|
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN
|
Facility
|
IP
|
$22.74
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Aetna Commercial |
$19.64
|
| Rate for Payer: Cash Price |
$13.64
|
| Rate for Payer: Cigna All Commercial |
$19.62
|
| Rate for Payer: CORVEL All Commercial |
$21.14
|
| Rate for Payer: Coventry All Commercial |
$20.01
|
| Rate for Payer: Encore All Commercial |
$20.93
|
| Rate for Payer: Frontpath All Commercial |
$20.92
|
| Rate for Payer: Humana ChoiceCare |
$19.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.46
|
| Rate for Payer: PHCS All Commercial |
$17.05
|
| Rate for Payer: PHP All Commercial |
$17.24
|
| Rate for Payer: Sagamore Health Network All Products |
$17.55
|
| Rate for Payer: Signature Care EPO |
$18.87
|
| Rate for Payer: Signature Care PPO |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$17.92
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN
|
Facility
|
OP
|
$22.74
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Aetna Commercial |
$19.19
|
| Rate for Payer: Aetna Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.00
|
| Rate for Payer: Cash Price |
$13.64
|
| Rate for Payer: Cash Price |
$13.64
|
| Rate for Payer: Centivo All Commercial |
$12.37
|
| Rate for Payer: Cigna All Commercial |
$19.62
|
| Rate for Payer: CORVEL All Commercial |
$21.14
|
| Rate for Payer: Coventry All Commercial |
$20.01
|
| Rate for Payer: Encore All Commercial |
$20.93
|
| Rate for Payer: Frontpath All Commercial |
$20.92
|
| Rate for Payer: Humana ChoiceCare |
$19.64
|
| Rate for Payer: Humana Medicare |
$7.28
|
| Rate for Payer: Lucent All Commercial |
$12.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.46
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$17.05
|
| Rate for Payer: PHP All Commercial |
$17.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.87
|
| Rate for Payer: Sagamore Health Network All Products |
$17.55
|
| Rate for Payer: Signature Care EPO |
$18.87
|
| Rate for Payer: Signature Care PPO |
$20.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19.33
|
| Rate for Payer: United Healthcare Commercial |
$17.92
|
| Rate for Payer: United Healthcare Medicare |
$7.28
|
|
|
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
|
IP
|
$148.75
|
|
|
Service Code
|
NDC 00338011220
|
| Hospital Charge Code |
120518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.56 |
| Max. Negotiated Rate |
$138.34 |
| Rate for Payer: Aetna Commercial |
$128.52
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cigna All Commercial |
$128.37
|
| Rate for Payer: CORVEL All Commercial |
$138.34
|
| Rate for Payer: Coventry All Commercial |
$130.90
|
| Rate for Payer: Encore All Commercial |
$136.92
|
| Rate for Payer: Frontpath All Commercial |
$136.85
|
| Rate for Payer: Humana ChoiceCare |
$128.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.88
|
| Rate for Payer: PHCS All Commercial |
$111.56
|
| Rate for Payer: PHP All Commercial |
$112.81
|
| Rate for Payer: Sagamore Health Network All Products |
$114.83
|
| Rate for Payer: Signature Care EPO |
$123.46
|
| Rate for Payer: Signature Care PPO |
$130.90
|
| Rate for Payer: United Healthcare Commercial |
$117.22
|
|
|
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
|
OP
|
$148.75
|
|
|
Service Code
|
NDC 00338011220
|
| Hospital Charge Code |
120518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$138.34 |
| Rate for Payer: Aetna Commercial |
$125.55
|
| Rate for Payer: Aetna Medicare |
$47.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$85.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$92.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.36
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Centivo All Commercial |
$80.92
|
| Rate for Payer: Cigna All Commercial |
$128.37
|
| Rate for Payer: CORVEL All Commercial |
$138.34
|
| Rate for Payer: Coventry All Commercial |
$130.90
|
| Rate for Payer: Encore All Commercial |
$136.92
|
| Rate for Payer: Frontpath All Commercial |
$136.85
|
| Rate for Payer: Humana ChoiceCare |
$128.48
|
| Rate for Payer: Humana Medicare |
$47.60
|
| Rate for Payer: Lucent All Commercial |
$80.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.88
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$111.56
|
| Rate for Payer: PHP All Commercial |
$112.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$58.01
|
| Rate for Payer: Sagamore Health Network All Products |
$114.83
|
| Rate for Payer: Signature Care EPO |
$123.46
|
| Rate for Payer: Signature Care PPO |
$130.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$126.44
|
| Rate for Payer: United Healthcare Commercial |
$117.22
|
| Rate for Payer: United Healthcare Medicare |
$47.60
|
|
|
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 69374031925
|
| Hospital Charge Code |
120517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna All Commercial |
$90.61
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
|
|
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 69374031925
|
| Hospital Charge Code |
120517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$88.62
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$60.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.96
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Centivo All Commercial |
$57.12
|
| Rate for Payer: Cigna All Commercial |
$90.61
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Humana Medicare |
$33.60
|
| Rate for Payer: Lucent All Commercial |
$57.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.95
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
| Rate for Payer: United Healthcare Medicare |
$33.60
|
|
|
NORETHINDRONE ACETATE 5 MG ORAL TAB
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna All Commercial |
$2.28
|
| Rate for Payer: CORVEL All Commercial |
$2.45
|
| Rate for Payer: Coventry All Commercial |
$2.32
|
| Rate for Payer: Encore All Commercial |
$2.43
|
| Rate for Payer: Frontpath All Commercial |
$2.43
|
| Rate for Payer: Humana ChoiceCare |
$2.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.38
|
| Rate for Payer: PHCS All Commercial |
$1.98
|
| Rate for Payer: PHP All Commercial |
$2.00
|
| Rate for Payer: Sagamore Health Network All Products |
$2.04
|
| Rate for Payer: Signature Care EPO |
$2.19
|
| Rate for Payer: Signature Care PPO |
$2.32
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
|
|
NORETHINDRONE ACETATE 5 MG ORAL TAB
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Centivo All Commercial |
$1.44
|
| Rate for Payer: Cigna All Commercial |
$2.28
|
| Rate for Payer: CORVEL All Commercial |
$2.45
|
| Rate for Payer: Coventry All Commercial |
$2.32
|
| Rate for Payer: Encore All Commercial |
$2.43
|
| Rate for Payer: Frontpath All Commercial |
$2.43
|
| Rate for Payer: Humana ChoiceCare |
$2.28
|
| Rate for Payer: Humana Medicare |
$0.84
|
| Rate for Payer: Lucent All Commercial |
$1.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.38
|
| Rate for Payer: PHCS All Commercial |
$1.98
|
| Rate for Payer: PHP All Commercial |
$2.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.03
|
| Rate for Payer: Sagamore Health Network All Products |
$2.04
|
| Rate for Payer: Signature Care EPO |
$2.19
|
| Rate for Payer: Signature Care PPO |
$2.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.24
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
|
|
NORTRIPTYLINE 10 MG ORAL CAP
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 75907006901
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
NORTRIPTYLINE 10 MG ORAL CAP
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 75907006901
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.09
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Centivo All Commercial |
$0.70
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.41
|
| Rate for Payer: Lucent All Commercial |
$0.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
|
OP
|
$1.41
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna Commercial |
$1.19
|
| Rate for Payer: Aetna Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Centivo All Commercial |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.22
|
| Rate for Payer: CORVEL All Commercial |
$1.32
|
| Rate for Payer: Coventry All Commercial |
$1.24
|
| Rate for Payer: Encore All Commercial |
$1.30
|
| Rate for Payer: Frontpath All Commercial |
$1.30
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: Lucent All Commercial |
$0.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.55
|
| Rate for Payer: Sagamore Health Network All Products |
$1.09
|
| Rate for Payer: Signature Care EPO |
$1.17
|
| Rate for Payer: Signature Care PPO |
$1.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna All Commercial |
$1.22
|
| Rate for Payer: CORVEL All Commercial |
$1.32
|
| Rate for Payer: Coventry All Commercial |
$1.24
|
| Rate for Payer: Encore All Commercial |
$1.30
|
| Rate for Payer: Frontpath All Commercial |
$1.30
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1.09
|
| Rate for Payer: Signature Care EPO |
$1.17
|
| Rate for Payer: Signature Care PPO |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP CREA
|
Facility
|
OP
|
$21.95
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$20.41 |
| Rate for Payer: Aetna Commercial |
$18.52
|
| Rate for Payer: Aetna Medicare |
$7.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.72
|
| Rate for Payer: Cash Price |
$13.17
|
| Rate for Payer: Centivo All Commercial |
$11.94
|
| Rate for Payer: Cigna All Commercial |
$18.94
|
| Rate for Payer: CORVEL All Commercial |
$20.41
|
| Rate for Payer: Coventry All Commercial |
$19.31
|
| Rate for Payer: Encore All Commercial |
$20.20
|
| Rate for Payer: Frontpath All Commercial |
$20.19
|
| Rate for Payer: Humana ChoiceCare |
$18.95
|
| Rate for Payer: Humana Medicare |
$7.02
|
| Rate for Payer: Lucent All Commercial |
$11.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.75
|
| Rate for Payer: PHCS All Commercial |
$16.46
|
| Rate for Payer: PHP All Commercial |
$16.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.56
|
| Rate for Payer: Sagamore Health Network All Products |
$16.94
|
| Rate for Payer: Signature Care EPO |
$18.21
|
| Rate for Payer: Signature Care PPO |
$19.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.65
|
| Rate for Payer: United Healthcare Commercial |
$17.29
|
| Rate for Payer: United Healthcare Medicare |
$7.02
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP CREA
|
Facility
|
IP
|
$21.95
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.46 |
| Max. Negotiated Rate |
$20.41 |
| Rate for Payer: Aetna Commercial |
$18.96
|
| Rate for Payer: Cash Price |
$13.17
|
| Rate for Payer: Cigna All Commercial |
$18.94
|
| Rate for Payer: CORVEL All Commercial |
$20.41
|
| Rate for Payer: Coventry All Commercial |
$19.31
|
| Rate for Payer: Encore All Commercial |
$20.20
|
| Rate for Payer: Frontpath All Commercial |
$20.19
|
| Rate for Payer: Humana ChoiceCare |
$18.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.75
|
| Rate for Payer: PHCS All Commercial |
$16.46
|
| Rate for Payer: PHP All Commercial |
$16.64
|
| Rate for Payer: Sagamore Health Network All Products |
$16.94
|
| Rate for Payer: Signature Care EPO |
$18.21
|
| Rate for Payer: Signature Care PPO |
$19.31
|
| Rate for Payer: United Healthcare Commercial |
$17.29
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP POWD
|
Facility
|
OP
|
$107.42
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
39136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna Commercial |
$90.66
|
| Rate for Payer: Aetna Medicare |
$34.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$61.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.81
|
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Centivo All Commercial |
$58.43
|
| Rate for Payer: Cigna All Commercial |
$92.70
|
| Rate for Payer: CORVEL All Commercial |
$99.90
|
| Rate for Payer: Coventry All Commercial |
$94.53
|
| Rate for Payer: Encore All Commercial |
$98.88
|
| Rate for Payer: Frontpath All Commercial |
$98.82
|
| Rate for Payer: Humana ChoiceCare |
$92.77
|
| Rate for Payer: Humana Medicare |
$34.37
|
| Rate for Payer: Lucent All Commercial |
$58.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.67
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$80.56
|
| Rate for Payer: PHP All Commercial |
$81.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.89
|
| Rate for Payer: Sagamore Health Network All Products |
$82.92
|
| Rate for Payer: Signature Care EPO |
$89.15
|
| Rate for Payer: Signature Care PPO |
$94.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.30
|
| Rate for Payer: United Healthcare Commercial |
$84.64
|
| Rate for Payer: United Healthcare Medicare |
$34.37
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP POWD
|
Facility
|
IP
|
$107.42
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
39136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.56 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna Commercial |
$92.81
|
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Cigna All Commercial |
$92.70
|
| Rate for Payer: CORVEL All Commercial |
$99.90
|
| Rate for Payer: Coventry All Commercial |
$94.53
|
| Rate for Payer: Encore All Commercial |
$98.88
|
| Rate for Payer: Frontpath All Commercial |
$98.82
|
| Rate for Payer: Humana ChoiceCare |
$92.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.67
|
| Rate for Payer: PHCS All Commercial |
$80.56
|
| Rate for Payer: PHP All Commercial |
$81.46
|
| Rate for Payer: Sagamore Health Network All Products |
$82.92
|
| Rate for Payer: Signature Care EPO |
$89.15
|
| Rate for Payer: Signature Care PPO |
$94.53
|
| Rate for Payer: United Healthcare Commercial |
$84.64
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
|
OP
|
$11.69
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$9.87
|
| Rate for Payer: Aetna Medicare |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.11
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Centivo All Commercial |
$6.36
|
| Rate for Payer: Cigna All Commercial |
$10.09
|
| Rate for Payer: CORVEL All Commercial |
$10.87
|
| Rate for Payer: Coventry All Commercial |
$10.29
|
| Rate for Payer: Encore All Commercial |
$10.76
|
| Rate for Payer: Frontpath All Commercial |
$10.75
|
| Rate for Payer: Humana ChoiceCare |
$10.10
|
| Rate for Payer: Humana Medicare |
$3.74
|
| Rate for Payer: Lucent All Commercial |
$6.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.52
|
| Rate for Payer: PHCS All Commercial |
$8.77
|
| Rate for Payer: PHP All Commercial |
$8.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.56
|
| Rate for Payer: Sagamore Health Network All Products |
$9.02
|
| Rate for Payer: Signature Care EPO |
$9.70
|
| Rate for Payer: Signature Care PPO |
$10.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.94
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
| Rate for Payer: United Healthcare Medicare |
$3.74
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
|
IP
|
$11.69
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$10.10
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Cigna All Commercial |
$10.09
|
| Rate for Payer: CORVEL All Commercial |
$10.87
|
| Rate for Payer: Coventry All Commercial |
$10.29
|
| Rate for Payer: Encore All Commercial |
$10.76
|
| Rate for Payer: Frontpath All Commercial |
$10.75
|
| Rate for Payer: Humana ChoiceCare |
$10.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.52
|
| Rate for Payer: PHCS All Commercial |
$8.77
|
| Rate for Payer: PHP All Commercial |
$8.87
|
| Rate for Payer: Sagamore Health Network All Products |
$9.02
|
| Rate for Payer: Signature Care EPO |
$9.70
|
| Rate for Payer: Signature Care PPO |
$10.29
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
|
OP
|
$11.69
|
|
|
Service Code
|
NDC 00121086800
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$9.87
|
| Rate for Payer: Aetna Medicare |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.11
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Centivo All Commercial |
$6.36
|
| Rate for Payer: Cigna All Commercial |
$10.09
|
| Rate for Payer: CORVEL All Commercial |
$10.87
|
| Rate for Payer: Coventry All Commercial |
$10.29
|
| Rate for Payer: Encore All Commercial |
$10.76
|
| Rate for Payer: Frontpath All Commercial |
$10.75
|
| Rate for Payer: Humana ChoiceCare |
$10.10
|
| Rate for Payer: Humana Medicare |
$3.74
|
| Rate for Payer: Lucent All Commercial |
$6.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.52
|
| Rate for Payer: PHCS All Commercial |
$8.77
|
| Rate for Payer: PHP All Commercial |
$8.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.56
|
| Rate for Payer: Sagamore Health Network All Products |
$9.02
|
| Rate for Payer: Signature Care EPO |
$9.70
|
| Rate for Payer: Signature Care PPO |
$10.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.94
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
| Rate for Payer: United Healthcare Medicare |
$3.74
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
|
IP
|
$11.69
|
|
|
Service Code
|
NDC 00121086800
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$10.10
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Cigna All Commercial |
$10.09
|
| Rate for Payer: CORVEL All Commercial |
$10.87
|
| Rate for Payer: Coventry All Commercial |
$10.29
|
| Rate for Payer: Encore All Commercial |
$10.76
|
| Rate for Payer: Frontpath All Commercial |
$10.75
|
| Rate for Payer: Humana ChoiceCare |
$10.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.52
|
| Rate for Payer: PHCS All Commercial |
$8.77
|
| Rate for Payer: PHP All Commercial |
$8.87
|
| Rate for Payer: Sagamore Health Network All Products |
$9.02
|
| Rate for Payer: Signature Care EPO |
$9.70
|
| Rate for Payer: Signature Care PPO |
$10.29
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CREA
|
Facility
|
OP
|
$31.92
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$29.69 |
| Rate for Payer: Aetna Commercial |
$26.94
|
| Rate for Payer: Aetna Medicare |
$10.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.24
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Centivo All Commercial |
$17.36
|
| Rate for Payer: Cigna All Commercial |
$27.55
|
| Rate for Payer: CORVEL All Commercial |
$29.69
|
| Rate for Payer: Coventry All Commercial |
$28.09
|
| Rate for Payer: Encore All Commercial |
$29.38
|
| Rate for Payer: Frontpath All Commercial |
$29.37
|
| Rate for Payer: Humana ChoiceCare |
$27.57
|
| Rate for Payer: Humana Medicare |
$10.21
|
| Rate for Payer: Lucent All Commercial |
$17.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.73
|
| Rate for Payer: PHCS All Commercial |
$23.94
|
| Rate for Payer: PHP All Commercial |
$24.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.45
|
| Rate for Payer: Sagamore Health Network All Products |
$24.64
|
| Rate for Payer: Signature Care EPO |
$26.49
|
| Rate for Payer: Signature Care PPO |
$28.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.13
|
| Rate for Payer: United Healthcare Commercial |
$25.15
|
| Rate for Payer: United Healthcare Medicare |
$10.21
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CREA
|
Facility
|
IP
|
$31.92
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$29.69 |
| Rate for Payer: Aetna Commercial |
$27.58
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cigna All Commercial |
$27.55
|
| Rate for Payer: CORVEL All Commercial |
$29.69
|
| Rate for Payer: Coventry All Commercial |
$28.09
|
| Rate for Payer: Encore All Commercial |
$29.38
|
| Rate for Payer: Frontpath All Commercial |
$29.37
|
| Rate for Payer: Humana ChoiceCare |
$27.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.73
|
| Rate for Payer: PHCS All Commercial |
$23.94
|
| Rate for Payer: PHP All Commercial |
$24.21
|
| Rate for Payer: Sagamore Health Network All Products |
$24.64
|
| Rate for Payer: Signature Care EPO |
$26.49
|
| Rate for Payer: Signature Care PPO |
$28.09
|
| Rate for Payer: United Healthcare Commercial |
$25.15
|
|
|
OCRELIZUMAB 30 MG/ML IV SOLN
|
Facility
|
IP
|
$72,243.36
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
180498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54,182.52 |
| Max. Negotiated Rate |
$67,186.32 |
| Rate for Payer: Aetna Commercial |
$62,418.26
|
| Rate for Payer: Cash Price |
$43,346.02
|
| Rate for Payer: Cigna All Commercial |
$62,346.02
|
| Rate for Payer: CORVEL All Commercial |
$67,186.32
|
| Rate for Payer: Coventry All Commercial |
$63,574.16
|
| Rate for Payer: Encore All Commercial |
$66,500.01
|
| Rate for Payer: Frontpath All Commercial |
$66,463.89
|
| Rate for Payer: Humana ChoiceCare |
$62,396.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65,019.02
|
| Rate for Payer: PHCS All Commercial |
$54,182.52
|
| Rate for Payer: PHP All Commercial |
$54,789.36
|
| Rate for Payer: Sagamore Health Network All Products |
$55,771.87
|
| Rate for Payer: Signature Care EPO |
$59,961.99
|
| Rate for Payer: Signature Care PPO |
$63,574.16
|
| Rate for Payer: United Healthcare Commercial |
$56,927.77
|
|
|
OCRELIZUMAB 30 MG/ML IV SOLN
|
Facility
|
OP
|
$72,243.36
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
180498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.24 |
| Max. Negotiated Rate |
$67,186.32 |
| Rate for Payer: Aetna Commercial |
$60,973.40
|
| Rate for Payer: Aetna Medicare |
$23,117.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$72.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22,395.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$41,489.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45,159.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$72.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26,585.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25,429.66
|
| Rate for Payer: Cash Price |
$43,346.02
|
| Rate for Payer: Cash Price |
$43,346.02
|
| Rate for Payer: Centivo All Commercial |
$39,300.39
|
| Rate for Payer: Cigna All Commercial |
$62,346.02
|
| Rate for Payer: CORVEL All Commercial |
$67,186.32
|
| Rate for Payer: Coventry All Commercial |
$63,574.16
|
| Rate for Payer: Encore All Commercial |
$66,500.01
|
| Rate for Payer: Frontpath All Commercial |
$66,463.89
|
| Rate for Payer: Humana ChoiceCare |
$62,396.59
|
| Rate for Payer: Humana Medicare |
$23,117.88
|
| Rate for Payer: Lucent All Commercial |
$39,300.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65,019.02
|
| Rate for Payer: Managed Health Services Medicaid |
$72.24
|
| Rate for Payer: MDWise Medicaid |
$72.24
|
| Rate for Payer: PHCS All Commercial |
$54,182.52
|
| Rate for Payer: PHP All Commercial |
$54,789.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28,174.91
|
| Rate for Payer: Sagamore Health Network All Products |
$55,771.87
|
| Rate for Payer: Signature Care EPO |
$59,961.99
|
| Rate for Payer: Signature Care PPO |
$63,574.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$61,406.86
|
| Rate for Payer: United Healthcare Commercial |
$56,927.77
|
| Rate for Payer: United Healthcare Medicare |
$23,117.88
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN
|
Facility
|
OP
|
$179.70
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.71 |
| Max. Negotiated Rate |
$167.12 |
| Rate for Payer: Aetna Commercial |
$151.66
|
| Rate for Payer: Aetna Medicare |
$57.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$55.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$103.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$112.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$66.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$63.25
|
| Rate for Payer: Cash Price |
$107.82
|
| Rate for Payer: Centivo All Commercial |
$97.76
|
| Rate for Payer: Cigna All Commercial |
$155.08
|
| Rate for Payer: CORVEL All Commercial |
$167.12
|
| Rate for Payer: Coventry All Commercial |
$158.13
|
| Rate for Payer: Encore All Commercial |
$165.41
|
| Rate for Payer: Frontpath All Commercial |
$165.32
|
| Rate for Payer: Humana ChoiceCare |
$155.20
|
| Rate for Payer: Humana Medicare |
$57.50
|
| Rate for Payer: Lucent All Commercial |
$97.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$161.73
|
| Rate for Payer: PHCS All Commercial |
$134.77
|
| Rate for Payer: PHP All Commercial |
$136.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$70.08
|
| Rate for Payer: Sagamore Health Network All Products |
$138.73
|
| Rate for Payer: Signature Care EPO |
$149.15
|
| Rate for Payer: Signature Care PPO |
$158.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$152.74
|
| Rate for Payer: United Healthcare Commercial |
$141.60
|
| Rate for Payer: United Healthcare Medicare |
$57.50
|
|
