|
APR-DRG 42.00: VERTIGO AND OTHER LABYRINTH DISORDERS
|
Facility
|
IP
|
$7,348.73
|
|
|
Service Code
|
APR-DRG 1114
|
| Min. Negotiated Rate |
$2,537.10 |
| Max. Negotiated Rate |
$7,348.73 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$7,348.73
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$7,348.73
|
|
|
APR-DRG 42.00: VERTIGO AND OTHER LABYRINTH DISORDERS
|
Facility
|
IP
|
$4,236.32
|
|
|
Service Code
|
APR-DRG 1113
|
| Min. Negotiated Rate |
$2,537.10 |
| Max. Negotiated Rate |
$4,236.32 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$4,236.32
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$4,236.32
|
|
|
APR-DRG 42.00: VERTIGO AND OTHER LABYRINTH DISORDERS
|
Facility
|
IP
|
$3,242.09
|
|
|
Service Code
|
APR-DRG 1112
|
| Min. Negotiated Rate |
$2,537.10 |
| Max. Negotiated Rate |
$3,242.09 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$3,242.09
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$3,242.09
|
|
|
APR-DRG 42.00: VIRAL ILLNESS
|
Facility
|
IP
|
$1,902.02
|
|
|
Service Code
|
APR-DRG 7231
|
| Min. Negotiated Rate |
$1,303.79 |
| Max. Negotiated Rate |
$1,902.02 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,902.02
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$1,902.02
|
|
|
APR-DRG 42.00: VIRAL ILLNESS
|
Facility
|
IP
|
$8,645.56
|
|
|
Service Code
|
APR-DRG 7234
|
| Min. Negotiated Rate |
$6,272.27 |
| Max. Negotiated Rate |
$8,645.56 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$8,645.56
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$8,645.56
|
|
|
APR-DRG 42.00: VIRAL ILLNESS
|
Facility
|
IP
|
$2,723.35
|
|
|
Service Code
|
APR-DRG 7232
|
| Min. Negotiated Rate |
$1,867.59 |
| Max. Negotiated Rate |
$2,723.35 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$2,723.35
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$2,723.35
|
|
|
APR-DRG 42.00: VIRAL ILLNESS
|
Facility
|
IP
|
$4,495.69
|
|
|
Service Code
|
APR-DRG 7233
|
| Min. Negotiated Rate |
$3,312.32 |
| Max. Negotiated Rate |
$4,495.69 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$4,495.69
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$4,495.69
|
|
|
APR-DRG 42.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$9,510.12
|
|
|
Service Code
|
APR-DRG 0514
|
| Min. Negotiated Rate |
$4,757.06 |
| Max. Negotiated Rate |
$9,510.12 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$9,510.12
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$9,510.12
|
|
|
APR-DRG 42.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$3,804.05
|
|
|
Service Code
|
APR-DRG 0512
|
| Min. Negotiated Rate |
$2,219.96 |
| Max. Negotiated Rate |
$3,804.05 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$3,804.05
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$3,804.05
|
|
|
APR-DRG 42.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$2,809.81
|
|
|
Service Code
|
APR-DRG 0511
|
| Min. Negotiated Rate |
$1,620.92 |
| Max. Negotiated Rate |
$2,809.81 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$2,809.81
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$2,809.81
|
|
|
APR-DRG 42.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$5,965.44
|
|
|
Service Code
|
APR-DRG 0513
|
| Min. Negotiated Rate |
$4,122.79 |
| Max. Negotiated Rate |
$5,965.44 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$5,965.44
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$5,965.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
OP
|
$36.57
|
|
|
Service Code
|
NDC 70748017501
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$34.01 |
| Rate for Payer: Aetna Commercial |
$30.86
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.87
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Centivo All Commercial |
$19.89
|
| Rate for Payer: Cigna All Commercial |
$31.56
|
| Rate for Payer: CORVEL All Commercial |
$34.01
|
| Rate for Payer: Coventry All Commercial |
$32.18
|
| Rate for Payer: Encore All Commercial |
$33.66
|
| Rate for Payer: Frontpath All Commercial |
$33.64
|
| Rate for Payer: Humana ChoiceCare |
$31.58
|
| Rate for Payer: Humana Medicare |
$11.70
|
| Rate for Payer: Lucent All Commercial |
$19.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.91
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$27.43
|
| Rate for Payer: PHP All Commercial |
$27.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.26
|
| Rate for Payer: Sagamore Health Network All Products |
$28.23
|
| Rate for Payer: Signature Care EPO |
$30.35
|
| Rate for Payer: Signature Care PPO |
$32.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.08
|
| Rate for Payer: United Healthcare Commercial |
$28.82
|
| Rate for Payer: United Healthcare Medicare |
$11.70
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
IP
|
$36.57
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$34.01 |
| Rate for Payer: Aetna Commercial |
$31.59
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Cigna All Commercial |
$31.56
|
| Rate for Payer: CORVEL All Commercial |
$34.01
|
| Rate for Payer: Coventry All Commercial |
$32.18
|
| Rate for Payer: Encore All Commercial |
$33.66
|
| Rate for Payer: Frontpath All Commercial |
$33.64
|
| Rate for Payer: Humana ChoiceCare |
$31.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.91
|
| Rate for Payer: PHCS All Commercial |
$27.43
|
| Rate for Payer: PHP All Commercial |
$27.73
|
| Rate for Payer: Sagamore Health Network All Products |
$28.23
|
| Rate for Payer: Signature Care EPO |
$30.35
|
| Rate for Payer: Signature Care PPO |
$32.18
|
| Rate for Payer: United Healthcare Commercial |
$28.82
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
IP
|
$36.57
|
|
|
Service Code
|
NDC 70748017501
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$34.01 |
| Rate for Payer: Aetna Commercial |
$31.59
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Cigna All Commercial |
$31.56
|
| Rate for Payer: CORVEL All Commercial |
$34.01
|
| Rate for Payer: Coventry All Commercial |
$32.18
|
| Rate for Payer: Encore All Commercial |
$33.66
|
| Rate for Payer: Frontpath All Commercial |
$33.64
|
| Rate for Payer: Humana ChoiceCare |
$31.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.91
|
| Rate for Payer: PHCS All Commercial |
$27.43
|
| Rate for Payer: PHP All Commercial |
$27.73
|
| Rate for Payer: Sagamore Health Network All Products |
$28.23
|
| Rate for Payer: Signature Care EPO |
$30.35
|
| Rate for Payer: Signature Care PPO |
$32.18
|
| Rate for Payer: United Healthcare Commercial |
$28.82
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
OP
|
$36.57
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$34.01 |
| Rate for Payer: Aetna Commercial |
$30.86
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.87
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Cash Price |
$21.94
|
| Rate for Payer: Centivo All Commercial |
$19.89
|
| Rate for Payer: Cigna All Commercial |
$31.56
|
| Rate for Payer: CORVEL All Commercial |
$34.01
|
| Rate for Payer: Coventry All Commercial |
$32.18
|
| Rate for Payer: Encore All Commercial |
$33.66
|
| Rate for Payer: Frontpath All Commercial |
$33.64
|
| Rate for Payer: Humana ChoiceCare |
$31.58
|
| Rate for Payer: Humana Medicare |
$11.70
|
| Rate for Payer: Lucent All Commercial |
$19.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.91
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$27.43
|
| Rate for Payer: PHP All Commercial |
$27.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.26
|
| Rate for Payer: Sagamore Health Network All Products |
$28.23
|
| Rate for Payer: Signature Care EPO |
$30.35
|
| Rate for Payer: Signature Care PPO |
$32.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.08
|
| Rate for Payer: United Healthcare Commercial |
$28.82
|
| Rate for Payer: United Healthcare Medicare |
$11.70
|
|
|
ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN
|
Facility
|
OP
|
$436.50
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
109817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$405.94 |
| Rate for Payer: Aetna Commercial |
$368.41
|
| Rate for Payer: Aetna Medicare |
$139.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$135.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$250.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$272.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$160.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$153.65
|
| Rate for Payer: Cash Price |
$261.90
|
| Rate for Payer: Cash Price |
$261.90
|
| Rate for Payer: Centivo All Commercial |
$237.46
|
| Rate for Payer: Cigna All Commercial |
$376.70
|
| Rate for Payer: CORVEL All Commercial |
$405.94
|
| Rate for Payer: Coventry All Commercial |
$384.12
|
| Rate for Payer: Encore All Commercial |
$401.80
|
| Rate for Payer: Frontpath All Commercial |
$401.58
|
| Rate for Payer: Humana ChoiceCare |
$377.01
|
| Rate for Payer: Humana Medicare |
$139.68
|
| Rate for Payer: Lucent All Commercial |
$237.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$392.85
|
| Rate for Payer: Managed Health Services Medicaid |
$0.80
|
| Rate for Payer: MDWise Medicaid |
$0.80
|
| Rate for Payer: PHCS All Commercial |
$327.38
|
| Rate for Payer: PHP All Commercial |
$331.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$170.24
|
| Rate for Payer: Sagamore Health Network All Products |
$336.98
|
| Rate for Payer: Signature Care EPO |
$362.30
|
| Rate for Payer: Signature Care PPO |
$384.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$371.02
|
| Rate for Payer: United Healthcare Commercial |
$343.96
|
| Rate for Payer: United Healthcare Medicare |
$139.68
|
|
|
ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN
|
Facility
|
IP
|
$436.50
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
109817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$327.38 |
| Max. Negotiated Rate |
$405.94 |
| Rate for Payer: Aetna Commercial |
$377.14
|
| Rate for Payer: Cash Price |
$261.90
|
| Rate for Payer: Cigna All Commercial |
$376.70
|
| Rate for Payer: CORVEL All Commercial |
$405.94
|
| Rate for Payer: Coventry All Commercial |
$384.12
|
| Rate for Payer: Encore All Commercial |
$401.80
|
| Rate for Payer: Frontpath All Commercial |
$401.58
|
| Rate for Payer: Humana ChoiceCare |
$377.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$392.85
|
| Rate for Payer: PHCS All Commercial |
$327.38
|
| Rate for Payer: PHP All Commercial |
$331.04
|
| Rate for Payer: Sagamore Health Network All Products |
$336.98
|
| Rate for Payer: Signature Care EPO |
$362.30
|
| Rate for Payer: Signature Care PPO |
$384.12
|
| Rate for Payer: United Healthcare Commercial |
$343.96
|
|
|
ARIPIPRAZOLE 300 MG IM SERS
|
Facility
|
OP
|
$7,147.63
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$6,647.30 |
| Rate for Payer: Aetna Commercial |
$6,032.60
|
| Rate for Payer: Aetna Medicare |
$2,287.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$7.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,215.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,104.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,467.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$7.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,630.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,515.97
|
| Rate for Payer: Cash Price |
$4,288.58
|
| Rate for Payer: Cash Price |
$4,288.58
|
| Rate for Payer: Centivo All Commercial |
$3,888.31
|
| Rate for Payer: Cigna All Commercial |
$6,168.40
|
| Rate for Payer: CORVEL All Commercial |
$6,647.30
|
| Rate for Payer: Coventry All Commercial |
$6,289.91
|
| Rate for Payer: Encore All Commercial |
$6,579.39
|
| Rate for Payer: Frontpath All Commercial |
$6,575.82
|
| Rate for Payer: Humana ChoiceCare |
$6,173.41
|
| Rate for Payer: Humana Medicare |
$2,287.24
|
| Rate for Payer: Lucent All Commercial |
$3,888.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,432.87
|
| Rate for Payer: Managed Health Services Medicaid |
$7.62
|
| Rate for Payer: MDWise Medicaid |
$7.62
|
| Rate for Payer: PHCS All Commercial |
$5,360.72
|
| Rate for Payer: PHP All Commercial |
$5,420.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,787.58
|
| Rate for Payer: Sagamore Health Network All Products |
$5,517.97
|
| Rate for Payer: Signature Care EPO |
$5,932.53
|
| Rate for Payer: Signature Care PPO |
$6,289.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,075.49
|
| Rate for Payer: United Healthcare Commercial |
$5,632.33
|
| Rate for Payer: United Healthcare Medicare |
$2,287.24
|
|
|
ARIPIPRAZOLE 300 MG IM SERS
|
Facility
|
IP
|
$7,147.63
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,360.72 |
| Max. Negotiated Rate |
$6,647.30 |
| Rate for Payer: Aetna Commercial |
$6,175.55
|
| Rate for Payer: Cash Price |
$4,288.58
|
| Rate for Payer: Cigna All Commercial |
$6,168.40
|
| Rate for Payer: CORVEL All Commercial |
$6,647.30
|
| Rate for Payer: Coventry All Commercial |
$6,289.91
|
| Rate for Payer: Encore All Commercial |
$6,579.39
|
| Rate for Payer: Frontpath All Commercial |
$6,575.82
|
| Rate for Payer: Humana ChoiceCare |
$6,173.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,432.87
|
| Rate for Payer: PHCS All Commercial |
$5,360.72
|
| Rate for Payer: PHP All Commercial |
$5,420.76
|
| Rate for Payer: Sagamore Health Network All Products |
$5,517.97
|
| Rate for Payer: Signature Care EPO |
$5,932.53
|
| Rate for Payer: Signature Care PPO |
$6,289.91
|
| Rate for Payer: United Healthcare Commercial |
$5,632.33
|
|
|
ARIPIPRAZOLE 400 MG IM SERS
|
Facility
|
OP
|
$9,530.19
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$8,863.07 |
| Rate for Payer: Aetna Commercial |
$8,043.48
|
| Rate for Payer: Aetna Medicare |
$3,049.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$7.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,954.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,473.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,957.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$7.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,507.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,354.63
|
| Rate for Payer: Cash Price |
$5,718.11
|
| Rate for Payer: Cash Price |
$5,718.11
|
| Rate for Payer: Centivo All Commercial |
$5,184.42
|
| Rate for Payer: Cigna All Commercial |
$8,224.55
|
| Rate for Payer: CORVEL All Commercial |
$8,863.07
|
| Rate for Payer: Coventry All Commercial |
$8,386.56
|
| Rate for Payer: Encore All Commercial |
$8,772.54
|
| Rate for Payer: Frontpath All Commercial |
$8,767.77
|
| Rate for Payer: Humana ChoiceCare |
$8,231.22
|
| Rate for Payer: Humana Medicare |
$3,049.66
|
| Rate for Payer: Lucent All Commercial |
$5,184.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,577.17
|
| Rate for Payer: Managed Health Services Medicaid |
$7.62
|
| Rate for Payer: MDWise Medicaid |
$7.62
|
| Rate for Payer: PHCS All Commercial |
$7,147.64
|
| Rate for Payer: PHP All Commercial |
$7,227.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,716.77
|
| Rate for Payer: Sagamore Health Network All Products |
$7,357.30
|
| Rate for Payer: Signature Care EPO |
$7,910.05
|
| Rate for Payer: Signature Care PPO |
$8,386.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,100.66
|
| Rate for Payer: United Healthcare Commercial |
$7,509.79
|
| Rate for Payer: United Healthcare Medicare |
$3,049.66
|
|
|
ARIPIPRAZOLE 400 MG IM SERS
|
Facility
|
IP
|
$9,530.19
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,147.64 |
| Max. Negotiated Rate |
$8,863.07 |
| Rate for Payer: Aetna Commercial |
$8,234.08
|
| Rate for Payer: Cash Price |
$5,718.11
|
| Rate for Payer: Cigna All Commercial |
$8,224.55
|
| Rate for Payer: CORVEL All Commercial |
$8,863.07
|
| Rate for Payer: Coventry All Commercial |
$8,386.56
|
| Rate for Payer: Encore All Commercial |
$8,772.54
|
| Rate for Payer: Frontpath All Commercial |
$8,767.77
|
| Rate for Payer: Humana ChoiceCare |
$8,231.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,577.17
|
| Rate for Payer: PHCS All Commercial |
$7,147.64
|
| Rate for Payer: PHP All Commercial |
$7,227.69
|
| Rate for Payer: Sagamore Health Network All Products |
$7,357.30
|
| Rate for Payer: Signature Care EPO |
$7,910.05
|
| Rate for Payer: Signature Care PPO |
$8,386.56
|
| Rate for Payer: United Healthcare Commercial |
$7,509.79
|
|
|
ARIPIPRAZOLE 5 MG ORAL TAB
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
NDC 00904736706
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.45
|
| Rate for Payer: CORVEL All Commercial |
$2.64
|
| Rate for Payer: Coventry All Commercial |
$2.50
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.61
|
| Rate for Payer: Humana ChoiceCare |
$2.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.13
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Sagamore Health Network All Products |
$2.19
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.50
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
|
|
ARIPIPRAZOLE 5 MG ORAL TAB
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
NDC 00904736706
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Centivo All Commercial |
$1.55
|
| Rate for Payer: Cigna All Commercial |
$2.45
|
| Rate for Payer: CORVEL All Commercial |
$2.64
|
| Rate for Payer: Coventry All Commercial |
$2.50
|
| Rate for Payer: Encore All Commercial |
$2.62
|
| Rate for Payer: Frontpath All Commercial |
$2.61
|
| Rate for Payer: Humana ChoiceCare |
$2.45
|
| Rate for Payer: Humana Medicare |
$0.91
|
| Rate for Payer: Lucent All Commercial |
$1.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.56
|
| Rate for Payer: PHCS All Commercial |
$2.13
|
| Rate for Payer: PHP All Commercial |
$2.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$2.19
|
| Rate for Payer: Signature Care EPO |
$2.36
|
| Rate for Payer: Signature Care PPO |
$2.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.24
|
| Rate for Payer: United Healthcare Medicare |
$0.91
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG ORAL TAB
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.23
|
| Rate for Payer: Coventry All Commercial |
$0.22
|
| Rate for Payer: Encore All Commercial |
$0.23
|
| Rate for Payer: Frontpath All Commercial |
$0.23
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.22
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.19
|
| Rate for Payer: Sagamore Health Network All Products |
$0.19
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG ORAL TAB
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Aetna Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Centivo All Commercial |
$0.13
|
| Rate for Payer: Cigna All Commercial |
$0.21
|
| Rate for Payer: CORVEL All Commercial |
$0.23
|
| Rate for Payer: Coventry All Commercial |
$0.22
|
| Rate for Payer: Encore All Commercial |
$0.23
|
| Rate for Payer: Frontpath All Commercial |
$0.23
|
| Rate for Payer: Humana ChoiceCare |
$0.21
|
| Rate for Payer: Humana Medicare |
$0.08
|
| Rate for Payer: Lucent All Commercial |
$0.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.22
|
| Rate for Payer: PHCS All Commercial |
$0.18
|
| Rate for Payer: PHP All Commercial |
$0.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.10
|
| Rate for Payer: Sagamore Health Network All Products |
$0.19
|
| Rate for Payer: Signature Care EPO |
$0.20
|
| Rate for Payer: Signature Care PPO |
$0.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
|
