|
BUPROPION HCL 100 MG ORAL SR12
|
Facility
|
OP
|
$5.37
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
18385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Aetna Commercial |
$4.53
|
| Rate for Payer: Aetna Medicare |
$1.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.89
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Centivo All Commercial |
$2.92
|
| Rate for Payer: Cigna All Commercial |
$4.63
|
| Rate for Payer: CORVEL All Commercial |
$4.99
|
| Rate for Payer: Coventry All Commercial |
$4.72
|
| Rate for Payer: Encore All Commercial |
$4.94
|
| Rate for Payer: Frontpath All Commercial |
$4.94
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Humana Medicare |
$1.72
|
| Rate for Payer: Lucent All Commercial |
$2.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.83
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.09
|
| Rate for Payer: Sagamore Health Network All Products |
$4.14
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.56
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare |
$1.72
|
|
|
BUPROPION HCL 100 MG ORAL SR12
|
Facility
|
IP
|
$5.37
|
|
|
Service Code
|
NDC 68084069701
|
| Hospital Charge Code |
18385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cigna All Commercial |
$4.63
|
| Rate for Payer: CORVEL All Commercial |
$4.99
|
| Rate for Payer: Coventry All Commercial |
$4.72
|
| Rate for Payer: Encore All Commercial |
$4.94
|
| Rate for Payer: Frontpath All Commercial |
$4.94
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.83
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.07
|
| Rate for Payer: Sagamore Health Network All Products |
$4.14
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.72
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
OP
|
$7.22
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: Aetna Medicare |
$2.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.54
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Centivo All Commercial |
$3.93
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.72
|
| Rate for Payer: Coventry All Commercial |
$6.36
|
| Rate for Payer: Encore All Commercial |
$6.65
|
| Rate for Payer: Frontpath All Commercial |
$6.65
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Humana Medicare |
$2.31
|
| Rate for Payer: Lucent All Commercial |
$3.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.42
|
| Rate for Payer: PHP All Commercial |
$5.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.82
|
| Rate for Payer: Sagamore Health Network All Products |
$5.58
|
| Rate for Payer: Signature Care EPO |
$6.00
|
| Rate for Payer: Signature Care PPO |
$6.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.14
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
| Rate for Payer: United Healthcare Medicare |
$2.31
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
IP
|
$7.22
|
|
|
Service Code
|
NDC 50268014311
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.42 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna Commercial |
$6.24
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.72
|
| Rate for Payer: Coventry All Commercial |
$6.36
|
| Rate for Payer: Encore All Commercial |
$6.65
|
| Rate for Payer: Frontpath All Commercial |
$6.65
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.42
|
| Rate for Payer: PHP All Commercial |
$5.48
|
| Rate for Payer: Sagamore Health Network All Products |
$5.58
|
| Rate for Payer: Signature Care EPO |
$6.00
|
| Rate for Payer: Signature Care PPO |
$6.36
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
OP
|
$7.22
|
|
|
Service Code
|
NDC 50268014311
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: Aetna Medicare |
$2.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.54
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Centivo All Commercial |
$3.93
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.72
|
| Rate for Payer: Coventry All Commercial |
$6.36
|
| Rate for Payer: Encore All Commercial |
$6.65
|
| Rate for Payer: Frontpath All Commercial |
$6.65
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Humana Medicare |
$2.31
|
| Rate for Payer: Lucent All Commercial |
$3.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.42
|
| Rate for Payer: PHP All Commercial |
$5.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.82
|
| Rate for Payer: Sagamore Health Network All Products |
$5.58
|
| Rate for Payer: Signature Care EPO |
$6.00
|
| Rate for Payer: Signature Care PPO |
$6.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.14
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
| Rate for Payer: United Healthcare Medicare |
$2.31
|
|
|
BUPROPION HCL 100 MG ORAL TAB
|
Facility
|
IP
|
$7.22
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
9321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.42 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna Commercial |
$6.24
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna All Commercial |
$6.23
|
| Rate for Payer: CORVEL All Commercial |
$6.72
|
| Rate for Payer: Coventry All Commercial |
$6.36
|
| Rate for Payer: Encore All Commercial |
$6.65
|
| Rate for Payer: Frontpath All Commercial |
$6.65
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.50
|
| Rate for Payer: PHCS All Commercial |
$5.42
|
| Rate for Payer: PHP All Commercial |
$5.48
|
| Rate for Payer: Sagamore Health Network All Products |
$5.58
|
| Rate for Payer: Signature Care EPO |
$6.00
|
| Rate for Payer: Signature Care PPO |
$6.36
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
|
|
BUPROPION HCL 150 MG ORAL SR12
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 43598075260
|
| Hospital Charge Code |
18386
|
|
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 |
$1.05
|
| 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
|
|
|
BUPROPION HCL 150 MG ORAL SR12
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 43598075260
|
| Hospital Charge Code |
18386
|
|
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 |
$1.05
|
| 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
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
NDC 00904750561
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$9.07
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna All Commercial |
$9.06
|
| Rate for Payer: CORVEL All Commercial |
$9.76
|
| Rate for Payer: Coventry All Commercial |
$9.23
|
| Rate for Payer: Encore All Commercial |
$9.66
|
| Rate for Payer: Frontpath All Commercial |
$9.65
|
| Rate for Payer: Humana ChoiceCare |
$9.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.44
|
| Rate for Payer: PHCS All Commercial |
$7.87
|
| Rate for Payer: PHP All Commercial |
$7.96
|
| Rate for Payer: Sagamore Health Network All Products |
$8.10
|
| Rate for Payer: Signature Care EPO |
$8.71
|
| Rate for Payer: Signature Care PPO |
$9.23
|
| Rate for Payer: United Healthcare Commercial |
$8.27
|
|
|
BUPROPION HCL 150 MG ORAL TB24
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
NDC 00904750561
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$8.86
|
| Rate for Payer: Aetna Medicare |
$3.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.69
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Centivo All Commercial |
$5.71
|
| Rate for Payer: Cigna All Commercial |
$9.06
|
| Rate for Payer: CORVEL All Commercial |
$9.76
|
| Rate for Payer: Coventry All Commercial |
$9.23
|
| Rate for Payer: Encore All Commercial |
$9.66
|
| Rate for Payer: Frontpath All Commercial |
$9.65
|
| Rate for Payer: Humana ChoiceCare |
$9.06
|
| Rate for Payer: Humana Medicare |
$3.36
|
| Rate for Payer: Lucent All Commercial |
$5.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.44
|
| Rate for Payer: PHCS All Commercial |
$7.87
|
| Rate for Payer: PHP All Commercial |
$7.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.09
|
| Rate for Payer: Sagamore Health Network All Products |
$8.10
|
| Rate for Payer: Signature Care EPO |
$8.71
|
| Rate for Payer: Signature Care PPO |
$9.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.92
|
| Rate for Payer: United Healthcare Commercial |
$8.27
|
| Rate for Payer: United Healthcare Medicare |
$3.36
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS
|
Facility
|
IP
|
$50,792.67
|
|
|
Service Code
|
APR-DRG 8424
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$50,792.67 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS
|
Facility
|
IP
|
$20,533.21
|
|
|
Service Code
|
APR-DRG 8423
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$20,533.21 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS
|
Facility
|
IP
|
$7,305.50
|
|
|
Service Code
|
APR-DRG 8421
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$7,305.50 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS
|
Facility
|
IP
|
$11,023.09
|
|
|
Service Code
|
APR-DRG 8422
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$11,023.09 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
BUSPIRONE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 51079098620
|
| Hospital Charge Code |
9323
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.03
|
| Rate for Payer: Frontpath All Commercial |
$1.03
|
| Rate for Payer: Humana ChoiceCare |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.01
|
| Rate for Payer: PHCS All Commercial |
$0.84
|
| Rate for Payer: PHP All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.93
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
|
|
BUSPIRONE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 51079098620
|
| Hospital Charge Code |
9323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Centivo All Commercial |
$0.61
|
| Rate for Payer: Cigna All Commercial |
$0.97
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.99
|
| Rate for Payer: Encore All Commercial |
$1.03
|
| Rate for Payer: Frontpath All Commercial |
$1.03
|
| Rate for Payer: Humana ChoiceCare |
$0.97
|
| Rate for Payer: Humana Medicare |
$0.36
|
| Rate for Payer: Lucent All Commercial |
$0.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.01
|
| Rate for Payer: PHCS All Commercial |
$0.84
|
| Rate for Payer: PHP All Commercial |
$0.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.44
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.93
|
| Rate for Payer: Signature Care PPO |
$0.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
|
|
BUSPIRONE 15 MG ORAL TAB
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
NDC 50268013515
|
| Hospital Charge Code |
17464
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.16
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Centivo All Commercial |
$1.79
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.89
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.02
|
| Rate for Payer: Humana ChoiceCare |
$2.84
|
| Rate for Payer: Humana Medicare |
$1.05
|
| Rate for Payer: Lucent All Commercial |
$1.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| Rate for Payer: Signature Care PPO |
$2.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.79
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
| Rate for Payer: United Healthcare Medicare |
$1.05
|
|
|
BUSPIRONE 15 MG ORAL TAB
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
NDC 50268013515
|
| Hospital Charge Code |
17464
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.84
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cigna All Commercial |
$2.83
|
| Rate for Payer: CORVEL All Commercial |
$3.05
|
| Rate for Payer: Coventry All Commercial |
$2.89
|
| Rate for Payer: Encore All Commercial |
$3.02
|
| Rate for Payer: Frontpath All Commercial |
$3.02
|
| Rate for Payer: Humana ChoiceCare |
$2.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.95
|
| Rate for Payer: PHCS All Commercial |
$2.46
|
| Rate for Payer: PHP All Commercial |
$2.49
|
| Rate for Payer: Sagamore Health Network All Products |
$2.53
|
| Rate for Payer: Signature Care EPO |
$2.72
|
| Rate for Payer: Signature Care PPO |
$2.89
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-300-40 MG ORAL CAP
|
Facility
|
IP
|
$5.80
|
|
|
Service Code
|
NDC 70010004401
|
| Hospital Charge Code |
104993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna Commercial |
$5.01
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cigna All Commercial |
$5.01
|
| Rate for Payer: CORVEL All Commercial |
$5.40
|
| Rate for Payer: Coventry All Commercial |
$5.11
|
| Rate for Payer: Encore All Commercial |
$5.34
|
| Rate for Payer: Frontpath All Commercial |
$5.34
|
| Rate for Payer: Humana ChoiceCare |
$5.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.22
|
| Rate for Payer: PHCS All Commercial |
$4.35
|
| Rate for Payer: PHP All Commercial |
$4.40
|
| Rate for Payer: Sagamore Health Network All Products |
$4.48
|
| Rate for Payer: Signature Care EPO |
$4.82
|
| Rate for Payer: Signature Care PPO |
$5.11
|
| Rate for Payer: United Healthcare Commercial |
$4.57
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-300-40 MG ORAL CAP
|
Facility
|
OP
|
$5.80
|
|
|
Service Code
|
NDC 70010004401
|
| Hospital Charge Code |
104993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: Aetna Medicare |
$1.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.04
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Centivo All Commercial |
$3.16
|
| Rate for Payer: Cigna All Commercial |
$5.01
|
| Rate for Payer: CORVEL All Commercial |
$5.40
|
| Rate for Payer: Coventry All Commercial |
$5.11
|
| Rate for Payer: Encore All Commercial |
$5.34
|
| Rate for Payer: Frontpath All Commercial |
$5.34
|
| Rate for Payer: Humana ChoiceCare |
$5.01
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Lucent All Commercial |
$3.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.22
|
| Rate for Payer: PHCS All Commercial |
$4.35
|
| Rate for Payer: PHP All Commercial |
$4.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.26
|
| Rate for Payer: Sagamore Health Network All Products |
$4.48
|
| Rate for Payer: Signature Care EPO |
$4.82
|
| Rate for Payer: Signature Care PPO |
$5.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.93
|
| Rate for Payer: United Healthcare Commercial |
$4.57
|
| Rate for Payer: United Healthcare Medicare |
$1.86
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG ORAL TAB
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
NDC 00904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.50
|
| Rate for Payer: Aetna Medicare |
$2.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.29
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Centivo All Commercial |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.06
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$6.00
|
| Rate for Payer: Frontpath All Commercial |
$6.00
|
| Rate for Payer: Humana ChoiceCare |
$5.63
|
| Rate for Payer: Humana Medicare |
$2.09
|
| Rate for Payer: Lucent All Commercial |
$3.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.87
|
| Rate for Payer: PHCS All Commercial |
$4.89
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.54
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.41
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.54
|
| Rate for Payer: United Healthcare Commercial |
$5.14
|
| Rate for Payer: United Healthcare Medicare |
$2.09
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG ORAL TAB
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
NDC 00904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.63
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.06
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$6.00
|
| Rate for Payer: Frontpath All Commercial |
$6.00
|
| Rate for Payer: Humana ChoiceCare |
$5.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.87
|
| Rate for Payer: PHCS All Commercial |
$4.89
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.41
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: United Healthcare Commercial |
$5.14
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP SPR CMCH
|
Facility
|
OP
|
$362.82
|
|
|
Service Code
|
NDC 10223020104
|
| Hospital Charge Code |
14010009328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$337.42 |
| Rate for Payer: Aetna Commercial |
$306.22
|
| Rate for Payer: Aetna Medicare |
$116.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$112.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$208.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$226.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$133.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$127.71
|
| Rate for Payer: Cash Price |
$217.69
|
| Rate for Payer: Cash Price |
$217.69
|
| Rate for Payer: Centivo All Commercial |
$197.37
|
| Rate for Payer: Cigna All Commercial |
$313.11
|
| Rate for Payer: CORVEL All Commercial |
$337.42
|
| Rate for Payer: Coventry All Commercial |
$319.28
|
| Rate for Payer: Encore All Commercial |
$333.98
|
| Rate for Payer: Frontpath All Commercial |
$333.79
|
| Rate for Payer: Humana ChoiceCare |
$313.37
|
| Rate for Payer: Humana Medicare |
$116.10
|
| Rate for Payer: Lucent All Commercial |
$197.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$326.54
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$272.12
|
| Rate for Payer: PHP All Commercial |
$275.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$141.50
|
| Rate for Payer: Sagamore Health Network All Products |
$280.10
|
| Rate for Payer: Signature Care EPO |
$301.14
|
| Rate for Payer: Signature Care PPO |
$319.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$308.40
|
| Rate for Payer: United Healthcare Commercial |
$285.90
|
| Rate for Payer: United Healthcare Medicare |
$116.10
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP SPR CMCH
|
Facility
|
IP
|
$362.82
|
|
|
Service Code
|
NDC 10223020104
|
| Hospital Charge Code |
14010009328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$272.12 |
| Max. Negotiated Rate |
$337.42 |
| Rate for Payer: Aetna Commercial |
$313.48
|
| Rate for Payer: Cash Price |
$217.69
|
| Rate for Payer: Cigna All Commercial |
$313.11
|
| Rate for Payer: CORVEL All Commercial |
$337.42
|
| Rate for Payer: Coventry All Commercial |
$319.28
|
| Rate for Payer: Encore All Commercial |
$333.98
|
| Rate for Payer: Frontpath All Commercial |
$333.79
|
| Rate for Payer: Humana ChoiceCare |
$313.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$326.54
|
| Rate for Payer: PHCS All Commercial |
$272.12
|
| Rate for Payer: PHP All Commercial |
$275.16
|
| Rate for Payer: Sagamore Health Network All Products |
$280.10
|
| Rate for Payer: Signature Care EPO |
$301.14
|
| Rate for Payer: Signature Care PPO |
$319.28
|
| Rate for Payer: United Healthcare Commercial |
$285.90
|
|
|
BUTORPHANOL 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$45.35
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.01 |
| Max. Negotiated Rate |
$42.17 |
| Rate for Payer: Aetna Commercial |
$39.18
|
| Rate for Payer: Cash Price |
$27.21
|
| Rate for Payer: Cigna All Commercial |
$39.13
|
| Rate for Payer: CORVEL All Commercial |
$42.17
|
| Rate for Payer: Coventry All Commercial |
$39.90
|
| Rate for Payer: Encore All Commercial |
$41.74
|
| Rate for Payer: Frontpath All Commercial |
$41.72
|
| Rate for Payer: Humana ChoiceCare |
$39.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$40.81
|
| Rate for Payer: PHCS All Commercial |
$34.01
|
| Rate for Payer: PHP All Commercial |
$34.39
|
| Rate for Payer: Sagamore Health Network All Products |
$35.01
|
| Rate for Payer: Signature Care EPO |
$37.64
|
| Rate for Payer: Signature Care PPO |
$39.90
|
| Rate for Payer: United Healthcare Commercial |
$35.73
|
|
