|
GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TOP SPGE
|
Facility
IP
|
$78.83
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.13 |
| Max. Negotiated Rate |
$73.32 |
| Rate for Payer: Aetna Commercial |
$68.11
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Cigna All Commercial |
$68.03
|
| Rate for Payer: CORVEL All Commercial |
$73.32
|
| Rate for Payer: Coventry All Commercial |
$69.37
|
| Rate for Payer: Encore All Commercial |
$72.57
|
| Rate for Payer: Frontpath All Commercial |
$72.53
|
| Rate for Payer: Humana ChoiceCare |
$68.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.95
|
| Rate for Payer: PHCS All Commercial |
$59.13
|
| Rate for Payer: PHP All Commercial |
$59.79
|
| Rate for Payer: Sagamore Health Network All Products |
$60.86
|
| Rate for Payer: Signature Care EPO |
$65.43
|
| Rate for Payer: Signature Care PPO |
$69.37
|
| Rate for Payer: United Healthcare Commercial |
$62.12
|
|
|
GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TOP SPGE
|
Facility
OP
|
$78.83
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.02 |
| Max. Negotiated Rate |
$73.32 |
| Rate for Payer: Aetna Commercial |
$66.54
|
| Rate for Payer: Aetna Medicare |
$26.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$45.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.62
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Centivo All Commercial |
$40.21
|
| Rate for Payer: Cigna All Commercial |
$68.03
|
| Rate for Payer: CORVEL All Commercial |
$73.32
|
| Rate for Payer: Coventry All Commercial |
$69.37
|
| Rate for Payer: Encore All Commercial |
$72.57
|
| Rate for Payer: Frontpath All Commercial |
$72.53
|
| Rate for Payer: Humana ChoiceCare |
$68.09
|
| Rate for Payer: Humana Medicare |
$40.21
|
| Rate for Payer: Lucent All Commercial |
$40.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.95
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$59.13
|
| Rate for Payer: PHP All Commercial |
$59.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.75
|
| Rate for Payer: Sagamore Health Network All Products |
$60.86
|
| Rate for Payer: Signature Care EPO |
$65.43
|
| Rate for Payer: Signature Care PPO |
$69.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.01
|
| Rate for Payer: United Healthcare Commercial |
$62.12
|
| Rate for Payer: United Healthcare Medicare |
$26.02
|
|
|
GEMFIBROZIL 600 MG ORAL TAB
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 69097082103
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna Commercial |
$0.87
|
| Rate for Payer: Aetna Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Centivo All Commercial |
$0.52
|
| Rate for Payer: Cigna All Commercial |
$0.89
|
| Rate for Payer: CORVEL All Commercial |
$0.96
|
| Rate for Payer: Coventry All Commercial |
$0.91
|
| Rate for Payer: Encore All Commercial |
$0.95
|
| Rate for Payer: Frontpath All Commercial |
$0.95
|
| Rate for Payer: Humana ChoiceCare |
$0.89
|
| Rate for Payer: Humana Medicare |
$0.52
|
| Rate for Payer: Lucent All Commercial |
$0.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.93
|
| Rate for Payer: PHCS All Commercial |
$0.77
|
| Rate for Payer: PHP All Commercial |
$0.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.40
|
| Rate for Payer: Sagamore Health Network All Products |
$0.79
|
| Rate for Payer: Signature Care EPO |
$0.85
|
| Rate for Payer: Signature Care PPO |
$0.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
|
|
GEMFIBROZIL 600 MG ORAL TAB
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 69097082103
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna All Commercial |
$0.89
|
| Rate for Payer: CORVEL All Commercial |
$0.96
|
| Rate for Payer: Coventry All Commercial |
$0.91
|
| Rate for Payer: Encore All Commercial |
$0.95
|
| Rate for Payer: Frontpath All Commercial |
$0.95
|
| Rate for Payer: Humana ChoiceCare |
$0.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.93
|
| Rate for Payer: PHCS All Commercial |
$0.77
|
| Rate for Payer: PHP All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$0.79
|
| Rate for Payer: Signature Care EPO |
$0.85
|
| Rate for Payer: Signature Care PPO |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
OP
|
$30.74
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Aetna Commercial |
$25.95
|
| Rate for Payer: Aetna Medicare |
$10.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.16
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Centivo All Commercial |
$15.68
|
| Rate for Payer: Cigna All Commercial |
$26.53
|
| Rate for Payer: CORVEL All Commercial |
$28.59
|
| Rate for Payer: Coventry All Commercial |
$27.05
|
| Rate for Payer: Encore All Commercial |
$28.30
|
| Rate for Payer: Frontpath All Commercial |
$28.28
|
| Rate for Payer: Humana ChoiceCare |
$26.55
|
| Rate for Payer: Humana Medicare |
$15.68
|
| Rate for Payer: Lucent All Commercial |
$15.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.67
|
| Rate for Payer: PHCS All Commercial |
$23.06
|
| Rate for Payer: PHP All Commercial |
$23.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.99
|
| Rate for Payer: Sagamore Health Network All Products |
$23.73
|
| Rate for Payer: Signature Care EPO |
$25.52
|
| Rate for Payer: Signature Care PPO |
$27.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.13
|
| Rate for Payer: United Healthcare Commercial |
$24.23
|
| Rate for Payer: United Healthcare Medicare |
$10.15
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
IP
|
$30.74
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.06 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Aetna Commercial |
$26.56
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cigna All Commercial |
$26.53
|
| Rate for Payer: CORVEL All Commercial |
$28.59
|
| Rate for Payer: Coventry All Commercial |
$27.05
|
| Rate for Payer: Encore All Commercial |
$28.30
|
| Rate for Payer: Frontpath All Commercial |
$28.28
|
| Rate for Payer: Humana ChoiceCare |
$26.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.67
|
| Rate for Payer: PHCS All Commercial |
$23.06
|
| Rate for Payer: PHP All Commercial |
$23.32
|
| Rate for Payer: Sagamore Health Network All Products |
$23.73
|
| Rate for Payer: Signature Care EPO |
$25.52
|
| Rate for Payer: Signature Care PPO |
$27.05
|
| Rate for Payer: United Healthcare Commercial |
$24.23
|
|
|
GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN
|
Facility
IP
|
$43.19
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
119249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$40.17 |
| Rate for Payer: Aetna Commercial |
$37.32
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Cigna All Commercial |
$37.27
|
| Rate for Payer: CORVEL All Commercial |
$40.17
|
| Rate for Payer: Coventry All Commercial |
$38.01
|
| Rate for Payer: Encore All Commercial |
$39.76
|
| Rate for Payer: Frontpath All Commercial |
$39.73
|
| Rate for Payer: Humana ChoiceCare |
$37.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.87
|
| Rate for Payer: PHCS All Commercial |
$32.39
|
| Rate for Payer: PHP All Commercial |
$32.76
|
| Rate for Payer: Sagamore Health Network All Products |
$33.34
|
| Rate for Payer: Signature Care EPO |
$35.85
|
| Rate for Payer: Signature Care PPO |
$38.01
|
| Rate for Payer: United Healthcare Commercial |
$34.03
|
|
|
GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML INJ SOLN
|
Facility
OP
|
$43.19
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
119249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$40.17 |
| Rate for Payer: Aetna Commercial |
$36.45
|
| Rate for Payer: Aetna Medicare |
$14.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.68
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Centivo All Commercial |
$22.03
|
| Rate for Payer: Cigna All Commercial |
$37.27
|
| Rate for Payer: CORVEL All Commercial |
$40.17
|
| Rate for Payer: Coventry All Commercial |
$38.01
|
| Rate for Payer: Encore All Commercial |
$39.76
|
| Rate for Payer: Frontpath All Commercial |
$39.73
|
| Rate for Payer: Humana ChoiceCare |
$37.30
|
| Rate for Payer: Humana Medicare |
$22.03
|
| Rate for Payer: Lucent All Commercial |
$22.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.87
|
| Rate for Payer: PHCS All Commercial |
$32.39
|
| Rate for Payer: PHP All Commercial |
$32.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.84
|
| Rate for Payer: Sagamore Health Network All Products |
$33.34
|
| Rate for Payer: Signature Care EPO |
$35.85
|
| Rate for Payer: Signature Care PPO |
$38.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$36.71
|
| Rate for Payer: United Healthcare Commercial |
$34.03
|
| Rate for Payer: United Healthcare Medicare |
$14.25
|
|
|
GENTIAN VIOLET 1 % TOP SOLN
|
Facility
OP
|
$49.15
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$45.71 |
| Rate for Payer: Aetna Commercial |
$41.48
|
| Rate for Payer: Aetna Medicare |
$16.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.84
|
| Rate for Payer: Cash Price |
$30.47
|
| Rate for Payer: Cash Price |
$30.47
|
| Rate for Payer: Centivo All Commercial |
$25.06
|
| Rate for Payer: Cigna All Commercial |
$42.41
|
| Rate for Payer: CORVEL All Commercial |
$45.71
|
| Rate for Payer: Coventry All Commercial |
$43.25
|
| Rate for Payer: Encore All Commercial |
$45.24
|
| Rate for Payer: Frontpath All Commercial |
$45.22
|
| Rate for Payer: Humana ChoiceCare |
$42.45
|
| Rate for Payer: Humana Medicare |
$25.06
|
| Rate for Payer: Lucent All Commercial |
$25.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.23
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$36.86
|
| Rate for Payer: PHP All Commercial |
$37.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.17
|
| Rate for Payer: Sagamore Health Network All Products |
$37.94
|
| Rate for Payer: Signature Care EPO |
$40.79
|
| Rate for Payer: Signature Care PPO |
$43.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.77
|
| Rate for Payer: United Healthcare Commercial |
$38.73
|
| Rate for Payer: United Healthcare Medicare |
$16.22
|
|
|
GENTIAN VIOLET 1 % TOP SOLN
|
Facility
IP
|
$49.15
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.86 |
| Max. Negotiated Rate |
$45.71 |
| Rate for Payer: Aetna Commercial |
$42.46
|
| Rate for Payer: Cash Price |
$30.47
|
| Rate for Payer: Cigna All Commercial |
$42.41
|
| Rate for Payer: CORVEL All Commercial |
$45.71
|
| Rate for Payer: Coventry All Commercial |
$43.25
|
| Rate for Payer: Encore All Commercial |
$45.24
|
| Rate for Payer: Frontpath All Commercial |
$45.22
|
| Rate for Payer: Humana ChoiceCare |
$42.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.23
|
| Rate for Payer: PHCS All Commercial |
$36.86
|
| Rate for Payer: PHP All Commercial |
$37.27
|
| Rate for Payer: Sagamore Health Network All Products |
$37.94
|
| Rate for Payer: Signature Care EPO |
$40.79
|
| Rate for Payer: Signature Care PPO |
$43.25
|
| Rate for Payer: United Healthcare Commercial |
$38.73
|
|
|
GLIMEPIRIDE 2 MG ORAL TAB
|
Facility
IP
|
$2.91
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
GLIMEPIRIDE 2 MG ORAL TAB
|
Facility
OP
|
$2.91
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Centivo All Commercial |
$1.49
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Humana Medicare |
$1.49
|
| Rate for Payer: Lucent All Commercial |
$1.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.14
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.48
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
IP
|
$8.20
|
|
|
Service Code
|
NDC 60687076821
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna Commercial |
$7.08
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna All Commercial |
$7.07
|
| Rate for Payer: CORVEL All Commercial |
$7.62
|
| Rate for Payer: Coventry All Commercial |
$7.21
|
| Rate for Payer: Encore All Commercial |
$7.55
|
| Rate for Payer: Frontpath All Commercial |
$7.54
|
| Rate for Payer: Humana ChoiceCare |
$7.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.38
|
| Rate for Payer: PHCS All Commercial |
$6.15
|
| Rate for Payer: PHP All Commercial |
$6.22
|
| Rate for Payer: Sagamore Health Network All Products |
$6.33
|
| Rate for Payer: Signature Care EPO |
$6.80
|
| Rate for Payer: Signature Care PPO |
$7.21
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
IP
|
$8.20
|
|
|
Service Code
|
NDC 60687076811
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna Commercial |
$7.08
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna All Commercial |
$7.07
|
| Rate for Payer: CORVEL All Commercial |
$7.62
|
| Rate for Payer: Coventry All Commercial |
$7.21
|
| Rate for Payer: Encore All Commercial |
$7.55
|
| Rate for Payer: Frontpath All Commercial |
$7.54
|
| Rate for Payer: Humana ChoiceCare |
$7.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.38
|
| Rate for Payer: PHCS All Commercial |
$6.15
|
| Rate for Payer: PHP All Commercial |
$6.22
|
| Rate for Payer: Sagamore Health Network All Products |
$6.33
|
| Rate for Payer: Signature Care EPO |
$6.80
|
| Rate for Payer: Signature Care PPO |
$7.21
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
OP
|
$8.20
|
|
|
Service Code
|
NDC 60687076811
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.98
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Centivo All Commercial |
$4.18
|
| Rate for Payer: Cigna All Commercial |
$7.07
|
| Rate for Payer: CORVEL All Commercial |
$7.62
|
| Rate for Payer: Coventry All Commercial |
$7.21
|
| Rate for Payer: Encore All Commercial |
$7.55
|
| Rate for Payer: Frontpath All Commercial |
$7.54
|
| Rate for Payer: Humana ChoiceCare |
$7.08
|
| Rate for Payer: Humana Medicare |
$4.18
|
| Rate for Payer: Lucent All Commercial |
$4.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.38
|
| Rate for Payer: PHCS All Commercial |
$6.15
|
| Rate for Payer: PHP All Commercial |
$6.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.20
|
| Rate for Payer: Sagamore Health Network All Products |
$6.33
|
| Rate for Payer: Signature Care EPO |
$6.80
|
| Rate for Payer: Signature Care PPO |
$7.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.97
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
| Rate for Payer: United Healthcare Medicare |
$2.71
|
|
|
GLIPIZIDE 2.5 MG ORAL TR24
|
Facility
OP
|
$8.20
|
|
|
Service Code
|
NDC 60687076821
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.98
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Centivo All Commercial |
$4.18
|
| Rate for Payer: Cigna All Commercial |
$7.07
|
| Rate for Payer: CORVEL All Commercial |
$7.62
|
| Rate for Payer: Coventry All Commercial |
$7.21
|
| Rate for Payer: Encore All Commercial |
$7.55
|
| Rate for Payer: Frontpath All Commercial |
$7.54
|
| Rate for Payer: Humana ChoiceCare |
$7.08
|
| Rate for Payer: Humana Medicare |
$4.18
|
| Rate for Payer: Lucent All Commercial |
$4.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.38
|
| Rate for Payer: PHCS All Commercial |
$6.15
|
| Rate for Payer: PHP All Commercial |
$6.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.20
|
| Rate for Payer: Sagamore Health Network All Products |
$6.33
|
| Rate for Payer: Signature Care EPO |
$6.80
|
| Rate for Payer: Signature Care PPO |
$7.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.97
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
| Rate for Payer: United Healthcare Medicare |
$2.71
|
|
|
GLIPIZIDE 5 MG ORAL TAB
|
Facility
IP
|
$1.74
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
GLIPIZIDE 5 MG ORAL TAB
|
Facility
OP
|
$1.74
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Centivo All Commercial |
$0.89
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Humana Medicare |
$0.89
|
| Rate for Payer: Lucent All Commercial |
$0.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
GLIPIZIDE 5 MG ORAL TR24
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
NDC 59762054101
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
|
|
GLIPIZIDE 5 MG ORAL TR24
|
Facility
OP
|
$1.09
|
|
|
Service Code
|
NDC 59762054101
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Centivo All Commercial |
$0.56
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.02
|
| Rate for Payer: Coventry All Commercial |
$0.96
|
| Rate for Payer: Encore All Commercial |
$1.01
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.82
|
| Rate for Payer: PHP All Commercial |
$0.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.91
|
| Rate for Payer: Signature Care PPO |
$0.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
|
|
GLUCAGON 1 MG INJ SOLR
|
Facility
IP
|
$1,108.20
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
111859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$831.15 |
| Max. Negotiated Rate |
$1,030.63 |
| Rate for Payer: Aetna Commercial |
$957.48
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Cigna All Commercial |
$956.38
|
| Rate for Payer: CORVEL All Commercial |
$1,030.63
|
| Rate for Payer: Coventry All Commercial |
$975.22
|
| Rate for Payer: Encore All Commercial |
$1,020.10
|
| Rate for Payer: Frontpath All Commercial |
$1,019.54
|
| Rate for Payer: Humana ChoiceCare |
$957.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$997.38
|
| Rate for Payer: PHCS All Commercial |
$831.15
|
| Rate for Payer: PHP All Commercial |
$840.46
|
| Rate for Payer: Sagamore Health Network All Products |
$855.53
|
| Rate for Payer: Signature Care EPO |
$919.81
|
| Rate for Payer: Signature Care PPO |
$975.22
|
| Rate for Payer: United Healthcare Commercial |
$873.26
|
|
|
GLUCAGON 1 MG INJ SOLR
|
Facility
OP
|
$1,108.20
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
111859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.18 |
| Max. Negotiated Rate |
$1,030.63 |
| Rate for Payer: Aetna Commercial |
$935.32
|
| Rate for Payer: Aetna Medicare |
$365.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$365.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$636.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$692.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$180.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$420.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$402.28
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Centivo All Commercial |
$565.18
|
| Rate for Payer: Cigna All Commercial |
$956.38
|
| Rate for Payer: CORVEL All Commercial |
$1,030.63
|
| Rate for Payer: Coventry All Commercial |
$975.22
|
| Rate for Payer: Encore All Commercial |
$1,020.10
|
| Rate for Payer: Frontpath All Commercial |
$1,019.54
|
| Rate for Payer: Humana ChoiceCare |
$957.15
|
| Rate for Payer: Humana Medicare |
$565.18
|
| Rate for Payer: Lucent All Commercial |
$565.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$997.38
|
| Rate for Payer: Managed Health Services Medicaid |
$180.18
|
| Rate for Payer: MDWise Medicaid |
$180.18
|
| Rate for Payer: PHCS All Commercial |
$831.15
|
| Rate for Payer: PHP All Commercial |
$840.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$432.20
|
| Rate for Payer: Sagamore Health Network All Products |
$855.53
|
| Rate for Payer: Signature Care EPO |
$919.81
|
| Rate for Payer: Signature Care PPO |
$975.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$941.97
|
| Rate for Payer: United Healthcare Commercial |
$873.26
|
| Rate for Payer: United Healthcare Medicare |
$365.71
|
|
|
GLUCAGON 1 MG/ML INJ SOLR
|
Facility
OP
|
$502.70
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.89 |
| Max. Negotiated Rate |
$467.51 |
| Rate for Payer: Aetna Commercial |
$424.28
|
| Rate for Payer: Aetna Medicare |
$165.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$165.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$288.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$314.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$180.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$190.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$182.48
|
| Rate for Payer: Cash Price |
$311.67
|
| Rate for Payer: Cash Price |
$311.67
|
| Rate for Payer: Centivo All Commercial |
$256.38
|
| Rate for Payer: Cigna All Commercial |
$433.83
|
| Rate for Payer: CORVEL All Commercial |
$467.51
|
| Rate for Payer: Coventry All Commercial |
$442.38
|
| Rate for Payer: Encore All Commercial |
$462.74
|
| Rate for Payer: Frontpath All Commercial |
$462.48
|
| Rate for Payer: Humana ChoiceCare |
$434.18
|
| Rate for Payer: Humana Medicare |
$256.38
|
| Rate for Payer: Lucent All Commercial |
$256.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$452.43
|
| Rate for Payer: Managed Health Services Medicaid |
$180.18
|
| Rate for Payer: MDWise Medicaid |
$180.18
|
| Rate for Payer: PHCS All Commercial |
$377.02
|
| Rate for Payer: PHP All Commercial |
$381.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$196.05
|
| Rate for Payer: Sagamore Health Network All Products |
$388.08
|
| Rate for Payer: Signature Care EPO |
$417.24
|
| Rate for Payer: Signature Care PPO |
$442.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$427.30
|
| Rate for Payer: United Healthcare Commercial |
$396.13
|
| Rate for Payer: United Healthcare Medicare |
$165.89
|
|
|
GLUCAGON 1 MG/ML INJ SOLR
|
Facility
IP
|
$502.70
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
121354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$377.02 |
| Max. Negotiated Rate |
$467.51 |
| Rate for Payer: Aetna Commercial |
$434.33
|
| Rate for Payer: Cash Price |
$311.67
|
| Rate for Payer: Cigna All Commercial |
$433.83
|
| Rate for Payer: CORVEL All Commercial |
$467.51
|
| Rate for Payer: Coventry All Commercial |
$442.38
|
| Rate for Payer: Encore All Commercial |
$462.74
|
| Rate for Payer: Frontpath All Commercial |
$462.48
|
| Rate for Payer: Humana ChoiceCare |
$434.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$452.43
|
| Rate for Payer: PHCS All Commercial |
$377.02
|
| Rate for Payer: PHP All Commercial |
$381.25
|
| Rate for Payer: Sagamore Health Network All Products |
$388.08
|
| Rate for Payer: Signature Care EPO |
$417.24
|
| Rate for Payer: Signature Care PPO |
$442.38
|
| Rate for Payer: United Healthcare Commercial |
$396.13
|
|
|
GLUCAGON 1 MG/ML INJ SOLR S.O. (CAMERON)
|
Facility
IP
|
$1,108.20
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
140121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$831.15 |
| Max. Negotiated Rate |
$1,030.63 |
| Rate for Payer: Aetna Commercial |
$957.48
|
| Rate for Payer: Cash Price |
$687.08
|
| Rate for Payer: Cigna All Commercial |
$956.38
|
| Rate for Payer: CORVEL All Commercial |
$1,030.63
|
| Rate for Payer: Coventry All Commercial |
$975.22
|
| Rate for Payer: Encore All Commercial |
$1,020.10
|
| Rate for Payer: Frontpath All Commercial |
$1,019.54
|
| Rate for Payer: Humana ChoiceCare |
$957.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$997.38
|
| Rate for Payer: PHCS All Commercial |
$831.15
|
| Rate for Payer: PHP All Commercial |
$840.46
|
| Rate for Payer: Sagamore Health Network All Products |
$855.53
|
| Rate for Payer: Signature Care EPO |
$919.81
|
| Rate for Payer: Signature Care PPO |
$975.22
|
| Rate for Payer: United Healthcare Commercial |
$873.26
|
|
