|
NITAZOXANIDE 500 MG ORAL TAB
|
Facility
OP
|
$687.27
|
|
|
Service Code
|
NDC 67546011114
|
| Hospital Charge Code |
39254
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.80 |
| Max. Negotiated Rate |
$639.16 |
| Rate for Payer: Aetna Commercial |
$580.05
|
| Rate for Payer: Aetna Medicare |
$226.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$226.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$394.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$429.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$260.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$249.48
|
| Rate for Payer: Cash Price |
$426.10
|
| Rate for Payer: Centivo All Commercial |
$350.51
|
| Rate for Payer: Cigna All Commercial |
$593.11
|
| Rate for Payer: CORVEL All Commercial |
$639.16
|
| Rate for Payer: Coventry All Commercial |
$604.79
|
| Rate for Payer: Encore All Commercial |
$632.63
|
| Rate for Payer: Frontpath All Commercial |
$632.28
|
| Rate for Payer: Humana ChoiceCare |
$593.59
|
| Rate for Payer: Humana Medicare |
$350.51
|
| Rate for Payer: Lucent All Commercial |
$350.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$618.54
|
| Rate for Payer: PHCS All Commercial |
$515.45
|
| Rate for Payer: PHP All Commercial |
$521.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$268.03
|
| Rate for Payer: Sagamore Health Network All Products |
$530.57
|
| Rate for Payer: Signature Care EPO |
$570.43
|
| Rate for Payer: Signature Care PPO |
$604.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$584.18
|
| Rate for Payer: United Healthcare Commercial |
$541.56
|
| Rate for Payer: United Healthcare Medicare |
$226.80
|
|
|
NITAZOXANIDE 500 MG ORAL TAB
|
Facility
IP
|
$687.27
|
|
|
Service Code
|
NDC 67546011114
|
| Hospital Charge Code |
39254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$515.45 |
| Max. Negotiated Rate |
$639.16 |
| Rate for Payer: Aetna Commercial |
$593.80
|
| Rate for Payer: Cash Price |
$426.10
|
| Rate for Payer: Cigna All Commercial |
$593.11
|
| Rate for Payer: CORVEL All Commercial |
$639.16
|
| Rate for Payer: Coventry All Commercial |
$604.79
|
| Rate for Payer: Encore All Commercial |
$632.63
|
| Rate for Payer: Frontpath All Commercial |
$632.28
|
| Rate for Payer: Humana ChoiceCare |
$593.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$618.54
|
| Rate for Payer: PHCS All Commercial |
$515.45
|
| Rate for Payer: PHP All Commercial |
$521.22
|
| Rate for Payer: Sagamore Health Network All Products |
$530.57
|
| Rate for Payer: Signature Care EPO |
$570.43
|
| Rate for Payer: Signature Care PPO |
$604.79
|
| Rate for Payer: United Healthcare Commercial |
$541.56
|
|
|
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAP
|
Facility
IP
|
$8.91
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
5595
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cigna All Commercial |
$7.69
|
| Rate for Payer: CORVEL All Commercial |
$8.29
|
| Rate for Payer: Coventry All Commercial |
$7.84
|
| Rate for Payer: Encore All Commercial |
$8.20
|
| Rate for Payer: Frontpath All Commercial |
$8.20
|
| Rate for Payer: Humana ChoiceCare |
$7.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.02
|
| Rate for Payer: PHCS All Commercial |
$6.68
|
| Rate for Payer: PHP All Commercial |
$6.76
|
| Rate for Payer: Sagamore Health Network All Products |
$6.88
|
| Rate for Payer: Signature Care EPO |
$7.40
|
| Rate for Payer: Signature Care PPO |
$7.84
|
| Rate for Payer: United Healthcare Commercial |
$7.02
|
|
|
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAP
|
Facility
OP
|
$8.91
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
5595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Aetna Medicare |
$2.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.23
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Centivo All Commercial |
$4.54
|
| Rate for Payer: Cigna All Commercial |
$7.69
|
| Rate for Payer: CORVEL All Commercial |
$8.29
|
| Rate for Payer: Coventry All Commercial |
$7.84
|
| Rate for Payer: Encore All Commercial |
$8.20
|
| Rate for Payer: Frontpath All Commercial |
$8.20
|
| Rate for Payer: Humana ChoiceCare |
$7.70
|
| Rate for Payer: Humana Medicare |
$4.54
|
| Rate for Payer: Lucent All Commercial |
$4.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.02
|
| Rate for Payer: PHCS All Commercial |
$6.68
|
| Rate for Payer: PHP All Commercial |
$6.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.48
|
| Rate for Payer: Sagamore Health Network All Products |
$6.88
|
| Rate for Payer: Signature Care EPO |
$7.40
|
| Rate for Payer: Signature Care PPO |
$7.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.57
|
| Rate for Payer: United Healthcare Commercial |
$7.02
|
| Rate for Payer: United Healthcare Medicare |
$2.94
|
|
|
NITROFURANTOIN MONOHYD/M-CRYST 100 MG ORAL CAP
|
Facility
OP
|
$13.41
|
|
|
Service Code
|
NDC 50268062515
|
| Hospital Charge Code |
10724
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Aetna Commercial |
$11.32
|
| Rate for Payer: Aetna Medicare |
$4.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.87
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Centivo All Commercial |
$6.84
|
| Rate for Payer: Cigna All Commercial |
$11.57
|
| Rate for Payer: CORVEL All Commercial |
$12.47
|
| Rate for Payer: Coventry All Commercial |
$11.80
|
| Rate for Payer: Encore All Commercial |
$12.35
|
| Rate for Payer: Frontpath All Commercial |
$12.34
|
| Rate for Payer: Humana ChoiceCare |
$11.58
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Lucent All Commercial |
$6.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.07
|
| Rate for Payer: PHCS All Commercial |
$10.06
|
| Rate for Payer: PHP All Commercial |
$10.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.23
|
| Rate for Payer: Sagamore Health Network All Products |
$10.35
|
| Rate for Payer: Signature Care EPO |
$11.13
|
| Rate for Payer: Signature Care PPO |
$11.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.40
|
| Rate for Payer: United Healthcare Commercial |
$10.57
|
| Rate for Payer: United Healthcare Medicare |
$4.43
|
|
|
NITROFURANTOIN MONOHYD/M-CRYST 100 MG ORAL CAP
|
Facility
IP
|
$13.41
|
|
|
Service Code
|
NDC 50268062515
|
| Hospital Charge Code |
10724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Aetna Commercial |
$11.59
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cigna All Commercial |
$11.57
|
| Rate for Payer: CORVEL All Commercial |
$12.47
|
| Rate for Payer: Coventry All Commercial |
$11.80
|
| Rate for Payer: Encore All Commercial |
$12.35
|
| Rate for Payer: Frontpath All Commercial |
$12.34
|
| Rate for Payer: Humana ChoiceCare |
$11.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.07
|
| Rate for Payer: PHCS All Commercial |
$10.06
|
| Rate for Payer: PHP All Commercial |
$10.17
|
| Rate for Payer: Sagamore Health Network All Products |
$10.35
|
| Rate for Payer: Signature Care EPO |
$11.13
|
| Rate for Payer: Signature Care PPO |
$11.80
|
| Rate for Payer: United Healthcare Commercial |
$10.57
|
|
|
NITROGLYCERIN 0.1 MG/HR TD PT24
|
Facility
IP
|
$3.55
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
27471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna All Commercial |
$3.06
|
| Rate for Payer: CORVEL All Commercial |
$3.30
|
| Rate for Payer: Coventry All Commercial |
$3.12
|
| Rate for Payer: Encore All Commercial |
$3.27
|
| Rate for Payer: Frontpath All Commercial |
$3.27
|
| Rate for Payer: Humana ChoiceCare |
$3.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.19
|
| Rate for Payer: PHCS All Commercial |
$2.66
|
| Rate for Payer: PHP All Commercial |
$2.69
|
| Rate for Payer: Sagamore Health Network All Products |
$2.74
|
| Rate for Payer: Signature Care EPO |
$2.95
|
| Rate for Payer: Signature Care PPO |
$3.12
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
|
|
NITROGLYCERIN 0.1 MG/HR TD PT24
|
Facility
OP
|
$3.55
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
27471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna Commercial |
$3.00
|
| Rate for Payer: Aetna Medicare |
$1.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.29
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Centivo All Commercial |
$1.81
|
| Rate for Payer: Cigna All Commercial |
$3.06
|
| Rate for Payer: CORVEL All Commercial |
$3.30
|
| Rate for Payer: Coventry All Commercial |
$3.12
|
| Rate for Payer: Encore All Commercial |
$3.27
|
| Rate for Payer: Frontpath All Commercial |
$3.27
|
| Rate for Payer: Humana ChoiceCare |
$3.07
|
| Rate for Payer: Humana Medicare |
$1.81
|
| Rate for Payer: Lucent All Commercial |
$1.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.19
|
| Rate for Payer: PHCS All Commercial |
$2.66
|
| Rate for Payer: PHP All Commercial |
$2.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.38
|
| Rate for Payer: Sagamore Health Network All Products |
$2.74
|
| Rate for Payer: Signature Care EPO |
$2.95
|
| Rate for Payer: Signature Care PPO |
$3.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.02
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$1.17
|
|
|
NITROGLYCERIN 0.2 MG/HR TD PT24
|
Facility
OP
|
$3.35
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
27472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna Commercial |
$2.83
|
| Rate for Payer: Aetna Medicare |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.22
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Centivo All Commercial |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.89
|
| Rate for Payer: CORVEL All Commercial |
$3.12
|
| Rate for Payer: Coventry All Commercial |
$2.95
|
| Rate for Payer: Encore All Commercial |
$3.09
|
| Rate for Payer: Frontpath All Commercial |
$3.08
|
| Rate for Payer: Humana ChoiceCare |
$2.90
|
| Rate for Payer: Humana Medicare |
$1.71
|
| Rate for Payer: Lucent All Commercial |
$1.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.02
|
| Rate for Payer: PHCS All Commercial |
$2.51
|
| Rate for Payer: PHP All Commercial |
$2.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.31
|
| Rate for Payer: Sagamore Health Network All Products |
$2.59
|
| Rate for Payer: Signature Care EPO |
$2.78
|
| Rate for Payer: Signature Care PPO |
$2.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.85
|
| Rate for Payer: United Healthcare Commercial |
$2.64
|
| Rate for Payer: United Healthcare Medicare |
$1.11
|
|
|
NITROGLYCERIN 0.2 MG/HR TD PT24
|
Facility
IP
|
$3.35
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
27472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cigna All Commercial |
$2.89
|
| Rate for Payer: CORVEL All Commercial |
$3.12
|
| Rate for Payer: Coventry All Commercial |
$2.95
|
| Rate for Payer: Encore All Commercial |
$3.09
|
| Rate for Payer: Frontpath All Commercial |
$3.08
|
| Rate for Payer: Humana ChoiceCare |
$2.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.02
|
| Rate for Payer: PHCS All Commercial |
$2.51
|
| Rate for Payer: PHP All Commercial |
$2.54
|
| Rate for Payer: Sagamore Health Network All Products |
$2.59
|
| Rate for Payer: Signature Care EPO |
$2.78
|
| Rate for Payer: Signature Care PPO |
$2.95
|
| Rate for Payer: United Healthcare Commercial |
$2.64
|
|
|
NITROGLYCERIN 0.4 MG SL SUBL
|
Facility
OP
|
$61.25
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
5604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$51.70
|
| Rate for Payer: Aetna Medicare |
$20.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$35.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$38.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.23
|
| Rate for Payer: Cash Price |
$37.98
|
| Rate for Payer: Centivo All Commercial |
$31.24
|
| Rate for Payer: Cigna All Commercial |
$52.86
|
| Rate for Payer: CORVEL All Commercial |
$56.96
|
| Rate for Payer: Coventry All Commercial |
$53.90
|
| Rate for Payer: Encore All Commercial |
$56.38
|
| Rate for Payer: Frontpath All Commercial |
$56.35
|
| Rate for Payer: Humana ChoiceCare |
$52.90
|
| Rate for Payer: Humana Medicare |
$31.24
|
| Rate for Payer: Lucent All Commercial |
$31.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.12
|
| Rate for Payer: PHCS All Commercial |
$45.94
|
| Rate for Payer: PHP All Commercial |
$46.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$47.28
|
| Rate for Payer: Signature Care EPO |
$50.84
|
| Rate for Payer: Signature Care PPO |
$53.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$52.06
|
| Rate for Payer: United Healthcare Commercial |
$48.26
|
| Rate for Payer: United Healthcare Medicare |
$20.21
|
|
|
NITROGLYCERIN 0.4 MG SL SUBL
|
Facility
IP
|
$61.25
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
5604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.94 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$52.92
|
| Rate for Payer: Cash Price |
$37.98
|
| Rate for Payer: Cigna All Commercial |
$52.86
|
| Rate for Payer: CORVEL All Commercial |
$56.96
|
| Rate for Payer: Coventry All Commercial |
$53.90
|
| Rate for Payer: Encore All Commercial |
$56.38
|
| Rate for Payer: Frontpath All Commercial |
$56.35
|
| Rate for Payer: Humana ChoiceCare |
$52.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.12
|
| Rate for Payer: PHCS All Commercial |
$45.94
|
| Rate for Payer: PHP All Commercial |
$46.45
|
| Rate for Payer: Sagamore Health Network All Products |
$47.28
|
| Rate for Payer: Signature Care EPO |
$50.84
|
| Rate for Payer: Signature Care PPO |
$53.90
|
| Rate for Payer: United Healthcare Commercial |
$48.26
|
|
|
NITROGLYCERIN 2 % TD OINT
|
Facility
OP
|
$16.08
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
5606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: Aetna Medicare |
$5.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$9.97
|
| Rate for Payer: Centivo All Commercial |
$8.20
|
| Rate for Payer: Cigna All Commercial |
$13.88
|
| Rate for Payer: CORVEL All Commercial |
$14.95
|
| Rate for Payer: Coventry All Commercial |
$14.15
|
| Rate for Payer: Encore All Commercial |
$14.80
|
| Rate for Payer: Frontpath All Commercial |
$14.79
|
| Rate for Payer: Humana ChoiceCare |
$13.89
|
| Rate for Payer: Humana Medicare |
$8.20
|
| Rate for Payer: Lucent All Commercial |
$8.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.47
|
| Rate for Payer: PHCS All Commercial |
$12.06
|
| Rate for Payer: PHP All Commercial |
$12.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.27
|
| Rate for Payer: Sagamore Health Network All Products |
$12.41
|
| Rate for Payer: Signature Care EPO |
$13.35
|
| Rate for Payer: Signature Care PPO |
$14.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.67
|
| Rate for Payer: United Healthcare Commercial |
$12.67
|
| Rate for Payer: United Healthcare Medicare |
$5.31
|
|
|
NITROGLYCERIN 2 % TD OINT
|
Facility
IP
|
$16.08
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
5606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$13.89
|
| Rate for Payer: Cash Price |
$9.97
|
| Rate for Payer: Cigna All Commercial |
$13.88
|
| Rate for Payer: CORVEL All Commercial |
$14.95
|
| Rate for Payer: Coventry All Commercial |
$14.15
|
| Rate for Payer: Encore All Commercial |
$14.80
|
| Rate for Payer: Frontpath All Commercial |
$14.79
|
| Rate for Payer: Humana ChoiceCare |
$13.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.47
|
| Rate for Payer: PHCS All Commercial |
$12.06
|
| Rate for Payer: PHP All Commercial |
$12.19
|
| Rate for Payer: Sagamore Health Network All Products |
$12.41
|
| Rate for Payer: Signature Care EPO |
$13.35
|
| Rate for Payer: Signature Care PPO |
$14.15
|
| Rate for Payer: United Healthcare Commercial |
$12.67
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TL SPRY
|
Facility
OP
|
$570.65
|
|
|
Service Code
|
NDC 28595012049
|
| Hospital Charge Code |
27096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.32 |
| Max. Negotiated Rate |
$530.71 |
| Rate for Payer: Aetna Commercial |
$481.63
|
| Rate for Payer: Aetna Medicare |
$188.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$188.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$327.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$356.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$216.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$207.15
|
| Rate for Payer: Cash Price |
$353.81
|
| Rate for Payer: Centivo All Commercial |
$291.03
|
| Rate for Payer: Cigna All Commercial |
$492.47
|
| Rate for Payer: CORVEL All Commercial |
$530.71
|
| Rate for Payer: Coventry All Commercial |
$502.18
|
| Rate for Payer: Encore All Commercial |
$525.29
|
| Rate for Payer: Frontpath All Commercial |
$525.00
|
| Rate for Payer: Humana ChoiceCare |
$492.87
|
| Rate for Payer: Humana Medicare |
$291.03
|
| Rate for Payer: Lucent All Commercial |
$291.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$513.59
|
| Rate for Payer: PHCS All Commercial |
$427.99
|
| Rate for Payer: PHP All Commercial |
$432.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$222.56
|
| Rate for Payer: Sagamore Health Network All Products |
$440.54
|
| Rate for Payer: Signature Care EPO |
$473.64
|
| Rate for Payer: Signature Care PPO |
$502.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$485.06
|
| Rate for Payer: United Healthcare Commercial |
$449.68
|
| Rate for Payer: United Healthcare Medicare |
$188.32
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TL SPRY
|
Facility
IP
|
$570.65
|
|
|
Service Code
|
NDC 28595012049
|
| Hospital Charge Code |
27096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$427.99 |
| Max. Negotiated Rate |
$530.71 |
| Rate for Payer: Aetna Commercial |
$493.05
|
| Rate for Payer: Cash Price |
$353.81
|
| Rate for Payer: Cigna All Commercial |
$492.47
|
| Rate for Payer: CORVEL All Commercial |
$530.71
|
| Rate for Payer: Coventry All Commercial |
$502.18
|
| Rate for Payer: Encore All Commercial |
$525.29
|
| Rate for Payer: Frontpath All Commercial |
$525.00
|
| Rate for Payer: Humana ChoiceCare |
$492.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$513.59
|
| Rate for Payer: PHCS All Commercial |
$427.99
|
| Rate for Payer: PHP All Commercial |
$432.78
|
| Rate for Payer: Sagamore Health Network All Products |
$440.54
|
| Rate for Payer: Signature Care EPO |
$473.64
|
| Rate for Payer: Signature Care PPO |
$502.18
|
| Rate for Payer: United Healthcare Commercial |
$449.68
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 25 MG/250 ML (100 MCG/ML) IV SOLN
|
Facility
OP
|
$143.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.36 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$121.11
|
| Rate for Payer: Aetna Medicare |
$47.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$82.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.09
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Centivo All Commercial |
$73.18
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Humana Medicare |
$73.18
|
| Rate for Payer: Lucent All Commercial |
$73.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.96
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.10
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.98
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
| Rate for Payer: United Healthcare Medicare |
$47.36
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 25 MG/250 ML (100 MCG/ML) IV SOLN
|
Facility
IP
|
$143.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.62 |
| Max. Negotiated Rate |
$133.46 |
| Rate for Payer: Aetna Commercial |
$123.98
|
| Rate for Payer: Cash Price |
$88.97
|
| Rate for Payer: Cigna All Commercial |
$123.84
|
| Rate for Payer: CORVEL All Commercial |
$133.46
|
| Rate for Payer: Coventry All Commercial |
$126.28
|
| Rate for Payer: Encore All Commercial |
$132.09
|
| Rate for Payer: Frontpath All Commercial |
$132.02
|
| Rate for Payer: Humana ChoiceCare |
$123.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.15
|
| Rate for Payer: PHCS All Commercial |
$107.62
|
| Rate for Payer: PHP All Commercial |
$108.83
|
| Rate for Payer: Sagamore Health Network All Products |
$110.78
|
| Rate for Payer: Signature Care EPO |
$119.10
|
| Rate for Payer: Signature Care PPO |
$126.28
|
| Rate for Payer: United Healthcare Commercial |
$113.08
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 50 MG/250 ML (200 MCG/ML) IV SOLN
|
Facility
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna Commercial |
$132.93
|
| Rate for Payer: Aetna Medicare |
$51.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$90.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.17
|
| Rate for Payer: Cash Price |
$97.65
|
| Rate for Payer: Centivo All Commercial |
$80.32
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.48
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Humana Medicare |
$80.32
|
| Rate for Payer: Lucent All Commercial |
$80.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.42
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.88
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
| Rate for Payer: United Healthcare Medicare |
$51.98
|
|
|
NITROGLYCERIN IN 5 % DEXTROSE 50 MG/250 ML (200 MCG/ML) IV SOLN
|
Facility
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
15859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.12 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna Commercial |
$136.08
|
| Rate for Payer: Cash Price |
$97.65
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.48
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
|
|
NITROPRUSSIDE 25 MG/ML IV SOLN
|
Facility
OP
|
$84.00
|
|
|
Service Code
|
NDC 70069026101
|
| Hospital Charge Code |
18908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$78.12 |
| Rate for Payer: Aetna Commercial |
$70.90
|
| Rate for Payer: Aetna Medicare |
$27.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$48.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.49
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Centivo All Commercial |
$42.84
|
| Rate for Payer: Cigna All Commercial |
$72.49
|
| Rate for Payer: CORVEL All Commercial |
$78.12
|
| Rate for Payer: Coventry All Commercial |
$73.92
|
| Rate for Payer: Encore All Commercial |
$77.32
|
| Rate for Payer: Frontpath All Commercial |
$77.28
|
| Rate for Payer: Humana ChoiceCare |
$72.55
|
| Rate for Payer: Humana Medicare |
$42.84
|
| Rate for Payer: Lucent All Commercial |
$42.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.60
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$63.00
|
| Rate for Payer: PHP All Commercial |
$63.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.76
|
| Rate for Payer: Sagamore Health Network All Products |
$64.85
|
| Rate for Payer: Signature Care EPO |
$69.72
|
| Rate for Payer: Signature Care PPO |
$73.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.40
|
| Rate for Payer: United Healthcare Commercial |
$66.19
|
| Rate for Payer: United Healthcare Medicare |
$27.72
|
|
|
NITROPRUSSIDE 25 MG/ML IV SOLN
|
Facility
IP
|
$84.00
|
|
|
Service Code
|
NDC 70069026101
|
| Hospital Charge Code |
18908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$78.12 |
| Rate for Payer: Aetna Commercial |
$72.58
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cigna All Commercial |
$72.49
|
| Rate for Payer: CORVEL All Commercial |
$78.12
|
| Rate for Payer: Coventry All Commercial |
$73.92
|
| Rate for Payer: Encore All Commercial |
$77.32
|
| Rate for Payer: Frontpath All Commercial |
$77.28
|
| Rate for Payer: Humana ChoiceCare |
$72.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.60
|
| Rate for Payer: PHCS All Commercial |
$63.00
|
| Rate for Payer: PHP All Commercial |
$63.71
|
| Rate for Payer: Sagamore Health Network All Products |
$64.85
|
| Rate for Payer: Signature Care EPO |
$69.72
|
| Rate for Payer: Signature Care PPO |
$73.92
|
| Rate for Payer: United Healthcare Commercial |
$66.19
|
|
|
N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG
|
Facility
OP
|
$803.65
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
170724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.90 |
| Max. Negotiated Rate |
$747.39 |
| Rate for Payer: Aetna Commercial |
$678.28
|
| Rate for Payer: Aetna Medicare |
$265.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$265.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$461.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$502.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$187.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$304.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$291.72
|
| Rate for Payer: Cash Price |
$498.26
|
| Rate for Payer: Cash Price |
$498.26
|
| Rate for Payer: Centivo All Commercial |
$409.86
|
| Rate for Payer: Cigna All Commercial |
$693.55
|
| Rate for Payer: CORVEL All Commercial |
$747.39
|
| Rate for Payer: Coventry All Commercial |
$707.21
|
| Rate for Payer: Encore All Commercial |
$739.76
|
| Rate for Payer: Frontpath All Commercial |
$739.36
|
| Rate for Payer: Humana ChoiceCare |
$694.11
|
| Rate for Payer: Humana Medicare |
$409.86
|
| Rate for Payer: Lucent All Commercial |
$409.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$723.28
|
| Rate for Payer: Managed Health Services Medicaid |
$187.90
|
| Rate for Payer: MDWise Medicaid |
$187.90
|
| Rate for Payer: PHCS All Commercial |
$602.74
|
| Rate for Payer: PHP All Commercial |
$609.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$313.42
|
| Rate for Payer: Sagamore Health Network All Products |
$620.42
|
| Rate for Payer: Signature Care EPO |
$667.03
|
| Rate for Payer: Signature Care PPO |
$707.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$683.10
|
| Rate for Payer: United Healthcare Commercial |
$633.28
|
| Rate for Payer: United Healthcare Medicare |
$265.20
|
|
|
N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG
|
Facility
IP
|
$803.65
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
170724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$602.74 |
| Max. Negotiated Rate |
$747.39 |
| Rate for Payer: Aetna Commercial |
$694.35
|
| Rate for Payer: Cash Price |
$498.26
|
| Rate for Payer: Cigna All Commercial |
$693.55
|
| Rate for Payer: CORVEL All Commercial |
$747.39
|
| Rate for Payer: Coventry All Commercial |
$707.21
|
| Rate for Payer: Encore All Commercial |
$739.76
|
| Rate for Payer: Frontpath All Commercial |
$739.36
|
| Rate for Payer: Humana ChoiceCare |
$694.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$723.28
|
| Rate for Payer: PHCS All Commercial |
$602.74
|
| Rate for Payer: PHP All Commercial |
$609.49
|
| Rate for Payer: Sagamore Health Network All Products |
$620.42
|
| Rate for Payer: Signature Care EPO |
$667.03
|
| Rate for Payer: Signature Care PPO |
$707.21
|
| Rate for Payer: United Healthcare Commercial |
$633.28
|
|
|
NON-FORMULARY/COMPOUND-ORAL LIQ CUSTOM
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 99999990050
|
| Hospital Charge Code |
900008
|
|
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
|
|
