|
Arthroscopy, shoulder, surgical; biceps tenodesis
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 29828
|
| Hospital Charge Code |
CPT-29828
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
Arthroscopy, shoulder, surgical; capsulorrhaphy
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29806
|
| Hospital Charge Code |
CPT-29806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29823
|
| Hospital Charge Code |
CPT-29823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29822
|
| Hospital Charge Code |
CPT-29822
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29826
|
| Hospital Charge Code |
CPT-29826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 29824
|
| Hospital Charge Code |
CPT-29824
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Arthroscopy, shoulder, surgical; repair of SLAP lesion
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29807
|
| Hospital Charge Code |
CPT-29807
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, shoulder, surgical; with rotator cuff repair
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29827
|
| Hospital Charge Code |
CPT-29827
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 27331
|
| Hospital Charge Code |
CPT-27331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 26075
|
| Hospital Charge Code |
CPT-26075
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG ORAL TAB
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Aetna Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Centivo All Commercial |
$0.12
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.22
|
| Rate for Payer: Coventry All Commercial |
$0.21
|
| Rate for Payer: Encore All Commercial |
$0.22
|
| Rate for Payer: Frontpath All Commercial |
$0.22
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Humana Medicare |
$0.12
|
| Rate for Payer: Lucent All Commercial |
$0.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.21
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.09
|
| Rate for Payer: Sagamore Health Network All Products |
$0.18
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG ORAL TAB
|
Facility
IP
|
$0.24
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.22
|
| Rate for Payer: Coventry All Commercial |
$0.21
|
| Rate for Payer: Encore All Commercial |
$0.22
|
| Rate for Payer: Frontpath All Commercial |
$0.22
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.21
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.18
|
| Rate for Payer: Sagamore Health Network All Products |
$0.18
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
|
|
ASPIRIN 300 MG RECT SUPP
|
Facility
IP
|
$10.05
|
|
|
Service Code
|
NDC 00574703412
|
| Hospital Charge Code |
693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$8.68
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna All Commercial |
$8.67
|
| Rate for Payer: CORVEL All Commercial |
$9.35
|
| Rate for Payer: Coventry All Commercial |
$8.85
|
| Rate for Payer: Encore All Commercial |
$9.25
|
| Rate for Payer: Frontpath All Commercial |
$9.25
|
| Rate for Payer: Humana ChoiceCare |
$8.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.05
|
| Rate for Payer: PHCS All Commercial |
$7.54
|
| Rate for Payer: PHP All Commercial |
$7.62
|
| Rate for Payer: Sagamore Health Network All Products |
$7.76
|
| Rate for Payer: Signature Care EPO |
$8.34
|
| Rate for Payer: Signature Care PPO |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$7.92
|
|
|
ASPIRIN 300 MG RECT SUPP
|
Facility
OP
|
$10.05
|
|
|
Service Code
|
NDC 00574703412
|
| Hospital Charge Code |
693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$8.48
|
| Rate for Payer: Aetna Medicare |
$3.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.65
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Centivo All Commercial |
$5.13
|
| Rate for Payer: Cigna All Commercial |
$8.67
|
| Rate for Payer: CORVEL All Commercial |
$9.35
|
| Rate for Payer: Coventry All Commercial |
$8.85
|
| Rate for Payer: Encore All Commercial |
$9.25
|
| Rate for Payer: Frontpath All Commercial |
$9.25
|
| Rate for Payer: Humana ChoiceCare |
$8.68
|
| Rate for Payer: Humana Medicare |
$5.13
|
| Rate for Payer: Lucent All Commercial |
$5.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.05
|
| Rate for Payer: PHCS All Commercial |
$7.54
|
| Rate for Payer: PHP All Commercial |
$7.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.92
|
| Rate for Payer: Sagamore Health Network All Products |
$7.76
|
| Rate for Payer: Signature Care EPO |
$8.34
|
| Rate for Payer: Signature Care PPO |
$8.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.54
|
| Rate for Payer: United Healthcare Commercial |
$7.92
|
| Rate for Payer: United Healthcare Medicare |
$3.32
|
|
|
ASPIRIN 325 MG ORAL TBEC
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 00536123201
|
| Hospital Charge Code |
685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna All Commercial |
$0.12
|
| Rate for Payer: CORVEL All Commercial |
$0.13
|
| Rate for Payer: Coventry All Commercial |
$0.12
|
| Rate for Payer: Encore All Commercial |
$0.13
|
| Rate for Payer: Frontpath All Commercial |
$0.13
|
| Rate for Payer: Humana ChoiceCare |
$0.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.13
|
| Rate for Payer: PHCS All Commercial |
$0.11
|
| Rate for Payer: PHP All Commercial |
$0.11
|
| Rate for Payer: Sagamore Health Network All Products |
$0.11
|
| Rate for Payer: Signature Care EPO |
$0.12
|
| Rate for Payer: Signature Care PPO |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
|
|
ASPIRIN 325 MG ORAL TBEC
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 00536123201
|
| Hospital Charge Code |
685
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Aetna Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Centivo All Commercial |
$0.07
|
| Rate for Payer: Cigna All Commercial |
$0.12
|
| Rate for Payer: CORVEL All Commercial |
$0.13
|
| Rate for Payer: Coventry All Commercial |
$0.12
|
| Rate for Payer: Encore All Commercial |
$0.13
|
| Rate for Payer: Frontpath All Commercial |
$0.13
|
| Rate for Payer: Humana ChoiceCare |
$0.12
|
| Rate for Payer: Humana Medicare |
$0.07
|
| Rate for Payer: Lucent All Commercial |
$0.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.13
|
| Rate for Payer: PHCS All Commercial |
$0.11
|
| Rate for Payer: PHP All Commercial |
$0.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.05
|
| Rate for Payer: Sagamore Health Network All Products |
$0.11
|
| Rate for Payer: Signature Care EPO |
$0.12
|
| Rate for Payer: Signature Care PPO |
$0.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
|
|
ASPIRIN 81 MG ORAL CHEW
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 66553000201
|
| Hospital Charge Code |
679
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna Commercial |
$0.51
|
| Rate for Payer: Aetna Medicare |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Centivo All Commercial |
$0.31
|
| Rate for Payer: Cigna All Commercial |
$0.52
|
| Rate for Payer: CORVEL All Commercial |
$0.56
|
| Rate for Payer: Coventry All Commercial |
$0.53
|
| Rate for Payer: Encore All Commercial |
$0.55
|
| Rate for Payer: Frontpath All Commercial |
$0.55
|
| Rate for Payer: Humana ChoiceCare |
$0.52
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Lucent All Commercial |
$0.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.54
|
| Rate for Payer: PHCS All Commercial |
$0.45
|
| Rate for Payer: PHP All Commercial |
$0.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.23
|
| Rate for Payer: Sagamore Health Network All Products |
$0.46
|
| Rate for Payer: Signature Care EPO |
$0.50
|
| Rate for Payer: Signature Care PPO |
$0.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
|
|
ASPIRIN 81 MG ORAL CHEW
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 66553000201
|
| Hospital Charge Code |
679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna All Commercial |
$0.52
|
| Rate for Payer: CORVEL All Commercial |
$0.56
|
| Rate for Payer: Coventry All Commercial |
$0.53
|
| Rate for Payer: Encore All Commercial |
$0.55
|
| Rate for Payer: Frontpath All Commercial |
$0.55
|
| Rate for Payer: Humana ChoiceCare |
$0.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.54
|
| Rate for Payer: PHCS All Commercial |
$0.45
|
| Rate for Payer: PHP All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.46
|
| Rate for Payer: Signature Care EPO |
$0.50
|
| Rate for Payer: Signature Care PPO |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
|
|
ASPIRIN 81 MG ORAL TBEC
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 63739021202
|
| Hospital Charge Code |
688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna All Commercial |
$0.34
|
| Rate for Payer: CORVEL All Commercial |
$0.37
|
| Rate for Payer: Coventry All Commercial |
$0.35
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.36
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.30
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.33
|
| Rate for Payer: Signature Care PPO |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
|
|
ASPIRIN 81 MG ORAL TBEC
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 63739021202
|
| Hospital Charge Code |
688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Centivo All Commercial |
$0.20
|
| Rate for Payer: Cigna All Commercial |
$0.34
|
| Rate for Payer: CORVEL All Commercial |
$0.37
|
| Rate for Payer: Coventry All Commercial |
$0.35
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.34
|
| Rate for Payer: Humana Medicare |
$0.20
|
| Rate for Payer: Lucent All Commercial |
$0.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.36
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.16
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.33
|
| Rate for Payer: Signature Care PPO |
$0.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
|
|
ATENOLOL 25 MG ORAL TAB
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 51079075920
|
| Hospital Charge Code |
717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Centivo All Commercial |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$1.13
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.13
|
| Rate for Payer: Humana Medicare |
$0.67
|
| Rate for Payer: Lucent All Commercial |
$0.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
ATENOLOL 25 MG ORAL TAB
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 51079075920
|
| Hospital Charge Code |
717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.13
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
ATENOLOL 50 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00093075210
|
| Hospital Charge Code |
718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
ATENOLOL 50 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00093075210
|
| Hospital Charge Code |
718
|
|
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
|
|
|
ATORVASTATIN 10 MG ORAL TAB
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 00904629061
|
| Hospital Charge Code |
19176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna Commercial |
$1.04
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Centivo All Commercial |
$0.63
|
| Rate for Payer: Cigna All Commercial |
$1.06
|
| Rate for Payer: CORVEL All Commercial |
$1.15
|
| Rate for Payer: Coventry All Commercial |
$1.08
|
| Rate for Payer: Encore All Commercial |
$1.13
|
| Rate for Payer: Frontpath All Commercial |
$1.13
|
| Rate for Payer: Humana ChoiceCare |
$1.06
|
| Rate for Payer: Humana Medicare |
$0.63
|
| Rate for Payer: Lucent All Commercial |
$0.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.11
|
| Rate for Payer: PHCS All Commercial |
$0.92
|
| Rate for Payer: PHP All Commercial |
$0.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.48
|
| Rate for Payer: Sagamore Health Network All Products |
$0.95
|
| Rate for Payer: Signature Care EPO |
$1.02
|
| Rate for Payer: Signature Care PPO |
$1.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
|
