|
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 |
$74.57 |
| Max. Negotiated Rate |
$260.49 |
| Rate for Payer: Aetna Commercial |
$236.40
|
| Rate for Payer: Aetna Medicare |
$92.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$92.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$160.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.68
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Centivo All Commercial |
$142.85
|
| 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 |
$142.85
|
| Rate for Payer: Lucent All Commercial |
$142.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.09
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| 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 |
$92.43
|
|
|
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 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
|
$344.90
|
|
|
Service Code
|
NDC 63323071220
|
| Hospital Charge Code |
205594
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$74.57 |
| Max. Negotiated Rate |
$320.76 |
| Rate for Payer: Aetna Commercial |
$291.10
|
| Rate for Payer: Aetna Medicare |
$113.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$113.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$198.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$215.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$130.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$125.20
|
| Rate for Payer: Cash Price |
$213.84
|
| Rate for Payer: Cash Price |
$213.84
|
| Rate for Payer: Centivo All Commercial |
$175.90
|
| 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 |
$175.90
|
| Rate for Payer: Lucent All Commercial |
$175.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.41
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| 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 |
$113.82
|
|
|
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 |
$74.57 |
| Max. Negotiated Rate |
$283.58 |
| Rate for Payer: Aetna Commercial |
$257.35
|
| Rate for Payer: Aetna Medicare |
$100.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$175.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$190.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.69
|
| Rate for Payer: Cash Price |
$189.05
|
| Rate for Payer: Cash Price |
$189.05
|
| Rate for Payer: Centivo All Commercial |
$155.51
|
| 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 |
$155.51
|
| Rate for Payer: Lucent All Commercial |
$155.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$274.43
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| 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 |
$100.62
|
|
|
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
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG IV SOLR
|
Facility
IP
|
$4,990.72
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
70287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,743.04 |
| Max. Negotiated Rate |
$4,641.37 |
| Rate for Payer: Aetna Commercial |
$4,311.98
|
| Rate for Payer: Cash Price |
$3,094.25
|
| Rate for Payer: Cigna All Commercial |
$4,306.99
|
| Rate for Payer: CORVEL All Commercial |
$4,641.37
|
| Rate for Payer: Coventry All Commercial |
$4,391.83
|
| Rate for Payer: Encore All Commercial |
$4,593.96
|
| Rate for Payer: Frontpath All Commercial |
$4,591.46
|
| Rate for Payer: Humana ChoiceCare |
$4,310.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,491.65
|
| Rate for Payer: PHCS All Commercial |
$3,743.04
|
| Rate for Payer: PHP All Commercial |
$3,784.96
|
| Rate for Payer: Sagamore Health Network All Products |
$3,852.84
|
| Rate for Payer: Signature Care EPO |
$4,142.30
|
| Rate for Payer: Signature Care PPO |
$4,391.83
|
| Rate for Payer: United Healthcare Commercial |
$3,932.69
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG IV SOLR
|
Facility
OP
|
$4,990.72
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
70287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.96 |
| Max. Negotiated Rate |
$4,641.37 |
| Rate for Payer: Aetna Commercial |
$4,212.17
|
| Rate for Payer: Aetna Medicare |
$1,646.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,646.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,866.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,119.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$57.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,893.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,811.63
|
| Rate for Payer: Cash Price |
$3,094.25
|
| Rate for Payer: Cash Price |
$3,094.25
|
| Rate for Payer: Centivo All Commercial |
$2,545.27
|
| Rate for Payer: Cigna All Commercial |
$4,306.99
|
| Rate for Payer: CORVEL All Commercial |
$4,641.37
|
| Rate for Payer: Coventry All Commercial |
$4,391.83
|
| Rate for Payer: Encore All Commercial |
$4,593.96
|
| Rate for Payer: Frontpath All Commercial |
$4,591.46
|
| Rate for Payer: Humana ChoiceCare |
$4,310.48
|
| Rate for Payer: Humana Medicare |
$2,545.27
|
| Rate for Payer: Lucent All Commercial |
$2,545.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,491.65
|
| Rate for Payer: Managed Health Services Medicaid |
$57.96
|
| Rate for Payer: MDWise Medicaid |
$57.96
|
| Rate for Payer: PHCS All Commercial |
$3,743.04
|
| Rate for Payer: PHP All Commercial |
$3,784.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,946.38
|
| Rate for Payer: Sagamore Health Network All Products |
$3,852.84
|
| Rate for Payer: Signature Care EPO |
$4,142.30
|
| Rate for Payer: Signature Care PPO |
$4,391.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,242.11
|
| Rate for Payer: United Healthcare Commercial |
$3,932.69
|
| Rate for Payer: United Healthcare Medicare |
$1,646.94
|
|
|
Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance
|
Facility
OP
|
$1,283.57
|
|
|
Service Code
|
CPT 49083
|
| Hospital Charge Code |
CPT-49083
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,283.57 |
| Max. Negotiated Rate |
$1,283.57 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,283.57
|
| Rate for Payer: Managed Health Services Medicaid |
$1,283.57
|
| Rate for Payer: MDWise Medicaid |
$1,283.57
|
|
|
ACAMPROSATE 333 MG ORAL TBEC
|
Facility
OP
|
$13.95
|
|
|
Service Code
|
NDC 60687012125
|
| Hospital Charge Code |
39720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Aetna Commercial |
$11.77
|
| Rate for Payer: Aetna Medicare |
$4.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.06
|
| Rate for Payer: Cash Price |
$8.65
|
| Rate for Payer: Centivo All Commercial |
$7.12
|
| Rate for Payer: Cigna All Commercial |
$12.04
|
| Rate for Payer: CORVEL All Commercial |
$12.97
|
| Rate for Payer: Coventry All Commercial |
$12.28
|
| Rate for Payer: Encore All Commercial |
$12.84
|
| Rate for Payer: Frontpath All Commercial |
$12.83
|
| Rate for Payer: Humana ChoiceCare |
$12.05
|
| Rate for Payer: Humana Medicare |
$7.12
|
| Rate for Payer: Lucent All Commercial |
$7.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.56
|
| Rate for Payer: PHCS All Commercial |
$10.46
|
| Rate for Payer: PHP All Commercial |
$10.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.44
|
| Rate for Payer: Sagamore Health Network All Products |
$10.77
|
| Rate for Payer: Signature Care EPO |
$11.58
|
| Rate for Payer: Signature Care PPO |
$12.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.86
|
| Rate for Payer: United Healthcare Commercial |
$10.99
|
| Rate for Payer: United Healthcare Medicare |
$4.60
|
|
|
ACAMPROSATE 333 MG ORAL TBEC
|
Facility
IP
|
$13.95
|
|
|
Service Code
|
NDC 60687012125
|
| Hospital Charge Code |
39720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: Cash Price |
$8.65
|
| Rate for Payer: Cigna All Commercial |
$12.04
|
| Rate for Payer: CORVEL All Commercial |
$12.97
|
| Rate for Payer: Coventry All Commercial |
$12.28
|
| Rate for Payer: Encore All Commercial |
$12.84
|
| Rate for Payer: Frontpath All Commercial |
$12.83
|
| Rate for Payer: Humana ChoiceCare |
$12.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.56
|
| Rate for Payer: PHCS All Commercial |
$10.46
|
| Rate for Payer: PHP All Commercial |
$10.58
|
| Rate for Payer: Sagamore Health Network All Products |
$10.77
|
| Rate for Payer: Signature Care EPO |
$11.58
|
| Rate for Payer: Signature Care PPO |
$12.28
|
| Rate for Payer: United Healthcare Commercial |
$10.99
|
|
|
ACETAMINOPHEN 10 MG/ML IV SOLN
|
Facility
OP
|
$40.60
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
108021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$37.76 |
| Rate for Payer: Aetna Commercial |
$34.27
|
| Rate for Payer: Aetna Medicare |
$13.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.74
|
| Rate for Payer: Cash Price |
$25.17
|
| Rate for Payer: Centivo All Commercial |
$20.71
|
| Rate for Payer: Cigna All Commercial |
$35.04
|
| Rate for Payer: CORVEL All Commercial |
$37.76
|
| Rate for Payer: Coventry All Commercial |
$35.73
|
| Rate for Payer: Encore All Commercial |
$37.37
|
| Rate for Payer: Frontpath All Commercial |
$37.35
|
| Rate for Payer: Humana ChoiceCare |
$35.07
|
| Rate for Payer: Humana Medicare |
$20.71
|
| Rate for Payer: Lucent All Commercial |
$20.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.54
|
| Rate for Payer: PHCS All Commercial |
$30.45
|
| Rate for Payer: PHP All Commercial |
$30.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.83
|
| Rate for Payer: Sagamore Health Network All Products |
$31.34
|
| Rate for Payer: Signature Care EPO |
$33.70
|
| Rate for Payer: Signature Care PPO |
$35.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34.51
|
| Rate for Payer: United Healthcare Commercial |
$31.99
|
| Rate for Payer: United Healthcare Medicare |
$13.40
|
|
|
ACETAMINOPHEN 10 MG/ML IV SOLN
|
Facility
IP
|
$40.60
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
108021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.45 |
| Max. Negotiated Rate |
$37.76 |
| Rate for Payer: Aetna Commercial |
$35.08
|
| Rate for Payer: Cash Price |
$25.17
|
| Rate for Payer: Cigna All Commercial |
$35.04
|
| Rate for Payer: CORVEL All Commercial |
$37.76
|
| Rate for Payer: Coventry All Commercial |
$35.73
|
| Rate for Payer: Encore All Commercial |
$37.37
|
| Rate for Payer: Frontpath All Commercial |
$37.35
|
| Rate for Payer: Humana ChoiceCare |
$35.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.54
|
| Rate for Payer: PHCS All Commercial |
$30.45
|
| Rate for Payer: PHP All Commercial |
$30.79
|
| Rate for Payer: Sagamore Health Network All Products |
$31.34
|
| Rate for Payer: Signature Care EPO |
$33.70
|
| Rate for Payer: Signature Care PPO |
$35.73
|
| Rate for Payer: United Healthcare Commercial |
$31.99
|
|
|
ACETAMINOPHEN 120 MG RECT SUPP
|
Facility
OP
|
$1.76
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| 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 |
$0.90
|
| Rate for Payer: Lucent All Commercial |
$0.90
|
| 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 |
$0.58
|
|
|
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
IP
|
$7.89
|
|
|
Service Code
|
NDC 81033000240
|
| Hospital Charge Code |
120837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.81
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Cigna All Commercial |
$6.81
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.26
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.10
|
| Rate for Payer: PHCS All Commercial |
$5.92
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$6.09
|
| Rate for Payer: Signature Care EPO |
$6.55
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLN
|
Facility
OP
|
$7.89
|
|
|
Service Code
|
NDC 81033000240
|
| Hospital Charge Code |
120837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.66
|
| Rate for Payer: Aetna Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Centivo All Commercial |
$4.02
|
| Rate for Payer: Cigna All Commercial |
$6.81
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.26
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Lucent All Commercial |
$4.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.10
|
| Rate for Payer: PHCS All Commercial |
$5.92
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.08
|
| Rate for Payer: Sagamore Health Network All Products |
$6.09
|
| Rate for Payer: Signature Care EPO |
$6.55
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.70
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
| Rate for Payer: United Healthcare Medicare |
$2.60
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSP
|
Facility
IP
|
$8.17
|
|
|
Service Code
|
NDC 00121188211
|
| Hospital Charge Code |
88504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.13 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.06
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna All Commercial |
$7.05
|
| Rate for Payer: CORVEL All Commercial |
$7.60
|
| Rate for Payer: Coventry All Commercial |
$7.19
|
| Rate for Payer: Encore All Commercial |
$7.52
|
| Rate for Payer: Frontpath All Commercial |
$7.52
|
| Rate for Payer: Humana ChoiceCare |
$7.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.35
|
| Rate for Payer: PHCS All Commercial |
$6.13
|
| Rate for Payer: PHP All Commercial |
$6.20
|
| Rate for Payer: Sagamore Health Network All Products |
$6.31
|
| Rate for Payer: Signature Care EPO |
$6.78
|
| Rate for Payer: Signature Care PPO |
$7.19
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
|
|
ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSP
|
Facility
OP
|
$8.17
|
|
|
Service Code
|
NDC 00121188211
|
| Hospital Charge Code |
88504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$6.90
|
| Rate for Payer: Aetna Medicare |
$2.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.97
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Centivo All Commercial |
$4.17
|
| Rate for Payer: Cigna All Commercial |
$7.05
|
| Rate for Payer: CORVEL All Commercial |
$7.60
|
| Rate for Payer: Coventry All Commercial |
$7.19
|
| Rate for Payer: Encore All Commercial |
$7.52
|
| Rate for Payer: Frontpath All Commercial |
$7.52
|
| Rate for Payer: Humana ChoiceCare |
$7.06
|
| Rate for Payer: Humana Medicare |
$4.17
|
| Rate for Payer: Lucent All Commercial |
$4.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.35
|
| Rate for Payer: PHCS All Commercial |
$6.13
|
| Rate for Payer: PHP All Commercial |
$6.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.19
|
| Rate for Payer: Sagamore Health Network All Products |
$6.31
|
| Rate for Payer: Signature Care EPO |
$6.78
|
| Rate for Payer: Signature Care PPO |
$7.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.95
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
| Rate for Payer: United Healthcare Medicare |
$2.70
|
|
|
ACETAMINOPHEN 325 MG ORAL TAB
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 50580045811
|
| Hospital Charge Code |
101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna All Commercial |
$0.29
|
| Rate for Payer: CORVEL All Commercial |
$0.31
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.31
|
| Rate for Payer: Frontpath All Commercial |
$0.31
|
| Rate for Payer: Humana ChoiceCare |
$0.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.30
|
| Rate for Payer: PHCS All Commercial |
$0.25
|
| Rate for Payer: PHP All Commercial |
$0.25
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.26
|
|
|
ACETAMINOPHEN 325 MG ORAL TAB
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 50580045811
|
| Hospital Charge Code |
101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna Commercial |
$0.28
|
| Rate for Payer: Aetna Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Centivo All Commercial |
$0.17
|
| Rate for Payer: Cigna All Commercial |
$0.29
|
| Rate for Payer: CORVEL All Commercial |
$0.31
|
| Rate for Payer: Coventry All Commercial |
$0.30
|
| Rate for Payer: Encore All Commercial |
$0.31
|
| Rate for Payer: Frontpath All Commercial |
$0.31
|
| Rate for Payer: Humana ChoiceCare |
$0.29
|
| Rate for Payer: Humana Medicare |
$0.17
|
| Rate for Payer: Lucent All Commercial |
$0.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.30
|
| Rate for Payer: PHCS All Commercial |
$0.25
|
| Rate for Payer: PHP All Commercial |
$0.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.13
|
| Rate for Payer: Sagamore Health Network All Products |
$0.26
|
| Rate for Payer: Signature Care EPO |
$0.28
|
| Rate for Payer: Signature Care PPO |
$0.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.26
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
|
|
ACETAMINOPHEN 325 MG RECT SUPP
|
Facility
OP
|
$4.59
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Aetna Medicare |
$1.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Centivo All Commercial |
$2.34
|
| Rate for Payer: Cigna All Commercial |
$3.96
|
| Rate for Payer: CORVEL All Commercial |
$4.26
|
| Rate for Payer: Coventry All Commercial |
$4.03
|
| Rate for Payer: Encore All Commercial |
$4.22
|
| Rate for Payer: Frontpath All Commercial |
$4.22
|
| Rate for Payer: Humana ChoiceCare |
$3.96
|
| Rate for Payer: Humana Medicare |
$2.34
|
| Rate for Payer: Lucent All Commercial |
$2.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.13
|
| Rate for Payer: PHCS All Commercial |
$3.44
|
| Rate for Payer: PHP All Commercial |
$3.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.79
|
| Rate for Payer: Sagamore Health Network All Products |
$3.54
|
| Rate for Payer: Signature Care EPO |
$3.81
|
| Rate for Payer: Signature Care PPO |
$4.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.90
|
| Rate for Payer: United Healthcare Commercial |
$3.61
|
| Rate for Payer: United Healthcare Medicare |
$1.51
|
|
|
ACETAMINOPHEN 325 MG RECT SUPP
|
Facility
IP
|
$4.59
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna All Commercial |
$3.96
|
| Rate for Payer: CORVEL All Commercial |
$4.26
|
| Rate for Payer: Coventry All Commercial |
$4.03
|
| Rate for Payer: Encore All Commercial |
$4.22
|
| Rate for Payer: Frontpath All Commercial |
$4.22
|
| Rate for Payer: Humana ChoiceCare |
$3.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.13
|
| Rate for Payer: PHCS All Commercial |
$3.44
|
| Rate for Payer: PHP All Commercial |
$3.48
|
| Rate for Payer: Sagamore Health Network All Products |
$3.54
|
| Rate for Payer: Signature Care EPO |
$3.81
|
| Rate for Payer: Signature Care PPO |
$4.03
|
| Rate for Payer: United Healthcare Commercial |
$3.61
|
|
|
ACETAMINOPHEN 500 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 50580045711
|
| Hospital Charge Code |
102
|
|
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
|
|
|
ACETAMINOPHEN 500 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 50580045711
|
| Hospital Charge Code |
102
|
|
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
|
|
