|
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
|
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 |
$21.70
|
| Rate for Payer: Cash Price |
$21.70
|
| 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
|
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 |
$65.10
|
| 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
|
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 |
$29.30
|
| Rate for Payer: Cash Price |
$29.30
|
| 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 |
$29.30
|
| 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
|
|
|
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 |
$33.64
|
| 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
|
$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 |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| 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
|
$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 |
$21.70
|
| 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
|
$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 |
$33.64
|
| Rate for Payer: Cash Price |
$33.64
|
| 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
|
|
|
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 |
$44.92
|
| 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 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 |
$44.92
|
| 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 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 |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| 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
|
|
|
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 |
$24.70
|
| 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 |
$3.70
|
| 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 |
$3.70
|
| 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
|
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 |
$1.15
|
| 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
|
|
|
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 |
$1.15
|
| 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
|
|
|
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 |
$2.48
|
| 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 |
$2.48
|
| 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
|
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 |
$205.79
|
| 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
|
|
|
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 |
$205.79
|
| 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
|
|
|
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 |
$123.52
|
| 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 |
$123.52
|
| 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 |
$205.20
|
| 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 |
$205.20
|
| 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
|
|
