|
MVI, ADULT NO.4, VIT K, 2 OF 2 600 MCG-60 MCG- 5 MCG/5 ML IV SOLN
|
Facility
OP
|
$33.71
|
|
|
Service Code
|
NDC 54643786209
|
| Hospital Charge Code |
182457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.23
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Centivo All Commercial |
$17.19
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Humana Medicare |
$17.19
|
| Rate for Payer: Lucent All Commercial |
$17.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.14
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.65
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
|
|
MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN
|
Facility
OP
|
$106.96
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
158853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.30 |
| Max. Negotiated Rate |
$99.47 |
| Rate for Payer: Aetna Commercial |
$90.27
|
| Rate for Payer: Aetna Medicare |
$35.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.83
|
| Rate for Payer: Cash Price |
$66.32
|
| Rate for Payer: Cash Price |
$66.32
|
| Rate for Payer: Centivo All Commercial |
$54.55
|
| Rate for Payer: Cigna All Commercial |
$92.31
|
| Rate for Payer: CORVEL All Commercial |
$99.47
|
| Rate for Payer: Coventry All Commercial |
$94.12
|
| Rate for Payer: Encore All Commercial |
$98.46
|
| Rate for Payer: Frontpath All Commercial |
$98.40
|
| Rate for Payer: Humana ChoiceCare |
$92.38
|
| Rate for Payer: Humana Medicare |
$54.55
|
| Rate for Payer: Lucent All Commercial |
$54.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.26
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$80.22
|
| Rate for Payer: PHP All Commercial |
$81.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.71
|
| Rate for Payer: Sagamore Health Network All Products |
$82.57
|
| Rate for Payer: Signature Care EPO |
$88.78
|
| Rate for Payer: Signature Care PPO |
$94.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.92
|
| Rate for Payer: United Healthcare Commercial |
$84.28
|
| Rate for Payer: United Healthcare Medicare |
$35.30
|
|
|
MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN
|
Facility
IP
|
$106.96
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
158853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.22 |
| Max. Negotiated Rate |
$99.47 |
| Rate for Payer: Aetna Commercial |
$92.41
|
| Rate for Payer: Cash Price |
$66.32
|
| Rate for Payer: Cigna All Commercial |
$92.31
|
| Rate for Payer: CORVEL All Commercial |
$99.47
|
| Rate for Payer: Coventry All Commercial |
$94.12
|
| Rate for Payer: Encore All Commercial |
$98.46
|
| Rate for Payer: Frontpath All Commercial |
$98.40
|
| Rate for Payer: Humana ChoiceCare |
$92.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.26
|
| Rate for Payer: PHCS All Commercial |
$80.22
|
| Rate for Payer: PHP All Commercial |
$81.12
|
| Rate for Payer: Sagamore Health Network All Products |
$82.57
|
| Rate for Payer: Signature Care EPO |
$88.78
|
| Rate for Payer: Signature Care PPO |
$94.12
|
| Rate for Payer: United Healthcare Commercial |
$84.28
|
|
|
NALBUPHINE 10 MG/ML INJ SOLN
|
Facility
OP
|
$24.77
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
5339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$8.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.99
|
| Rate for Payer: Cash Price |
$15.35
|
| Rate for Payer: Centivo All Commercial |
$12.63
|
| Rate for Payer: Cigna All Commercial |
$21.37
|
| Rate for Payer: CORVEL All Commercial |
$23.03
|
| Rate for Payer: Coventry All Commercial |
$21.79
|
| Rate for Payer: Encore All Commercial |
$22.80
|
| Rate for Payer: Frontpath All Commercial |
$22.78
|
| Rate for Payer: Humana ChoiceCare |
$21.39
|
| Rate for Payer: Humana Medicare |
$12.63
|
| Rate for Payer: Lucent All Commercial |
$12.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.29
|
| Rate for Payer: PHCS All Commercial |
$18.57
|
| Rate for Payer: PHP All Commercial |
$18.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.66
|
| Rate for Payer: Sagamore Health Network All Products |
$19.12
|
| Rate for Payer: Signature Care EPO |
$20.56
|
| Rate for Payer: Signature Care PPO |
$21.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.05
|
| Rate for Payer: United Healthcare Commercial |
$19.52
|
| Rate for Payer: United Healthcare Medicare |
$8.17
|
|
|
NALBUPHINE 10 MG/ML INJ SOLN
|
Facility
IP
|
$24.77
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
5339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.57 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna Commercial |
$21.40
|
| Rate for Payer: Cash Price |
$15.35
|
| Rate for Payer: Cigna All Commercial |
$21.37
|
| Rate for Payer: CORVEL All Commercial |
$23.03
|
| Rate for Payer: Coventry All Commercial |
$21.79
|
| Rate for Payer: Encore All Commercial |
$22.80
|
| Rate for Payer: Frontpath All Commercial |
$22.78
|
| Rate for Payer: Humana ChoiceCare |
$21.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.29
|
| Rate for Payer: PHCS All Commercial |
$18.57
|
| Rate for Payer: PHP All Commercial |
$18.78
|
| Rate for Payer: Sagamore Health Network All Products |
$19.12
|
| Rate for Payer: Signature Care EPO |
$20.56
|
| Rate for Payer: Signature Care PPO |
$21.79
|
| Rate for Payer: United Healthcare Commercial |
$19.52
|
|
|
NALOXONE 0.4 MG/ML INJECTION S.O.
|
Facility
IP
|
$25.23
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
40805373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.92 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna Commercial |
$21.80
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cigna All Commercial |
$21.77
|
| Rate for Payer: CORVEL All Commercial |
$23.46
|
| Rate for Payer: Coventry All Commercial |
$22.20
|
| Rate for Payer: Encore All Commercial |
$23.22
|
| Rate for Payer: Frontpath All Commercial |
$23.21
|
| Rate for Payer: Humana ChoiceCare |
$21.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.71
|
| Rate for Payer: PHCS All Commercial |
$18.92
|
| Rate for Payer: PHP All Commercial |
$19.13
|
| Rate for Payer: Sagamore Health Network All Products |
$19.48
|
| Rate for Payer: Signature Care EPO |
$20.94
|
| Rate for Payer: Signature Care PPO |
$22.20
|
| Rate for Payer: United Healthcare Commercial |
$19.88
|
|
|
NALOXONE 0.4 MG/ML INJECTION S.O.
|
Facility
OP
|
$25.23
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
40805373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna Commercial |
$21.29
|
| Rate for Payer: Aetna Medicare |
$8.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$16.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.16
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Centivo All Commercial |
$12.87
|
| Rate for Payer: Cigna All Commercial |
$21.77
|
| Rate for Payer: CORVEL All Commercial |
$23.46
|
| Rate for Payer: Coventry All Commercial |
$22.20
|
| Rate for Payer: Encore All Commercial |
$23.22
|
| Rate for Payer: Frontpath All Commercial |
$23.21
|
| Rate for Payer: Humana ChoiceCare |
$21.79
|
| Rate for Payer: Humana Medicare |
$12.87
|
| Rate for Payer: Lucent All Commercial |
$12.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.71
|
| Rate for Payer: Managed Health Services Medicaid |
$16.46
|
| Rate for Payer: MDWise Medicaid |
$16.46
|
| Rate for Payer: PHCS All Commercial |
$18.92
|
| Rate for Payer: PHP All Commercial |
$19.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.84
|
| Rate for Payer: Sagamore Health Network All Products |
$19.48
|
| Rate for Payer: Signature Care EPO |
$20.94
|
| Rate for Payer: Signature Care PPO |
$22.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.44
|
| Rate for Payer: United Healthcare Commercial |
$19.88
|
| Rate for Payer: United Healthcare Medicare |
$8.33
|
|
|
NALOXONE 0.4 MG/ML INJ SOLN
|
Facility
OP
|
$25.23
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
5373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna Commercial |
$21.29
|
| Rate for Payer: Aetna Medicare |
$8.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$16.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.16
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Centivo All Commercial |
$12.87
|
| Rate for Payer: Cigna All Commercial |
$21.77
|
| Rate for Payer: CORVEL All Commercial |
$23.46
|
| Rate for Payer: Coventry All Commercial |
$22.20
|
| Rate for Payer: Encore All Commercial |
$23.22
|
| Rate for Payer: Frontpath All Commercial |
$23.21
|
| Rate for Payer: Humana ChoiceCare |
$21.79
|
| Rate for Payer: Humana Medicare |
$12.87
|
| Rate for Payer: Lucent All Commercial |
$12.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.71
|
| Rate for Payer: Managed Health Services Medicaid |
$16.46
|
| Rate for Payer: MDWise Medicaid |
$16.46
|
| Rate for Payer: PHCS All Commercial |
$18.92
|
| Rate for Payer: PHP All Commercial |
$19.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.84
|
| Rate for Payer: Sagamore Health Network All Products |
$19.48
|
| Rate for Payer: Signature Care EPO |
$20.94
|
| Rate for Payer: Signature Care PPO |
$22.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.44
|
| Rate for Payer: United Healthcare Commercial |
$19.88
|
| Rate for Payer: United Healthcare Medicare |
$8.33
|
|
|
NALOXONE 0.4 MG/ML INJ SOLN
|
Facility
IP
|
$25.23
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
5373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.92 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna Commercial |
$21.80
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cigna All Commercial |
$21.77
|
| Rate for Payer: CORVEL All Commercial |
$23.46
|
| Rate for Payer: Coventry All Commercial |
$22.20
|
| Rate for Payer: Encore All Commercial |
$23.22
|
| Rate for Payer: Frontpath All Commercial |
$23.21
|
| Rate for Payer: Humana ChoiceCare |
$21.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.71
|
| Rate for Payer: PHCS All Commercial |
$18.92
|
| Rate for Payer: PHP All Commercial |
$19.13
|
| Rate for Payer: Sagamore Health Network All Products |
$19.48
|
| Rate for Payer: Signature Care EPO |
$20.94
|
| Rate for Payer: Signature Care PPO |
$22.20
|
| Rate for Payer: United Healthcare Commercial |
$19.88
|
|
|
NALOXONE 1 MG/ML INJ SYRG
|
Facility
IP
|
$197.33
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
5374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.00 |
| Max. Negotiated Rate |
$183.52 |
| Rate for Payer: Aetna Commercial |
$170.49
|
| Rate for Payer: Cash Price |
$122.34
|
| Rate for Payer: Cigna All Commercial |
$170.30
|
| Rate for Payer: CORVEL All Commercial |
$183.52
|
| Rate for Payer: Coventry All Commercial |
$173.65
|
| Rate for Payer: Encore All Commercial |
$181.64
|
| Rate for Payer: Frontpath All Commercial |
$181.54
|
| Rate for Payer: Humana ChoiceCare |
$170.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.60
|
| Rate for Payer: PHCS All Commercial |
$148.00
|
| Rate for Payer: PHP All Commercial |
$149.66
|
| Rate for Payer: Sagamore Health Network All Products |
$152.34
|
| Rate for Payer: Signature Care EPO |
$163.78
|
| Rate for Payer: Signature Care PPO |
$173.65
|
| Rate for Payer: United Healthcare Commercial |
$155.50
|
|
|
NALOXONE 1 MG/ML INJ SYRG
|
Facility
OP
|
$197.33
|
|
|
Service Code
|
HCPCS J2310
|
| Hospital Charge Code |
5374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.46 |
| Max. Negotiated Rate |
$183.52 |
| Rate for Payer: Aetna Commercial |
$166.55
|
| Rate for Payer: Aetna Medicare |
$65.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$65.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$113.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$123.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$16.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$74.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$71.63
|
| Rate for Payer: Cash Price |
$122.34
|
| Rate for Payer: Cash Price |
$122.34
|
| Rate for Payer: Centivo All Commercial |
$100.64
|
| Rate for Payer: Cigna All Commercial |
$170.30
|
| Rate for Payer: CORVEL All Commercial |
$183.52
|
| Rate for Payer: Coventry All Commercial |
$173.65
|
| Rate for Payer: Encore All Commercial |
$181.64
|
| Rate for Payer: Frontpath All Commercial |
$181.54
|
| Rate for Payer: Humana ChoiceCare |
$170.43
|
| Rate for Payer: Humana Medicare |
$100.64
|
| Rate for Payer: Lucent All Commercial |
$100.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.60
|
| Rate for Payer: Managed Health Services Medicaid |
$16.46
|
| Rate for Payer: MDWise Medicaid |
$16.46
|
| Rate for Payer: PHCS All Commercial |
$148.00
|
| Rate for Payer: PHP All Commercial |
$149.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.96
|
| Rate for Payer: Sagamore Health Network All Products |
$152.34
|
| Rate for Payer: Signature Care EPO |
$163.78
|
| Rate for Payer: Signature Care PPO |
$173.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$167.73
|
| Rate for Payer: United Healthcare Commercial |
$155.50
|
| Rate for Payer: United Healthcare Medicare |
$65.12
|
|
|
NALTREXONE MICROSPHERES 380 MG IM SERR
|
Facility
OP
|
$5,448.07
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
76527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$5,066.70 |
| Rate for Payer: Aetna Commercial |
$4,598.17
|
| Rate for Payer: Aetna Medicare |
$1,797.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,797.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,128.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,405.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,067.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,977.65
|
| Rate for Payer: Cash Price |
$3,377.80
|
| Rate for Payer: Cash Price |
$3,377.80
|
| Rate for Payer: Centivo All Commercial |
$2,778.51
|
| Rate for Payer: Cigna All Commercial |
$4,701.68
|
| Rate for Payer: CORVEL All Commercial |
$5,066.70
|
| Rate for Payer: Coventry All Commercial |
$4,794.30
|
| Rate for Payer: Encore All Commercial |
$5,014.94
|
| Rate for Payer: Frontpath All Commercial |
$5,012.22
|
| Rate for Payer: Humana ChoiceCare |
$4,705.49
|
| Rate for Payer: Humana Medicare |
$2,778.51
|
| Rate for Payer: Lucent All Commercial |
$2,778.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,903.26
|
| Rate for Payer: Managed Health Services Medicaid |
$4.39
|
| Rate for Payer: MDWise Medicaid |
$4.39
|
| Rate for Payer: PHCS All Commercial |
$4,086.05
|
| Rate for Payer: PHP All Commercial |
$4,131.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,124.75
|
| Rate for Payer: Sagamore Health Network All Products |
$4,205.91
|
| Rate for Payer: Signature Care EPO |
$4,521.89
|
| Rate for Payer: Signature Care PPO |
$4,794.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,630.86
|
| Rate for Payer: United Healthcare Commercial |
$4,293.08
|
| Rate for Payer: United Healthcare Medicare |
$1,797.86
|
|
|
NALTREXONE MICROSPHERES 380 MG IM SERR
|
Facility
IP
|
$5,448.07
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
76527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,086.05 |
| Max. Negotiated Rate |
$5,066.70 |
| Rate for Payer: Aetna Commercial |
$4,707.13
|
| Rate for Payer: Cash Price |
$3,377.80
|
| Rate for Payer: Cigna All Commercial |
$4,701.68
|
| Rate for Payer: CORVEL All Commercial |
$5,066.70
|
| Rate for Payer: Coventry All Commercial |
$4,794.30
|
| Rate for Payer: Encore All Commercial |
$5,014.94
|
| Rate for Payer: Frontpath All Commercial |
$5,012.22
|
| Rate for Payer: Humana ChoiceCare |
$4,705.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,903.26
|
| Rate for Payer: PHCS All Commercial |
$4,086.05
|
| Rate for Payer: PHP All Commercial |
$4,131.81
|
| Rate for Payer: Sagamore Health Network All Products |
$4,205.91
|
| Rate for Payer: Signature Care EPO |
$4,521.89
|
| Rate for Payer: Signature Care PPO |
$4,794.30
|
| Rate for Payer: United Healthcare Commercial |
$4,293.08
|
|
|
NAPROXEN 500 MG ORAL TAB
|
Facility
IP
|
$1.48
|
|
|
Service Code
|
NDC 60687049101
|
| Hospital Charge Code |
5393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.30
|
| Rate for Payer: Encore All Commercial |
$1.36
|
| Rate for Payer: Frontpath All Commercial |
$1.36
|
| Rate for Payer: Humana ChoiceCare |
$1.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.33
|
| Rate for Payer: PHCS All Commercial |
$1.11
|
| Rate for Payer: PHP All Commercial |
$1.12
|
| Rate for Payer: Sagamore Health Network All Products |
$1.14
|
| Rate for Payer: Signature Care EPO |
$1.23
|
| Rate for Payer: Signature Care PPO |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
NAPROXEN 500 MG ORAL TAB
|
Facility
OP
|
$1.48
|
|
|
Service Code
|
NDC 60687049101
|
| Hospital Charge Code |
5393
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.25
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.75
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.30
|
| Rate for Payer: Encore All Commercial |
$1.36
|
| Rate for Payer: Frontpath All Commercial |
$1.36
|
| Rate for Payer: Humana ChoiceCare |
$1.28
|
| Rate for Payer: Humana Medicare |
$0.75
|
| Rate for Payer: Lucent All Commercial |
$0.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.33
|
| Rate for Payer: PHCS All Commercial |
$1.11
|
| Rate for Payer: PHP All Commercial |
$1.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.14
|
| Rate for Payer: Signature Care EPO |
$1.23
|
| Rate for Payer: Signature Care PPO |
$1.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
NAPROXEN SODIUM 220 MG ORAL TAB
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 70000020102
|
| Hospital Charge Code |
13135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Aetna Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Centivo All Commercial |
$0.22
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.39
|
| Rate for Payer: Frontpath All Commercial |
$0.39
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.22
|
| Rate for Payer: Lucent All Commercial |
$0.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.38
|
| Rate for Payer: PHCS All Commercial |
$0.32
|
| Rate for Payer: PHP All Commercial |
$0.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.17
|
| Rate for Payer: Sagamore Health Network All Products |
$0.33
|
| Rate for Payer: Signature Care EPO |
$0.35
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
|
|
NAPROXEN SODIUM 220 MG ORAL TAB
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 70000020102
|
| Hospital Charge Code |
13135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna All Commercial |
$0.37
|
| Rate for Payer: CORVEL All Commercial |
$0.40
|
| Rate for Payer: Coventry All Commercial |
$0.38
|
| Rate for Payer: Encore All Commercial |
$0.39
|
| Rate for Payer: Frontpath All Commercial |
$0.39
|
| Rate for Payer: Humana ChoiceCare |
$0.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.38
|
| Rate for Payer: PHCS All Commercial |
$0.32
|
| Rate for Payer: PHP All Commercial |
$0.32
|
| Rate for Payer: Sagamore Health Network All Products |
$0.33
|
| Rate for Payer: Signature Care EPO |
$0.35
|
| Rate for Payer: Signature Care PPO |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
IP
|
$12.25
|
|
|
Service Code
|
NDC 00904718904
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$11.39 |
| Rate for Payer: Aetna Commercial |
$10.58
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cigna All Commercial |
$10.57
|
| Rate for Payer: CORVEL All Commercial |
$11.39
|
| Rate for Payer: Coventry All Commercial |
$10.78
|
| Rate for Payer: Encore All Commercial |
$11.28
|
| Rate for Payer: Frontpath All Commercial |
$11.27
|
| Rate for Payer: Humana ChoiceCare |
$10.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.02
|
| Rate for Payer: PHCS All Commercial |
$9.19
|
| Rate for Payer: PHP All Commercial |
$9.29
|
| Rate for Payer: Sagamore Health Network All Products |
$9.46
|
| Rate for Payer: Signature Care EPO |
$10.17
|
| Rate for Payer: Signature Care PPO |
$10.78
|
| Rate for Payer: United Healthcare Commercial |
$9.65
|
|
|
NEBIVOLOL 5 MG ORAL TAB
|
Facility
OP
|
$12.25
|
|
|
Service Code
|
NDC 00904718904
|
| Hospital Charge Code |
89284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$11.39 |
| Rate for Payer: Aetna Commercial |
$10.34
|
| Rate for Payer: Aetna Medicare |
$4.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.45
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Centivo All Commercial |
$6.25
|
| Rate for Payer: Cigna All Commercial |
$10.57
|
| Rate for Payer: CORVEL All Commercial |
$11.39
|
| Rate for Payer: Coventry All Commercial |
$10.78
|
| Rate for Payer: Encore All Commercial |
$11.28
|
| Rate for Payer: Frontpath All Commercial |
$11.27
|
| Rate for Payer: Humana ChoiceCare |
$10.58
|
| Rate for Payer: Humana Medicare |
$6.25
|
| Rate for Payer: Lucent All Commercial |
$6.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.02
|
| Rate for Payer: PHCS All Commercial |
$9.19
|
| Rate for Payer: PHP All Commercial |
$9.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.78
|
| Rate for Payer: Sagamore Health Network All Products |
$9.46
|
| Rate for Payer: Signature Care EPO |
$10.17
|
| Rate for Payer: Signature Care PPO |
$10.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$9.65
|
| Rate for Payer: United Healthcare Medicare |
$4.04
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
118303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$37.28 |
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UNIT-UNIT TOP OIPK
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
118303
|
|
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
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT
|
Facility
IP
|
$18.89
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna Commercial |
$16.32
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cigna All Commercial |
$16.30
|
| Rate for Payer: CORVEL All Commercial |
$17.56
|
| Rate for Payer: Coventry All Commercial |
$16.62
|
| Rate for Payer: Encore All Commercial |
$17.38
|
| Rate for Payer: Frontpath All Commercial |
$17.38
|
| Rate for Payer: Humana ChoiceCare |
$16.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.00
|
| Rate for Payer: PHCS All Commercial |
$14.16
|
| Rate for Payer: PHP All Commercial |
$14.32
|
| Rate for Payer: Sagamore Health Network All Products |
$14.58
|
| Rate for Payer: Signature Care EPO |
$15.68
|
| Rate for Payer: Signature Care PPO |
$16.62
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
|
|
NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TOP OINT
|
Facility
OP
|
$18.89
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna Medicare |
$6.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.86
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Centivo All Commercial |
$9.63
|
| Rate for Payer: Cigna All Commercial |
$16.30
|
| Rate for Payer: CORVEL All Commercial |
$17.56
|
| Rate for Payer: Coventry All Commercial |
$16.62
|
| Rate for Payer: Encore All Commercial |
$17.38
|
| Rate for Payer: Frontpath All Commercial |
$17.38
|
| Rate for Payer: Humana ChoiceCare |
$16.31
|
| Rate for Payer: Humana Medicare |
$9.63
|
| Rate for Payer: Lucent All Commercial |
$9.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.00
|
| Rate for Payer: PHCS All Commercial |
$14.16
|
| Rate for Payer: PHP All Commercial |
$14.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.37
|
| Rate for Payer: Sagamore Health Network All Products |
$14.58
|
| Rate for Payer: Signature Care EPO |
$15.68
|
| Rate for Payer: Signature Care PPO |
$16.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.05
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$6.23
|
|
|
NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OTIC DRPS
|
Facility
OP
|
$278.11
|
|
|
Service Code
|
NDC 24208063562
|
| Hospital Charge Code |
28810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$258.64 |
| Rate for Payer: Aetna Commercial |
$234.72
|
| Rate for Payer: Aetna Medicare |
$91.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$91.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$159.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$173.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$105.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$100.95
|
| Rate for Payer: Cash Price |
$172.43
|
| Rate for Payer: Cash Price |
$172.43
|
| Rate for Payer: Centivo All Commercial |
$141.84
|
| Rate for Payer: Cigna All Commercial |
$240.01
|
| Rate for Payer: CORVEL All Commercial |
$258.64
|
| Rate for Payer: Coventry All Commercial |
$244.74
|
| Rate for Payer: Encore All Commercial |
$256.00
|
| Rate for Payer: Frontpath All Commercial |
$255.86
|
| Rate for Payer: Humana ChoiceCare |
$240.20
|
| Rate for Payer: Humana Medicare |
$141.84
|
| Rate for Payer: Lucent All Commercial |
$141.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$250.30
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$208.58
|
| Rate for Payer: PHP All Commercial |
$210.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$108.46
|
| Rate for Payer: Sagamore Health Network All Products |
$214.70
|
| Rate for Payer: Signature Care EPO |
$230.83
|
| Rate for Payer: Signature Care PPO |
$244.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$236.39
|
| Rate for Payer: United Healthcare Commercial |
$219.15
|
| Rate for Payer: United Healthcare Medicare |
$91.78
|
|
|
NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OTIC DRPS
|
Facility
IP
|
$278.11
|
|
|
Service Code
|
NDC 24208063562
|
| Hospital Charge Code |
28810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$208.58 |
| Max. Negotiated Rate |
$258.64 |
| Rate for Payer: Aetna Commercial |
$240.29
|
| Rate for Payer: Cash Price |
$172.43
|
| Rate for Payer: Cigna All Commercial |
$240.01
|
| Rate for Payer: CORVEL All Commercial |
$258.64
|
| Rate for Payer: Coventry All Commercial |
$244.74
|
| Rate for Payer: Encore All Commercial |
$256.00
|
| Rate for Payer: Frontpath All Commercial |
$255.86
|
| Rate for Payer: Humana ChoiceCare |
$240.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$250.30
|
| Rate for Payer: PHCS All Commercial |
$208.58
|
| Rate for Payer: PHP All Commercial |
$210.92
|
| Rate for Payer: Sagamore Health Network All Products |
$214.70
|
| Rate for Payer: Signature Care EPO |
$230.83
|
| Rate for Payer: Signature Care PPO |
$244.74
|
| Rate for Payer: United Healthcare Commercial |
$219.15
|
|
