|
WARFARIN 3 MG ORAL TAB
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 00832121401
|
| Hospital Charge Code |
19433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.65
|
| 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: 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: 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: United Healthcare Commercial |
$0.85
|
|
|
WARFARIN 5 MG ORAL TAB
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 62584099401
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.56
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.67
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.63
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.37
|
| Rate for Payer: Sagamore Health Network All Products |
$1.40
|
| Rate for Payer: Signature Care EPO |
$1.50
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
WARFARIN 5 MG ORAL TAB
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 62584099401
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.56
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.67
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.63
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.40
|
| Rate for Payer: Signature Care EPO |
$1.50
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
WARFARIN 7.5 MG ORAL TAB
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 00832121801
|
| Hospital Charge Code |
8752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna All Commercial |
$1.54
|
| Rate for Payer: CORVEL All Commercial |
$1.66
|
| Rate for Payer: Coventry All Commercial |
$1.57
|
| Rate for Payer: Encore All Commercial |
$1.64
|
| Rate for Payer: Frontpath All Commercial |
$1.64
|
| Rate for Payer: Humana ChoiceCare |
$1.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.35
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.48
|
| Rate for Payer: Signature Care PPO |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
WARFARIN 7.5 MG ORAL TAB
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 00832121801
|
| Hospital Charge Code |
8752
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.12
|
| 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 |
$1.07
|
| Rate for Payer: Centivo All Commercial |
$0.97
|
| Rate for Payer: Cigna All Commercial |
$1.54
|
| Rate for Payer: CORVEL All Commercial |
$1.66
|
| Rate for Payer: Coventry All Commercial |
$1.57
|
| Rate for Payer: Encore All Commercial |
$1.64
|
| Rate for Payer: Frontpath All Commercial |
$1.64
|
| Rate for Payer: Humana ChoiceCare |
$1.54
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.48
|
| Rate for Payer: Signature Care PPO |
$1.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
WATER FOR INJECT, BACTERIOSTAT INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00409397703
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
WATER FOR INJECT, BACTERIOSTAT INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00409397703
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
WATER FOR INJECTION, STERILE INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
WATER FOR INJECTION, STERILE INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
WATER FOR INJECTION, STERILE IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338001306
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
|
|
WATER FOR INJECTION, STERILE IV SOLP
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 00264785000
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.86
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Centivo All Commercial |
$15.23
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana Medicare |
$8.96
|
| Rate for Payer: Lucent All Commercial |
$15.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.92
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$8.96
|
|
|
WATER FOR INJECTION, STERILE IV SOLP
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00264785000
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$24.19
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
|
|
WATER FOR INJECTION, STERILE IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338001306
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
WATER FOR INJECTION VIAL - NO CHARGE
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 00409488720
|
| Hospital Charge Code |
800314
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 00990797308
|
| Hospital Charge Code |
7485
|
|
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
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00338000404
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 00990797308
|
| Hospital Charge Code |
7485
|
|
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
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$54.25
|
|
|
Service Code
|
NDC 00990613922
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna Commercial |
$46.87
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cigna All Commercial |
$46.82
|
| Rate for Payer: CORVEL All Commercial |
$50.45
|
| Rate for Payer: Coventry All Commercial |
$47.74
|
| Rate for Payer: Encore All Commercial |
$49.94
|
| Rate for Payer: Frontpath All Commercial |
$49.91
|
| Rate for Payer: Humana ChoiceCare |
$46.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.83
|
| Rate for Payer: PHCS All Commercial |
$40.69
|
| Rate for Payer: PHP All Commercial |
$41.14
|
| Rate for Payer: Sagamore Health Network All Products |
$41.88
|
| Rate for Payer: Signature Care EPO |
$45.03
|
| Rate for Payer: Signature Care PPO |
$47.74
|
| Rate for Payer: United Healthcare Commercial |
$42.75
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$54.25
|
|
|
Service Code
|
NDC 00990613922
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna Commercial |
$45.79
|
| Rate for Payer: Aetna Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$31.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.10
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Centivo All Commercial |
$29.51
|
| Rate for Payer: Cigna All Commercial |
$46.82
|
| Rate for Payer: CORVEL All Commercial |
$50.45
|
| Rate for Payer: Coventry All Commercial |
$47.74
|
| Rate for Payer: Encore All Commercial |
$49.94
|
| Rate for Payer: Frontpath All Commercial |
$49.91
|
| Rate for Payer: Humana ChoiceCare |
$46.86
|
| Rate for Payer: Humana Medicare |
$17.36
|
| Rate for Payer: Lucent All Commercial |
$29.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.83
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$40.69
|
| Rate for Payer: PHP All Commercial |
$41.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.16
|
| Rate for Payer: Sagamore Health Network All Products |
$41.88
|
| Rate for Payer: Signature Care EPO |
$45.03
|
| Rate for Payer: Signature Care PPO |
$47.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.11
|
| Rate for Payer: United Healthcare Commercial |
$42.75
|
| Rate for Payer: United Healthcare Medicare |
$17.36
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00338000404
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.32
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Centivo All Commercial |
$19.04
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$11.20
|
| Rate for Payer: Lucent All Commercial |
$19.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
OP
|
$47.25
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$39.88
|
| Rate for Payer: Aetna Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.63
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Centivo All Commercial |
$25.70
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Humana Medicare |
$15.12
|
| Rate for Payer: Lucent All Commercial |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.43
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
| Rate for Payer: United Healthcare Medicare |
$15.12
|
|
|
WATER FOR IRRIGATION, STERILE IR SOLN
|
Facility
|
IP
|
$47.25
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.44 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT
|
Facility
|
IP
|
$72.45
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
119525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$67.38 |
| Rate for Payer: Aetna Commercial |
$62.59
|
| Rate for Payer: Cash Price |
$43.47
|
| Rate for Payer: Cigna All Commercial |
$62.52
|
| Rate for Payer: CORVEL All Commercial |
$67.38
|
| Rate for Payer: Coventry All Commercial |
$63.75
|
| Rate for Payer: Encore All Commercial |
$66.69
|
| Rate for Payer: Frontpath All Commercial |
$66.65
|
| Rate for Payer: Humana ChoiceCare |
$62.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.20
|
| Rate for Payer: PHCS All Commercial |
$54.34
|
| Rate for Payer: PHP All Commercial |
$54.94
|
| Rate for Payer: Sagamore Health Network All Products |
$55.93
|
| Rate for Payer: Signature Care EPO |
$60.13
|
| Rate for Payer: Signature Care PPO |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$57.09
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8-42.5 % OPHT OINT
|
Facility
|
OP
|
$72.45
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
119525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$67.38 |
| Rate for Payer: Aetna Commercial |
$61.15
|
| Rate for Payer: Aetna Medicare |
$23.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$41.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.50
|
| Rate for Payer: Cash Price |
$43.47
|
| Rate for Payer: Centivo All Commercial |
$39.41
|
| Rate for Payer: Cigna All Commercial |
$62.52
|
| Rate for Payer: CORVEL All Commercial |
$67.38
|
| Rate for Payer: Coventry All Commercial |
$63.75
|
| Rate for Payer: Encore All Commercial |
$66.69
|
| Rate for Payer: Frontpath All Commercial |
$66.65
|
| Rate for Payer: Humana ChoiceCare |
$62.57
|
| Rate for Payer: Humana Medicare |
$23.18
|
| Rate for Payer: Lucent All Commercial |
$39.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.20
|
| Rate for Payer: PHCS All Commercial |
$54.34
|
| Rate for Payer: PHP All Commercial |
$54.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.25
|
| Rate for Payer: Sagamore Health Network All Products |
$55.93
|
| Rate for Payer: Signature Care EPO |
$60.13
|
| Rate for Payer: Signature Care PPO |
$63.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$57.09
|
| Rate for Payer: United Healthcare Medicare |
$23.18
|
|
|
WHITE PETROLATUM-MINERAL OIL 83-15 % OPHT OINT
|
Facility
|
OP
|
$39.84
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
119339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna Medicare |
$12.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.02
|
| Rate for Payer: Cash Price |
$23.90
|
| Rate for Payer: Cash Price |
$23.90
|
| Rate for Payer: Centivo All Commercial |
$21.67
|
| Rate for Payer: Cigna All Commercial |
$34.38
|
| Rate for Payer: CORVEL All Commercial |
$37.05
|
| Rate for Payer: Coventry All Commercial |
$35.06
|
| Rate for Payer: Encore All Commercial |
$36.67
|
| Rate for Payer: Frontpath All Commercial |
$36.65
|
| Rate for Payer: Humana ChoiceCare |
$34.41
|
| Rate for Payer: Humana Medicare |
$12.75
|
| Rate for Payer: Lucent All Commercial |
$21.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$29.88
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.54
|
| Rate for Payer: Sagamore Health Network All Products |
$30.75
|
| Rate for Payer: Signature Care EPO |
$33.06
|
| Rate for Payer: Signature Care PPO |
$35.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.86
|
| Rate for Payer: United Healthcare Commercial |
$31.39
|
| Rate for Payer: United Healthcare Medicare |
$12.75
|
|
