|
ACETAMINOPHEN 325 MG RECT SUPP
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: Aetna Medicare |
$1.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.65
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Centivo All Commercial |
$2.55
|
| 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: Humana Medicare |
$1.50
|
| Rate for Payer: Lucent All Commercial |
$2.55
|
| 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: Plain Church Group Ministry All Commercial |
$1.83
|
| 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: Three Rivers Preferred All Commercial |
$3.99
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
| Rate for Payer: United Healthcare Medicare |
$1.50
|
|
|
ACETAMINOPHEN 500 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 50580045711
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
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
|
|
|
ACETAMINOPHEN 650 MG RECT SUPP
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 45802073032
|
| Hospital Charge Code |
105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.11
|
| Rate for Payer: Aetna Medicare |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Centivo All Commercial |
$1.36
|
| Rate for Payer: Cigna All Commercial |
$2.16
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.20
|
| Rate for Payer: Encore All Commercial |
$2.30
|
| Rate for Payer: Frontpath All Commercial |
$2.30
|
| Rate for Payer: Humana ChoiceCare |
$2.16
|
| Rate for Payer: Humana Medicare |
$0.80
|
| Rate for Payer: Lucent All Commercial |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.25
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.97
|
| Rate for Payer: Sagamore Health Network All Products |
$1.93
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.12
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
| Rate for Payer: United Healthcare Medicare |
$0.80
|
|
|
ACETAMINOPHEN 650 MG RECT SUPP
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 45802073032
|
| Hospital Charge Code |
105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna All Commercial |
$2.16
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.20
|
| Rate for Payer: Encore All Commercial |
$2.30
|
| Rate for Payer: Frontpath All Commercial |
$2.30
|
| Rate for Payer: Humana ChoiceCare |
$2.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.25
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.90
|
| Rate for Payer: Sagamore Health Network All Products |
$1.93
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
|
|
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406048462
|
| Hospital Charge Code |
14087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406048462
|
| Hospital Charge Code |
14087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
ACETAZOLAMIDE 500 MG ORAL CPER
|
Facility
|
IP
|
$29.04
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.09
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna All Commercial |
$25.06
|
| Rate for Payer: CORVEL All Commercial |
$27.00
|
| Rate for Payer: Coventry All Commercial |
$25.55
|
| Rate for Payer: Encore All Commercial |
$26.73
|
| Rate for Payer: Frontpath All Commercial |
$26.71
|
| Rate for Payer: Humana ChoiceCare |
$25.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.13
|
| Rate for Payer: PHCS All Commercial |
$21.78
|
| Rate for Payer: PHP All Commercial |
$22.02
|
| Rate for Payer: Sagamore Health Network All Products |
$22.42
|
| Rate for Payer: Signature Care EPO |
$24.10
|
| Rate for Payer: Signature Care PPO |
$25.55
|
| Rate for Payer: United Healthcare Commercial |
$22.88
|
|
|
ACETAZOLAMIDE 500 MG ORAL CPER
|
Facility
|
OP
|
$29.04
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$24.51
|
| Rate for Payer: Aetna Medicare |
$9.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.22
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Centivo All Commercial |
$15.80
|
| Rate for Payer: Cigna All Commercial |
$25.06
|
| Rate for Payer: CORVEL All Commercial |
$27.00
|
| Rate for Payer: Coventry All Commercial |
$25.55
|
| Rate for Payer: Encore All Commercial |
$26.73
|
| Rate for Payer: Frontpath All Commercial |
$26.71
|
| Rate for Payer: Humana ChoiceCare |
$25.08
|
| Rate for Payer: Humana Medicare |
$9.29
|
| Rate for Payer: Lucent All Commercial |
$15.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.13
|
| Rate for Payer: PHCS All Commercial |
$21.78
|
| Rate for Payer: PHP All Commercial |
$22.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.32
|
| Rate for Payer: Sagamore Health Network All Products |
$22.42
|
| Rate for Payer: Signature Care EPO |
$24.10
|
| Rate for Payer: Signature Care PPO |
$25.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.68
|
| Rate for Payer: United Healthcare Commercial |
$22.88
|
| Rate for Payer: United Healthcare Medicare |
$9.29
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN
|
Facility
|
IP
|
$246.33
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.75 |
| Max. Negotiated Rate |
$229.09 |
| Rate for Payer: Aetna Commercial |
$212.83
|
| Rate for Payer: Cash Price |
$152.72
|
| Rate for Payer: Cigna All Commercial |
$212.58
|
| Rate for Payer: CORVEL All Commercial |
$229.09
|
| Rate for Payer: Coventry All Commercial |
$216.77
|
| Rate for Payer: Encore All Commercial |
$226.75
|
| Rate for Payer: Frontpath All Commercial |
$226.62
|
| Rate for Payer: Humana ChoiceCare |
$212.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.70
|
| Rate for Payer: PHCS All Commercial |
$184.75
|
| Rate for Payer: PHP All Commercial |
$186.82
|
| Rate for Payer: Sagamore Health Network All Products |
$190.17
|
| Rate for Payer: Signature Care EPO |
$204.45
|
| Rate for Payer: Signature Care PPO |
$216.77
|
| Rate for Payer: United Healthcare Commercial |
$194.11
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN
|
Facility
|
OP
|
$246.33
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$229.09 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Medicare |
$78.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$76.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$141.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$153.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.71
|
| Rate for Payer: Cash Price |
$152.72
|
| Rate for Payer: Cash Price |
$152.72
|
| Rate for Payer: Centivo All Commercial |
$134.00
|
| Rate for Payer: Cigna All Commercial |
$212.58
|
| Rate for Payer: CORVEL All Commercial |
$229.09
|
| Rate for Payer: Coventry All Commercial |
$216.77
|
| Rate for Payer: Encore All Commercial |
$226.75
|
| Rate for Payer: Frontpath All Commercial |
$226.62
|
| Rate for Payer: Humana ChoiceCare |
$212.76
|
| Rate for Payer: Humana Medicare |
$78.83
|
| Rate for Payer: Lucent All Commercial |
$134.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$221.70
|
| Rate for Payer: Managed Health Services Medicaid |
$0.44
|
| Rate for Payer: MDWise Medicaid |
$0.44
|
| Rate for Payer: PHCS All Commercial |
$184.75
|
| Rate for Payer: PHP All Commercial |
$186.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.07
|
| Rate for Payer: Sagamore Health Network All Products |
$190.17
|
| Rate for Payer: Signature Care EPO |
$204.45
|
| Rate for Payer: Signature Care PPO |
$216.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$209.38
|
| Rate for Payer: United Healthcare Commercial |
$194.11
|
| Rate for Payer: United Healthcare Medicare |
$78.83
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN
|
Facility
|
OP
|
$120.93
|
|
|
Service Code
|
NDC 00517760425
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.49 |
| Max. Negotiated Rate |
$112.47 |
| Rate for Payer: Aetna Commercial |
$102.07
|
| Rate for Payer: Aetna Medicare |
$38.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$69.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.57
|
| Rate for Payer: Cash Price |
$74.98
|
| Rate for Payer: Centivo All Commercial |
$65.79
|
| Rate for Payer: Cigna All Commercial |
$104.36
|
| Rate for Payer: CORVEL All Commercial |
$112.47
|
| Rate for Payer: Coventry All Commercial |
$106.42
|
| Rate for Payer: Encore All Commercial |
$111.32
|
| Rate for Payer: Frontpath All Commercial |
$111.26
|
| Rate for Payer: Humana ChoiceCare |
$104.45
|
| Rate for Payer: Humana Medicare |
$38.70
|
| Rate for Payer: Lucent All Commercial |
$65.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.84
|
| Rate for Payer: PHCS All Commercial |
$90.70
|
| Rate for Payer: PHP All Commercial |
$91.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.16
|
| Rate for Payer: Sagamore Health Network All Products |
$93.36
|
| Rate for Payer: Signature Care EPO |
$100.37
|
| Rate for Payer: Signature Care PPO |
$106.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$102.79
|
| Rate for Payer: United Healthcare Commercial |
$95.29
|
| Rate for Payer: United Healthcare Medicare |
$38.70
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN
|
Facility
|
IP
|
$120.93
|
|
|
Service Code
|
NDC 00517760425
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.70 |
| Max. Negotiated Rate |
$112.47 |
| Rate for Payer: Aetna Commercial |
$104.49
|
| Rate for Payer: Cash Price |
$74.98
|
| Rate for Payer: Cigna All Commercial |
$104.36
|
| Rate for Payer: CORVEL All Commercial |
$112.47
|
| Rate for Payer: Coventry All Commercial |
$106.42
|
| Rate for Payer: Encore All Commercial |
$111.32
|
| Rate for Payer: Frontpath All Commercial |
$111.26
|
| Rate for Payer: Humana ChoiceCare |
$104.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.84
|
| Rate for Payer: PHCS All Commercial |
$90.70
|
| Rate for Payer: PHP All Commercial |
$91.71
|
| Rate for Payer: Sagamore Health Network All Products |
$93.36
|
| Rate for Payer: Signature Care EPO |
$100.37
|
| Rate for Payer: Signature Care PPO |
$106.42
|
| Rate for Payer: United Healthcare Commercial |
$95.29
|
|
|
ACETYLCYSTEINE 600 MG ORAL CAP
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 27434000211
|
| Hospital Charge Code |
118614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna Commercial |
$1.07
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.07
|
| Rate for Payer: CORVEL All Commercial |
$1.15
|
| Rate for Payer: Coventry All Commercial |
$1.09
|
| Rate for Payer: Encore All Commercial |
$1.14
|
| Rate for Payer: Frontpath All Commercial |
$1.14
|
| Rate for Payer: Humana ChoiceCare |
$1.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.12
|
| Rate for Payer: PHCS All Commercial |
$0.93
|
| Rate for Payer: PHP All Commercial |
$0.94
|
| Rate for Payer: Sagamore Health Network All Products |
$0.96
|
| Rate for Payer: Signature Care EPO |
$1.03
|
| Rate for Payer: Signature Care PPO |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$0.98
|
|
|
ACETYLCYSTEINE 600 MG ORAL CAP
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 27434000211
|
| Hospital Charge Code |
118614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.05
|
| Rate for Payer: Aetna Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Centivo All Commercial |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$1.07
|
| Rate for Payer: CORVEL All Commercial |
$1.15
|
| Rate for Payer: Coventry All Commercial |
$1.09
|
| Rate for Payer: Encore All Commercial |
$1.14
|
| Rate for Payer: Frontpath All Commercial |
$1.14
|
| Rate for Payer: Humana ChoiceCare |
$1.07
|
| Rate for Payer: Humana Medicare |
$0.40
|
| Rate for Payer: Lucent All Commercial |
$0.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.12
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$0.93
|
| Rate for Payer: PHP All Commercial |
$0.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.48
|
| Rate for Payer: Sagamore Health Network All Products |
$0.96
|
| Rate for Payer: Signature Care EPO |
$1.03
|
| Rate for Payer: Signature Care PPO |
$1.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.98
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP
|
Facility
|
OP
|
$111.72
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
117013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$103.90 |
| Rate for Payer: Aetna Commercial |
$94.29
|
| Rate for Payer: Aetna Medicare |
$35.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$69.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.33
|
| Rate for Payer: Cash Price |
$69.27
|
| Rate for Payer: Cash Price |
$69.27
|
| Rate for Payer: Centivo All Commercial |
$60.78
|
| Rate for Payer: Cigna All Commercial |
$96.41
|
| Rate for Payer: CORVEL All Commercial |
$103.90
|
| Rate for Payer: Coventry All Commercial |
$98.31
|
| Rate for Payer: Encore All Commercial |
$102.84
|
| Rate for Payer: Frontpath All Commercial |
$102.78
|
| Rate for Payer: Humana ChoiceCare |
$96.49
|
| Rate for Payer: Humana Medicare |
$35.75
|
| Rate for Payer: Lucent All Commercial |
$60.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.55
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$83.79
|
| Rate for Payer: PHP All Commercial |
$84.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.57
|
| Rate for Payer: Sagamore Health Network All Products |
$86.25
|
| Rate for Payer: Signature Care EPO |
$92.73
|
| Rate for Payer: Signature Care PPO |
$98.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$94.96
|
| Rate for Payer: United Healthcare Commercial |
$88.04
|
| Rate for Payer: United Healthcare Medicare |
$35.75
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP
|
Facility
|
IP
|
$111.72
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
117013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$103.90 |
| Rate for Payer: Aetna Commercial |
$96.53
|
| Rate for Payer: Cash Price |
$69.27
|
| Rate for Payer: Cigna All Commercial |
$96.41
|
| Rate for Payer: CORVEL All Commercial |
$103.90
|
| Rate for Payer: Coventry All Commercial |
$98.31
|
| Rate for Payer: Encore All Commercial |
$102.84
|
| Rate for Payer: Frontpath All Commercial |
$102.78
|
| Rate for Payer: Humana ChoiceCare |
$96.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.55
|
| Rate for Payer: PHCS All Commercial |
$83.79
|
| Rate for Payer: PHP All Commercial |
$84.73
|
| Rate for Payer: Sagamore Health Network All Products |
$86.25
|
| Rate for Payer: Signature Care EPO |
$92.73
|
| Rate for Payer: Signature Care PPO |
$98.31
|
| Rate for Payer: United Healthcare Commercial |
$88.04
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML ORAL SUSP
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 00574052074
|
| Hospital Charge Code |
117010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$93.74 |
| Rate for Payer: Aetna Commercial |
$87.09
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna All Commercial |
$86.99
|
| Rate for Payer: CORVEL All Commercial |
$93.74
|
| Rate for Payer: Coventry All Commercial |
$88.70
|
| Rate for Payer: Encore All Commercial |
$92.79
|
| Rate for Payer: Frontpath All Commercial |
$92.74
|
| Rate for Payer: Humana ChoiceCare |
$87.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.72
|
| Rate for Payer: PHCS All Commercial |
$75.60
|
| Rate for Payer: PHP All Commercial |
$76.45
|
| Rate for Payer: Sagamore Health Network All Products |
$77.82
|
| Rate for Payer: Signature Care EPO |
$83.66
|
| Rate for Payer: Signature Care PPO |
$88.70
|
| Rate for Payer: United Healthcare Commercial |
$79.43
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML ORAL SUSP
|
Facility
|
OP
|
$100.80
|
|
|
Service Code
|
NDC 00574052074
|
| Hospital Charge Code |
117010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$93.74 |
| Rate for Payer: Aetna Commercial |
$85.08
|
| Rate for Payer: Aetna Medicare |
$32.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$57.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.48
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Centivo All Commercial |
$54.84
|
| Rate for Payer: Cigna All Commercial |
$86.99
|
| Rate for Payer: CORVEL All Commercial |
$93.74
|
| Rate for Payer: Coventry All Commercial |
$88.70
|
| Rate for Payer: Encore All Commercial |
$92.79
|
| Rate for Payer: Frontpath All Commercial |
$92.74
|
| Rate for Payer: Humana ChoiceCare |
$87.06
|
| Rate for Payer: Humana Medicare |
$32.26
|
| Rate for Payer: Lucent All Commercial |
$54.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.72
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$75.60
|
| Rate for Payer: PHP All Commercial |
$76.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.31
|
| Rate for Payer: Sagamore Health Network All Products |
$77.82
|
| Rate for Payer: Signature Care EPO |
$83.66
|
| Rate for Payer: Signature Care PPO |
$88.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.68
|
| Rate for Payer: United Healthcare Commercial |
$79.43
|
| Rate for Payer: United Healthcare Medicare |
$32.26
|
|
|
ACUTE ANXIETY & DELIRIUM STATES
|
Facility
|
IP
|
$5,576.39
|
|
|
Service Code
|
APR-DRG 7563
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$5,576.39 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
ACUTE ANXIETY & DELIRIUM STATES
|
Facility
|
IP
|
$3,933.73
|
|
|
Service Code
|
APR-DRG 7562
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$3,933.73 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
ACUTE ANXIETY & DELIRIUM STATES
|
Facility
|
IP
|
$2,420.76
|
|
|
Service Code
|
APR-DRG 7561
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,420.76 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
ACUTE ANXIETY & DELIRIUM STATES
|
Facility
|
IP
|
$9,726.25
|
|
|
Service Code
|
APR-DRG 7564
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$9,726.25 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
ACYCLOVIR 200 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
8969
|
|
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
|
|
|
ACYCLOVIR 200 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
