|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$18.89
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna Commercial |
$16.32
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna All Commercial |
$16.30
|
| Rate for Payer: CORVEL All Commercial |
$17.56
|
| Rate for Payer: Coventry All Commercial |
$16.62
|
| Rate for Payer: Encore All Commercial |
$17.38
|
| Rate for Payer: Frontpath All Commercial |
$17.38
|
| Rate for Payer: Humana ChoiceCare |
$16.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.00
|
| Rate for Payer: PHCS All Commercial |
$14.16
|
| Rate for Payer: PHP All Commercial |
$14.32
|
| Rate for Payer: Sagamore Health Network All Products |
$14.58
|
| Rate for Payer: Signature Care EPO |
$15.68
|
| Rate for Payer: Signature Care PPO |
$16.62
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$18.89
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna Medicare |
$6.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.65
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Centivo All Commercial |
$10.27
|
| Rate for Payer: Cigna All Commercial |
$16.30
|
| Rate for Payer: CORVEL All Commercial |
$17.56
|
| Rate for Payer: Coventry All Commercial |
$16.62
|
| Rate for Payer: Encore All Commercial |
$17.38
|
| Rate for Payer: Frontpath All Commercial |
$17.38
|
| Rate for Payer: Humana ChoiceCare |
$16.31
|
| Rate for Payer: Humana Medicare |
$6.04
|
| Rate for Payer: Lucent All Commercial |
$10.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.00
|
| Rate for Payer: PHCS All Commercial |
$14.16
|
| Rate for Payer: PHP All Commercial |
$14.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.37
|
| Rate for Payer: Sagamore Health Network All Products |
$14.58
|
| Rate for Payer: Signature Care EPO |
$15.68
|
| Rate for Payer: Signature Care PPO |
$16.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.05
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$6.04
|
|
|
NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OTIC DRPS
|
Facility
|
IP
|
$243.25
|
|
|
Service Code
|
NDC 24208063562
|
| Hospital Charge Code |
28810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.44 |
| Max. Negotiated Rate |
$226.22 |
| Rate for Payer: Aetna Commercial |
$210.17
|
| Rate for Payer: Cash Price |
$145.95
|
| Rate for Payer: Cigna All Commercial |
$209.92
|
| Rate for Payer: CORVEL All Commercial |
$226.22
|
| Rate for Payer: Coventry All Commercial |
$214.06
|
| Rate for Payer: Encore All Commercial |
$223.91
|
| Rate for Payer: Frontpath All Commercial |
$223.79
|
| Rate for Payer: Humana ChoiceCare |
$210.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.93
|
| Rate for Payer: PHCS All Commercial |
$182.44
|
| Rate for Payer: PHP All Commercial |
$184.48
|
| Rate for Payer: Sagamore Health Network All Products |
$187.79
|
| Rate for Payer: Signature Care EPO |
$201.90
|
| Rate for Payer: Signature Care PPO |
$214.06
|
| Rate for Payer: United Healthcare Commercial |
$191.68
|
|
|
NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OTIC DRPS
|
Facility
|
OP
|
$243.25
|
|
|
Service Code
|
NDC 24208063562
|
| Hospital Charge Code |
28810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$226.22 |
| Rate for Payer: Aetna Commercial |
$205.30
|
| Rate for Payer: Aetna Medicare |
$77.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$75.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$139.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$152.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$85.62
|
| Rate for Payer: Cash Price |
$145.95
|
| Rate for Payer: Cash Price |
$145.95
|
| Rate for Payer: Centivo All Commercial |
$132.33
|
| Rate for Payer: Cigna All Commercial |
$209.92
|
| Rate for Payer: CORVEL All Commercial |
$226.22
|
| Rate for Payer: Coventry All Commercial |
$214.06
|
| Rate for Payer: Encore All Commercial |
$223.91
|
| Rate for Payer: Frontpath All Commercial |
$223.79
|
| Rate for Payer: Humana ChoiceCare |
$210.10
|
| Rate for Payer: Humana Medicare |
$77.84
|
| Rate for Payer: Lucent All Commercial |
$132.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.93
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$182.44
|
| Rate for Payer: PHP All Commercial |
$184.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$94.87
|
| Rate for Payer: Sagamore Health Network All Products |
$187.79
|
| Rate for Payer: Signature Care EPO |
$201.90
|
| Rate for Payer: Signature Care PPO |
$214.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$206.76
|
| Rate for Payer: United Healthcare Commercial |
$191.68
|
| Rate for Payer: United Healthcare Medicare |
$77.84
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2710
|
| Hospital Charge Code |
165302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2710
|
| Hospital Charge Code |
165302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
NETARSUDIL 0.02 % OPHT DROP
|
Facility
|
OP
|
$1,253.12
|
|
|
Service Code
|
NDC 70727049725
|
| Hospital Charge Code |
184178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.47 |
| Max. Negotiated Rate |
$1,165.40 |
| Rate for Payer: Aetna Commercial |
$1,057.63
|
| Rate for Payer: Aetna Medicare |
$401.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$388.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$719.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$783.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$461.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$441.10
|
| Rate for Payer: Cash Price |
$751.87
|
| Rate for Payer: Centivo All Commercial |
$681.70
|
| Rate for Payer: Cigna All Commercial |
$1,081.44
|
| Rate for Payer: CORVEL All Commercial |
$1,165.40
|
| Rate for Payer: Coventry All Commercial |
$1,102.75
|
| Rate for Payer: Encore All Commercial |
$1,153.50
|
| Rate for Payer: Frontpath All Commercial |
$1,152.87
|
| Rate for Payer: Humana ChoiceCare |
$1,082.32
|
| Rate for Payer: Humana Medicare |
$401.00
|
| Rate for Payer: Lucent All Commercial |
$681.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,127.81
|
| Rate for Payer: PHCS All Commercial |
$939.84
|
| Rate for Payer: PHP All Commercial |
$950.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$488.72
|
| Rate for Payer: Sagamore Health Network All Products |
$967.41
|
| Rate for Payer: Signature Care EPO |
$1,040.09
|
| Rate for Payer: Signature Care PPO |
$1,102.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,065.15
|
| Rate for Payer: United Healthcare Commercial |
$987.46
|
| Rate for Payer: United Healthcare Medicare |
$401.00
|
|
|
NETARSUDIL 0.02 % OPHT DROP
|
Facility
|
IP
|
$1,253.12
|
|
|
Service Code
|
NDC 70727049725
|
| Hospital Charge Code |
184178
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$939.84 |
| Max. Negotiated Rate |
$1,165.40 |
| Rate for Payer: Aetna Commercial |
$1,082.70
|
| Rate for Payer: Cash Price |
$751.87
|
| Rate for Payer: Cigna All Commercial |
$1,081.44
|
| Rate for Payer: CORVEL All Commercial |
$1,165.40
|
| Rate for Payer: Coventry All Commercial |
$1,102.75
|
| Rate for Payer: Encore All Commercial |
$1,153.50
|
| Rate for Payer: Frontpath All Commercial |
$1,152.87
|
| Rate for Payer: Humana ChoiceCare |
$1,082.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,127.81
|
| Rate for Payer: PHCS All Commercial |
$939.84
|
| Rate for Payer: PHP All Commercial |
$950.37
|
| Rate for Payer: Sagamore Health Network All Products |
$967.41
|
| Rate for Payer: Signature Care EPO |
$1,040.09
|
| Rate for Payer: Signature Care PPO |
$1,102.75
|
| Rate for Payer: United Healthcare Commercial |
$987.46
|
|
|
NICARDIPINE 25 MG/10 ML IV SOLN
|
Facility
|
OP
|
$79.24
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
12370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.56 |
| Max. Negotiated Rate |
$73.69 |
| Rate for Payer: Aetna Commercial |
$66.88
|
| Rate for Payer: Aetna Medicare |
$25.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.89
|
| Rate for Payer: Cash Price |
$47.54
|
| Rate for Payer: Centivo All Commercial |
$43.11
|
| Rate for Payer: Cigna All Commercial |
$68.38
|
| Rate for Payer: CORVEL All Commercial |
$73.69
|
| Rate for Payer: Coventry All Commercial |
$69.73
|
| Rate for Payer: Encore All Commercial |
$72.94
|
| Rate for Payer: Frontpath All Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$68.44
|
| Rate for Payer: Humana Medicare |
$25.36
|
| Rate for Payer: Lucent All Commercial |
$43.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.32
|
| Rate for Payer: PHCS All Commercial |
$59.43
|
| Rate for Payer: PHP All Commercial |
$60.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.90
|
| Rate for Payer: Sagamore Health Network All Products |
$61.17
|
| Rate for Payer: Signature Care EPO |
$65.77
|
| Rate for Payer: Signature Care PPO |
$69.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.35
|
| Rate for Payer: United Healthcare Commercial |
$62.44
|
| Rate for Payer: United Healthcare Medicare |
$25.36
|
|
|
NICARDIPINE 25 MG/10 ML IV SOLN
|
Facility
|
IP
|
$79.24
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
12370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.43 |
| Max. Negotiated Rate |
$73.69 |
| Rate for Payer: Aetna Commercial |
$68.46
|
| Rate for Payer: Cash Price |
$47.54
|
| Rate for Payer: Cigna All Commercial |
$68.38
|
| Rate for Payer: CORVEL All Commercial |
$73.69
|
| Rate for Payer: Coventry All Commercial |
$69.73
|
| Rate for Payer: Encore All Commercial |
$72.94
|
| Rate for Payer: Frontpath All Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$68.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.32
|
| Rate for Payer: PHCS All Commercial |
$59.43
|
| Rate for Payer: PHP All Commercial |
$60.10
|
| Rate for Payer: Sagamore Health Network All Products |
$61.17
|
| Rate for Payer: Signature Care EPO |
$65.77
|
| Rate for Payer: Signature Care PPO |
$69.73
|
| Rate for Payer: United Healthcare Commercial |
$62.44
|
|
|
NICARDIPINE 40 MG/200 ML (200 MCG/ML) INFUSION
|
Facility
|
OP
|
$411.60
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
94576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$382.79 |
| Rate for Payer: Aetna Commercial |
$347.39
|
| Rate for Payer: Aetna Medicare |
$131.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$127.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$236.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$257.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$151.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$144.88
|
| Rate for Payer: Cash Price |
$246.96
|
| Rate for Payer: Centivo All Commercial |
$223.91
|
| Rate for Payer: Cigna All Commercial |
$355.21
|
| Rate for Payer: CORVEL All Commercial |
$382.79
|
| Rate for Payer: Coventry All Commercial |
$362.21
|
| Rate for Payer: Encore All Commercial |
$378.88
|
| Rate for Payer: Frontpath All Commercial |
$378.67
|
| Rate for Payer: Humana ChoiceCare |
$355.50
|
| Rate for Payer: Humana Medicare |
$131.71
|
| Rate for Payer: Lucent All Commercial |
$223.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$370.44
|
| Rate for Payer: PHCS All Commercial |
$308.70
|
| Rate for Payer: PHP All Commercial |
$312.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$160.52
|
| Rate for Payer: Sagamore Health Network All Products |
$317.76
|
| Rate for Payer: Signature Care EPO |
$341.63
|
| Rate for Payer: Signature Care PPO |
$362.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$349.86
|
| Rate for Payer: United Healthcare Commercial |
$324.34
|
| Rate for Payer: United Healthcare Medicare |
$131.71
|
|
|
NICARDIPINE 40 MG/200 ML (200 MCG/ML) INFUSION
|
Facility
|
IP
|
$411.60
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
94576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$382.79 |
| Rate for Payer: Aetna Commercial |
$355.62
|
| Rate for Payer: Cash Price |
$246.96
|
| Rate for Payer: Cigna All Commercial |
$355.21
|
| Rate for Payer: CORVEL All Commercial |
$382.79
|
| Rate for Payer: Coventry All Commercial |
$362.21
|
| Rate for Payer: Encore All Commercial |
$378.88
|
| Rate for Payer: Frontpath All Commercial |
$378.67
|
| Rate for Payer: Humana ChoiceCare |
$355.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$370.44
|
| Rate for Payer: PHCS All Commercial |
$308.70
|
| Rate for Payer: PHP All Commercial |
$312.16
|
| Rate for Payer: Sagamore Health Network All Products |
$317.76
|
| Rate for Payer: Signature Care EPO |
$341.63
|
| Rate for Payer: Signature Care PPO |
$362.21
|
| Rate for Payer: United Healthcare Commercial |
$324.34
|
|
|
NICOTINE 14 MG/24 HR TD PT24
|
Facility
|
OP
|
$11.99
|
|
|
Service Code
|
NDC 00536110788
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.15 |
| Rate for Payer: Aetna Commercial |
$10.12
|
| Rate for Payer: Aetna Medicare |
$3.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.22
|
| Rate for Payer: Cash Price |
$7.19
|
| Rate for Payer: Centivo All Commercial |
$6.52
|
| Rate for Payer: Cigna All Commercial |
$10.35
|
| Rate for Payer: CORVEL All Commercial |
$11.15
|
| Rate for Payer: Coventry All Commercial |
$10.55
|
| Rate for Payer: Encore All Commercial |
$11.04
|
| Rate for Payer: Frontpath All Commercial |
$11.03
|
| Rate for Payer: Humana ChoiceCare |
$10.36
|
| Rate for Payer: Humana Medicare |
$3.84
|
| Rate for Payer: Lucent All Commercial |
$6.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.79
|
| Rate for Payer: PHCS All Commercial |
$8.99
|
| Rate for Payer: PHP All Commercial |
$9.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.68
|
| Rate for Payer: Sagamore Health Network All Products |
$9.26
|
| Rate for Payer: Signature Care EPO |
$9.95
|
| Rate for Payer: Signature Care PPO |
$10.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.19
|
| Rate for Payer: United Healthcare Commercial |
$9.45
|
| Rate for Payer: United Healthcare Medicare |
$3.84
|
|
|
NICOTINE 14 MG/24 HR TD PT24
|
Facility
|
IP
|
$11.99
|
|
|
Service Code
|
NDC 00536110788
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$11.15 |
| Rate for Payer: Aetna Commercial |
$10.36
|
| Rate for Payer: Cash Price |
$7.19
|
| Rate for Payer: Cigna All Commercial |
$10.35
|
| Rate for Payer: CORVEL All Commercial |
$11.15
|
| Rate for Payer: Coventry All Commercial |
$10.55
|
| Rate for Payer: Encore All Commercial |
$11.04
|
| Rate for Payer: Frontpath All Commercial |
$11.03
|
| Rate for Payer: Humana ChoiceCare |
$10.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.79
|
| Rate for Payer: PHCS All Commercial |
$8.99
|
| Rate for Payer: PHP All Commercial |
$9.09
|
| Rate for Payer: Sagamore Health Network All Products |
$9.26
|
| Rate for Payer: Signature Care EPO |
$9.95
|
| Rate for Payer: Signature Care PPO |
$10.55
|
| Rate for Payer: United Healthcare Commercial |
$9.45
|
|
|
NICOTINE 21 MG/24 HR TD PT24
|
Facility
|
OP
|
$14.23
|
|
|
Service Code
|
NDC 00536589653
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$13.23 |
| Rate for Payer: Aetna Commercial |
$12.01
|
| Rate for Payer: Aetna Medicare |
$4.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.01
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Centivo All Commercial |
$7.74
|
| Rate for Payer: Cigna All Commercial |
$12.28
|
| Rate for Payer: CORVEL All Commercial |
$13.23
|
| Rate for Payer: Coventry All Commercial |
$12.52
|
| Rate for Payer: Encore All Commercial |
$13.10
|
| Rate for Payer: Frontpath All Commercial |
$13.09
|
| Rate for Payer: Humana ChoiceCare |
$12.29
|
| Rate for Payer: Humana Medicare |
$4.55
|
| Rate for Payer: Lucent All Commercial |
$7.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.81
|
| Rate for Payer: PHCS All Commercial |
$10.67
|
| Rate for Payer: PHP All Commercial |
$10.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.55
|
| Rate for Payer: Sagamore Health Network All Products |
$10.99
|
| Rate for Payer: Signature Care EPO |
$11.81
|
| Rate for Payer: Signature Care PPO |
$12.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.10
|
| Rate for Payer: United Healthcare Commercial |
$11.21
|
| Rate for Payer: United Healthcare Medicare |
$4.55
|
|
|
NICOTINE 21 MG/24 HR TD PT24
|
Facility
|
IP
|
$14.23
|
|
|
Service Code
|
NDC 00536589653
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.67 |
| Max. Negotiated Rate |
$13.23 |
| Rate for Payer: Aetna Commercial |
$12.30
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Cigna All Commercial |
$12.28
|
| Rate for Payer: CORVEL All Commercial |
$13.23
|
| Rate for Payer: Coventry All Commercial |
$12.52
|
| Rate for Payer: Encore All Commercial |
$13.10
|
| Rate for Payer: Frontpath All Commercial |
$13.09
|
| Rate for Payer: Humana ChoiceCare |
$12.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.81
|
| Rate for Payer: PHCS All Commercial |
$10.67
|
| Rate for Payer: PHP All Commercial |
$10.79
|
| Rate for Payer: Sagamore Health Network All Products |
$10.99
|
| Rate for Payer: Signature Care EPO |
$11.81
|
| Rate for Payer: Signature Care PPO |
$12.52
|
| Rate for Payer: United Healthcare Commercial |
$11.21
|
|
|
NICOTINE 7 MG/24 HR TD PT24
|
Facility
|
IP
|
$14.77
|
|
|
Service Code
|
NDC 00536589453
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$13.74 |
| Rate for Payer: Aetna Commercial |
$12.76
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: Cigna All Commercial |
$12.75
|
| Rate for Payer: CORVEL All Commercial |
$13.74
|
| Rate for Payer: Coventry All Commercial |
$13.00
|
| Rate for Payer: Encore All Commercial |
$13.60
|
| Rate for Payer: Frontpath All Commercial |
$13.59
|
| Rate for Payer: Humana ChoiceCare |
$12.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$11.08
|
| Rate for Payer: PHP All Commercial |
$11.20
|
| Rate for Payer: Sagamore Health Network All Products |
$11.40
|
| Rate for Payer: Signature Care EPO |
$12.26
|
| Rate for Payer: Signature Care PPO |
$13.00
|
| Rate for Payer: United Healthcare Commercial |
$11.64
|
|
|
NICOTINE 7 MG/24 HR TD PT24
|
Facility
|
OP
|
$14.77
|
|
|
Service Code
|
NDC 00536589453
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$13.74 |
| Rate for Payer: Aetna Commercial |
$12.47
|
| Rate for Payer: Aetna Medicare |
$4.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: Centivo All Commercial |
$8.03
|
| Rate for Payer: Cigna All Commercial |
$12.75
|
| Rate for Payer: CORVEL All Commercial |
$13.74
|
| Rate for Payer: Coventry All Commercial |
$13.00
|
| Rate for Payer: Encore All Commercial |
$13.60
|
| Rate for Payer: Frontpath All Commercial |
$13.59
|
| Rate for Payer: Humana ChoiceCare |
$12.76
|
| Rate for Payer: Humana Medicare |
$4.73
|
| Rate for Payer: Lucent All Commercial |
$8.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$11.08
|
| Rate for Payer: PHP All Commercial |
$11.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.76
|
| Rate for Payer: Sagamore Health Network All Products |
$11.40
|
| Rate for Payer: Signature Care EPO |
$12.26
|
| Rate for Payer: Signature Care PPO |
$13.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.55
|
| Rate for Payer: United Healthcare Commercial |
$11.64
|
| Rate for Payer: United Healthcare Medicare |
$4.73
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCL GUM
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 00536136234
|
| Hospital Charge Code |
10717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna All Commercial |
$2.58
|
| Rate for Payer: CORVEL All Commercial |
$2.78
|
| Rate for Payer: Coventry All Commercial |
$2.63
|
| Rate for Payer: Encore All Commercial |
$2.75
|
| Rate for Payer: Frontpath All Commercial |
$2.75
|
| Rate for Payer: Humana ChoiceCare |
$2.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.69
|
| Rate for Payer: PHCS All Commercial |
$2.24
|
| Rate for Payer: PHP All Commercial |
$2.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.31
|
| Rate for Payer: Signature Care EPO |
$2.48
|
| Rate for Payer: Signature Care PPO |
$2.63
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCL GUM
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
NDC 00536136234
|
| Hospital Charge Code |
10717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.05
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Centivo All Commercial |
$1.63
|
| Rate for Payer: Cigna All Commercial |
$2.58
|
| Rate for Payer: CORVEL All Commercial |
$2.78
|
| Rate for Payer: Coventry All Commercial |
$2.63
|
| Rate for Payer: Encore All Commercial |
$2.75
|
| Rate for Payer: Frontpath All Commercial |
$2.75
|
| Rate for Payer: Humana ChoiceCare |
$2.58
|
| Rate for Payer: Humana Medicare |
$0.96
|
| Rate for Payer: Lucent All Commercial |
$1.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.69
|
| Rate for Payer: PHCS All Commercial |
$2.24
|
| Rate for Payer: PHP All Commercial |
$2.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.17
|
| Rate for Payer: Sagamore Health Network All Products |
$2.31
|
| Rate for Payer: Signature Care EPO |
$2.48
|
| Rate for Payer: Signature Care PPO |
$2.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.54
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
|
|
NIFEDIPINE 10 MG ORAL CAP
|
Facility
|
OP
|
$4.90
|
|
|
Service Code
|
NDC 00904722961
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$4.14
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.72
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Centivo All Commercial |
$2.67
|
| Rate for Payer: Cigna All Commercial |
$4.23
|
| Rate for Payer: CORVEL All Commercial |
$4.56
|
| Rate for Payer: Coventry All Commercial |
$4.31
|
| Rate for Payer: Encore All Commercial |
$4.51
|
| Rate for Payer: Frontpath All Commercial |
$4.51
|
| Rate for Payer: Humana ChoiceCare |
$4.23
|
| Rate for Payer: Humana Medicare |
$1.57
|
| Rate for Payer: Lucent All Commercial |
$2.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.41
|
| Rate for Payer: PHCS All Commercial |
$3.67
|
| Rate for Payer: PHP All Commercial |
$3.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.91
|
| Rate for Payer: Sagamore Health Network All Products |
$3.78
|
| Rate for Payer: Signature Care EPO |
$4.07
|
| Rate for Payer: Signature Care PPO |
$4.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.17
|
| Rate for Payer: United Healthcare Commercial |
$3.86
|
| Rate for Payer: United Healthcare Medicare |
$1.57
|
|
|
NIFEDIPINE 10 MG ORAL CAP
|
Facility
|
IP
|
$4.90
|
|
|
Service Code
|
NDC 00904722961
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$4.23
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna All Commercial |
$4.23
|
| Rate for Payer: CORVEL All Commercial |
$4.56
|
| Rate for Payer: Coventry All Commercial |
$4.31
|
| Rate for Payer: Encore All Commercial |
$4.51
|
| Rate for Payer: Frontpath All Commercial |
$4.51
|
| Rate for Payer: Humana ChoiceCare |
$4.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.41
|
| Rate for Payer: PHCS All Commercial |
$3.67
|
| Rate for Payer: PHP All Commercial |
$3.72
|
| Rate for Payer: Sagamore Health Network All Products |
$3.78
|
| Rate for Payer: Signature Care EPO |
$4.07
|
| Rate for Payer: Signature Care PPO |
$4.31
|
| Rate for Payer: United Healthcare Commercial |
$3.86
|
|
|
NIFEDIPINE 30 MG ORAL TR24
|
Facility
|
OP
|
$5.92
|
|
|
Service Code
|
NDC 68084059701
|
| Hospital Charge Code |
27333
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$5.51 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Aetna Medicare |
$1.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Centivo All Commercial |
$3.22
|
| Rate for Payer: Cigna All Commercial |
$5.11
|
| Rate for Payer: CORVEL All Commercial |
$5.51
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.45
|
| Rate for Payer: Frontpath All Commercial |
$5.45
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Humana Medicare |
$1.90
|
| Rate for Payer: Lucent All Commercial |
$3.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.33
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.31
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.92
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.03
|
| Rate for Payer: United Healthcare Commercial |
$4.67
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
|
|
NIFEDIPINE 30 MG ORAL TR24
|
Facility
|
IP
|
$5.92
|
|
|
Service Code
|
NDC 68084059701
|
| Hospital Charge Code |
27333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$5.51 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$5.11
|
| Rate for Payer: CORVEL All Commercial |
$5.51
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.45
|
| Rate for Payer: Frontpath All Commercial |
$5.45
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.33
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.92
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: United Healthcare Commercial |
$4.67
|
|
|
NIRSEVIMAB-ALIP 100 MG/ML IM SYRG
|
Facility
|
IP
|
$2,043.78
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
202293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,532.84 |
| Max. Negotiated Rate |
$1,900.72 |
| Rate for Payer: Aetna Commercial |
$1,765.83
|
| Rate for Payer: Cash Price |
$1,226.27
|
| Rate for Payer: Cigna All Commercial |
$1,763.79
|
| Rate for Payer: CORVEL All Commercial |
$1,900.72
|
| Rate for Payer: Coventry All Commercial |
$1,798.53
|
| Rate for Payer: Encore All Commercial |
$1,881.30
|
| Rate for Payer: Frontpath All Commercial |
$1,880.28
|
| Rate for Payer: Humana ChoiceCare |
$1,765.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,839.41
|
| Rate for Payer: PHCS All Commercial |
$1,532.84
|
| Rate for Payer: PHP All Commercial |
$1,550.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1,577.80
|
| Rate for Payer: Signature Care EPO |
$1,696.34
|
| Rate for Payer: Signature Care PPO |
$1,798.53
|
| Rate for Payer: United Healthcare Commercial |
$1,610.50
|
|
