|
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 |
$0.24
|
| 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 |
$0.24
|
| 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 |
$0.62
|
| 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 |
$0.62
|
| 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
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$800.42
|
|
|
Service Code
|
CPT 56620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$800.42 |
| Max. Negotiated Rate |
$800.42 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$800.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$800.42
|
| Rate for Payer: Managed Health Services Medicaid |
$800.42
|
| Rate for Payer: MDWise Medicaid |
$800.42
|
|
|
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 |
$0.69
|
| 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 |
$0.69
|
| 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
|
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 |
$1.08
|
| 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 2.5 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 |
$1.08
|
| 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 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 |
$1.17
|
| 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 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 |
$1.17
|
| 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 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 |
$0.67
|
| 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
|
|
|
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 |
$0.67
|
| 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
|
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 |
$1.12
|
| 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 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 |
$1.12
|
| 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 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 |
$1.11
|
| 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 |
$1.11
|
| 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
|
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 |
$11.16
|
| 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 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 |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| 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 |
$11.16
|
| 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 |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| 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 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 |
$26.04
|
| Rate for Payer: Cash Price |
$26.04
|
| 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
|
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 |
$17.36
|
| 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 |
$26.04
|
| 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, 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 |
$17.36
|
| Rate for Payer: Cash Price |
$17.36
|
| 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
|
|
