|
NIRSEVIMAB-ALIP 100 MG/ML IM SYRG
|
Facility
|
OP
|
$2,043.78
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
202293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$633.57 |
| Max. Negotiated Rate |
$1,900.72 |
| Rate for Payer: Aetna Commercial |
$1,724.95
|
| Rate for Payer: Aetna Medicare |
$654.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$633.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,173.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,277.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$752.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$719.41
|
| Rate for Payer: Cash Price |
$1,226.27
|
| Rate for Payer: Centivo All Commercial |
$1,111.82
|
| 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: Humana Medicare |
$654.01
|
| Rate for Payer: Lucent All Commercial |
$1,111.82
|
| 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: Plain Church Group Ministry All Commercial |
$797.08
|
| 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: Three Rivers Preferred All Commercial |
$1,737.22
|
| Rate for Payer: United Healthcare Commercial |
$1,610.50
|
| Rate for Payer: United Healthcare Medicare |
$654.01
|
|
|
NITAZOXANIDE 500 MG ORAL TAB
|
Facility
|
IP
|
$679.30
|
|
|
Service Code
|
NDC 67546011114
|
| Hospital Charge Code |
39254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$509.47 |
| Max. Negotiated Rate |
$631.74 |
| Rate for Payer: Aetna Commercial |
$586.91
|
| Rate for Payer: Cash Price |
$407.58
|
| Rate for Payer: Cigna All Commercial |
$586.23
|
| Rate for Payer: CORVEL All Commercial |
$631.74
|
| Rate for Payer: Coventry All Commercial |
$597.78
|
| Rate for Payer: Encore All Commercial |
$625.29
|
| Rate for Payer: Frontpath All Commercial |
$624.95
|
| Rate for Payer: Humana ChoiceCare |
$586.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$611.37
|
| Rate for Payer: PHCS All Commercial |
$509.47
|
| Rate for Payer: PHP All Commercial |
$515.18
|
| Rate for Payer: Sagamore Health Network All Products |
$524.42
|
| Rate for Payer: Signature Care EPO |
$563.81
|
| Rate for Payer: Signature Care PPO |
$597.78
|
| Rate for Payer: United Healthcare Commercial |
$535.28
|
|
|
NITAZOXANIDE 500 MG ORAL TAB
|
Facility
|
OP
|
$679.30
|
|
|
Service Code
|
NDC 67546011114
|
| Hospital Charge Code |
39254
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.58 |
| Max. Negotiated Rate |
$631.74 |
| Rate for Payer: Aetna Commercial |
$573.32
|
| Rate for Payer: Aetna Medicare |
$217.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$210.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$390.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$424.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$249.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$239.11
|
| Rate for Payer: Cash Price |
$407.58
|
| Rate for Payer: Centivo All Commercial |
$369.54
|
| Rate for Payer: Cigna All Commercial |
$586.23
|
| Rate for Payer: CORVEL All Commercial |
$631.74
|
| Rate for Payer: Coventry All Commercial |
$597.78
|
| Rate for Payer: Encore All Commercial |
$625.29
|
| Rate for Payer: Frontpath All Commercial |
$624.95
|
| Rate for Payer: Humana ChoiceCare |
$586.71
|
| Rate for Payer: Humana Medicare |
$217.37
|
| Rate for Payer: Lucent All Commercial |
$369.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$611.37
|
| Rate for Payer: PHCS All Commercial |
$509.47
|
| Rate for Payer: PHP All Commercial |
$515.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$264.93
|
| Rate for Payer: Sagamore Health Network All Products |
$524.42
|
| Rate for Payer: Signature Care EPO |
$563.81
|
| Rate for Payer: Signature Care PPO |
$597.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$577.40
|
| Rate for Payer: United Healthcare Commercial |
$535.28
|
| Rate for Payer: United Healthcare Medicare |
$217.37
|
|
|
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAP
|
Facility
|
OP
|
$8.92
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
5595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.53
|
| Rate for Payer: Aetna Medicare |
$2.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.14
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: Centivo All Commercial |
$4.85
|
| Rate for Payer: Cigna All Commercial |
$7.70
|
| Rate for Payer: CORVEL All Commercial |
$8.29
|
| Rate for Payer: Coventry All Commercial |
$7.85
|
| Rate for Payer: Encore All Commercial |
$8.21
|
| Rate for Payer: Frontpath All Commercial |
$8.20
|
| Rate for Payer: Humana ChoiceCare |
$7.70
|
| Rate for Payer: Humana Medicare |
$2.85
|
| Rate for Payer: Lucent All Commercial |
$4.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.03
|
| Rate for Payer: PHCS All Commercial |
$6.69
|
| Rate for Payer: PHP All Commercial |
$6.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.48
|
| Rate for Payer: Sagamore Health Network All Products |
$6.88
|
| Rate for Payer: Signature Care EPO |
$7.40
|
| Rate for Payer: Signature Care PPO |
$7.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.58
|
| Rate for Payer: United Healthcare Commercial |
$7.03
|
| Rate for Payer: United Healthcare Medicare |
$2.85
|
|
|
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAP
|
Facility
|
IP
|
$8.92
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
5595
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.71
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: Cigna All Commercial |
$7.70
|
| Rate for Payer: CORVEL All Commercial |
$8.29
|
| Rate for Payer: Coventry All Commercial |
$7.85
|
| Rate for Payer: Encore All Commercial |
$8.21
|
| Rate for Payer: Frontpath All Commercial |
$8.20
|
| Rate for Payer: Humana ChoiceCare |
$7.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.03
|
| Rate for Payer: PHCS All Commercial |
$6.69
|
| Rate for Payer: PHP All Commercial |
$6.76
|
| Rate for Payer: Sagamore Health Network All Products |
$6.88
|
| Rate for Payer: Signature Care EPO |
$7.40
|
| Rate for Payer: Signature Care PPO |
$7.85
|
| Rate for Payer: United Healthcare Commercial |
$7.03
|
|
|
NITROFURANTOIN MONOHYD/M-CRYST 100 MG ORAL CAP
|
Facility
|
OP
|
$14.91
|
|
|
Service Code
|
NDC 00904713761
|
| Hospital Charge Code |
10724
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.58
|
| Rate for Payer: Aetna Medicare |
$4.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.25
|
| Rate for Payer: Cash Price |
$8.95
|
| Rate for Payer: Centivo All Commercial |
$8.11
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Humana Medicare |
$4.77
|
| Rate for Payer: Lucent All Commercial |
$8.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.81
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
| Rate for Payer: United Healthcare Medicare |
$4.77
|
|
|
NITROFURANTOIN MONOHYD/M-CRYST 100 MG ORAL CAP
|
Facility
|
IP
|
$14.91
|
|
|
Service Code
|
NDC 00904713761
|
| Hospital Charge Code |
10724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Cash Price |
$8.95
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
|
|
NITROGLYCERIN 0.1 MG/HR TD PT24
|
Facility
|
OP
|
$3.62
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
27471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.05
|
| Rate for Payer: Aetna Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Centivo All Commercial |
$1.97
|
| Rate for Payer: Cigna All Commercial |
$3.12
|
| Rate for Payer: CORVEL All Commercial |
$3.37
|
| Rate for Payer: Coventry All Commercial |
$3.18
|
| Rate for Payer: Encore All Commercial |
$3.33
|
| Rate for Payer: Frontpath All Commercial |
$3.33
|
| Rate for Payer: Humana ChoiceCare |
$3.13
|
| Rate for Payer: Humana Medicare |
$1.16
|
| Rate for Payer: Lucent All Commercial |
$1.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.26
|
| Rate for Payer: PHCS All Commercial |
$2.71
|
| Rate for Payer: PHP All Commercial |
$2.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.41
|
| Rate for Payer: Sagamore Health Network All Products |
$2.79
|
| Rate for Payer: Signature Care EPO |
$3.00
|
| Rate for Payer: Signature Care PPO |
$3.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.08
|
| Rate for Payer: United Healthcare Commercial |
$2.85
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
|
|
NITROGLYCERIN 0.1 MG/HR TD PT24
|
Facility
|
IP
|
$3.62
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
27471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna All Commercial |
$3.12
|
| Rate for Payer: CORVEL All Commercial |
$3.37
|
| Rate for Payer: Coventry All Commercial |
$3.18
|
| Rate for Payer: Encore All Commercial |
$3.33
|
| Rate for Payer: Frontpath All Commercial |
$3.33
|
| Rate for Payer: Humana ChoiceCare |
$3.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.26
|
| Rate for Payer: PHCS All Commercial |
$2.71
|
| Rate for Payer: PHP All Commercial |
$2.74
|
| Rate for Payer: Sagamore Health Network All Products |
$2.79
|
| Rate for Payer: Signature Care EPO |
$3.00
|
| Rate for Payer: Signature Care PPO |
$3.18
|
| Rate for Payer: United Healthcare Commercial |
$2.85
|
|
|
NITROGLYCERIN 0.2 MG/HR TD PT24
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
27472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna Commercial |
$2.83
|
| Rate for Payer: Aetna Medicare |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Centivo All Commercial |
$1.82
|
| Rate for Payer: Cigna All Commercial |
$2.89
|
| Rate for Payer: CORVEL All Commercial |
$3.12
|
| Rate for Payer: Coventry All Commercial |
$2.95
|
| Rate for Payer: Encore All Commercial |
$3.09
|
| Rate for Payer: Frontpath All Commercial |
$3.08
|
| Rate for Payer: Humana ChoiceCare |
$2.90
|
| Rate for Payer: Humana Medicare |
$1.07
|
| Rate for Payer: Lucent All Commercial |
$1.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.02
|
| Rate for Payer: PHCS All Commercial |
$2.51
|
| Rate for Payer: PHP All Commercial |
$2.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.31
|
| Rate for Payer: Sagamore Health Network All Products |
$2.59
|
| Rate for Payer: Signature Care EPO |
$2.78
|
| Rate for Payer: Signature Care PPO |
$2.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.85
|
| Rate for Payer: United Healthcare Commercial |
$2.64
|
| Rate for Payer: United Healthcare Medicare |
$1.07
|
|
|
NITROGLYCERIN 0.2 MG/HR TD PT24
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
27472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna All Commercial |
$2.89
|
| Rate for Payer: CORVEL All Commercial |
$3.12
|
| Rate for Payer: Coventry All Commercial |
$2.95
|
| Rate for Payer: Encore All Commercial |
$3.09
|
| Rate for Payer: Frontpath All Commercial |
$3.08
|
| Rate for Payer: Humana ChoiceCare |
$2.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.02
|
| Rate for Payer: PHCS All Commercial |
$2.51
|
| Rate for Payer: PHP All Commercial |
$2.54
|
| Rate for Payer: Sagamore Health Network All Products |
$2.59
|
| Rate for Payer: Signature Care EPO |
$2.78
|
| Rate for Payer: Signature Care PPO |
$2.95
|
| Rate for Payer: United Healthcare Commercial |
$2.64
|
|
|
NITROGLYCERIN 0.4 MG SL SUBL
|
Facility
|
IP
|
$61.25
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
5604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.94 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$52.92
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: Cigna All Commercial |
$52.86
|
| Rate for Payer: CORVEL All Commercial |
$56.96
|
| Rate for Payer: Coventry All Commercial |
$53.90
|
| Rate for Payer: Encore All Commercial |
$56.38
|
| Rate for Payer: Frontpath All Commercial |
$56.35
|
| Rate for Payer: Humana ChoiceCare |
$52.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.12
|
| Rate for Payer: PHCS All Commercial |
$45.94
|
| Rate for Payer: PHP All Commercial |
$46.45
|
| Rate for Payer: Sagamore Health Network All Products |
$47.28
|
| Rate for Payer: Signature Care EPO |
$50.84
|
| Rate for Payer: Signature Care PPO |
$53.90
|
| Rate for Payer: United Healthcare Commercial |
$48.27
|
|
|
NITROGLYCERIN 0.4 MG SL SUBL
|
Facility
|
OP
|
$61.25
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
5604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$51.70
|
| Rate for Payer: Aetna Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$35.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$38.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.56
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: Centivo All Commercial |
$33.32
|
| Rate for Payer: Cigna All Commercial |
$52.86
|
| Rate for Payer: CORVEL All Commercial |
$56.96
|
| Rate for Payer: Coventry All Commercial |
$53.90
|
| Rate for Payer: Encore All Commercial |
$56.38
|
| Rate for Payer: Frontpath All Commercial |
$56.35
|
| Rate for Payer: Humana ChoiceCare |
$52.90
|
| Rate for Payer: Humana Medicare |
$19.60
|
| Rate for Payer: Lucent All Commercial |
$33.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.12
|
| Rate for Payer: PHCS All Commercial |
$45.94
|
| Rate for Payer: PHP All Commercial |
$46.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$47.28
|
| Rate for Payer: Signature Care EPO |
$50.84
|
| Rate for Payer: Signature Care PPO |
$53.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$52.06
|
| Rate for Payer: United Healthcare Commercial |
$48.27
|
| Rate for Payer: United Healthcare Medicare |
$19.60
|
|
|
NITROGLYCERIN 2 % TD OINT
|
Facility
|
OP
|
$15.90
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
5606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna Commercial |
$13.42
|
| Rate for Payer: Aetna Medicare |
$5.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Centivo All Commercial |
$8.65
|
| Rate for Payer: Cigna All Commercial |
$13.72
|
| Rate for Payer: CORVEL All Commercial |
$14.78
|
| Rate for Payer: Coventry All Commercial |
$13.99
|
| Rate for Payer: Encore All Commercial |
$14.63
|
| Rate for Payer: Frontpath All Commercial |
$14.63
|
| Rate for Payer: Humana ChoiceCare |
$13.73
|
| Rate for Payer: Humana Medicare |
$5.09
|
| Rate for Payer: Lucent All Commercial |
$8.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.31
|
| Rate for Payer: PHCS All Commercial |
$11.92
|
| Rate for Payer: PHP All Commercial |
$12.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.20
|
| Rate for Payer: Sagamore Health Network All Products |
$12.27
|
| Rate for Payer: Signature Care EPO |
$13.19
|
| Rate for Payer: Signature Care PPO |
$13.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.51
|
| Rate for Payer: United Healthcare Commercial |
$12.53
|
| Rate for Payer: United Healthcare Medicare |
$5.09
|
|
|
NITROGLYCERIN 2 % TD OINT
|
Facility
|
IP
|
$15.90
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
5606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cigna All Commercial |
$13.72
|
| Rate for Payer: CORVEL All Commercial |
$14.78
|
| Rate for Payer: Coventry All Commercial |
$13.99
|
| Rate for Payer: Encore All Commercial |
$14.63
|
| Rate for Payer: Frontpath All Commercial |
$14.63
|
| Rate for Payer: Humana ChoiceCare |
$13.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.31
|
| Rate for Payer: PHCS All Commercial |
$11.92
|
| Rate for Payer: PHP All Commercial |
$12.06
|
| Rate for Payer: Sagamore Health Network All Products |
$12.27
|
| Rate for Payer: Signature Care EPO |
$13.19
|
| Rate for Payer: Signature Care PPO |
$13.99
|
| Rate for Payer: United Healthcare Commercial |
$12.53
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TL SPRY
|
Facility
|
OP
|
$554.04
|
|
|
Service Code
|
NDC 28595012049
|
| Hospital Charge Code |
27096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.75 |
| Max. Negotiated Rate |
$515.26 |
| Rate for Payer: Aetna Commercial |
$467.61
|
| Rate for Payer: Aetna Medicare |
$177.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$171.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$318.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$346.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$203.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$195.02
|
| Rate for Payer: Cash Price |
$332.43
|
| Rate for Payer: Centivo All Commercial |
$301.40
|
| Rate for Payer: Cigna All Commercial |
$478.14
|
| Rate for Payer: CORVEL All Commercial |
$515.26
|
| Rate for Payer: Coventry All Commercial |
$487.56
|
| Rate for Payer: Encore All Commercial |
$510.00
|
| Rate for Payer: Frontpath All Commercial |
$509.72
|
| Rate for Payer: Humana ChoiceCare |
$478.53
|
| Rate for Payer: Humana Medicare |
$177.29
|
| Rate for Payer: Lucent All Commercial |
$301.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$498.64
|
| Rate for Payer: PHCS All Commercial |
$415.53
|
| Rate for Payer: PHP All Commercial |
$420.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$216.08
|
| Rate for Payer: Sagamore Health Network All Products |
$427.72
|
| Rate for Payer: Signature Care EPO |
$459.86
|
| Rate for Payer: Signature Care PPO |
$487.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$470.94
|
| Rate for Payer: United Healthcare Commercial |
$436.59
|
| Rate for Payer: United Healthcare Medicare |
$177.29
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TL SPRY
|
Facility
|
IP
|
$554.04
|
|
|
Service Code
|
NDC 28595012049
|
| Hospital Charge Code |
27096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$415.53 |
| Max. Negotiated Rate |
$515.26 |
| Rate for Payer: Aetna Commercial |
$478.69
|
| Rate for Payer: Cash Price |
$332.43
|
| Rate for Payer: Cigna All Commercial |
$478.14
|
| Rate for Payer: CORVEL All Commercial |
$515.26
|
| Rate for Payer: Coventry All Commercial |
$487.56
|
| Rate for Payer: Encore All Commercial |
$510.00
|
| Rate for Payer: Frontpath All Commercial |
$509.72
|
| Rate for Payer: Humana ChoiceCare |
$478.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$498.64
|
| Rate for Payer: PHCS All Commercial |
$415.53
|
| Rate for Payer: PHP All Commercial |
$420.19
|
| Rate for Payer: Sagamore Health Network All Products |
$427.72
|
| Rate for Payer: Signature Care EPO |
$459.86
|
| Rate for Payer: Signature Care PPO |
$487.56
|
| Rate for Payer: United Healthcare Commercial |
$436.59
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 25 MG/250 ML (100 MCG/ML) IV SOLN
|
Facility
|
IP
|
$143.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.62 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$123.98
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.11
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 25 MG/250 ML (100 MCG/ML) IV SOLN
|
Facility
|
OP
|
$143.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.48 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$121.11
|
| Rate for Payer: Aetna Medicare |
$45.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.51
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Centivo All Commercial |
$78.06
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Humana Medicare |
$45.92
|
| Rate for Payer: Lucent All Commercial |
$78.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.97
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.11
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.97
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
| Rate for Payer: United Healthcare Medicare |
$45.92
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 50 MG/250 ML (200 MCG/ML) IV SOLN
|
Facility
|
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.12 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$136.08
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 50 MG/250 ML (200 MCG/ML) IV SOLN
|
Facility
|
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.83 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$132.93
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$90.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.44
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Centivo All Commercial |
$85.68
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Humana Medicare |
$50.40
|
| Rate for Payer: Lucent All Commercial |
$85.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.42
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.88
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
| Rate for Payer: United Healthcare Medicare |
$50.40
|
|
|
NITROPRUSSIDE 25 MG/ML IV SOLN
|
Facility
|
IP
|
$83.02
|
|
|
Service Code
|
NDC 70069026101
|
| Hospital Charge Code |
18908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.27 |
| Max. Negotiated Rate |
$77.21 |
| Rate for Payer: Aetna Commercial |
$71.73
|
| Rate for Payer: Cash Price |
$49.81
|
| Rate for Payer: Cigna All Commercial |
$71.65
|
| Rate for Payer: CORVEL All Commercial |
$77.21
|
| Rate for Payer: Coventry All Commercial |
$73.06
|
| Rate for Payer: Encore All Commercial |
$76.42
|
| Rate for Payer: Frontpath All Commercial |
$76.38
|
| Rate for Payer: Humana ChoiceCare |
$71.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.72
|
| Rate for Payer: PHCS All Commercial |
$62.27
|
| Rate for Payer: PHP All Commercial |
$62.96
|
| Rate for Payer: Sagamore Health Network All Products |
$64.09
|
| Rate for Payer: Signature Care EPO |
$68.91
|
| Rate for Payer: Signature Care PPO |
$73.06
|
| Rate for Payer: United Healthcare Commercial |
$65.42
|
|
|
NITROPRUSSIDE 25 MG/ML IV SOLN
|
Facility
|
OP
|
$83.02
|
|
|
Service Code
|
NDC 70069026101
|
| Hospital Charge Code |
18908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$77.21 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Aetna Medicare |
$26.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.22
|
| Rate for Payer: Cash Price |
$49.81
|
| Rate for Payer: Cash Price |
$49.81
|
| Rate for Payer: Centivo All Commercial |
$45.16
|
| Rate for Payer: Cigna All Commercial |
$71.65
|
| Rate for Payer: CORVEL All Commercial |
$77.21
|
| Rate for Payer: Coventry All Commercial |
$73.06
|
| Rate for Payer: Encore All Commercial |
$76.42
|
| Rate for Payer: Frontpath All Commercial |
$76.38
|
| Rate for Payer: Humana ChoiceCare |
$71.70
|
| Rate for Payer: Humana Medicare |
$26.57
|
| Rate for Payer: Lucent All Commercial |
$45.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.72
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$62.27
|
| Rate for Payer: PHP All Commercial |
$62.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.38
|
| Rate for Payer: Sagamore Health Network All Products |
$64.09
|
| Rate for Payer: Signature Care EPO |
$68.91
|
| Rate for Payer: Signature Care PPO |
$73.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.57
|
| Rate for Payer: United Healthcare Commercial |
$65.42
|
| Rate for Payer: United Healthcare Medicare |
$26.57
|
|
|
N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG
|
Facility
|
OP
|
$865.53
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
170724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.90 |
| Max. Negotiated Rate |
$804.94 |
| Rate for Payer: Aetna Commercial |
$730.51
|
| Rate for Payer: Aetna Medicare |
$276.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$216.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$268.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$497.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$541.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$216.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$318.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$304.67
|
| Rate for Payer: Cash Price |
$519.32
|
| Rate for Payer: Cash Price |
$519.32
|
| Rate for Payer: Centivo All Commercial |
$470.85
|
| Rate for Payer: Cigna All Commercial |
$746.95
|
| Rate for Payer: CORVEL All Commercial |
$804.94
|
| Rate for Payer: Coventry All Commercial |
$761.67
|
| Rate for Payer: Encore All Commercial |
$796.72
|
| Rate for Payer: Frontpath All Commercial |
$796.29
|
| Rate for Payer: Humana ChoiceCare |
$747.56
|
| Rate for Payer: Humana Medicare |
$276.97
|
| Rate for Payer: Lucent All Commercial |
$470.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$778.98
|
| Rate for Payer: Managed Health Services Medicaid |
$216.90
|
| Rate for Payer: MDWise Medicaid |
$216.90
|
| Rate for Payer: PHCS All Commercial |
$649.15
|
| Rate for Payer: PHP All Commercial |
$656.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$337.56
|
| Rate for Payer: Sagamore Health Network All Products |
$668.19
|
| Rate for Payer: Signature Care EPO |
$718.39
|
| Rate for Payer: Signature Care PPO |
$761.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$735.70
|
| Rate for Payer: United Healthcare Commercial |
$682.04
|
| Rate for Payer: United Healthcare Medicare |
$276.97
|
|
|
N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG
|
Facility
|
IP
|
$865.53
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
170724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$649.15 |
| Max. Negotiated Rate |
$804.94 |
| Rate for Payer: Aetna Commercial |
$747.82
|
| Rate for Payer: Cash Price |
$519.32
|
| Rate for Payer: Cigna All Commercial |
$746.95
|
| Rate for Payer: CORVEL All Commercial |
$804.94
|
| Rate for Payer: Coventry All Commercial |
$761.67
|
| Rate for Payer: Encore All Commercial |
$796.72
|
| Rate for Payer: Frontpath All Commercial |
$796.29
|
| Rate for Payer: Humana ChoiceCare |
$747.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$778.98
|
| Rate for Payer: PHCS All Commercial |
$649.15
|
| Rate for Payer: PHP All Commercial |
$656.42
|
| Rate for Payer: Sagamore Health Network All Products |
$668.19
|
| Rate for Payer: Signature Care EPO |
$718.39
|
| Rate for Payer: Signature Care PPO |
$761.67
|
| Rate for Payer: United Healthcare Commercial |
$682.04
|
|
