|
ZOLEDRONIC AC-MANNITOL-0.9NACL 4 MG/100 ML IV PGBK
|
Facility
|
IP
|
$262.50
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
165810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.88 |
| Max. Negotiated Rate |
$244.12 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna All Commercial |
$226.54
|
| Rate for Payer: CORVEL All Commercial |
$244.12
|
| Rate for Payer: Coventry All Commercial |
$231.00
|
| Rate for Payer: Encore All Commercial |
$241.63
|
| Rate for Payer: Frontpath All Commercial |
$241.50
|
| Rate for Payer: Humana ChoiceCare |
$226.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$236.25
|
| Rate for Payer: PHCS All Commercial |
$196.88
|
| Rate for Payer: PHP All Commercial |
$199.08
|
| Rate for Payer: Sagamore Health Network All Products |
$202.65
|
| Rate for Payer: Signature Care EPO |
$217.88
|
| Rate for Payer: Signature Care PPO |
$231.00
|
| Rate for Payer: United Healthcare Commercial |
$206.85
|
|
|
ZOLEDRONIC AC-MANNITOL-0.9NACL 4 MG/100 ML IV PGBK
|
Facility
|
OP
|
$262.50
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
165810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$244.12 |
| Rate for Payer: Aetna Commercial |
$221.55
|
| Rate for Payer: Aetna Medicare |
$84.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$3.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$150.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$164.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$3.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$96.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$92.40
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Centivo All Commercial |
$142.80
|
| Rate for Payer: Cigna All Commercial |
$226.54
|
| Rate for Payer: CORVEL All Commercial |
$244.12
|
| Rate for Payer: Coventry All Commercial |
$231.00
|
| Rate for Payer: Encore All Commercial |
$241.63
|
| Rate for Payer: Frontpath All Commercial |
$241.50
|
| Rate for Payer: Humana ChoiceCare |
$226.72
|
| Rate for Payer: Humana Medicare |
$84.00
|
| Rate for Payer: Lucent All Commercial |
$142.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$236.25
|
| Rate for Payer: Managed Health Services Medicaid |
$3.94
|
| Rate for Payer: MDWise Medicaid |
$3.94
|
| Rate for Payer: PHCS All Commercial |
$196.88
|
| Rate for Payer: PHP All Commercial |
$199.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$102.38
|
| Rate for Payer: Sagamore Health Network All Products |
$202.65
|
| Rate for Payer: Signature Care EPO |
$217.88
|
| Rate for Payer: Signature Care PPO |
$231.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$223.12
|
| Rate for Payer: United Healthcare Commercial |
$206.85
|
| Rate for Payer: United Healthcare Medicare |
$84.00
|
|
|
ZOLPIDEM 5 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904608261
|
| Hospital Charge Code |
11701
|
|
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
|
|
|
ZOLPIDEM 5 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904608261
|
| Hospital Charge Code |
11701
|
|
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
|
|
