|
MVI, ADULT NO.4, VIT K, 1 OF 2 3,300 UNIT- 150 MCG/5 ML IV SOLN
|
Facility
|
IP
|
$33.71
|
|
|
Service Code
|
NDC 54643786208
|
| Hospital Charge Code |
182456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.12
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
|
|
MVI, ADULT NO.4, VIT K, 2 OF 2 600 MCG-60 MCG- 5 MCG/5 ML IV SOLN
|
Facility
|
IP
|
$33.71
|
|
|
Service Code
|
NDC 54643786209
|
| Hospital Charge Code |
182457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.12
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
|
|
MVI, ADULT NO.4, VIT K, 2 OF 2 600 MCG-60 MCG- 5 MCG/5 ML IV SOLN
|
Facility
|
OP
|
$33.71
|
|
|
Service Code
|
NDC 54643786209
|
| Hospital Charge Code |
182457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Medicare |
$10.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.86
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Centivo All Commercial |
$18.34
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Humana Medicare |
$10.79
|
| Rate for Payer: Lucent All Commercial |
$18.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.14
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.65
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
| Rate for Payer: United Healthcare Medicare |
$10.79
|
|
|
MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN
|
Facility
|
OP
|
$107.66
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
158853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$100.12 |
| Rate for Payer: Aetna Commercial |
$90.87
|
| Rate for Payer: Aetna Medicare |
$34.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$61.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.90
|
| Rate for Payer: Cash Price |
$64.60
|
| Rate for Payer: Cash Price |
$64.60
|
| Rate for Payer: Centivo All Commercial |
$58.57
|
| Rate for Payer: Cigna All Commercial |
$92.91
|
| Rate for Payer: CORVEL All Commercial |
$100.12
|
| Rate for Payer: Coventry All Commercial |
$94.74
|
| Rate for Payer: Encore All Commercial |
$99.10
|
| Rate for Payer: Frontpath All Commercial |
$99.05
|
| Rate for Payer: Humana ChoiceCare |
$92.99
|
| Rate for Payer: Humana Medicare |
$34.45
|
| Rate for Payer: Lucent All Commercial |
$58.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.89
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$80.75
|
| Rate for Payer: PHP All Commercial |
$81.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.99
|
| Rate for Payer: Sagamore Health Network All Products |
$83.11
|
| Rate for Payer: Signature Care EPO |
$89.36
|
| Rate for Payer: Signature Care PPO |
$94.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.51
|
| Rate for Payer: United Healthcare Commercial |
$84.84
|
| Rate for Payer: United Healthcare Medicare |
$34.45
|
|
|
MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN
|
Facility
|
IP
|
$107.66
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
158853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$100.12 |
| Rate for Payer: Aetna Commercial |
$93.02
|
| Rate for Payer: Cash Price |
$64.60
|
| Rate for Payer: Cigna All Commercial |
$92.91
|
| Rate for Payer: CORVEL All Commercial |
$100.12
|
| Rate for Payer: Coventry All Commercial |
$94.74
|
| Rate for Payer: Encore All Commercial |
$99.10
|
| Rate for Payer: Frontpath All Commercial |
$99.05
|
| Rate for Payer: Humana ChoiceCare |
$92.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.89
|
| Rate for Payer: PHCS All Commercial |
$80.75
|
| Rate for Payer: PHP All Commercial |
$81.65
|
| Rate for Payer: Sagamore Health Network All Products |
$83.11
|
| Rate for Payer: Signature Care EPO |
$89.36
|
| Rate for Payer: Signature Care PPO |
$94.74
|
| Rate for Payer: United Healthcare Commercial |
$84.84
|
|
|
NALBUPHINE 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
5339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Aetna Commercial |
$20.66
|
| Rate for Payer: Aetna Medicare |
$7.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.62
|
| Rate for Payer: Cash Price |
$14.69
|
| Rate for Payer: Centivo All Commercial |
$13.32
|
| Rate for Payer: Cigna All Commercial |
$21.13
|
| Rate for Payer: CORVEL All Commercial |
$22.77
|
| Rate for Payer: Coventry All Commercial |
$21.54
|
| Rate for Payer: Encore All Commercial |
$22.53
|
| Rate for Payer: Frontpath All Commercial |
$22.52
|
| Rate for Payer: Humana ChoiceCare |
$21.14
|
| Rate for Payer: Humana Medicare |
$7.83
|
| Rate for Payer: Lucent All Commercial |
$13.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.03
|
| Rate for Payer: PHCS All Commercial |
$18.36
|
| Rate for Payer: PHP All Commercial |
$18.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.55
|
| Rate for Payer: Sagamore Health Network All Products |
$18.90
|
| Rate for Payer: Signature Care EPO |
$20.32
|
| Rate for Payer: Signature Care PPO |
$21.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.81
|
| Rate for Payer: United Healthcare Commercial |
$19.29
|
| Rate for Payer: United Healthcare Medicare |
$7.83
|
|
|
NALBUPHINE 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
5339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Cash Price |
$14.69
|
| Rate for Payer: Cigna All Commercial |
$21.13
|
| Rate for Payer: CORVEL All Commercial |
$22.77
|
| Rate for Payer: Coventry All Commercial |
$21.54
|
| Rate for Payer: Encore All Commercial |
$22.53
|
| Rate for Payer: Frontpath All Commercial |
$22.52
|
| Rate for Payer: Humana ChoiceCare |
$21.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.03
|
| Rate for Payer: PHCS All Commercial |
$18.36
|
| Rate for Payer: PHP All Commercial |
$18.56
|
| Rate for Payer: Sagamore Health Network All Products |
$18.90
|
| Rate for Payer: Signature Care EPO |
$20.32
|
| Rate for Payer: Signature Care PPO |
$21.54
|
| Rate for Payer: United Healthcare Commercial |
$19.29
|
|
|
NALOXONE 0.4 MG/ML INJECTION S.O.
|
Facility
|
OP
|
$24.93
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
40805373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Aetna Medicare |
$7.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.78
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Centivo All Commercial |
$13.56
|
| Rate for Payer: Cigna All Commercial |
$21.52
|
| Rate for Payer: CORVEL All Commercial |
$23.19
|
| Rate for Payer: Coventry All Commercial |
$21.94
|
| Rate for Payer: Encore All Commercial |
$22.95
|
| Rate for Payer: Frontpath All Commercial |
$22.94
|
| Rate for Payer: Humana ChoiceCare |
$21.54
|
| Rate for Payer: Humana Medicare |
$7.98
|
| Rate for Payer: Lucent All Commercial |
$13.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.44
|
| Rate for Payer: PHCS All Commercial |
$18.70
|
| Rate for Payer: PHP All Commercial |
$18.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.72
|
| Rate for Payer: Sagamore Health Network All Products |
$19.25
|
| Rate for Payer: Signature Care EPO |
$20.70
|
| Rate for Payer: Signature Care PPO |
$21.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.19
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
| Rate for Payer: United Healthcare Medicare |
$7.98
|
|
|
NALOXONE 0.4 MG/ML INJECTION S.O.
|
Facility
|
IP
|
$24.93
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
40805373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Aetna Commercial |
$21.54
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Cigna All Commercial |
$21.52
|
| Rate for Payer: CORVEL All Commercial |
$23.19
|
| Rate for Payer: Coventry All Commercial |
$21.94
|
| Rate for Payer: Encore All Commercial |
$22.95
|
| Rate for Payer: Frontpath All Commercial |
$22.94
|
| Rate for Payer: Humana ChoiceCare |
$21.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.44
|
| Rate for Payer: PHCS All Commercial |
$18.70
|
| Rate for Payer: PHP All Commercial |
$18.91
|
| Rate for Payer: Sagamore Health Network All Products |
$19.25
|
| Rate for Payer: Signature Care EPO |
$20.70
|
| Rate for Payer: Signature Care PPO |
$21.94
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
|
|
NALOXONE 0.4 MG/ML INJ SOLN
|
Facility
|
OP
|
$24.93
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
5373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Aetna Medicare |
$7.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.78
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Centivo All Commercial |
$13.56
|
| Rate for Payer: Cigna All Commercial |
$21.52
|
| Rate for Payer: CORVEL All Commercial |
$23.19
|
| Rate for Payer: Coventry All Commercial |
$21.94
|
| Rate for Payer: Encore All Commercial |
$22.95
|
| Rate for Payer: Frontpath All Commercial |
$22.94
|
| Rate for Payer: Humana ChoiceCare |
$21.54
|
| Rate for Payer: Humana Medicare |
$7.98
|
| Rate for Payer: Lucent All Commercial |
$13.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.44
|
| Rate for Payer: PHCS All Commercial |
$18.70
|
| Rate for Payer: PHP All Commercial |
$18.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.72
|
| Rate for Payer: Sagamore Health Network All Products |
$19.25
|
| Rate for Payer: Signature Care EPO |
$20.70
|
| Rate for Payer: Signature Care PPO |
$21.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.19
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
| Rate for Payer: United Healthcare Medicare |
$7.98
|
|
|
NALOXONE 0.4 MG/ML INJ SOLN
|
Facility
|
IP
|
$24.93
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
5373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Aetna Commercial |
$21.54
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Cigna All Commercial |
$21.52
|
| Rate for Payer: CORVEL All Commercial |
$23.19
|
| Rate for Payer: Coventry All Commercial |
$21.94
|
| Rate for Payer: Encore All Commercial |
$22.95
|
| Rate for Payer: Frontpath All Commercial |
$22.94
|
| Rate for Payer: Humana ChoiceCare |
$21.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.44
|
| Rate for Payer: PHCS All Commercial |
$18.70
|
| Rate for Payer: PHP All Commercial |
$18.91
|
| Rate for Payer: Sagamore Health Network All Products |
$19.25
|
| Rate for Payer: Signature Care EPO |
$20.70
|
| Rate for Payer: Signature Care PPO |
$21.94
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
|
|
NALOXONE 1 MG/ML INJ SYRG
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
5374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.29 |
| Max. Negotiated Rate |
$181.39 |
| Rate for Payer: Aetna Commercial |
$168.52
|
| Rate for Payer: Cash Price |
$117.03
|
| Rate for Payer: Cigna All Commercial |
$168.33
|
| Rate for Payer: CORVEL All Commercial |
$181.39
|
| Rate for Payer: Coventry All Commercial |
$171.64
|
| Rate for Payer: Encore All Commercial |
$179.54
|
| Rate for Payer: Frontpath All Commercial |
$179.44
|
| Rate for Payer: Humana ChoiceCare |
$168.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.54
|
| Rate for Payer: PHCS All Commercial |
$146.29
|
| Rate for Payer: PHP All Commercial |
$147.92
|
| Rate for Payer: Sagamore Health Network All Products |
$150.58
|
| Rate for Payer: Signature Care EPO |
$161.89
|
| Rate for Payer: Signature Care PPO |
$171.64
|
| Rate for Payer: United Healthcare Commercial |
$153.70
|
|
|
NALOXONE 1 MG/ML INJ SYRG
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
HCPCS J2313
|
| Hospital Charge Code |
5374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$181.39 |
| Rate for Payer: Aetna Commercial |
$164.62
|
| Rate for Payer: Aetna Medicare |
$62.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$112.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$121.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.66
|
| Rate for Payer: Cash Price |
$117.03
|
| Rate for Payer: Centivo All Commercial |
$106.11
|
| Rate for Payer: Cigna All Commercial |
$168.33
|
| Rate for Payer: CORVEL All Commercial |
$181.39
|
| Rate for Payer: Coventry All Commercial |
$171.64
|
| Rate for Payer: Encore All Commercial |
$179.54
|
| Rate for Payer: Frontpath All Commercial |
$179.44
|
| Rate for Payer: Humana ChoiceCare |
$168.46
|
| Rate for Payer: Humana Medicare |
$62.42
|
| Rate for Payer: Lucent All Commercial |
$106.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.54
|
| Rate for Payer: PHCS All Commercial |
$146.29
|
| Rate for Payer: PHP All Commercial |
$147.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.07
|
| Rate for Payer: Sagamore Health Network All Products |
$150.58
|
| Rate for Payer: Signature Care EPO |
$161.89
|
| Rate for Payer: Signature Care PPO |
$171.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$165.79
|
| Rate for Payer: United Healthcare Commercial |
$153.70
|
| Rate for Payer: United Healthcare Medicare |
$62.42
|
|
|
NALTREXONE MICROSPHERES 380 MG IM SERR
|
Facility
|
OP
|
$5,546.42
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
76527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$5,158.17 |
| Rate for Payer: Aetna Commercial |
$4,681.17
|
| Rate for Payer: Aetna Medicare |
$1,774.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$4.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,719.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,185.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,467.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$4.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,041.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,952.34
|
| Rate for Payer: Cash Price |
$3,327.85
|
| Rate for Payer: Cash Price |
$3,327.85
|
| Rate for Payer: Centivo All Commercial |
$3,017.25
|
| Rate for Payer: Cigna All Commercial |
$4,786.56
|
| Rate for Payer: CORVEL All Commercial |
$5,158.17
|
| Rate for Payer: Coventry All Commercial |
$4,880.85
|
| Rate for Payer: Encore All Commercial |
$5,105.48
|
| Rate for Payer: Frontpath All Commercial |
$5,102.70
|
| Rate for Payer: Humana ChoiceCare |
$4,790.44
|
| Rate for Payer: Humana Medicare |
$1,774.85
|
| Rate for Payer: Lucent All Commercial |
$3,017.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,991.77
|
| Rate for Payer: Managed Health Services Medicaid |
$4.67
|
| Rate for Payer: MDWise Medicaid |
$4.67
|
| Rate for Payer: PHCS All Commercial |
$4,159.81
|
| Rate for Payer: PHP All Commercial |
$4,206.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,163.10
|
| Rate for Payer: Sagamore Health Network All Products |
$4,281.83
|
| Rate for Payer: Signature Care EPO |
$4,603.52
|
| Rate for Payer: Signature Care PPO |
$4,880.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,714.45
|
| Rate for Payer: United Healthcare Commercial |
$4,370.58
|
| Rate for Payer: United Healthcare Medicare |
$1,774.85
|
|
|
NALTREXONE MICROSPHERES 380 MG IM SERR
|
Facility
|
IP
|
$5,546.42
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
76527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,159.81 |
| Max. Negotiated Rate |
$5,158.17 |
| Rate for Payer: Aetna Commercial |
$4,792.10
|
| Rate for Payer: Cash Price |
$3,327.85
|
| Rate for Payer: Cigna All Commercial |
$4,786.56
|
| Rate for Payer: CORVEL All Commercial |
$5,158.17
|
| Rate for Payer: Coventry All Commercial |
$4,880.85
|
| Rate for Payer: Encore All Commercial |
$5,105.48
|
| Rate for Payer: Frontpath All Commercial |
$5,102.70
|
| Rate for Payer: Humana ChoiceCare |
$4,790.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,991.77
|
| Rate for Payer: PHCS All Commercial |
$4,159.81
|
| Rate for Payer: PHP All Commercial |
$4,206.40
|
| Rate for Payer: Sagamore Health Network All Products |
$4,281.83
|
| Rate for Payer: Signature Care EPO |
$4,603.52
|
| Rate for Payer: Signature Care PPO |
$4,880.85
|
| Rate for Payer: United Healthcare Commercial |
$4,370.58
|
|
|
NAPROXEN 500 MG ORAL TAB
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 60687049101
|
| Hospital Charge Code |
5393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
|
|
NAPROXEN 500 MG ORAL TAB
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 60687049101
|
| Hospital Charge Code |
5393
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Aetna Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Centivo All Commercial |
$0.85
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Humana Medicare |
$0.50
|
| Rate for Payer: Lucent All Commercial |
$0.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
|
|
NAPROXEN SODIUM 220 MG ORAL TAB
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 70000020102
|
| Hospital Charge Code |
13135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna Commercial |
$0.39
|
| Rate for Payer: Aetna Medicare |
$0.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Centivo All Commercial |
$0.25
|
| Rate for Payer: Cigna All Commercial |
$0.40
|
| Rate for Payer: CORVEL All Commercial |
$0.43
|
| Rate for Payer: Coventry All Commercial |
$0.41
|
| Rate for Payer: Encore All Commercial |
$0.43
|
| Rate for Payer: Frontpath All Commercial |
$0.43
|
| Rate for Payer: Humana ChoiceCare |
$0.40
|
| Rate for Payer: Humana Medicare |
$0.15
|
| Rate for Payer: Lucent All Commercial |
$0.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.42
|
| Rate for Payer: PHCS All Commercial |
$0.35
|
| Rate for Payer: PHP All Commercial |
$0.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.18
|
| Rate for Payer: Sagamore Health Network All Products |
$0.36
|
| Rate for Payer: Signature Care EPO |
$0.38
|
| Rate for Payer: Signature Care PPO |
$0.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
|
|
NAPROXEN SODIUM 220 MG ORAL TAB
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 70000020102
|
| Hospital Charge Code |
13135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna All Commercial |
$0.40
|
| Rate for Payer: CORVEL All Commercial |
$0.43
|
| Rate for Payer: Coventry All Commercial |
$0.41
|
| Rate for Payer: Encore All Commercial |
$0.43
|
| Rate for Payer: Frontpath All Commercial |
$0.43
|
| Rate for Payer: Humana ChoiceCare |
$0.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.42
|
| Rate for Payer: PHCS All Commercial |
$0.35
|
| Rate for Payer: PHP All Commercial |
$0.35
|
| Rate for Payer: Sagamore Health Network All Products |
$0.36
|
| Rate for Payer: Signature Care EPO |
$0.38
|
| Rate for Payer: Signature Care PPO |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
|
OP
|
$17.86
|
|
|
Service Code
|
NDC 60687064111
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$16.61 |
| Rate for Payer: Aetna Commercial |
$15.08
|
| Rate for Payer: Aetna Medicare |
$5.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.29
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Centivo All Commercial |
$9.72
|
| Rate for Payer: Cigna All Commercial |
$15.42
|
| Rate for Payer: CORVEL All Commercial |
$16.61
|
| Rate for Payer: Coventry All Commercial |
$15.72
|
| Rate for Payer: Encore All Commercial |
$16.44
|
| Rate for Payer: Frontpath All Commercial |
$16.43
|
| Rate for Payer: Humana ChoiceCare |
$15.43
|
| Rate for Payer: Humana Medicare |
$5.72
|
| Rate for Payer: Lucent All Commercial |
$9.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.08
|
| Rate for Payer: PHCS All Commercial |
$13.40
|
| Rate for Payer: PHP All Commercial |
$13.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.97
|
| Rate for Payer: Sagamore Health Network All Products |
$13.79
|
| Rate for Payer: Signature Care EPO |
$14.83
|
| Rate for Payer: Signature Care PPO |
$15.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.18
|
| Rate for Payer: United Healthcare Commercial |
$14.08
|
| Rate for Payer: United Healthcare Medicare |
$5.72
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
|
OP
|
$17.86
|
|
|
Service Code
|
NDC 60687064121
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$16.61 |
| Rate for Payer: Aetna Commercial |
$15.08
|
| Rate for Payer: Aetna Medicare |
$5.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.29
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Centivo All Commercial |
$9.72
|
| Rate for Payer: Cigna All Commercial |
$15.42
|
| Rate for Payer: CORVEL All Commercial |
$16.61
|
| Rate for Payer: Coventry All Commercial |
$15.72
|
| Rate for Payer: Encore All Commercial |
$16.44
|
| Rate for Payer: Frontpath All Commercial |
$16.43
|
| Rate for Payer: Humana ChoiceCare |
$15.43
|
| Rate for Payer: Humana Medicare |
$5.72
|
| Rate for Payer: Lucent All Commercial |
$9.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.08
|
| Rate for Payer: PHCS All Commercial |
$13.40
|
| Rate for Payer: PHP All Commercial |
$13.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.97
|
| Rate for Payer: Sagamore Health Network All Products |
$13.79
|
| Rate for Payer: Signature Care EPO |
$14.83
|
| Rate for Payer: Signature Care PPO |
$15.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.18
|
| Rate for Payer: United Healthcare Commercial |
$14.08
|
| Rate for Payer: United Healthcare Medicare |
$5.72
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
|
IP
|
$17.86
|
|
|
Service Code
|
NDC 60687064121
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$16.61 |
| Rate for Payer: Aetna Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna All Commercial |
$15.42
|
| Rate for Payer: CORVEL All Commercial |
$16.61
|
| Rate for Payer: Coventry All Commercial |
$15.72
|
| Rate for Payer: Encore All Commercial |
$16.44
|
| Rate for Payer: Frontpath All Commercial |
$16.43
|
| Rate for Payer: Humana ChoiceCare |
$15.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.08
|
| Rate for Payer: PHCS All Commercial |
$13.40
|
| Rate for Payer: PHP All Commercial |
$13.55
|
| Rate for Payer: Sagamore Health Network All Products |
$13.79
|
| Rate for Payer: Signature Care EPO |
$14.83
|
| Rate for Payer: Signature Care PPO |
$15.72
|
| Rate for Payer: United Healthcare Commercial |
$14.08
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
|
IP
|
$17.86
|
|
|
Service Code
|
NDC 60687064111
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$16.61 |
| Rate for Payer: Aetna Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna All Commercial |
$15.42
|
| Rate for Payer: CORVEL All Commercial |
$16.61
|
| Rate for Payer: Coventry All Commercial |
$15.72
|
| Rate for Payer: Encore All Commercial |
$16.44
|
| Rate for Payer: Frontpath All Commercial |
$16.43
|
| Rate for Payer: Humana ChoiceCare |
$15.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.08
|
| Rate for Payer: PHCS All Commercial |
$13.40
|
| Rate for Payer: PHP All Commercial |
$13.55
|
| Rate for Payer: Sagamore Health Network All Products |
$13.79
|
| Rate for Payer: Signature Care EPO |
$14.83
|
| Rate for Payer: Signature Care PPO |
$15.72
|
| Rate for Payer: United Healthcare Commercial |
$14.08
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
118303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| 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 Hoosier Healthwise/HIP |
$9.56
|
| 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: 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: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
118303
|
|
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
|
|
