|
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 650 MG RECT SUPP
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 45802073032
|
| Hospital Charge Code |
105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.11
|
| Rate for Payer: Aetna Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Centivo All Commercial |
$1.27
|
| 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 |
$1.27
|
| Rate for Payer: Lucent All Commercial |
$1.27
|
| 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 |
$0.82
|
|
|
ACETAMINOPHEN-CODEINE 120-12 MG/5 ML ORAL SOLN
|
Facility
IP
|
$36.42
|
|
|
Service Code
|
NDC 50383007916
|
| Hospital Charge Code |
110535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.32 |
| Max. Negotiated Rate |
$33.87 |
| Rate for Payer: Aetna Commercial |
$31.47
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cigna All Commercial |
$31.43
|
| Rate for Payer: CORVEL All Commercial |
$33.87
|
| Rate for Payer: Coventry All Commercial |
$32.05
|
| Rate for Payer: Encore All Commercial |
$33.53
|
| Rate for Payer: Frontpath All Commercial |
$33.51
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.78
|
| Rate for Payer: PHCS All Commercial |
$27.32
|
| Rate for Payer: PHP All Commercial |
$27.62
|
| Rate for Payer: Sagamore Health Network All Products |
$28.12
|
| Rate for Payer: Signature Care EPO |
$30.23
|
| Rate for Payer: Signature Care PPO |
$32.05
|
| Rate for Payer: United Healthcare Commercial |
$28.70
|
|
|
ACETAMINOPHEN-CODEINE 120-12 MG/5 ML ORAL SOLN
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 503830079
|
| Hospital Charge Code |
110535
|
|
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
|
|
|
ACETAMINOPHEN-CODEINE 120-12 MG/5 ML ORAL SOLN
|
Facility
OP
|
$36.42
|
|
|
Service Code
|
NDC 50383007916
|
| Hospital Charge Code |
110535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.02 |
| Max. Negotiated Rate |
$33.87 |
| Rate for Payer: Aetna Commercial |
$30.74
|
| Rate for Payer: Aetna Medicare |
$12.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.22
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Centivo All Commercial |
$18.57
|
| Rate for Payer: Cigna All Commercial |
$31.43
|
| Rate for Payer: CORVEL All Commercial |
$33.87
|
| Rate for Payer: Coventry All Commercial |
$32.05
|
| Rate for Payer: Encore All Commercial |
$33.53
|
| Rate for Payer: Frontpath All Commercial |
$33.51
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Humana Medicare |
$18.57
|
| Rate for Payer: Lucent All Commercial |
$18.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.78
|
| Rate for Payer: PHCS All Commercial |
$27.32
|
| Rate for Payer: PHP All Commercial |
$27.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.20
|
| Rate for Payer: Sagamore Health Network All Products |
$28.12
|
| Rate for Payer: Signature Care EPO |
$30.23
|
| Rate for Payer: Signature Care PPO |
$32.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.96
|
| Rate for Payer: United Healthcare Commercial |
$28.70
|
| Rate for Payer: United Healthcare Medicare |
$12.02
|
|
|
ACETAMINOPHEN-CODEINE 120-12 MG/5 ML ORAL SOLN
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 503830079
|
| Hospital Charge Code |
110535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| 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 |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| 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 |
$1.32
|
|
|
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
|
|
|
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 |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| 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 |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| 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 |
$1.32
|
|
|
ACETAZOLAMIDE 500 MG ORAL CPER
|
Facility
IP
|
$28.50
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.37 |
| Max. Negotiated Rate |
$26.50 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Cigna All Commercial |
$24.59
|
| Rate for Payer: CORVEL All Commercial |
$26.50
|
| Rate for Payer: Coventry All Commercial |
$25.08
|
| Rate for Payer: Encore All Commercial |
$26.23
|
| Rate for Payer: Frontpath All Commercial |
$26.22
|
| Rate for Payer: Humana ChoiceCare |
$24.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.65
|
| Rate for Payer: PHCS All Commercial |
$21.37
|
| Rate for Payer: PHP All Commercial |
$21.61
|
| Rate for Payer: Sagamore Health Network All Products |
$22.00
|
| Rate for Payer: Signature Care EPO |
$23.65
|
| Rate for Payer: Signature Care PPO |
$25.08
|
| Rate for Payer: United Healthcare Commercial |
$22.46
|
|
|
ACETAZOLAMIDE 500 MG ORAL CPER
|
Facility
OP
|
$28.50
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.40 |
| Max. Negotiated Rate |
$26.50 |
| Rate for Payer: Aetna Commercial |
$24.05
|
| Rate for Payer: Aetna Medicare |
$9.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.34
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Centivo All Commercial |
$14.53
|
| Rate for Payer: Cigna All Commercial |
$24.59
|
| Rate for Payer: CORVEL All Commercial |
$26.50
|
| Rate for Payer: Coventry All Commercial |
$25.08
|
| Rate for Payer: Encore All Commercial |
$26.23
|
| Rate for Payer: Frontpath All Commercial |
$26.22
|
| Rate for Payer: Humana ChoiceCare |
$24.61
|
| Rate for Payer: Humana Medicare |
$14.53
|
| Rate for Payer: Lucent All Commercial |
$14.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.65
|
| Rate for Payer: PHCS All Commercial |
$21.37
|
| Rate for Payer: PHP All Commercial |
$21.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.11
|
| Rate for Payer: Sagamore Health Network All Products |
$22.00
|
| Rate for Payer: Signature Care EPO |
$23.65
|
| Rate for Payer: Signature Care PPO |
$25.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.22
|
| Rate for Payer: United Healthcare Commercial |
$22.46
|
| Rate for Payer: United Healthcare Medicare |
$9.40
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN
|
Facility
OP
|
$258.93
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$240.80 |
| Rate for Payer: Aetna Commercial |
$218.54
|
| Rate for Payer: Aetna Medicare |
$85.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$85.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$148.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$161.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$98.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.99
|
| Rate for Payer: Cash Price |
$160.54
|
| Rate for Payer: Cash Price |
$160.54
|
| Rate for Payer: Centivo All Commercial |
$132.05
|
| Rate for Payer: Cigna All Commercial |
$223.46
|
| Rate for Payer: CORVEL All Commercial |
$240.80
|
| Rate for Payer: Coventry All Commercial |
$227.86
|
| Rate for Payer: Encore All Commercial |
$238.35
|
| Rate for Payer: Frontpath All Commercial |
$238.22
|
| Rate for Payer: Humana ChoiceCare |
$223.64
|
| Rate for Payer: Humana Medicare |
$132.05
|
| Rate for Payer: Lucent All Commercial |
$132.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$233.04
|
| Rate for Payer: Managed Health Services Medicaid |
$0.65
|
| Rate for Payer: MDWise Medicaid |
$0.65
|
| Rate for Payer: PHCS All Commercial |
$194.20
|
| Rate for Payer: PHP All Commercial |
$196.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$100.98
|
| Rate for Payer: Sagamore Health Network All Products |
$199.89
|
| Rate for Payer: Signature Care EPO |
$214.91
|
| Rate for Payer: Signature Care PPO |
$227.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$220.09
|
| Rate for Payer: United Healthcare Commercial |
$204.04
|
| Rate for Payer: United Healthcare Medicare |
$85.45
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN
|
Facility
IP
|
$258.93
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$194.20 |
| Max. Negotiated Rate |
$240.80 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Cash Price |
$160.54
|
| Rate for Payer: Cigna All Commercial |
$223.46
|
| Rate for Payer: CORVEL All Commercial |
$240.80
|
| Rate for Payer: Coventry All Commercial |
$227.86
|
| Rate for Payer: Encore All Commercial |
$238.35
|
| Rate for Payer: Frontpath All Commercial |
$238.22
|
| Rate for Payer: Humana ChoiceCare |
$223.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$233.04
|
| Rate for Payer: PHCS All Commercial |
$194.20
|
| Rate for Payer: PHP All Commercial |
$196.37
|
| Rate for Payer: Sagamore Health Network All Products |
$199.89
|
| Rate for Payer: Signature Care EPO |
$214.91
|
| Rate for Payer: Signature Care PPO |
$227.86
|
| Rate for Payer: United Healthcare Commercial |
$204.04
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN
|
Facility
IP
|
$122.08
|
|
|
Service Code
|
NDC 00517760425
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.56 |
| Max. Negotiated Rate |
$113.53 |
| Rate for Payer: Aetna Commercial |
$105.48
|
| Rate for Payer: Cash Price |
$75.69
|
| Rate for Payer: Cigna All Commercial |
$105.36
|
| Rate for Payer: CORVEL All Commercial |
$113.53
|
| Rate for Payer: Coventry All Commercial |
$107.43
|
| Rate for Payer: Encore All Commercial |
$112.37
|
| Rate for Payer: Frontpath All Commercial |
$112.31
|
| Rate for Payer: Humana ChoiceCare |
$105.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$109.87
|
| Rate for Payer: PHCS All Commercial |
$91.56
|
| Rate for Payer: PHP All Commercial |
$92.59
|
| Rate for Payer: Sagamore Health Network All Products |
$94.25
|
| Rate for Payer: Signature Care EPO |
$101.33
|
| Rate for Payer: Signature Care PPO |
$107.43
|
| Rate for Payer: United Healthcare Commercial |
$96.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN
|
Facility
OP
|
$122.08
|
|
|
Service Code
|
NDC 00517760425
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.29 |
| Max. Negotiated Rate |
$113.53 |
| Rate for Payer: Aetna Commercial |
$103.04
|
| Rate for Payer: Aetna Medicare |
$40.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$40.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$70.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$76.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.32
|
| Rate for Payer: Cash Price |
$75.69
|
| Rate for Payer: Centivo All Commercial |
$62.26
|
| Rate for Payer: Cigna All Commercial |
$105.36
|
| Rate for Payer: CORVEL All Commercial |
$113.53
|
| Rate for Payer: Coventry All Commercial |
$107.43
|
| Rate for Payer: Encore All Commercial |
$112.37
|
| Rate for Payer: Frontpath All Commercial |
$112.31
|
| Rate for Payer: Humana ChoiceCare |
$105.44
|
| Rate for Payer: Humana Medicare |
$62.26
|
| Rate for Payer: Lucent All Commercial |
$62.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$109.87
|
| Rate for Payer: PHCS All Commercial |
$91.56
|
| Rate for Payer: PHP All Commercial |
$92.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.61
|
| Rate for Payer: Sagamore Health Network All Products |
$94.25
|
| Rate for Payer: Signature Care EPO |
$101.33
|
| Rate for Payer: Signature Care PPO |
$107.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$103.77
|
| Rate for Payer: United Healthcare Commercial |
$96.20
|
| Rate for Payer: United Healthcare Medicare |
$40.29
|
|
|
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 |
$0.41 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.05
|
| Rate for Payer: Aetna Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.45
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Centivo All Commercial |
$0.63
|
| 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 |
$0.63
|
| Rate for Payer: Lucent All Commercial |
$0.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.12
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 |
$0.41
|
|
|
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 |
$36.87 |
| Max. Negotiated Rate |
$103.90 |
| Rate for Payer: Aetna Commercial |
$94.29
|
| Rate for Payer: Aetna Medicare |
$36.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$64.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$69.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.55
|
| Rate for Payer: Cash Price |
$69.27
|
| Rate for Payer: Cash Price |
$69.27
|
| Rate for Payer: Centivo All Commercial |
$56.98
|
| 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 |
$56.98
|
| Rate for Payer: Lucent All Commercial |
$56.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$100.55
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 |
$36.87
|
|
|
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
OP
|
$98.28
|
|
|
Service Code
|
NDC 00574052074
|
| Hospital Charge Code |
117010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.43 |
| Max. Negotiated Rate |
$91.40 |
| Rate for Payer: Aetna Commercial |
$82.95
|
| Rate for Payer: Aetna Medicare |
$32.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$56.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$61.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.68
|
| Rate for Payer: Cash Price |
$60.93
|
| Rate for Payer: Cash Price |
$60.93
|
| Rate for Payer: Centivo All Commercial |
$50.12
|
| Rate for Payer: Cigna All Commercial |
$84.82
|
| Rate for Payer: CORVEL All Commercial |
$91.40
|
| Rate for Payer: Coventry All Commercial |
$86.49
|
| Rate for Payer: Encore All Commercial |
$90.47
|
| Rate for Payer: Frontpath All Commercial |
$90.42
|
| Rate for Payer: Humana ChoiceCare |
$84.88
|
| Rate for Payer: Humana Medicare |
$50.12
|
| Rate for Payer: Lucent All Commercial |
$50.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.45
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$73.71
|
| Rate for Payer: PHP All Commercial |
$74.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.33
|
| Rate for Payer: Sagamore Health Network All Products |
$75.87
|
| Rate for Payer: Signature Care EPO |
$81.57
|
| Rate for Payer: Signature Care PPO |
$86.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$83.54
|
| Rate for Payer: United Healthcare Commercial |
$77.44
|
| Rate for Payer: United Healthcare Medicare |
$32.43
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML ORAL SUSP
|
Facility
IP
|
$98.28
|
|
|
Service Code
|
NDC 00574052074
|
| Hospital Charge Code |
117010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.71 |
| Max. Negotiated Rate |
$91.40 |
| Rate for Payer: Aetna Commercial |
$84.91
|
| Rate for Payer: Cash Price |
$60.93
|
| Rate for Payer: Cigna All Commercial |
$84.82
|
| Rate for Payer: CORVEL All Commercial |
$91.40
|
| Rate for Payer: Coventry All Commercial |
$86.49
|
| Rate for Payer: Encore All Commercial |
$90.47
|
| Rate for Payer: Frontpath All Commercial |
$90.42
|
| Rate for Payer: Humana ChoiceCare |
$84.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.45
|
| Rate for Payer: PHCS All Commercial |
$73.71
|
| Rate for Payer: PHP All Commercial |
$74.54
|
| Rate for Payer: Sagamore Health Network All Products |
$75.87
|
| Rate for Payer: Signature Care EPO |
$81.57
|
| Rate for Payer: Signature Care PPO |
$86.49
|
| Rate for Payer: United Healthcare Commercial |
$77.44
|
|
|
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 |
$0.33 |
| 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
|
|
|
ACYCLOVIR 5 % TOP CREA
|
Facility
IP
|
$948.50
|
|
|
Service Code
|
NDC 00187099445
|
| Hospital Charge Code |
8967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$711.38 |
| Max. Negotiated Rate |
$882.10 |
| Rate for Payer: Aetna Commercial |
$819.50
|
| Rate for Payer: Cash Price |
$588.07
|
| Rate for Payer: Cigna All Commercial |
$818.56
|
| Rate for Payer: CORVEL All Commercial |
$882.10
|
| Rate for Payer: Coventry All Commercial |
$834.68
|
| Rate for Payer: Encore All Commercial |
$873.09
|
| Rate for Payer: Frontpath All Commercial |
$872.62
|
| Rate for Payer: Humana ChoiceCare |
$819.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.65
|
| Rate for Payer: PHCS All Commercial |
$711.38
|
| Rate for Payer: PHP All Commercial |
$719.34
|
| Rate for Payer: Sagamore Health Network All Products |
$732.24
|
| Rate for Payer: Signature Care EPO |
$787.26
|
| Rate for Payer: Signature Care PPO |
$834.68
|
| Rate for Payer: United Healthcare Commercial |
$747.42
|
|
|
ACYCLOVIR 5 % TOP CREA
|
Facility
OP
|
$948.50
|
|
|
Service Code
|
NDC 00187099445
|
| Hospital Charge Code |
8967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$313.00 |
| Max. Negotiated Rate |
$882.10 |
| Rate for Payer: Aetna Commercial |
$800.53
|
| Rate for Payer: Aetna Medicare |
$313.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$313.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$544.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$592.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$359.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$344.31
|
| Rate for Payer: Cash Price |
$588.07
|
| Rate for Payer: Centivo All Commercial |
$483.74
|
| Rate for Payer: Cigna All Commercial |
$818.56
|
| Rate for Payer: CORVEL All Commercial |
$882.10
|
| Rate for Payer: Coventry All Commercial |
$834.68
|
| Rate for Payer: Encore All Commercial |
$873.09
|
| Rate for Payer: Frontpath All Commercial |
$872.62
|
| Rate for Payer: Humana ChoiceCare |
$819.22
|
| Rate for Payer: Humana Medicare |
$483.74
|
| Rate for Payer: Lucent All Commercial |
$483.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.65
|
| Rate for Payer: PHCS All Commercial |
$711.38
|
| Rate for Payer: PHP All Commercial |
$719.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$369.92
|
| Rate for Payer: Sagamore Health Network All Products |
$732.24
|
| Rate for Payer: Signature Care EPO |
$787.26
|
| Rate for Payer: Signature Care PPO |
$834.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$806.22
|
| Rate for Payer: United Healthcare Commercial |
$747.42
|
| Rate for Payer: United Healthcare Medicare |
$313.00
|
|
|
ACYCLOVIR SODIUM 50 MG/ML IV SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
23128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
