|
WHITE PETROLATUM-MINERAL OIL 83-15 % OPHT OINT
|
Facility
|
IP
|
$39.84
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
119339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.88 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Aetna Commercial |
$34.42
|
| Rate for Payer: Cash Price |
$23.90
|
| 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: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: PHCS All Commercial |
$29.88
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| 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: United Healthcare Commercial |
$31.39
|
|
|
WHITE PETROLATUM TOP GEL
|
Facility
|
OP
|
$5.96
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$5.03
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.10
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Centivo All Commercial |
$3.24
|
| Rate for Payer: Cigna All Commercial |
$5.15
|
| Rate for Payer: CORVEL All Commercial |
$5.55
|
| Rate for Payer: Coventry All Commercial |
$5.25
|
| Rate for Payer: Encore All Commercial |
$5.49
|
| Rate for Payer: Frontpath All Commercial |
$5.49
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Humana Medicare |
$1.91
|
| Rate for Payer: Lucent All Commercial |
$3.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.37
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.33
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.95
|
| Rate for Payer: Signature Care PPO |
$5.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.07
|
| Rate for Payer: United Healthcare Commercial |
$4.70
|
| Rate for Payer: United Healthcare Medicare |
$1.91
|
|
|
WHITE PETROLATUM TOP GEL
|
Facility
|
IP
|
$5.96
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cigna All Commercial |
$5.15
|
| Rate for Payer: CORVEL All Commercial |
$5.55
|
| Rate for Payer: Coventry All Commercial |
$5.25
|
| Rate for Payer: Encore All Commercial |
$5.49
|
| Rate for Payer: Frontpath All Commercial |
$5.49
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.37
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.95
|
| Rate for Payer: Signature Care PPO |
$5.25
|
| Rate for Payer: United Healthcare Commercial |
$4.70
|
|
|
WHITE PETROLATUM TOP OIPK
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 84521000686
|
| Hospital Charge Code |
158550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna All Commercial |
$1.60
|
| Rate for Payer: CORVEL All Commercial |
$1.73
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.71
|
| Rate for Payer: Frontpath All Commercial |
$1.71
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.67
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.41
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.54
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
|
|
WHITE PETROLATUM TOP OIPK
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 84521000686
|
| Hospital Charge Code |
158550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Aetna Medicare |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Centivo All Commercial |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.60
|
| Rate for Payer: CORVEL All Commercial |
$1.73
|
| Rate for Payer: Coventry All Commercial |
$1.63
|
| Rate for Payer: Encore All Commercial |
$1.71
|
| Rate for Payer: Frontpath All Commercial |
$1.71
|
| Rate for Payer: Humana ChoiceCare |
$1.60
|
| Rate for Payer: Humana Medicare |
$0.59
|
| Rate for Payer: Lucent All Commercial |
$1.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.67
|
| Rate for Payer: PHCS All Commercial |
$1.39
|
| Rate for Payer: PHP All Commercial |
$1.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.72
|
| Rate for Payer: Sagamore Health Network All Products |
$1.43
|
| Rate for Payer: Signature Care EPO |
$1.54
|
| Rate for Payer: Signature Care PPO |
$1.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
| Rate for Payer: United Healthcare Medicare |
$0.59
|
|
|
ZALEPLON 10 MG ORAL CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 29300013201
|
| Hospital Charge Code |
25998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
ZALEPLON 10 MG ORAL CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 29300013201
|
| Hospital Charge Code |
25998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
ZANAMIVIR 5 MG/ACTUATION INHL DSDV
|
Facility
|
OP
|
$331.92
|
|
|
Service Code
|
NDC 00173068101
|
| Hospital Charge Code |
28245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$308.69 |
| Rate for Payer: Aetna Commercial |
$280.14
|
| Rate for Payer: Aetna Medicare |
$106.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$190.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$207.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$122.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.84
|
| Rate for Payer: Cash Price |
$199.15
|
| Rate for Payer: Centivo All Commercial |
$180.56
|
| Rate for Payer: Cigna All Commercial |
$286.45
|
| Rate for Payer: CORVEL All Commercial |
$308.69
|
| Rate for Payer: Coventry All Commercial |
$292.09
|
| Rate for Payer: Encore All Commercial |
$305.53
|
| Rate for Payer: Frontpath All Commercial |
$305.37
|
| Rate for Payer: Humana ChoiceCare |
$286.68
|
| Rate for Payer: Humana Medicare |
$106.21
|
| Rate for Payer: Lucent All Commercial |
$180.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$298.73
|
| Rate for Payer: PHCS All Commercial |
$248.94
|
| Rate for Payer: PHP All Commercial |
$251.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$129.45
|
| Rate for Payer: Sagamore Health Network All Products |
$256.24
|
| Rate for Payer: Signature Care EPO |
$275.49
|
| Rate for Payer: Signature Care PPO |
$292.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$282.13
|
| Rate for Payer: United Healthcare Commercial |
$261.55
|
| Rate for Payer: United Healthcare Medicare |
$106.21
|
|
|
ZANAMIVIR 5 MG/ACTUATION INHL DSDV
|
Facility
|
IP
|
$331.92
|
|
|
Service Code
|
NDC 00173068101
|
| Hospital Charge Code |
28245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.94 |
| Max. Negotiated Rate |
$308.69 |
| Rate for Payer: Aetna Commercial |
$286.78
|
| Rate for Payer: Cash Price |
$199.15
|
| Rate for Payer: Cigna All Commercial |
$286.45
|
| Rate for Payer: CORVEL All Commercial |
$308.69
|
| Rate for Payer: Coventry All Commercial |
$292.09
|
| Rate for Payer: Encore All Commercial |
$305.53
|
| Rate for Payer: Frontpath All Commercial |
$305.37
|
| Rate for Payer: Humana ChoiceCare |
$286.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$298.73
|
| Rate for Payer: PHCS All Commercial |
$248.94
|
| Rate for Payer: PHP All Commercial |
$251.73
|
| Rate for Payer: Sagamore Health Network All Products |
$256.24
|
| Rate for Payer: Signature Care EPO |
$275.49
|
| Rate for Payer: Signature Care PPO |
$292.09
|
| Rate for Payer: United Healthcare Commercial |
$261.55
|
|
|
ZIDOVUDINE 10 MG/ML IV SOLN
|
Facility
|
IP
|
$199.22
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.41 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Aetna Commercial |
$172.13
|
| Rate for Payer: Cash Price |
$119.53
|
| Rate for Payer: Cigna All Commercial |
$171.93
|
| Rate for Payer: CORVEL All Commercial |
$185.27
|
| Rate for Payer: Coventry All Commercial |
$175.31
|
| Rate for Payer: Encore All Commercial |
$183.38
|
| Rate for Payer: Frontpath All Commercial |
$183.28
|
| Rate for Payer: Humana ChoiceCare |
$172.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.30
|
| Rate for Payer: PHCS All Commercial |
$149.41
|
| Rate for Payer: PHP All Commercial |
$151.09
|
| Rate for Payer: Sagamore Health Network All Products |
$153.80
|
| Rate for Payer: Signature Care EPO |
$165.35
|
| Rate for Payer: Signature Care PPO |
$175.31
|
| Rate for Payer: United Healthcare Commercial |
$156.99
|
|
|
ZIDOVUDINE 10 MG/ML IV SOLN
|
Facility
|
OP
|
$199.22
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.76 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Aetna Commercial |
$168.14
|
| Rate for Payer: Aetna Medicare |
$63.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$61.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$114.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$124.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$73.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$70.13
|
| Rate for Payer: Cash Price |
$119.53
|
| Rate for Payer: Centivo All Commercial |
$108.38
|
| Rate for Payer: Cigna All Commercial |
$171.93
|
| Rate for Payer: CORVEL All Commercial |
$185.27
|
| Rate for Payer: Coventry All Commercial |
$175.31
|
| Rate for Payer: Encore All Commercial |
$183.38
|
| Rate for Payer: Frontpath All Commercial |
$183.28
|
| Rate for Payer: Humana ChoiceCare |
$172.07
|
| Rate for Payer: Humana Medicare |
$63.75
|
| Rate for Payer: Lucent All Commercial |
$108.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.30
|
| Rate for Payer: PHCS All Commercial |
$149.41
|
| Rate for Payer: PHP All Commercial |
$151.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$77.70
|
| Rate for Payer: Sagamore Health Network All Products |
$153.80
|
| Rate for Payer: Signature Care EPO |
$165.35
|
| Rate for Payer: Signature Care PPO |
$175.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$169.34
|
| Rate for Payer: United Healthcare Commercial |
$156.99
|
| Rate for Payer: United Healthcare Medicare |
$63.75
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRP
|
Facility
|
IP
|
$330.96
|
|
|
Service Code
|
NDC 65862004824
|
| Hospital Charge Code |
11693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.22 |
| Max. Negotiated Rate |
$307.79 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Cash Price |
$198.58
|
| Rate for Payer: Cigna All Commercial |
$285.62
|
| Rate for Payer: CORVEL All Commercial |
$307.79
|
| Rate for Payer: Coventry All Commercial |
$291.24
|
| Rate for Payer: Encore All Commercial |
$304.65
|
| Rate for Payer: Frontpath All Commercial |
$304.48
|
| Rate for Payer: Humana ChoiceCare |
$285.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.86
|
| Rate for Payer: PHCS All Commercial |
$248.22
|
| Rate for Payer: PHP All Commercial |
$251.00
|
| Rate for Payer: Sagamore Health Network All Products |
$255.50
|
| Rate for Payer: Signature Care EPO |
$274.70
|
| Rate for Payer: Signature Care PPO |
$291.24
|
| Rate for Payer: United Healthcare Commercial |
$260.80
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRP
|
Facility
|
OP
|
$330.96
|
|
|
Service Code
|
NDC 65862004824
|
| Hospital Charge Code |
11693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.60 |
| Max. Negotiated Rate |
$307.79 |
| Rate for Payer: Aetna Commercial |
$279.33
|
| Rate for Payer: Aetna Medicare |
$105.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$190.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.50
|
| Rate for Payer: Cash Price |
$198.58
|
| Rate for Payer: Centivo All Commercial |
$180.04
|
| Rate for Payer: Cigna All Commercial |
$285.62
|
| Rate for Payer: CORVEL All Commercial |
$307.79
|
| Rate for Payer: Coventry All Commercial |
$291.24
|
| Rate for Payer: Encore All Commercial |
$304.65
|
| Rate for Payer: Frontpath All Commercial |
$304.48
|
| Rate for Payer: Humana ChoiceCare |
$285.85
|
| Rate for Payer: Humana Medicare |
$105.91
|
| Rate for Payer: Lucent All Commercial |
$180.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.86
|
| Rate for Payer: PHCS All Commercial |
$248.22
|
| Rate for Payer: PHP All Commercial |
$251.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$129.07
|
| Rate for Payer: Sagamore Health Network All Products |
$255.50
|
| Rate for Payer: Signature Care EPO |
$274.70
|
| Rate for Payer: Signature Care PPO |
$291.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$281.32
|
| Rate for Payer: United Healthcare Commercial |
$260.80
|
| Rate for Payer: United Healthcare Medicare |
$105.91
|
|
|
ZINC GLUCONATE 50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 93295013588
|
| Hospital Charge Code |
8872
|
|
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
|
|
|
ZINC GLUCONATE 50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 93295013588
|
| Hospital Charge Code |
8872
|
|
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
|
|
|
ZINC OXIDE 20 % TOP OINT
|
Facility
|
OP
|
$41.95
|
|
|
Service Code
|
NDC 75834017001
|
| Hospital Charge Code |
8874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$39.01 |
| Rate for Payer: Aetna Commercial |
$35.40
|
| Rate for Payer: Aetna Medicare |
$13.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.77
|
| Rate for Payer: Cash Price |
$25.17
|
| Rate for Payer: Centivo All Commercial |
$22.82
|
| Rate for Payer: Cigna All Commercial |
$36.20
|
| Rate for Payer: CORVEL All Commercial |
$39.01
|
| Rate for Payer: Coventry All Commercial |
$36.91
|
| Rate for Payer: Encore All Commercial |
$38.61
|
| Rate for Payer: Frontpath All Commercial |
$38.59
|
| Rate for Payer: Humana ChoiceCare |
$36.23
|
| Rate for Payer: Humana Medicare |
$13.42
|
| Rate for Payer: Lucent All Commercial |
$22.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.75
|
| Rate for Payer: PHCS All Commercial |
$31.46
|
| Rate for Payer: PHP All Commercial |
$31.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.36
|
| Rate for Payer: Sagamore Health Network All Products |
$32.38
|
| Rate for Payer: Signature Care EPO |
$34.82
|
| Rate for Payer: Signature Care PPO |
$36.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.65
|
| Rate for Payer: United Healthcare Commercial |
$33.05
|
| Rate for Payer: United Healthcare Medicare |
$13.42
|
|
|
ZINC OXIDE 20 % TOP OINT
|
Facility
|
IP
|
$41.95
|
|
|
Service Code
|
NDC 75834017001
|
| Hospital Charge Code |
8874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$39.01 |
| Rate for Payer: Aetna Commercial |
$36.24
|
| Rate for Payer: Cash Price |
$25.17
|
| Rate for Payer: Cigna All Commercial |
$36.20
|
| Rate for Payer: CORVEL All Commercial |
$39.01
|
| Rate for Payer: Coventry All Commercial |
$36.91
|
| Rate for Payer: Encore All Commercial |
$38.61
|
| Rate for Payer: Frontpath All Commercial |
$38.59
|
| Rate for Payer: Humana ChoiceCare |
$36.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.75
|
| Rate for Payer: PHCS All Commercial |
$31.46
|
| Rate for Payer: PHP All Commercial |
$31.81
|
| Rate for Payer: Sagamore Health Network All Products |
$32.38
|
| Rate for Payer: Signature Care EPO |
$34.82
|
| Rate for Payer: Signature Care PPO |
$36.91
|
| Rate for Payer: United Healthcare Commercial |
$33.05
|
|
|
ZIPRASIDONE HCL 20 MG ORAL CAP
|
Facility
|
IP
|
$15.43
|
|
|
Service Code
|
NDC 00904626908
|
| Hospital Charge Code |
29778
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$14.35 |
| Rate for Payer: Aetna Commercial |
$13.33
|
| Rate for Payer: Cash Price |
$9.26
|
| Rate for Payer: Cigna All Commercial |
$13.31
|
| Rate for Payer: CORVEL All Commercial |
$14.35
|
| Rate for Payer: Coventry All Commercial |
$13.58
|
| Rate for Payer: Encore All Commercial |
$14.20
|
| Rate for Payer: Frontpath All Commercial |
$14.19
|
| Rate for Payer: Humana ChoiceCare |
$13.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.89
|
| Rate for Payer: PHCS All Commercial |
$11.57
|
| Rate for Payer: PHP All Commercial |
$11.70
|
| Rate for Payer: Sagamore Health Network All Products |
$11.91
|
| Rate for Payer: Signature Care EPO |
$12.81
|
| Rate for Payer: Signature Care PPO |
$13.58
|
| Rate for Payer: United Healthcare Commercial |
$12.16
|
|
|
ZIPRASIDONE HCL 20 MG ORAL CAP
|
Facility
|
OP
|
$15.43
|
|
|
Service Code
|
NDC 00904626908
|
| Hospital Charge Code |
29778
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$14.35 |
| Rate for Payer: Aetna Commercial |
$13.02
|
| Rate for Payer: Aetna Medicare |
$4.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.43
|
| Rate for Payer: Cash Price |
$9.26
|
| Rate for Payer: Centivo All Commercial |
$8.39
|
| Rate for Payer: Cigna All Commercial |
$13.31
|
| Rate for Payer: CORVEL All Commercial |
$14.35
|
| Rate for Payer: Coventry All Commercial |
$13.58
|
| Rate for Payer: Encore All Commercial |
$14.20
|
| Rate for Payer: Frontpath All Commercial |
$14.19
|
| Rate for Payer: Humana ChoiceCare |
$13.33
|
| Rate for Payer: Humana Medicare |
$4.94
|
| Rate for Payer: Lucent All Commercial |
$8.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.89
|
| Rate for Payer: PHCS All Commercial |
$11.57
|
| Rate for Payer: PHP All Commercial |
$11.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.02
|
| Rate for Payer: Sagamore Health Network All Products |
$11.91
|
| Rate for Payer: Signature Care EPO |
$12.81
|
| Rate for Payer: Signature Care PPO |
$13.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.11
|
| Rate for Payer: United Healthcare Commercial |
$12.16
|
| Rate for Payer: United Healthcare Medicare |
$4.94
|
|
|
ZIPRASIDONE MESYLATE 20 MG/ML (FINAL CONC.) IM SOLR
|
Facility
|
IP
|
$107.93
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
33175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.94 |
| Max. Negotiated Rate |
$100.37 |
| Rate for Payer: Aetna Commercial |
$93.25
|
| Rate for Payer: Cash Price |
$64.76
|
| Rate for Payer: Cigna All Commercial |
$93.14
|
| Rate for Payer: CORVEL All Commercial |
$100.37
|
| Rate for Payer: Coventry All Commercial |
$94.97
|
| Rate for Payer: Encore All Commercial |
$99.35
|
| Rate for Payer: Frontpath All Commercial |
$99.29
|
| Rate for Payer: Humana ChoiceCare |
$93.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.13
|
| Rate for Payer: PHCS All Commercial |
$80.94
|
| Rate for Payer: PHP All Commercial |
$81.85
|
| Rate for Payer: Sagamore Health Network All Products |
$83.32
|
| Rate for Payer: Signature Care EPO |
$89.58
|
| Rate for Payer: Signature Care PPO |
$94.97
|
| Rate for Payer: United Healthcare Commercial |
$85.05
|
|
|
ZIPRASIDONE MESYLATE 20 MG/ML (FINAL CONC.) IM SOLR
|
Facility
|
OP
|
$107.93
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
33175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$100.37 |
| Rate for Payer: Aetna Commercial |
$91.09
|
| Rate for Payer: Aetna Medicare |
$34.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$10.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$61.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.46
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$10.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.99
|
| Rate for Payer: Cash Price |
$64.76
|
| Rate for Payer: Cash Price |
$64.76
|
| Rate for Payer: Centivo All Commercial |
$58.71
|
| Rate for Payer: Cigna All Commercial |
$93.14
|
| Rate for Payer: CORVEL All Commercial |
$100.37
|
| Rate for Payer: Coventry All Commercial |
$94.97
|
| Rate for Payer: Encore All Commercial |
$99.35
|
| Rate for Payer: Frontpath All Commercial |
$99.29
|
| Rate for Payer: Humana ChoiceCare |
$93.22
|
| Rate for Payer: Humana Medicare |
$34.54
|
| Rate for Payer: Lucent All Commercial |
$58.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.13
|
| Rate for Payer: Managed Health Services Medicaid |
$10.45
|
| Rate for Payer: MDWise Medicaid |
$10.45
|
| Rate for Payer: PHCS All Commercial |
$80.94
|
| Rate for Payer: PHP All Commercial |
$81.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.09
|
| Rate for Payer: Sagamore Health Network All Products |
$83.32
|
| Rate for Payer: Signature Care EPO |
$89.58
|
| Rate for Payer: Signature Care PPO |
$94.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.74
|
| Rate for Payer: United Healthcare Commercial |
$85.05
|
| Rate for Payer: United Healthcare Medicare |
$34.54
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN
|
Facility
|
IP
|
$52.57
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
35640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.43 |
| Max. Negotiated Rate |
$48.89 |
| Rate for Payer: Aetna Commercial |
$45.42
|
| Rate for Payer: Cash Price |
$31.54
|
| Rate for Payer: Cigna All Commercial |
$45.37
|
| Rate for Payer: CORVEL All Commercial |
$48.89
|
| Rate for Payer: Coventry All Commercial |
$46.26
|
| Rate for Payer: Encore All Commercial |
$48.39
|
| Rate for Payer: Frontpath All Commercial |
$48.36
|
| Rate for Payer: Humana ChoiceCare |
$45.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.31
|
| Rate for Payer: PHCS All Commercial |
$39.43
|
| Rate for Payer: PHP All Commercial |
$39.87
|
| Rate for Payer: Sagamore Health Network All Products |
$40.58
|
| Rate for Payer: Signature Care EPO |
$43.63
|
| Rate for Payer: Signature Care PPO |
$46.26
|
| Rate for Payer: United Healthcare Commercial |
$41.43
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN
|
Facility
|
OP
|
$52.57
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
35640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$48.89 |
| Rate for Payer: Aetna Commercial |
$44.37
|
| Rate for Payer: Aetna Medicare |
$16.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$3.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$30.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$3.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.50
|
| Rate for Payer: Cash Price |
$31.54
|
| Rate for Payer: Cash Price |
$31.54
|
| Rate for Payer: Centivo All Commercial |
$28.60
|
| Rate for Payer: Cigna All Commercial |
$45.37
|
| Rate for Payer: CORVEL All Commercial |
$48.89
|
| Rate for Payer: Coventry All Commercial |
$46.26
|
| Rate for Payer: Encore All Commercial |
$48.39
|
| Rate for Payer: Frontpath All Commercial |
$48.36
|
| Rate for Payer: Humana ChoiceCare |
$45.40
|
| Rate for Payer: Humana Medicare |
$16.82
|
| Rate for Payer: Lucent All Commercial |
$28.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.31
|
| Rate for Payer: Managed Health Services Medicaid |
$3.94
|
| Rate for Payer: MDWise Medicaid |
$3.94
|
| Rate for Payer: PHCS All Commercial |
$39.43
|
| Rate for Payer: PHP All Commercial |
$39.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.50
|
| Rate for Payer: Sagamore Health Network All Products |
$40.58
|
| Rate for Payer: Signature Care EPO |
$43.63
|
| Rate for Payer: Signature Care PPO |
$46.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44.68
|
| Rate for Payer: United Healthcare Commercial |
$41.43
|
| Rate for Payer: United Healthcare Medicare |
$16.82
|
|
|
ZOLEDRONIC ACID-MANNITOL-WATER 5 MG/100 ML IV PGBK
|
Facility
|
OP
|
$513.60
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
81434
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$477.65 |
| Rate for Payer: Aetna Commercial |
$433.48
|
| Rate for Payer: Aetna Medicare |
$164.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$3.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$159.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$294.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$321.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$3.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$189.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$180.79
|
| Rate for Payer: Cash Price |
$308.16
|
| Rate for Payer: Cash Price |
$308.16
|
| Rate for Payer: Centivo All Commercial |
$279.40
|
| Rate for Payer: Cigna All Commercial |
$443.24
|
| Rate for Payer: CORVEL All Commercial |
$477.65
|
| Rate for Payer: Coventry All Commercial |
$451.97
|
| Rate for Payer: Encore All Commercial |
$472.77
|
| Rate for Payer: Frontpath All Commercial |
$472.51
|
| Rate for Payer: Humana ChoiceCare |
$443.60
|
| Rate for Payer: Humana Medicare |
$164.35
|
| Rate for Payer: Lucent All Commercial |
$279.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$462.24
|
| Rate for Payer: Managed Health Services Medicaid |
$3.94
|
| Rate for Payer: MDWise Medicaid |
$3.94
|
| Rate for Payer: PHCS All Commercial |
$385.20
|
| Rate for Payer: PHP All Commercial |
$389.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$200.30
|
| Rate for Payer: Sagamore Health Network All Products |
$396.50
|
| Rate for Payer: Signature Care EPO |
$426.29
|
| Rate for Payer: Signature Care PPO |
$451.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$436.56
|
| Rate for Payer: United Healthcare Commercial |
$404.72
|
| Rate for Payer: United Healthcare Medicare |
$164.35
|
|
|
ZOLEDRONIC ACID-MANNITOL-WATER 5 MG/100 ML IV PGBK
|
Facility
|
IP
|
$513.60
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
81434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$385.20 |
| Max. Negotiated Rate |
$477.65 |
| Rate for Payer: Aetna Commercial |
$443.75
|
| Rate for Payer: Cash Price |
$308.16
|
| Rate for Payer: Cigna All Commercial |
$443.24
|
| Rate for Payer: CORVEL All Commercial |
$477.65
|
| Rate for Payer: Coventry All Commercial |
$451.97
|
| Rate for Payer: Encore All Commercial |
$472.77
|
| Rate for Payer: Frontpath All Commercial |
$472.51
|
| Rate for Payer: Humana ChoiceCare |
$443.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$462.24
|
| Rate for Payer: PHCS All Commercial |
$385.20
|
| Rate for Payer: PHP All Commercial |
$389.51
|
| Rate for Payer: Sagamore Health Network All Products |
$396.50
|
| Rate for Payer: Signature Care EPO |
$426.29
|
| Rate for Payer: Signature Care PPO |
$451.97
|
| Rate for Payer: United Healthcare Commercial |
$404.72
|
|
