|
VENLAFAXINE 37.5 MG ORAL CP24
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
27857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna Medicare |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.22
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Centivo All Commercial |
$1.89
|
| Rate for Payer: Cigna All Commercial |
$3.00
|
| Rate for Payer: CORVEL All Commercial |
$3.23
|
| Rate for Payer: Coventry All Commercial |
$3.06
|
| Rate for Payer: Encore All Commercial |
$3.20
|
| Rate for Payer: Frontpath All Commercial |
$3.19
|
| Rate for Payer: Humana ChoiceCare |
$3.00
|
| Rate for Payer: Humana Medicare |
$1.11
|
| Rate for Payer: Lucent All Commercial |
$1.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.12
|
| Rate for Payer: PHCS All Commercial |
$2.60
|
| Rate for Payer: PHP All Commercial |
$2.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.35
|
| Rate for Payer: Sagamore Health Network All Products |
$2.68
|
| Rate for Payer: Signature Care EPO |
$2.88
|
| Rate for Payer: Signature Care PPO |
$3.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.95
|
| Rate for Payer: United Healthcare Commercial |
$2.74
|
| Rate for Payer: United Healthcare Medicare |
$1.11
|
|
|
VENLAFAXINE 37.5 MG ORAL CP24
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
27857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cigna All Commercial |
$3.00
|
| Rate for Payer: CORVEL All Commercial |
$3.23
|
| Rate for Payer: Coventry All Commercial |
$3.06
|
| Rate for Payer: Encore All Commercial |
$3.20
|
| Rate for Payer: Frontpath All Commercial |
$3.19
|
| Rate for Payer: Humana ChoiceCare |
$3.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.12
|
| Rate for Payer: PHCS All Commercial |
$2.60
|
| Rate for Payer: PHP All Commercial |
$2.63
|
| Rate for Payer: Sagamore Health Network All Products |
$2.68
|
| Rate for Payer: Signature Care EPO |
$2.88
|
| Rate for Payer: Signature Care PPO |
$3.06
|
| Rate for Payer: United Healthcare Commercial |
$2.74
|
|
|
VENLAFAXINE 50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 57664039488
|
| Hospital Charge Code |
12204
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
VENLAFAXINE 50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 57664039488
|
| Hospital Charge Code |
12204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
VERAPAMIL 120 MG ORAL TBER
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
11639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
VERAPAMIL 120 MG ORAL TBER
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
11639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
VERAPAMIL 180 MG ORAL C24P
|
Facility
|
OP
|
$8.48
|
|
|
Service Code
|
NDC 00378638001
|
| Hospital Charge Code |
23150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna Commercial |
$7.15
|
| Rate for Payer: Aetna Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.98
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Centivo All Commercial |
$4.61
|
| Rate for Payer: Cigna All Commercial |
$7.32
|
| Rate for Payer: CORVEL All Commercial |
$7.88
|
| Rate for Payer: Coventry All Commercial |
$7.46
|
| Rate for Payer: Encore All Commercial |
$7.80
|
| Rate for Payer: Frontpath All Commercial |
$7.80
|
| Rate for Payer: Humana ChoiceCare |
$7.32
|
| Rate for Payer: Humana Medicare |
$2.71
|
| Rate for Payer: Lucent All Commercial |
$4.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.63
|
| Rate for Payer: PHCS All Commercial |
$6.36
|
| Rate for Payer: PHP All Commercial |
$6.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.31
|
| Rate for Payer: Sagamore Health Network All Products |
$6.54
|
| Rate for Payer: Signature Care EPO |
$7.04
|
| Rate for Payer: Signature Care PPO |
$7.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.21
|
| Rate for Payer: United Healthcare Commercial |
$6.68
|
| Rate for Payer: United Healthcare Medicare |
$2.71
|
|
|
VERAPAMIL 180 MG ORAL C24P
|
Facility
|
IP
|
$8.48
|
|
|
Service Code
|
NDC 00378638001
|
| Hospital Charge Code |
23150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cigna All Commercial |
$7.32
|
| Rate for Payer: CORVEL All Commercial |
$7.88
|
| Rate for Payer: Coventry All Commercial |
$7.46
|
| Rate for Payer: Encore All Commercial |
$7.80
|
| Rate for Payer: Frontpath All Commercial |
$7.80
|
| Rate for Payer: Humana ChoiceCare |
$7.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.63
|
| Rate for Payer: PHCS All Commercial |
$6.36
|
| Rate for Payer: PHP All Commercial |
$6.43
|
| Rate for Payer: Sagamore Health Network All Products |
$6.54
|
| Rate for Payer: Signature Care EPO |
$7.04
|
| Rate for Payer: Signature Care PPO |
$7.46
|
| Rate for Payer: United Healthcare Commercial |
$6.68
|
|
|
VERAPAMIL 2.5 MG/ML IV SOLN
|
Facility
|
IP
|
$82.42
|
|
|
Service Code
|
NDC 00409401101
|
| Hospital Charge Code |
8527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.81 |
| Max. Negotiated Rate |
$76.65 |
| Rate for Payer: Aetna Commercial |
$71.21
|
| Rate for Payer: Cash Price |
$49.45
|
| Rate for Payer: Cigna All Commercial |
$71.13
|
| Rate for Payer: CORVEL All Commercial |
$76.65
|
| Rate for Payer: Coventry All Commercial |
$72.53
|
| Rate for Payer: Encore All Commercial |
$75.87
|
| Rate for Payer: Frontpath All Commercial |
$75.82
|
| Rate for Payer: Humana ChoiceCare |
$71.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.18
|
| Rate for Payer: PHCS All Commercial |
$61.81
|
| Rate for Payer: PHP All Commercial |
$62.51
|
| Rate for Payer: Sagamore Health Network All Products |
$63.63
|
| Rate for Payer: Signature Care EPO |
$68.41
|
| Rate for Payer: Signature Care PPO |
$72.53
|
| Rate for Payer: United Healthcare Commercial |
$64.95
|
|
|
VERAPAMIL 2.5 MG/ML IV SOLN
|
Facility
|
OP
|
$82.42
|
|
|
Service Code
|
NDC 00409401101
|
| Hospital Charge Code |
8527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$76.65 |
| Rate for Payer: Aetna Commercial |
$69.56
|
| Rate for Payer: Aetna Medicare |
$26.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.01
|
| Rate for Payer: Cash Price |
$49.45
|
| Rate for Payer: Cash Price |
$49.45
|
| Rate for Payer: Centivo All Commercial |
$44.84
|
| Rate for Payer: Cigna All Commercial |
$71.13
|
| Rate for Payer: CORVEL All Commercial |
$76.65
|
| Rate for Payer: Coventry All Commercial |
$72.53
|
| Rate for Payer: Encore All Commercial |
$75.87
|
| Rate for Payer: Frontpath All Commercial |
$75.82
|
| Rate for Payer: Humana ChoiceCare |
$71.18
|
| Rate for Payer: Humana Medicare |
$26.37
|
| Rate for Payer: Lucent All Commercial |
$44.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$61.81
|
| Rate for Payer: PHP All Commercial |
$62.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.14
|
| Rate for Payer: Sagamore Health Network All Products |
$63.63
|
| Rate for Payer: Signature Care EPO |
$68.41
|
| Rate for Payer: Signature Care PPO |
$72.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.06
|
| Rate for Payer: United Healthcare Commercial |
$64.95
|
| Rate for Payer: United Healthcare Medicare |
$26.37
|
|
|
VIT A,C AND E-LUTEIN-MINERALS 300 MCG-200 MG-27 MG-2 MG ORAL TAB
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 00536509008
|
| Hospital Charge Code |
118185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.40
|
| Rate for Payer: Frontpath All Commercial |
$0.40
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.39
|
| Rate for Payer: PHCS All Commercial |
$0.33
|
| Rate for Payer: PHP All Commercial |
$0.33
|
| Rate for Payer: Sagamore Health Network All Products |
$0.34
|
| Rate for Payer: Signature Care EPO |
$0.36
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
|
|
VIT A,C AND E-LUTEIN-MINERALS 300 MCG-200 MG-27 MG-2 MG ORAL TAB
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 00536509008
|
| Hospital Charge Code |
118185
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Aetna Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Centivo All Commercial |
$0.24
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.40
|
| Rate for Payer: Frontpath All Commercial |
$0.40
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.14
|
| Rate for Payer: Lucent All Commercial |
$0.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.39
|
| Rate for Payer: PHCS All Commercial |
$0.33
|
| Rate for Payer: PHP All Commercial |
$0.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.17
|
| Rate for Payer: Sagamore Health Network All Products |
$0.34
|
| Rate for Payer: Signature Care EPO |
$0.36
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
|
|
VITAMIN A 10000 UNITS ORAL CAP
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
|
|
VITAMIN A 10000 UNITS ORAL CAP
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna Commercial |
$0.24
|
| Rate for Payer: Aetna Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Centivo All Commercial |
$0.16
|
| Rate for Payer: Cigna All Commercial |
$0.25
|
| Rate for Payer: CORVEL All Commercial |
$0.27
|
| Rate for Payer: Coventry All Commercial |
$0.25
|
| Rate for Payer: Encore All Commercial |
$0.26
|
| Rate for Payer: Frontpath All Commercial |
$0.26
|
| Rate for Payer: Humana ChoiceCare |
$0.25
|
| Rate for Payer: Humana Medicare |
$0.09
|
| Rate for Payer: Lucent All Commercial |
$0.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.26
|
| Rate for Payer: PHCS All Commercial |
$0.22
|
| Rate for Payer: PHP All Commercial |
$0.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.11
|
| Rate for Payer: Sagamore Health Network All Products |
$0.22
|
| Rate for Payer: Signature Care EPO |
$0.24
|
| Rate for Payer: Signature Care PPO |
$0.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
|
|
VITAMIN B COMPLEX ORAL CAP
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 79854020080
|
| Hospital Charge Code |
804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna All Commercial |
$0.33
|
| Rate for Payer: CORVEL All Commercial |
$0.36
|
| Rate for Payer: Coventry All Commercial |
$0.34
|
| Rate for Payer: Encore All Commercial |
$0.35
|
| Rate for Payer: Frontpath All Commercial |
$0.35
|
| Rate for Payer: Humana ChoiceCare |
$0.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.35
|
| Rate for Payer: PHCS All Commercial |
$0.29
|
| Rate for Payer: PHP All Commercial |
$0.29
|
| Rate for Payer: Sagamore Health Network All Products |
$0.30
|
| Rate for Payer: Signature Care EPO |
$0.32
|
| Rate for Payer: Signature Care PPO |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
|
|
VITAMIN B COMPLEX ORAL CAP
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 79854020080
|
| Hospital Charge Code |
804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Medicare |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Centivo All Commercial |
$0.21
|
| Rate for Payer: Cigna All Commercial |
$0.33
|
| Rate for Payer: CORVEL All Commercial |
$0.36
|
| Rate for Payer: Coventry All Commercial |
$0.34
|
| Rate for Payer: Encore All Commercial |
$0.35
|
| Rate for Payer: Frontpath All Commercial |
$0.35
|
| Rate for Payer: Humana ChoiceCare |
$0.33
|
| Rate for Payer: Humana Medicare |
$0.12
|
| Rate for Payer: Lucent All Commercial |
$0.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.35
|
| Rate for Payer: PHCS All Commercial |
$0.29
|
| Rate for Payer: PHP All Commercial |
$0.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.15
|
| Rate for Payer: Sagamore Health Network All Products |
$0.30
|
| Rate for Payer: Signature Care EPO |
$0.32
|
| Rate for Payer: Signature Care PPO |
$0.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 40985021245
|
| Hospital Charge Code |
108850
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 40985021245
|
| Hospital Charge Code |
108850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
WARFARIN 1 MG ORAL TAB
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
NDC 00832121101
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$0.95
|
| Rate for Payer: CORVEL All Commercial |
$1.03
|
| Rate for Payer: Coventry All Commercial |
$0.97
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Sagamore Health Network All Products |
$0.85
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.97
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
|
|
WARFARIN 1 MG ORAL TAB
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
NDC 00832121101
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna Commercial |
$0.93
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Centivo All Commercial |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.95
|
| Rate for Payer: CORVEL All Commercial |
$1.03
|
| Rate for Payer: Coventry All Commercial |
$0.97
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Humana Medicare |
$0.35
|
| Rate for Payer: Lucent All Commercial |
$0.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.85
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
|
|
WARFARIN 2.5 MG ORAL TAB
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 68084002701
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.62
|
| 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 |
$1.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
WARFARIN 2.5 MG ORAL TAB
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 68084002701
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Centivo All Commercial |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.62
|
| 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 |
$1.51
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| 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 |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| 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 |
$0.56
|
|
|
WARFARIN 2 MG ORAL TAB
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 62584098401
|
| Hospital Charge Code |
8749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna Commercial |
$1.59
|
| Rate for Payer: Aetna Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Centivo All Commercial |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.63
|
| Rate for Payer: CORVEL All Commercial |
$1.75
|
| Rate for Payer: Coventry All Commercial |
$1.66
|
| Rate for Payer: Encore All Commercial |
$1.73
|
| Rate for Payer: Frontpath All Commercial |
$1.73
|
| Rate for Payer: Humana ChoiceCare |
$1.63
|
| Rate for Payer: Humana Medicare |
$0.60
|
| Rate for Payer: Lucent All Commercial |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.69
|
| Rate for Payer: PHCS All Commercial |
$1.41
|
| Rate for Payer: PHP All Commercial |
$1.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.73
|
| Rate for Payer: Sagamore Health Network All Products |
$1.45
|
| Rate for Payer: Signature Care EPO |
$1.56
|
| Rate for Payer: Signature Care PPO |
$1.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
|
|
WARFARIN 2 MG ORAL TAB
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 62584098401
|
| Hospital Charge Code |
8749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.63
|
| Rate for Payer: CORVEL All Commercial |
$1.75
|
| Rate for Payer: Coventry All Commercial |
$1.66
|
| Rate for Payer: Encore All Commercial |
$1.73
|
| Rate for Payer: Frontpath All Commercial |
$1.73
|
| Rate for Payer: Humana ChoiceCare |
$1.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.69
|
| Rate for Payer: PHCS All Commercial |
$1.41
|
| Rate for Payer: PHP All Commercial |
$1.43
|
| Rate for Payer: Sagamore Health Network All Products |
$1.45
|
| Rate for Payer: Signature Care EPO |
$1.56
|
| Rate for Payer: Signature Care PPO |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
|
|
WARFARIN 3 MG ORAL TAB
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 00832121401
|
| Hospital Charge Code |
19433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Centivo All Commercial |
$0.59
|
| Rate for Payer: Cigna All Commercial |
$0.94
|
| Rate for Payer: CORVEL All Commercial |
$1.01
|
| Rate for Payer: Coventry All Commercial |
$0.95
|
| Rate for Payer: Encore All Commercial |
$1.00
|
| Rate for Payer: Frontpath All Commercial |
$1.00
|
| Rate for Payer: Humana ChoiceCare |
$0.94
|
| Rate for Payer: Humana Medicare |
$0.35
|
| Rate for Payer: Lucent All Commercial |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.98
|
| Rate for Payer: PHCS All Commercial |
$0.81
|
| Rate for Payer: PHP All Commercial |
$0.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.42
|
| Rate for Payer: Sagamore Health Network All Products |
$0.84
|
| Rate for Payer: Signature Care EPO |
$0.90
|
| Rate for Payer: Signature Care PPO |
$0.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$0.85
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
|
