath All Commercial |
$1.22
|
| Rate for Payer: Humana ChoiceCare |
$1.14
|
| Rate for Payer: Humana Medicare |
$0.67
|
| Rate for Payer: Lucent All Commercial |
$0.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.19
|
| Rate for Payer: PHCS All Commercial |
$0.99
|
| Rate for Payer: PHP All Commercial |
$1.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.02
|
| Rate for Payer: Signature Care EPO |
$1.10
|
| Rate for Payer: Signature Care PPO |
$1.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
COLCHICINE 0.6 MG ORAL TAB
|
Facility
|
OP
|
$19.87
|
|
|
Service Code
|
NDC 00904712004
|
| Hospital Charge Code |
1821
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$18.48 |
| Rate for Payer: Aetna Commercial |
$16.77
|
| Rate for Payer: Aetna Medicare |
$6.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.21
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Centivo All Commercial |
$10.13
|
| Rate for Payer: Cigna All Commercial |
$17.14
|
| Rate for Payer: CORVEL All Commercial |
$18.48
|
| Rate for Payer: Coventry All Commercial |
$17.48
|
| Rate for Payer: Encore All Commercial |
$18.29
|
| Rate for Payer: Frontpath All Commercial |
$18.28
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Humana Medicare |
$10.13
|
| Rate for Payer: Lucent All Commercial |
$10.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.88
|
| Rate for Payer: PHCS All Commercial |
$14.90
|
| Rate for Payer: PHP All Commercial |
$15.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.75
|
| Rate for Payer: Sagamore Health Network All Products |
$15.34
|
| Rate for Payer: Signature Care EPO |
$16.49
|
| Rate for Payer: Signature Care PPO |
$17.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.89
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
| Rate for Payer: United Healthcare Medicare |
$6.56
|
|
|
COLCHICINE 0.6 MG ORAL TAB
|
Facility
|
IP
|
$19.87
|
|
|
Service Code
|
NDC 00904712004
|
| Hospital Charge Code |
1821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.90 |
| Max. Negotiated Rate |
$18.48 |
| Rate for Payer: Aetna Commercial |
$17.16
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Cigna All Commercial |
$17.14
|
| Rate for Payer: CORVEL All Commercial |
$18.48
|
| Rate for Payer: Coventry All Commercial |
$17.48
|
| Rate for Payer: Encore All Commercial |
$18.29
|
| Rate for Payer: Frontpath All Commercial |
$18.28
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.88
|
| Rate for Payer: PHCS All Commercial |
$14.90
|
| Rate for Payer: PHP All Commercial |
$15.07
|
| Rate for Payer: Sagamore Health Network All Products |
$15.34
|
| Rate for Payer: Signature Care EPO |
$16.49
|
| Rate for Payer: Signature Care PPO |
$17.48
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
|
|
COLESEVELAM 625 MG ORAL TAB
|
Facility
|
IP
|
$30.45
|
|
|
Service Code
|
NDC 60687038525
|
| Hospital Charge Code |
28372
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.84 |
| Max. Negotiated Rate |
$28.32 |
| Rate for Payer: Aetna Commercial |
$26.31
|
| Rate for Payer: Cash Price |
$18.88
|
| Rate for Payer: Cigna All Commercial |
$26.28
|
| Rate for Payer: CORVEL All Commercial |
$28.32
|
| Rate for Payer: Coventry All Commercial |
$26.80
|
| Rate for Payer: Encore All Commercial |
$28.03
|
| Rate for Payer: Frontpath All Commercial |
$28.01
|
| Rate for Payer: Humana ChoiceCare |
$26.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.40
|
| Rate for Payer: PHCS All Commercial |
$22.84
|
| Rate for Payer: PHP All Commercial |
$23.09
|
| Rate for Payer: Sagamore Health Network All Products |
$23.51
|
| Rate for Payer: Signature Care EPO |
$25.27
|
| Rate for Payer: Signature Care PPO |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
|
|
COLESEVELAM 625 MG ORAL TAB
|
Facility
|
OP
|
$30.45
|
|
|
Service Code
|
NDC 60687038525
|
| Hospital Charge Code |
28372
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$28.32 |
| Rate for Payer: Aetna Commercial |
$25.70
|
| Rate for Payer: Aetna Medicare |
$10.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.05
|
| Rate for Payer: Cash Price |
$18.88
|
| Rate for Payer: Centivo All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$26.28
|
| Rate for Payer: CORVEL All Commercial |
$28.32
|
| Rate for Payer: Coventry All Commercial |
$26.80
|
| Rate for Payer: Encore All Commercial |
$28.03
|
| Rate for Payer: Frontpath All Commercial |
$28.01
|
| Rate for Payer: Humana ChoiceCare |
$26.30
|
| Rate for Payer: Humana Medicare |
$15.53
|
| Rate for Payer: Lucent All Commercial |
$15.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.40
|
| Rate for Payer: PHCS All Commercial |
$22.84
|
| Rate for Payer: PHP All Commercial |
$23.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.88
|
| Rate for Payer: Sagamore Health Network All Products |
$23.51
|
| Rate for Payer: Signature Care EPO |
$25.27
|
| Rate for Payer: Signature Care PPO |
$26.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.88
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$10.05
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 250 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$1,147.08
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
9682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,066.78 |
| Rate for Payer: Aetna Commercial |
$968.14
|
| Rate for Payer: Aetna Medicare |
$378.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$378.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$658.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$717.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$435.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$416.39
|
| Rate for Payer: Cash Price |
$711.19
|
| Rate for Payer: Cash Price |
$711.19
|
| Rate for Payer: Centivo All Commercial |
$585.01
|
| Rate for Payer: Cigna All Commercial |
$989.93
|
| Rate for Payer: CORVEL All Commercial |
$1,066.78
|
| Rate for Payer: Coventry All Commercial |
$1,009.43
|
| Rate for Payer: Encore All Commercial |
$1,055.89
|
| Rate for Payer: Frontpath All Commercial |
$1,055.31
|
| Rate for Payer: Humana ChoiceCare |
$990.73
|
| Rate for Payer: Humana Medicare |
$585.01
|
| Rate for Payer: Lucent All Commercial |
$585.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,032.37
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$860.31
|
| Rate for Payer: PHP All Commercial |
$869.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$447.36
|
| Rate for Payer: Sagamore Health Network All Products |
$885.55
|
| Rate for Payer: Signature Care EPO |
$952.08
|
| Rate for Payer: Signature Care PPO |
$1,009.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$975.02
|
| Rate for Payer: United Healthcare Commercial |
$903.90
|
| Rate for Payer: United Healthcare Medicare |
$378.54
|
|
|
COLLAGENASE CLOSTRIDIUM HISTO. 250 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$1,147.08
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
9682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$860.31 |
| Max. Negotiated Rate |
$1,066.78 |
| Rate for Payer: Aetna Commercial |
$991.08
|
| Rate for Payer: Cash Price |
$711.19
|
| Rate for Payer: Cigna All Commercial |
$989.93
|
| Rate for Payer: CORVEL All Commercial |
$1,066.78
|
| Rate for Payer: Coventry All Commercial |
$1,009.43
|
| Rate for Payer: Encore All Commercial |
$1,055.89
|
| Rate for Payer: Frontpath All Commercial |
$1,055.31
|
| Rate for Payer: Humana ChoiceCare |
$990.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,032.37
|
| Rate for Payer: PHCS All Commercial |
$860.31
|
| Rate for Payer: PHP All Commercial |
$869.95
|
| Rate for Payer: Sagamore Health Network All Products |
$885.55
|
| Rate for Payer: Signature Care EPO |
$952.08
|
| Rate for Payer: Signature Care PPO |
$1,009.43
|
| Rate for Payer: United Healthcare Commercial |
$903.90
|
|
|
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 45378
|
| Hospital Charge Code |
CPT-45378
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Colonoscopy, flexible; with biopsy, single or multiple
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45380
|
| Hospital Charge Code |
CPT-45380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Colonoscopy, flexible; with control of bleeding, any method
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45382
|
| Hospital Charge Code |
CPT-45382
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Colonoscopy, flexible; with directed submucosal injection(s), any substance
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45381
|
| Hospital Charge Code |
CPT-45381
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
