|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
OP
|
$280.10
|
|
|
Service Code
|
NDC 63323071210
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$260.49 |
| Rate for Payer: Aetna Commercial |
$236.40
|
| Rate for Payer: Aetna Medicare |
$89.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$86.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$160.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$98.59
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Centivo All Commercial |
$152.37
|
| Rate for Payer: Cigna All Commercial |
$241.72
|
| Rate for Payer: CORVEL All Commercial |
$260.49
|
| Rate for Payer: Coventry All Commercial |
$246.49
|
| Rate for Payer: Encore All Commercial |
$257.83
|
| Rate for Payer: Frontpath All Commercial |
$257.69
|
| Rate for Payer: Humana ChoiceCare |
$241.92
|
| Rate for Payer: Humana Medicare |
$89.63
|
| Rate for Payer: Lucent All Commercial |
$152.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.09
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$210.07
|
| Rate for Payer: PHP All Commercial |
$212.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.24
|
| Rate for Payer: Sagamore Health Network All Products |
$216.24
|
| Rate for Payer: Signature Care EPO |
$232.48
|
| Rate for Payer: Signature Care PPO |
$246.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$238.08
|
| Rate for Payer: United Healthcare Commercial |
$220.72
|
| Rate for Payer: United Healthcare Medicare |
$89.63
|
|
|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
OP
|
$344.90
|
|
|
Service Code
|
NDC 63323071220
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$320.76 |
| Rate for Payer: Aetna Commercial |
$291.10
|
| Rate for Payer: Aetna Medicare |
$110.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$198.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$215.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$126.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$121.41
|
| Rate for Payer: Cash Price |
$213.84
|
| Rate for Payer: Cash Price |
$213.84
|
| Rate for Payer: Centivo All Commercial |
$187.63
|
| Rate for Payer: Cigna All Commercial |
$297.65
|
| Rate for Payer: CORVEL All Commercial |
$320.76
|
| Rate for Payer: Coventry All Commercial |
$303.52
|
| Rate for Payer: Encore All Commercial |
$317.48
|
| Rate for Payer: Frontpath All Commercial |
$317.31
|
| Rate for Payer: Humana ChoiceCare |
$297.89
|
| Rate for Payer: Humana Medicare |
$110.37
|
| Rate for Payer: Lucent All Commercial |
$187.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.41
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$258.68
|
| Rate for Payer: PHP All Commercial |
$261.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$134.51
|
| Rate for Payer: Sagamore Health Network All Products |
$266.27
|
| Rate for Payer: Signature Care EPO |
$286.27
|
| Rate for Payer: Signature Care PPO |
$303.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$293.17
|
| Rate for Payer: United Healthcare Commercial |
$271.78
|
| Rate for Payer: United Healthcare Medicare |
$110.37
|
|
|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
IP
|
$304.92
|
|
|
Service Code
|
NDC 63323071215
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$228.69 |
| Max. Negotiated Rate |
$283.58 |
| Rate for Payer: Aetna Commercial |
$263.45
|
| Rate for Payer: Cash Price |
$189.05
|
| Rate for Payer: Cigna All Commercial |
$263.15
|
| Rate for Payer: CORVEL All Commercial |
$283.58
|
| Rate for Payer: Coventry All Commercial |
$268.33
|
| Rate for Payer: Encore All Commercial |
$280.68
|
| Rate for Payer: Frontpath All Commercial |
$280.53
|
| Rate for Payer: Humana ChoiceCare |
$263.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$274.43
|
| Rate for Payer: PHCS All Commercial |
$228.69
|
| Rate for Payer: PHP All Commercial |
$231.25
|
| Rate for Payer: Sagamore Health Network All Products |
$235.40
|
| Rate for Payer: Signature Care EPO |
$253.08
|
| Rate for Payer: Signature Care PPO |
$268.33
|
| Rate for Payer: United Healthcare Commercial |
$240.28
|
|
|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
OP
|
$304.92
|
|
|
Service Code
|
NDC 63323071215
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$283.58 |
| Rate for Payer: Aetna Commercial |
$257.35
|
| Rate for Payer: Aetna Medicare |
$97.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$94.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$175.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$190.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$112.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$107.33
|
| Rate for Payer: Cash Price |
$189.05
|
| Rate for Payer: Cash Price |
$189.05
|
| Rate for Payer: Centivo All Commercial |
$165.88
|
| Rate for Payer: Cigna All Commercial |
$263.15
|
| Rate for Payer: CORVEL All Commercial |
$283.58
|
| Rate for Payer: Coventry All Commercial |
$268.33
|
| Rate for Payer: Encore All Commercial |
$280.68
|
| Rate for Payer: Frontpath All Commercial |
$280.53
|
| Rate for Payer: Humana ChoiceCare |
$263.36
|
| Rate for Payer: Humana Medicare |
$97.57
|
| Rate for Payer: Lucent All Commercial |
$165.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$274.43
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$228.69
|
| Rate for Payer: PHP All Commercial |
$231.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$118.92
|
| Rate for Payer: Sagamore Health Network All Products |
$235.40
|
| Rate for Payer: Signature Care EPO |
$253.08
|
| Rate for Payer: Signature Care PPO |
$268.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$259.18
|
| Rate for Payer: United Healthcare Commercial |
$240.28
|
| Rate for Payer: United Healthcare Medicare |
$97.57
|
|
|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
IP
|
$280.10
|
|
|
Service Code
|
NDC 63323071210
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$210.07 |
| Max. Negotiated Rate |
$260.49 |
| Rate for Payer: Aetna Commercial |
$242.00
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Cigna All Commercial |
$241.72
|
| Rate for Payer: CORVEL All Commercial |
$260.49
|
| Rate for Payer: Coventry All Commercial |
$246.49
|
| Rate for Payer: Encore All Commercial |
$257.83
|
| Rate for Payer: Frontpath All Commercial |
$257.69
|
| Rate for Payer: Humana ChoiceCare |
$241.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.09
|
| Rate for Payer: PHCS All Commercial |
$210.07
|
| Rate for Payer: PHP All Commercial |
$212.43
|
| Rate for Payer: Sagamore Health Network All Products |
$216.24
|
| Rate for Payer: Signature Care EPO |
$232.48
|
| Rate for Payer: Signature Care PPO |
$246.49
|
| Rate for Payer: United Healthcare Commercial |
$220.72
|
|
|
AA 3.31 %-D10.8W-FATS-ELYTE 10 3.31-10.8-3.9 % IV EMUL
|
Facility
|
IP
|
$344.90
|
|
|
Service Code
|
NDC 63323071220
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$258.68 |
| Max. Negotiated Rate |
$320.76 |
| Rate for Payer: Aetna Commercial |
$298.00
|
| Rate for Payer: Cash Price |
$213.84
|
| Rate for Payer: Cigna All Commercial |
$297.65
|
| Rate for Payer: CORVEL All Commercial |
$320.76
|
| Rate for Payer: Coventry All Commercial |
$303.52
|
| Rate for Payer: Encore All Commercial |
$317.48
|
| Rate for Payer: Frontpath All Commercial |
$317.31
|
| Rate for Payer: Humana ChoiceCare |
$297.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.41
|
| Rate for Payer: PHCS All Commercial |
$258.68
|
| Rate for Payer: PHP All Commercial |
$261.58
|
| Rate for Payer: Sagamore Health Network All Products |
$266.27
|
| Rate for Payer: Signature Care EPO |
$286.27
|
| Rate for Payer: Signature Care PPO |
$303.52
|
| Rate for Payer: United Healthcare Commercial |
$271.78
|
|
|
AA 4.25 % NO.1-DEXTROSE 5 % 4.25 % IV SOLP
|
Facility
|
OP
|
$468.00
|
|
|
Service Code
|
NDC 00338108904
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$435.24 |
| Rate for Payer: Aetna Commercial |
$394.99
|
| Rate for Payer: Aetna Medicare |
$149.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$145.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$268.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$292.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$172.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$164.74
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Centivo All Commercial |
$254.59
|
| Rate for Payer: Cigna All Commercial |
$403.88
|
| Rate for Payer: CORVEL All Commercial |
$435.24
|
| Rate for Payer: Coventry All Commercial |
$411.84
|
| Rate for Payer: Encore All Commercial |
$430.79
|
| Rate for Payer: Frontpath All Commercial |
$430.56
|
| Rate for Payer: Humana ChoiceCare |
$404.21
|
| Rate for Payer: Humana Medicare |
$149.76
|
| Rate for Payer: Lucent All Commercial |
$254.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$421.20
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$351.00
|
| Rate for Payer: PHP All Commercial |
$354.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$182.52
|
| Rate for Payer: Sagamore Health Network All Products |
$361.30
|
| Rate for Payer: Signature Care EPO |
$388.44
|
| Rate for Payer: Signature Care PPO |
$411.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$397.80
|
| Rate for Payer: United Healthcare Commercial |
$368.78
|
| Rate for Payer: United Healthcare Medicare |
$149.76
|
|
|
AA 4.25 % NO.1-DEXTROSE 5 % 4.25 % IV SOLP
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
NDC 00338113303
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$242.23
|
| Rate for Payer: Aetna Medicare |
$91.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$164.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$179.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$105.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.02
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Centivo All Commercial |
$156.13
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Humana Medicare |
$91.84
|
| Rate for Payer: Lucent All Commercial |
$156.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$111.93
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$243.95
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
| Rate for Payer: United Healthcare Medicare |
$91.84
|
|
|
AA 4.25 % NO.1-DEXTROSE 5 % 4.25 % IV SOLP
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
NDC 00338113303
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$215.25 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$247.97
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
|
|
AA 4.25 % NO.1-DEXTROSE 5 % 4.25 % IV SOLP
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
NDC 00338108904
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$435.24 |
| Rate for Payer: Aetna Commercial |
$404.35
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Cigna All Commercial |
$403.88
|
| Rate for Payer: CORVEL All Commercial |
$435.24
|
| Rate for Payer: Coventry All Commercial |
$411.84
|
| Rate for Payer: Encore All Commercial |
$430.79
|
| Rate for Payer: Frontpath All Commercial |
$430.56
|
| Rate for Payer: Humana ChoiceCare |
$404.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$421.20
|
| Rate for Payer: PHCS All Commercial |
$351.00
|
| Rate for Payer: PHP All Commercial |
$354.93
|
| Rate for Payer: Sagamore Health Network All Products |
$361.30
|
| Rate for Payer: Signature Care EPO |
$388.44
|
| Rate for Payer: Signature Care PPO |
$411.84
|
| Rate for Payer: United Healthcare Commercial |
$368.78
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG IV SOLR
|
Facility
|
IP
|
$5,165.41
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
70287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,874.05 |
| Max. Negotiated Rate |
$4,803.83 |
| Rate for Payer: Aetna Commercial |
$4,462.91
|
| Rate for Payer: Cash Price |
$3,202.55
|
| Rate for Payer: Cigna All Commercial |
$4,457.74
|
| Rate for Payer: CORVEL All Commercial |
$4,803.83
|
| Rate for Payer: Coventry All Commercial |
$4,545.56
|
| Rate for Payer: Encore All Commercial |
$4,754.76
|
| Rate for Payer: Frontpath All Commercial |
$4,752.17
|
| Rate for Payer: Humana ChoiceCare |
$4,461.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,648.86
|
| Rate for Payer: PHCS All Commercial |
$3,874.05
|
| Rate for Payer: PHP All Commercial |
$3,917.44
|
| Rate for Payer: Sagamore Health Network All Products |
$3,987.69
|
| Rate for Payer: Signature Care EPO |
$4,287.29
|
| Rate for Payer: Signature Care PPO |
$4,545.56
|
| Rate for Payer: United Healthcare Commercial |
$4,070.34
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG IV SOLR
|
Facility
|
OP
|
$5,165.41
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
70287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.57 |
| Max. Negotiated Rate |
$4,803.83 |
| Rate for Payer: Aetna Commercial |
$4,359.60
|
| Rate for Payer: Aetna Medicare |
$1,652.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$63.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,601.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,966.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,228.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$63.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,900.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,818.22
|
| Rate for Payer: Cash Price |
$3,202.55
|
| Rate for Payer: Cash Price |
$3,202.55
|
| Rate for Payer: Centivo All Commercial |
$2,809.98
|
| Rate for Payer: Cigna All Commercial |
$4,457.74
|
| Rate for Payer: CORVEL All Commercial |
$4,803.83
|
| Rate for Payer: Coventry All Commercial |
$4,545.56
|
| Rate for Payer: Encore All Commercial |
$4,754.76
|
| Rate for Payer: Frontpath All Commercial |
$4,752.17
|
| Rate for Payer: Humana ChoiceCare |
$4,461.36
|
| Rate for Payer: Humana Medicare |
$1,652.93
|
| Rate for Payer: Lucent All Commercial |
$2,809.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,648.86
|
| Rate for Payer: Managed Health Services Medicaid |
$63.57
|
| Rate for Payer: MDWise Medicaid |
$63.57
|
| Rate for Payer: PHCS All Commercial |
$3,874.05
|
| Rate for Payer: PHP All Commercial |
$3,917.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,014.51
|
| Rate for Payer: Sagamore Health Network All Products |
$3,987.69
|
| Rate for Payer: Signature Care EPO |
$4,287.29
|
| Rate for Payer: Signature Care PPO |
$4,545.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,390.59
|
| Rate for Payer: United Healthcare Commercial |
$4,070.34
|
| Rate for Payer: United Healthcare Medicare |
$1,652.93
|
|
|
ACAMPROSATE 333 MG ORAL TBEC
|
Facility
|
IP
|
$3.63
|
|
|
Service Code
|
NDC 68462043518
|
| Hospital Charge Code |
39720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.14
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna All Commercial |
$3.14
|
| Rate for Payer: CORVEL All Commercial |
$3.38
|
| Rate for Payer: Coventry All Commercial |
$3.20
|
| Rate for Payer: Encore All Commercial |
$3.34
|
| Rate for Payer: Frontpath All Commercial |
$3.34
|
| Rate for Payer: Humana ChoiceCare |
$3.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.27
|
| Rate for Payer: PHCS All Commercial |
$2.72
|
| Rate for Payer: PHP All Commercial |
$2.76
|
| Rate for Payer: Sagamore Health Network All Products |
$2.80
|
| Rate for Payer: Signature Care EPO |
$3.02
|
| Rate for Payer: Signature Care PPO |
$3.20
|
| Rate for Payer: United Healthcare Commercial |
$2.86
|
|
|
ACAMPROSATE 333 MG ORAL TBEC
|
Facility
|
OP
|
$3.63
|
|
|
Service Code
|
NDC 68462043518
|
| Hospital Charge Code |
39720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Aetna Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Centivo All Commercial |
$1.98
|
| Rate for Payer: Cigna All Commercial |
$3.14
|
| Rate for Payer: CORVEL All Commercial |
$3.38
|
| Rate for Payer: Coventry All Commercial |
$3.20
|
| Rate for Payer: Encore All Commercial |
$3.34
|
| Rate for Payer: Frontpath All Commercial |
$3.34
|
| Rate for Payer: Humana ChoiceCare |
$3.14
|
| Rate for Payer: Humana Medicare |
$1.16
|
| Rate for Payer: Lucent All Commercial |
$1.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.27
|
| Rate for Payer: PHCS All Commercial |
$2.72
|
| Rate for Payer: PHP All Commercial |
$2.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.42
|
| Rate for Payer: Sagamore Health Network All Products |
$2.80
|
| Rate for Payer: Signature Care EPO |
$3.02
|
| Rate for Payer: Signature Care PPO |
$3.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.09
|
| Rate for Payer: United Healthcare Commercial |
$2.86
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
|
|
ACETAMINOPHEN 10 MG/ML IV SOLN
|
Facility
|
IP
|
$39.90
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
108021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.93 |
| Max. Negotiated Rate |
$37.11 |
| Rate for Payer: Aetna Commercial |
$34.47
|
| Rate for Payer: Cash Price |
$24.74
|
| Rate for Payer: Cigna All Commercial |
$34.43
|
| Rate for Payer: CORVEL All Commercial |
$37.11
|
| Rate for Payer: Coventry All Commercial |
$35.11
|
| Rate for Payer: Encore All Commercial |
$36.73
|
| Rate for Payer: Frontpath All Commercial |
$36.71
|
| Rate for Payer: Humana ChoiceCare |
$34.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.91
|
| Rate for Payer: PHCS All Commercial |
$29.93
|
| Rate for Payer: PHP All Commercial |
$30.26
|
| Rate for Payer: Sagamore Health Network All Products |
$30.80
|
| Rate for Payer: Signature Care EPO |
$33.12
|
| Rate for Payer: Signature Care PPO |
$35.11
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
|
|
ACETAMINOPHEN 10 MG/ML IV SOLN
|
Facility
|
OP
|
$39.90
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.37 |
| Max. Negotiated Rate |
$37.11 |
| Rate for Payer: Aetna Commercial |
$33.68
|
| Rate for Payer: Aetna Medicare |
$12.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.04
|
| Rate for Payer: Cash Price |
$24.74
|
| Rate for Payer: Centivo All Commercial |
$21.71
|
| Rate for Payer: Cigna All Commercial |
$34.43
|
| Rate for Payer: CORVEL All Commercial |
$37.11
|
| Rate for Payer: Coventry All Commercial |
$35.11
|
| Rate for Payer: Encore All Commercial |
$36.73
|
| Rate for Payer: Frontpath All Commercial |
$36.71
|
| Rate for Payer: Humana ChoiceCare |
$34.46
|
| Rate for Payer: Humana Medicare |
$12.77
|
| Rate for Payer: Lucent All Commercial |
$21.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.91
|
| Rate for Payer: PHCS All Commercial |
$29.93
|
| Rate for Payer: PHP All Commercial |
$30.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.56
|
| Rate for Payer: Sagamore Health Network All Products |
$30.80
|
| Rate for Payer: Signature Care EPO |
$33.12
|
| Rate for Payer: Signature Care PPO |
$35.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.91
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
| Rate for Payer: United Healthcare Medicare |
$12.77
|
|
|
ACETAMINOPHEN 120 MG RECT SUPP
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.96
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.58
|
| Rate for Payer: PHCS All Commercial |
$1.32
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.49
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
ACETAMINOPHEN 120 MG RECT SUPP
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.52
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.55
|
| Rate for Payer: Encore All Commercial |
$1.62
|
| Rate for Payer: Frontpath All Commercial |
$1.62
|
| Rate for Payer: Humana ChoiceCare |
$1.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.58
|
| Rate for Payer: PHCS All Commercial |
$1.32
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$1.36
|
| Rate for Payer: Signature Care EPO |
$1.46
|
| Rate for Payer: Signature Care PPO |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLN
|
Facility
|
OP
|
$8.03
|
|
|
Service Code
|
NDC 81033000240
|
| Hospital Charge Code |
120837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna Commercial |
$6.78
|
| Rate for Payer: Aetna Medicare |
$2.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.83
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Centivo All Commercial |
$4.37
|
| Rate for Payer: Cigna All Commercial |
$6.93
|
| Rate for Payer: CORVEL All Commercial |
$7.47
|
| Rate for Payer: Coventry All Commercial |
$7.07
|
| Rate for Payer: Encore All Commercial |
$7.39
|
| Rate for Payer: Frontpath All Commercial |
$7.39
|
| Rate for Payer: Humana ChoiceCare |
$6.93
|
| Rate for Payer: Humana Medicare |
$2.57
|
| Rate for Payer: Lucent All Commercial |
$4.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.23
|
| Rate for Payer: PHCS All Commercial |
$6.02
|
| Rate for Payer: PHP All Commercial |
$6.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.13
|
| Rate for Payer: Sagamore Health Network All Products |
$6.20
|
| Rate for Payer: Signature Care EPO |
$6.66
|
| Rate for Payer: Signature Care PPO |
$7.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.82
|
| Rate for Payer: United Healthcare Commercial |
$6.33
|
| Rate for Payer: United Healthcare Medicare |
$2.57
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLN
|
Facility
|
IP
|
$8.03
|
|
|
Service Code
|
NDC 81033000240
|
| Hospital Charge Code |
120837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Cigna All Commercial |
$6.93
|
| Rate for Payer: CORVEL All Commercial |
$7.47
|
| Rate for Payer: Coventry All Commercial |
$7.07
|
| Rate for Payer: Encore All Commercial |
$7.39
|
| Rate for Payer: Frontpath All Commercial |
$7.39
|
| Rate for Payer: Humana ChoiceCare |
$6.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.23
|
| Rate for Payer: PHCS All Commercial |
$6.02
|
| Rate for Payer: PHP All Commercial |
$6.09
|
| Rate for Payer: Sagamore Health Network All Products |
$6.20
|
| Rate for Payer: Signature Care EPO |
$6.66
|
| Rate for Payer: Signature Care PPO |
$7.07
|
| Rate for Payer: United Healthcare Commercial |
$6.33
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSP
|
Facility
|
OP
|
$8.74
|
|
|
Service Code
|
NDC 00121188211
|
| Hospital Charge Code |
88504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.13 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Aetna Medicare |
$2.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.08
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Centivo All Commercial |
$4.75
|
| Rate for Payer: Cigna All Commercial |
$7.54
|
| Rate for Payer: CORVEL All Commercial |
$8.13
|
| Rate for Payer: Coventry All Commercial |
$7.69
|
| Rate for Payer: Encore All Commercial |
$8.05
|
| Rate for Payer: Frontpath All Commercial |
$8.04
|
| Rate for Payer: Humana ChoiceCare |
$7.55
|
| Rate for Payer: Humana Medicare |
$2.80
|
| Rate for Payer: Lucent All Commercial |
$4.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.87
|
| Rate for Payer: PHCS All Commercial |
$6.55
|
| Rate for Payer: PHP All Commercial |
$6.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.41
|
| Rate for Payer: Sagamore Health Network All Products |
$6.75
|
| Rate for Payer: Signature Care EPO |
$7.25
|
| Rate for Payer: Signature Care PPO |
$7.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.43
|
| Rate for Payer: United Healthcare Commercial |
$6.89
|
| Rate for Payer: United Healthcare Medicare |
$2.80
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSP
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
NDC 00121188211
|
| Hospital Charge Code |
88504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$8.13 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna All Commercial |
$7.54
|
| Rate for Payer: CORVEL All Commercial |
$8.13
|
| Rate for Payer: Coventry All Commercial |
$7.69
|
| Rate for Payer: Encore All Commercial |
$8.05
|
| Rate for Payer: Frontpath All Commercial |
$8.04
|
| Rate for Payer: Humana ChoiceCare |
$7.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.87
|
| Rate for Payer: PHCS All Commercial |
$6.55
|
| Rate for Payer: PHP All Commercial |
$6.63
|
| Rate for Payer: Sagamore Health Network All Products |
$6.75
|
| Rate for Payer: Signature Care EPO |
$7.25
|
| Rate for Payer: Signature Care PPO |
$7.69
|
| Rate for Payer: United Healthcare Commercial |
$6.89
|
|
|
ACETAMINOPHEN 325 MG ORAL TAB
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 50580045811
|
| Hospital Charge Code |
101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna All Commercial |
$0.35
|
| Rate for Payer: CORVEL All Commercial |
$0.38
|
| Rate for Payer: Coventry All Commercial |
$0.36
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.37
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.31
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.34
|
| Rate for Payer: Signature Care PPO |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
|
|
ACETAMINOPHEN 325 MG ORAL TAB
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 50580045811
|
| Hospital Charge Code |
101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Centivo All Commercial |
$0.22
|
| Rate for Payer: Cigna All Commercial |
$0.35
|
| Rate for Payer: CORVEL All Commercial |
$0.38
|
| Rate for Payer: Coventry All Commercial |
$0.36
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.35
|
| Rate for Payer: Humana Medicare |
$0.13
|
| Rate for Payer: Lucent All Commercial |
$0.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.37
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.16
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.34
|
| Rate for Payer: Signature Care PPO |
$0.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
|
|
ACETAMINOPHEN 325 MG RECT SUPP
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$4.05
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Cigna All Commercial |
$4.05
|
| Rate for Payer: CORVEL All Commercial |
$4.36
|
| Rate for Payer: Coventry All Commercial |
$4.13
|
| Rate for Payer: Encore All Commercial |
$4.32
|
| Rate for Payer: Frontpath All Commercial |
$4.31
|
| Rate for Payer: Humana ChoiceCare |
$4.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.22
|
| Rate for Payer: PHCS All Commercial |
$3.52
|
| Rate for Payer: PHP All Commercial |
$3.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.62
|
| Rate for Payer: Signature Care EPO |
$3.89
|
| Rate for Payer: Signature Care PPO |
$4.13
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
|
