|
NON-FORMULARY/COMPOUND-ORAL LIQ CUSTOM
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 99999990050
|
| Hospital Charge Code |
900008
|
|
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
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN
|
Facility
OP
|
$22.09
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna Medicare |
$7.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.02
|
| Rate for Payer: Cash Price |
$13.70
|
| Rate for Payer: Cash Price |
$13.70
|
| Rate for Payer: Centivo All Commercial |
$11.27
|
| Rate for Payer: Cigna All Commercial |
$19.07
|
| Rate for Payer: CORVEL All Commercial |
$20.55
|
| Rate for Payer: Coventry All Commercial |
$19.44
|
| Rate for Payer: Encore All Commercial |
$20.34
|
| Rate for Payer: Frontpath All Commercial |
$20.32
|
| Rate for Payer: Humana ChoiceCare |
$19.08
|
| Rate for Payer: Humana Medicare |
$11.27
|
| Rate for Payer: Lucent All Commercial |
$11.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.88
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$16.57
|
| Rate for Payer: PHP All Commercial |
$16.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.62
|
| Rate for Payer: Sagamore Health Network All Products |
$17.06
|
| Rate for Payer: Signature Care EPO |
$18.34
|
| Rate for Payer: Signature Care PPO |
$19.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.78
|
| Rate for Payer: United Healthcare Commercial |
$17.41
|
| Rate for Payer: United Healthcare Medicare |
$7.29
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN
|
Facility
IP
|
$22.09
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$20.55 |
| Rate for Payer: Aetna Commercial |
$19.09
|
| Rate for Payer: Cash Price |
$13.70
|
| Rate for Payer: Cigna All Commercial |
$19.07
|
| Rate for Payer: CORVEL All Commercial |
$20.55
|
| Rate for Payer: Coventry All Commercial |
$19.44
|
| Rate for Payer: Encore All Commercial |
$20.34
|
| Rate for Payer: Frontpath All Commercial |
$20.32
|
| Rate for Payer: Humana ChoiceCare |
$19.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.88
|
| Rate for Payer: PHCS All Commercial |
$16.57
|
| Rate for Payer: PHP All Commercial |
$16.75
|
| Rate for Payer: Sagamore Health Network All Products |
$17.06
|
| Rate for Payer: Signature Care EPO |
$18.34
|
| Rate for Payer: Signature Care PPO |
$19.44
|
| Rate for Payer: United Healthcare Commercial |
$17.41
|
|
|
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
OP
|
$150.50
|
|
|
Service Code
|
NDC 00338011220
|
| Hospital Charge Code |
120518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$139.96 |
| Rate for Payer: Aetna Commercial |
$127.02
|
| Rate for Payer: Aetna Medicare |
$49.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$86.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$94.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$54.63
|
| Rate for Payer: Cash Price |
$93.31
|
| Rate for Payer: Cash Price |
$93.31
|
| Rate for Payer: Centivo All Commercial |
$76.76
|
| Rate for Payer: Cigna All Commercial |
$129.88
|
| Rate for Payer: CORVEL All Commercial |
$139.96
|
| Rate for Payer: Coventry All Commercial |
$132.44
|
| Rate for Payer: Encore All Commercial |
$138.54
|
| Rate for Payer: Frontpath All Commercial |
$138.46
|
| Rate for Payer: Humana ChoiceCare |
$129.99
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Lucent All Commercial |
$76.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$135.45
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$112.88
|
| Rate for Payer: PHP All Commercial |
$114.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$58.70
|
| Rate for Payer: Sagamore Health Network All Products |
$116.19
|
| Rate for Payer: Signature Care EPO |
$124.92
|
| Rate for Payer: Signature Care PPO |
$132.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$127.92
|
| Rate for Payer: United Healthcare Commercial |
$118.59
|
| Rate for Payer: United Healthcare Medicare |
$49.66
|
|
|
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
IP
|
$150.50
|
|
|
Service Code
|
NDC 00338011220
|
| Hospital Charge Code |
120518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.88 |
| Max. Negotiated Rate |
$139.96 |
| Rate for Payer: Aetna Commercial |
$130.03
|
| Rate for Payer: Cash Price |
$93.31
|
| Rate for Payer: Cigna All Commercial |
$129.88
|
| Rate for Payer: CORVEL All Commercial |
$139.96
|
| Rate for Payer: Coventry All Commercial |
$132.44
|
| Rate for Payer: Encore All Commercial |
$138.54
|
| Rate for Payer: Frontpath All Commercial |
$138.46
|
| Rate for Payer: Humana ChoiceCare |
$129.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$135.45
|
| Rate for Payer: PHCS All Commercial |
$112.88
|
| Rate for Payer: PHP All Commercial |
$114.14
|
| Rate for Payer: Sagamore Health Network All Products |
$116.19
|
| Rate for Payer: Signature Care EPO |
$124.92
|
| Rate for Payer: Signature Care PPO |
$132.44
|
| Rate for Payer: United Healthcare Commercial |
$118.59
|
|
|
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
IP
|
$105.00
|
|
|
Service Code
|
NDC 69374031925
|
| Hospital Charge Code |
120517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$90.72
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
|
|
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
NDC 69374031925
|
| Hospital Charge Code |
120517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$88.62
|
| Rate for Payer: Aetna Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.12
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Centivo All Commercial |
$53.55
|
| Rate for Payer: Cigna All Commercial |
$90.62
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Humana Medicare |
$53.55
|
| Rate for Payer: Lucent All Commercial |
$53.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.95
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
| Rate for Payer: United Healthcare Medicare |
$34.65
|
|
|
NORETHINDRONE ACETATE 5 MG ORAL TAB
|
Facility
OP
|
$3.70
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: Aetna Medicare |
$1.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.34
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Centivo All Commercial |
$1.89
|
| Rate for Payer: Cigna All Commercial |
$3.20
|
| Rate for Payer: CORVEL All Commercial |
$3.44
|
| Rate for Payer: Coventry All Commercial |
$3.26
|
| Rate for Payer: Encore All Commercial |
$3.41
|
| Rate for Payer: Frontpath All Commercial |
$3.41
|
| Rate for Payer: Humana ChoiceCare |
$3.20
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Lucent All Commercial |
$1.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.33
|
| Rate for Payer: PHCS All Commercial |
$2.78
|
| Rate for Payer: PHP All Commercial |
$2.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.44
|
| Rate for Payer: Sagamore Health Network All Products |
$2.86
|
| Rate for Payer: Signature Care EPO |
$3.07
|
| Rate for Payer: Signature Care PPO |
$3.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.15
|
| Rate for Payer: United Healthcare Commercial |
$2.92
|
| Rate for Payer: United Healthcare Medicare |
$1.22
|
|
|
NORETHINDRONE ACETATE 5 MG ORAL TAB
|
Facility
IP
|
$3.70
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna All Commercial |
$3.20
|
| Rate for Payer: CORVEL All Commercial |
$3.44
|
| Rate for Payer: Coventry All Commercial |
$3.26
|
| Rate for Payer: Encore All Commercial |
$3.41
|
| Rate for Payer: Frontpath All Commercial |
$3.41
|
| Rate for Payer: Humana ChoiceCare |
$3.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.33
|
| Rate for Payer: PHCS All Commercial |
$2.78
|
| Rate for Payer: PHP All Commercial |
$2.81
|
| Rate for Payer: Sagamore Health Network All Products |
$2.86
|
| Rate for Payer: Signature Care EPO |
$3.07
|
| Rate for Payer: Signature Care PPO |
$3.26
|
| Rate for Payer: United Healthcare Commercial |
$2.92
|
|
|
NORTRIPTYLINE 10 MG ORAL CAP
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
NDC 75907006901
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.09
|
| 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 |
$0.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Centivo All Commercial |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.66
|
| Rate for Payer: Lucent All Commercial |
$0.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
NORTRIPTYLINE 10 MG ORAL CAP
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
NDC 75907006901
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.20
|
| Rate for Payer: Coventry All Commercial |
$1.14
|
| Rate for Payer: Encore All Commercial |
$1.19
|
| Rate for Payer: Frontpath All Commercial |
$1.19
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.97
|
| Rate for Payer: PHP All Commercial |
$0.98
|
| Rate for Payer: Sagamore Health Network All Products |
$1.00
|
| Rate for Payer: Signature Care EPO |
$1.07
|
| Rate for Payer: Signature Care PPO |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
OP
|
$2.66
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Aetna Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Centivo All Commercial |
$1.36
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.47
|
| Rate for Payer: Coventry All Commercial |
$2.34
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Humana Medicare |
$1.36
|
| Rate for Payer: Lucent All Commercial |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.39
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.04
|
| Rate for Payer: Sagamore Health Network All Products |
$2.05
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.26
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$0.88
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
IP
|
$2.66
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.47
|
| Rate for Payer: Coventry All Commercial |
$2.34
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.39
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Sagamore Health Network All Products |
$2.05
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.34
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
OP
|
$2.66
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Aetna Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Centivo All Commercial |
$1.36
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.47
|
| Rate for Payer: Coventry All Commercial |
$2.34
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Humana Medicare |
$1.36
|
| Rate for Payer: Lucent All Commercial |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.39
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.04
|
| Rate for Payer: Sagamore Health Network All Products |
$2.05
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.26
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$0.88
|
|
|
NORTRIPTYLINE 25 MG ORAL CAP
|
Facility
IP
|
$2.66
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.47
|
| Rate for Payer: Coventry All Commercial |
$2.34
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.39
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Sagamore Health Network All Products |
$2.05
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.34
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP CREA
|
Facility
IP
|
$27.41
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.55 |
| Max. Negotiated Rate |
$25.49 |
| Rate for Payer: Aetna Commercial |
$23.68
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cigna All Commercial |
$23.65
|
| Rate for Payer: CORVEL All Commercial |
$25.49
|
| Rate for Payer: Coventry All Commercial |
$24.12
|
| Rate for Payer: Encore All Commercial |
$25.23
|
| Rate for Payer: Frontpath All Commercial |
$25.21
|
| Rate for Payer: Humana ChoiceCare |
$23.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.66
|
| Rate for Payer: PHCS All Commercial |
$20.55
|
| Rate for Payer: PHP All Commercial |
$20.78
|
| Rate for Payer: Sagamore Health Network All Products |
$21.16
|
| Rate for Payer: Signature Care EPO |
$22.75
|
| Rate for Payer: Signature Care PPO |
$24.12
|
| Rate for Payer: United Healthcare Commercial |
$21.60
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP CREA
|
Facility
OP
|
$27.41
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$25.49 |
| Rate for Payer: Aetna Commercial |
$23.13
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.95
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Centivo All Commercial |
$13.98
|
| Rate for Payer: Cigna All Commercial |
$23.65
|
| Rate for Payer: CORVEL All Commercial |
$25.49
|
| Rate for Payer: Coventry All Commercial |
$24.12
|
| Rate for Payer: Encore All Commercial |
$25.23
|
| Rate for Payer: Frontpath All Commercial |
$25.21
|
| Rate for Payer: Humana ChoiceCare |
$23.67
|
| Rate for Payer: Humana Medicare |
$13.98
|
| Rate for Payer: Lucent All Commercial |
$13.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.66
|
| Rate for Payer: PHCS All Commercial |
$20.55
|
| Rate for Payer: PHP All Commercial |
$20.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.69
|
| Rate for Payer: Sagamore Health Network All Products |
$21.16
|
| Rate for Payer: Signature Care EPO |
$22.75
|
| Rate for Payer: Signature Care PPO |
$24.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.29
|
| Rate for Payer: United Healthcare Commercial |
$21.60
|
| Rate for Payer: United Healthcare Medicare |
$9.04
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP POWD
|
Facility
OP
|
$45.57
|
|
|
Service Code
|
NDC 68308015215
|
| Hospital Charge Code |
39136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.04 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: Aetna Commercial |
$38.46
|
| Rate for Payer: Aetna Medicare |
$15.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$26.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.54
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Centivo All Commercial |
$23.24
|
| Rate for Payer: Cigna All Commercial |
$39.33
|
| Rate for Payer: CORVEL All Commercial |
$42.38
|
| Rate for Payer: Coventry All Commercial |
$40.10
|
| Rate for Payer: Encore All Commercial |
$41.95
|
| Rate for Payer: Frontpath All Commercial |
$41.92
|
| Rate for Payer: Humana ChoiceCare |
$39.36
|
| Rate for Payer: Humana Medicare |
$23.24
|
| Rate for Payer: Lucent All Commercial |
$23.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.01
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$34.18
|
| Rate for Payer: PHP All Commercial |
$34.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.77
|
| Rate for Payer: Sagamore Health Network All Products |
$35.18
|
| Rate for Payer: Signature Care EPO |
$37.82
|
| Rate for Payer: Signature Care PPO |
$40.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$38.73
|
| Rate for Payer: United Healthcare Commercial |
$35.91
|
| Rate for Payer: United Healthcare Medicare |
$15.04
|
|
|
NYSTATIN 100000 UNIT/GRAM TOP POWD
|
Facility
IP
|
$45.57
|
|
|
Service Code
|
NDC 68308015215
|
| Hospital Charge Code |
39136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: Aetna Commercial |
$39.37
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Cigna All Commercial |
$39.33
|
| Rate for Payer: CORVEL All Commercial |
$42.38
|
| Rate for Payer: Coventry All Commercial |
$40.10
|
| Rate for Payer: Encore All Commercial |
$41.95
|
| Rate for Payer: Frontpath All Commercial |
$41.92
|
| Rate for Payer: Humana ChoiceCare |
$39.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.01
|
| Rate for Payer: PHCS All Commercial |
$34.18
|
| Rate for Payer: PHP All Commercial |
$34.56
|
| Rate for Payer: Sagamore Health Network All Products |
$35.18
|
| Rate for Payer: Signature Care EPO |
$37.82
|
| Rate for Payer: Signature Care PPO |
$40.10
|
| Rate for Payer: United Healthcare Commercial |
$35.91
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
OP
|
$118.44
|
|
|
Service Code
|
NDC 60432053760
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$110.15 |
| Rate for Payer: Aetna Commercial |
$99.96
|
| Rate for Payer: Aetna Medicare |
$39.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$68.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$74.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.99
|
| Rate for Payer: Cash Price |
$73.43
|
| Rate for Payer: Centivo All Commercial |
$60.40
|
| Rate for Payer: Cigna All Commercial |
$102.21
|
| Rate for Payer: CORVEL All Commercial |
$110.15
|
| Rate for Payer: Coventry All Commercial |
$104.23
|
| Rate for Payer: Encore All Commercial |
$109.02
|
| Rate for Payer: Frontpath All Commercial |
$108.96
|
| Rate for Payer: Humana ChoiceCare |
$102.30
|
| Rate for Payer: Humana Medicare |
$60.40
|
| Rate for Payer: Lucent All Commercial |
$60.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.60
|
| Rate for Payer: PHCS All Commercial |
$88.83
|
| Rate for Payer: PHP All Commercial |
$89.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.19
|
| Rate for Payer: Sagamore Health Network All Products |
$91.44
|
| Rate for Payer: Signature Care EPO |
$98.31
|
| Rate for Payer: Signature Care PPO |
$104.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$100.67
|
| Rate for Payer: United Healthcare Commercial |
$93.33
|
| Rate for Payer: United Healthcare Medicare |
$39.09
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
IP
|
$118.44
|
|
|
Service Code
|
NDC 60432053760
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.83 |
| Max. Negotiated Rate |
$110.15 |
| Rate for Payer: Aetna Commercial |
$102.33
|
| Rate for Payer: Cash Price |
$73.43
|
| Rate for Payer: Cigna All Commercial |
$102.21
|
| Rate for Payer: CORVEL All Commercial |
$110.15
|
| Rate for Payer: Coventry All Commercial |
$104.23
|
| Rate for Payer: Encore All Commercial |
$109.02
|
| Rate for Payer: Frontpath All Commercial |
$108.96
|
| Rate for Payer: Humana ChoiceCare |
$102.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.60
|
| Rate for Payer: PHCS All Commercial |
$88.83
|
| Rate for Payer: PHP All Commercial |
$89.82
|
| Rate for Payer: Sagamore Health Network All Products |
$91.44
|
| Rate for Payer: Signature Care EPO |
$98.31
|
| Rate for Payer: Signature Care PPO |
$104.23
|
| Rate for Payer: United Healthcare Commercial |
$93.33
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
OP
|
$7.74
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$7.19 |
| Rate for Payer: Aetna Commercial |
$6.53
|
| Rate for Payer: Aetna Medicare |
$2.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.81
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Centivo All Commercial |
$3.94
|
| Rate for Payer: Cigna All Commercial |
$6.68
|
| Rate for Payer: CORVEL All Commercial |
$7.19
|
| Rate for Payer: Coventry All Commercial |
$6.81
|
| Rate for Payer: Encore All Commercial |
$7.12
|
| Rate for Payer: Frontpath All Commercial |
$7.12
|
| Rate for Payer: Humana ChoiceCare |
$6.68
|
| Rate for Payer: Humana Medicare |
$3.94
|
| Rate for Payer: Lucent All Commercial |
$3.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.96
|
| Rate for Payer: PHCS All Commercial |
$5.80
|
| Rate for Payer: PHP All Commercial |
$5.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.02
|
| Rate for Payer: Sagamore Health Network All Products |
$5.97
|
| Rate for Payer: Signature Care EPO |
$6.42
|
| Rate for Payer: Signature Care PPO |
$6.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.57
|
| Rate for Payer: United Healthcare Commercial |
$6.10
|
| Rate for Payer: United Healthcare Medicare |
$2.55
|
|
|
NYSTATIN 100000 UNITS/ML ORAL SUSP
|
Facility
IP
|
$7.74
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$7.19 |
| Rate for Payer: Aetna Commercial |
$6.68
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna All Commercial |
$6.68
|
| Rate for Payer: CORVEL All Commercial |
$7.19
|
| Rate for Payer: Coventry All Commercial |
$6.81
|
| Rate for Payer: Encore All Commercial |
$7.12
|
| Rate for Payer: Frontpath All Commercial |
$7.12
|
| Rate for Payer: Humana ChoiceCare |
$6.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.96
|
| Rate for Payer: PHCS All Commercial |
$5.80
|
| Rate for Payer: PHP All Commercial |
$5.87
|
| Rate for Payer: Sagamore Health Network All Products |
$5.97
|
| Rate for Payer: Signature Care EPO |
$6.42
|
| Rate for Payer: Signature Care PPO |
$6.81
|
| Rate for Payer: United Healthcare Commercial |
$6.10
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CREA
|
Facility
OP
|
$51.66
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$48.04 |
| Rate for Payer: Aetna Commercial |
$43.60
|
| Rate for Payer: Aetna Medicare |
$17.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.75
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Centivo All Commercial |
$26.35
|
| Rate for Payer: Cigna All Commercial |
$44.58
|
| Rate for Payer: CORVEL All Commercial |
$48.04
|
| Rate for Payer: Coventry All Commercial |
$45.46
|
| Rate for Payer: Encore All Commercial |
$47.55
|
| Rate for Payer: Frontpath All Commercial |
$47.53
|
| Rate for Payer: Humana ChoiceCare |
$44.62
|
| Rate for Payer: Humana Medicare |
$26.35
|
| Rate for Payer: Lucent All Commercial |
$26.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.49
|
| Rate for Payer: PHCS All Commercial |
$38.74
|
| Rate for Payer: PHP All Commercial |
$39.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.15
|
| Rate for Payer: Sagamore Health Network All Products |
$39.88
|
| Rate for Payer: Signature Care EPO |
$42.88
|
| Rate for Payer: Signature Care PPO |
$45.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.91
|
| Rate for Payer: United Healthcare Commercial |
$40.71
|
| Rate for Payer: United Healthcare Medicare |
$17.05
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TOP CREA
|
Facility
IP
|
$51.66
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$48.04 |
| Rate for Payer: Aetna Commercial |
$44.63
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Cigna All Commercial |
$44.58
|
| Rate for Payer: CORVEL All Commercial |
$48.04
|
| Rate for Payer: Coventry All Commercial |
$45.46
|
| Rate for Payer: Encore All Commercial |
$47.55
|
| Rate for Payer: Frontpath All Commercial |
$47.53
|
| Rate for Payer: Humana ChoiceCare |
$44.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.49
|
| Rate for Payer: PHCS All Commercial |
$38.74
|
| Rate for Payer: PHP All Commercial |
$39.18
|
| Rate for Payer: Sagamore Health Network All Products |
$39.88
|
| Rate for Payer: Signature Care EPO |
$42.88
|
| Rate for Payer: Signature Care PPO |
$45.46
|
| Rate for Payer: United Healthcare Commercial |
$40.71
|
|
