|
ALBUTEROL INHALER ED PACK (CAMERON)
|
Facility
OP
|
$75.43
|
|
|
Service Code
|
NDC 001730682
|
| Hospital Charge Code |
1401000800173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$70.15 |
| Rate for Payer: Aetna Commercial |
$63.66
|
| Rate for Payer: Aetna Medicare |
$24.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.38
|
| Rate for Payer: Cash Price |
$46.77
|
| Rate for Payer: Centivo All Commercial |
$38.47
|
| Rate for Payer: Cigna All Commercial |
$65.10
|
| Rate for Payer: CORVEL All Commercial |
$70.15
|
| Rate for Payer: Coventry All Commercial |
$66.38
|
| Rate for Payer: Encore All Commercial |
$69.44
|
| Rate for Payer: Frontpath All Commercial |
$69.40
|
| Rate for Payer: Humana ChoiceCare |
$65.15
|
| Rate for Payer: Humana Medicare |
$38.47
|
| Rate for Payer: Lucent All Commercial |
$38.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.89
|
| Rate for Payer: PHCS All Commercial |
$56.57
|
| Rate for Payer: PHP All Commercial |
$57.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.42
|
| Rate for Payer: Sagamore Health Network All Products |
$58.23
|
| Rate for Payer: Signature Care EPO |
$62.61
|
| Rate for Payer: Signature Care PPO |
$66.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$64.12
|
| Rate for Payer: United Healthcare Commercial |
$59.44
|
| Rate for Payer: United Healthcare Medicare |
$24.89
|
|
|
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU
|
Facility
OP
|
$8.65
|
|
|
Service Code
|
NDC 00487990401
|
| Hospital Charge Code |
31578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$7.30
|
| Rate for Payer: Aetna Medicare |
$2.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.14
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Centivo All Commercial |
$4.41
|
| Rate for Payer: Cigna All Commercial |
$7.47
|
| Rate for Payer: CORVEL All Commercial |
$8.05
|
| Rate for Payer: Coventry All Commercial |
$7.61
|
| Rate for Payer: Encore All Commercial |
$7.96
|
| Rate for Payer: Frontpath All Commercial |
$7.96
|
| Rate for Payer: Humana ChoiceCare |
$7.47
|
| Rate for Payer: Humana Medicare |
$4.41
|
| Rate for Payer: Lucent All Commercial |
$4.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.79
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$6.49
|
| Rate for Payer: PHP All Commercial |
$6.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.37
|
| Rate for Payer: Sagamore Health Network All Products |
$6.68
|
| Rate for Payer: Signature Care EPO |
$7.18
|
| Rate for Payer: Signature Care PPO |
$7.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.35
|
| Rate for Payer: United Healthcare Commercial |
$6.82
|
| Rate for Payer: United Healthcare Medicare |
$2.86
|
|
|
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU
|
Facility
IP
|
$8.65
|
|
|
Service Code
|
NDC 00487990401
|
| Hospital Charge Code |
31578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$8.05 |
| Rate for Payer: Aetna Commercial |
$7.48
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Cigna All Commercial |
$7.47
|
| Rate for Payer: CORVEL All Commercial |
$8.05
|
| Rate for Payer: Coventry All Commercial |
$7.61
|
| Rate for Payer: Encore All Commercial |
$7.96
|
| Rate for Payer: Frontpath All Commercial |
$7.96
|
| Rate for Payer: Humana ChoiceCare |
$7.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.79
|
| Rate for Payer: PHCS All Commercial |
$6.49
|
| Rate for Payer: PHP All Commercial |
$6.56
|
| Rate for Payer: Sagamore Health Network All Products |
$6.68
|
| Rate for Payer: Signature Care EPO |
$7.18
|
| Rate for Payer: Signature Care PPO |
$7.61
|
| Rate for Payer: United Healthcare Commercial |
$6.82
|
|
|
ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INHL NEBU
|
Facility
OP
|
$1.83
|
|
|
Service Code
|
NDC 00487950101
|
| Hospital Charge Code |
250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.54
|
| Rate for Payer: Aetna Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Centivo All Commercial |
$0.93
|
| Rate for Payer: Cigna All Commercial |
$1.58
|
| Rate for Payer: CORVEL All Commercial |
$1.70
|
| Rate for Payer: Coventry All Commercial |
$1.61
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.68
|
| Rate for Payer: Humana ChoiceCare |
$1.58
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$0.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.37
|
| Rate for Payer: PHP All Commercial |
$1.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.52
|
| Rate for Payer: Signature Care PPO |
$1.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
|
|
ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INHL NEBU
|
Facility
IP
|
$1.83
|
|
|
Service Code
|
NDC 00487950101
|
| Hospital Charge Code |
250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.58
|
| Rate for Payer: CORVEL All Commercial |
$1.70
|
| Rate for Payer: Coventry All Commercial |
$1.61
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.68
|
| Rate for Payer: Humana ChoiceCare |
$1.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.37
|
| Rate for Payer: PHP All Commercial |
$1.39
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.52
|
| Rate for Payer: Signature Care PPO |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 70752102
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$0.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Centivo All Commercial |
$0.80
|
| Rate for Payer: Cigna All Commercial |
$1.36
|
| Rate for Payer: CORVEL All Commercial |
$1.46
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.45
|
| Rate for Payer: Frontpath All Commercial |
$1.45
|
| Rate for Payer: Humana ChoiceCare |
$1.36
|
| Rate for Payer: Humana Medicare |
$0.80
|
| Rate for Payer: Lucent All Commercial |
$0.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: PHCS All Commercial |
$1.18
|
| Rate for Payer: PHP All Commercial |
$1.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.52
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
IP
|
$152.31
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.23 |
| Max. Negotiated Rate |
$141.64 |
| Rate for Payer: Aetna Commercial |
$131.59
|
| Rate for Payer: Cash Price |
$94.43
|
| Rate for Payer: Cigna All Commercial |
$131.44
|
| Rate for Payer: CORVEL All Commercial |
$141.64
|
| Rate for Payer: Coventry All Commercial |
$134.03
|
| Rate for Payer: Encore All Commercial |
$140.20
|
| Rate for Payer: Frontpath All Commercial |
$140.12
|
| Rate for Payer: Humana ChoiceCare |
$131.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$137.08
|
| Rate for Payer: PHCS All Commercial |
$114.23
|
| Rate for Payer: PHP All Commercial |
$115.51
|
| Rate for Payer: Sagamore Health Network All Products |
$117.58
|
| Rate for Payer: Signature Care EPO |
$126.41
|
| Rate for Payer: Signature Care PPO |
$134.03
|
| Rate for Payer: United Healthcare Commercial |
$120.02
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
OP
|
$152.31
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.26 |
| Max. Negotiated Rate |
$141.64 |
| Rate for Payer: Aetna Commercial |
$128.55
|
| Rate for Payer: Aetna Medicare |
$50.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$50.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$87.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$95.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.29
|
| Rate for Payer: Cash Price |
$94.43
|
| Rate for Payer: Centivo All Commercial |
$77.68
|
| Rate for Payer: Cigna All Commercial |
$131.44
|
| Rate for Payer: CORVEL All Commercial |
$141.64
|
| Rate for Payer: Coventry All Commercial |
$134.03
|
| Rate for Payer: Encore All Commercial |
$140.20
|
| Rate for Payer: Frontpath All Commercial |
$140.12
|
| Rate for Payer: Humana ChoiceCare |
$131.55
|
| Rate for Payer: Humana Medicare |
$77.68
|
| Rate for Payer: Lucent All Commercial |
$77.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$137.08
|
| Rate for Payer: PHCS All Commercial |
$114.23
|
| Rate for Payer: PHP All Commercial |
$115.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$59.40
|
| Rate for Payer: Sagamore Health Network All Products |
$117.58
|
| Rate for Payer: Signature Care EPO |
$126.41
|
| Rate for Payer: Signature Care PPO |
$134.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$129.46
|
| Rate for Payer: United Healthcare Commercial |
$120.02
|
| Rate for Payer: United Healthcare Medicare |
$50.26
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
IP
|
$1.58
|
|
|
Service Code
|
NDC 70752102
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna All Commercial |
$1.36
|
| Rate for Payer: CORVEL All Commercial |
$1.46
|
| Rate for Payer: Coventry All Commercial |
$1.39
|
| Rate for Payer: Encore All Commercial |
$1.45
|
| Rate for Payer: Frontpath All Commercial |
$1.45
|
| Rate for Payer: Humana ChoiceCare |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.42
|
| Rate for Payer: PHCS All Commercial |
$1.18
|
| Rate for Payer: PHP All Commercial |
$1.19
|
| Rate for Payer: Sagamore Health Network All Products |
$1.22
|
| Rate for Payer: Signature Care EPO |
$1.31
|
| Rate for Payer: Signature Care PPO |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
IP
|
$75.43
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.57 |
| Max. Negotiated Rate |
$70.15 |
| Rate for Payer: Aetna Commercial |
$65.17
|
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Aetna Commercial |
$107.36
|
| Rate for Payer: Cash Price |
$62.23
|
| Rate for Payer: Cash Price |
$46.77
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cigna All Commercial |
$107.23
|
| Rate for Payer: Cigna All Commercial |
$86.62
|
| Rate for Payer: Cigna All Commercial |
$65.10
|
| Rate for Payer: CORVEL All Commercial |
$70.15
|
| Rate for Payer: CORVEL All Commercial |
$115.56
|
| Rate for Payer: CORVEL All Commercial |
$93.34
|
| Rate for Payer: Coventry All Commercial |
$66.38
|
| Rate for Payer: Coventry All Commercial |
$88.32
|
| Rate for Payer: Coventry All Commercial |
$109.34
|
| Rate for Payer: Encore All Commercial |
$114.38
|
| Rate for Payer: Encore All Commercial |
$69.44
|
| Rate for Payer: Encore All Commercial |
$92.39
|
| Rate for Payer: Frontpath All Commercial |
$69.40
|
| Rate for Payer: Frontpath All Commercial |
$114.31
|
| Rate for Payer: Frontpath All Commercial |
$92.34
|
| Rate for Payer: Humana ChoiceCare |
$65.15
|
| Rate for Payer: Humana ChoiceCare |
$86.69
|
| Rate for Payer: Humana ChoiceCare |
$107.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$111.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.89
|
| Rate for Payer: PHCS All Commercial |
$56.57
|
| Rate for Payer: PHCS All Commercial |
$93.19
|
| Rate for Payer: PHCS All Commercial |
$75.28
|
| Rate for Payer: PHP All Commercial |
$76.12
|
| Rate for Payer: PHP All Commercial |
$94.23
|
| Rate for Payer: PHP All Commercial |
$57.21
|
| Rate for Payer: Sagamore Health Network All Products |
$77.48
|
| Rate for Payer: Sagamore Health Network All Products |
$58.23
|
| Rate for Payer: Sagamore Health Network All Products |
$95.92
|
| Rate for Payer: Signature Care EPO |
$62.61
|
| Rate for Payer: Signature Care EPO |
$83.31
|
| Rate for Payer: Signature Care EPO |
$103.13
|
| Rate for Payer: Signature Care PPO |
$88.32
|
| Rate for Payer: Signature Care PPO |
$109.34
|
| Rate for Payer: Signature Care PPO |
$66.38
|
| Rate for Payer: United Healthcare Commercial |
$97.91
|
| Rate for Payer: United Healthcare Commercial |
$79.09
|
| Rate for Payer: United Healthcare Commercial |
$59.44
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
OP
|
$124.25
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.00 |
| Max. Negotiated Rate |
$115.56 |
| Rate for Payer: Aetna Commercial |
$104.87
|
| Rate for Payer: Aetna Commercial |
$63.66
|
| Rate for Payer: Aetna Commercial |
$84.71
|
| Rate for Payer: Aetna Medicare |
$41.00
|
| Rate for Payer: Aetna Medicare |
$33.12
|
| Rate for Payer: Aetna Medicare |
$24.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$57.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$71.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$77.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.10
|
| Rate for Payer: Cash Price |
$46.77
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cash Price |
$62.23
|
| Rate for Payer: Centivo All Commercial |
$38.47
|
| Rate for Payer: Centivo All Commercial |
$63.37
|
| Rate for Payer: Centivo All Commercial |
$51.19
|
| Rate for Payer: Cigna All Commercial |
$86.62
|
| Rate for Payer: Cigna All Commercial |
$107.23
|
| Rate for Payer: Cigna All Commercial |
$65.10
|
| Rate for Payer: CORVEL All Commercial |
$93.34
|
| Rate for Payer: CORVEL All Commercial |
$70.15
|
| Rate for Payer: CORVEL All Commercial |
$115.56
|
| Rate for Payer: Coventry All Commercial |
$66.38
|
| Rate for Payer: Coventry All Commercial |
$109.34
|
| Rate for Payer: Coventry All Commercial |
$88.32
|
| Rate for Payer: Encore All Commercial |
$114.38
|
| Rate for Payer: Encore All Commercial |
$69.44
|
| Rate for Payer: Encore All Commercial |
$92.39
|
| Rate for Payer: Frontpath All Commercial |
$69.40
|
| Rate for Payer: Frontpath All Commercial |
$114.31
|
| Rate for Payer: Frontpath All Commercial |
$92.34
|
| Rate for Payer: Humana ChoiceCare |
$107.32
|
| Rate for Payer: Humana ChoiceCare |
$86.69
|
| Rate for Payer: Humana ChoiceCare |
$65.15
|
| Rate for Payer: Humana Medicare |
$63.37
|
| Rate for Payer: Humana Medicare |
$51.19
|
| Rate for Payer: Humana Medicare |
$38.47
|
| Rate for Payer: Lucent All Commercial |
$63.37
|
| Rate for Payer: Lucent All Commercial |
$51.19
|
| Rate for Payer: Lucent All Commercial |
$38.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$111.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.33
|
| Rate for Payer: PHCS All Commercial |
$56.57
|
| Rate for Payer: PHCS All Commercial |
$75.28
|
| Rate for Payer: PHCS All Commercial |
$93.19
|
| Rate for Payer: PHP All Commercial |
$57.21
|
| Rate for Payer: PHP All Commercial |
$76.12
|
| Rate for Payer: PHP All Commercial |
$94.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$48.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.14
|
| Rate for Payer: Sagamore Health Network All Products |
$58.23
|
| Rate for Payer: Sagamore Health Network All Products |
$77.48
|
| Rate for Payer: Sagamore Health Network All Products |
$95.92
|
| Rate for Payer: Signature Care EPO |
$103.13
|
| Rate for Payer: Signature Care EPO |
$62.61
|
| Rate for Payer: Signature Care EPO |
$83.31
|
| Rate for Payer: Signature Care PPO |
$109.34
|
| Rate for Payer: Signature Care PPO |
$88.32
|
| Rate for Payer: Signature Care PPO |
$66.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$105.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$64.12
|
| Rate for Payer: United Healthcare Commercial |
$79.09
|
| Rate for Payer: United Healthcare Commercial |
$59.44
|
| Rate for Payer: United Healthcare Commercial |
$97.91
|
| Rate for Payer: United Healthcare Medicare |
$24.89
|
| Rate for Payer: United Healthcare Medicare |
$33.12
|
| Rate for Payer: United Healthcare Medicare |
$41.00
|
|
|
ALIROCUMAB 150 MG/ML SUBQ PNIJ
|
Facility
OP
|
$1,201.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
173401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$396.33 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,013.64
|
| Rate for Payer: Aetna Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$689.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$750.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$455.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$435.96
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Centivo All Commercial |
$612.51
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Humana Medicare |
$612.51
|
| Rate for Payer: Lucent All Commercial |
$612.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$468.39
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,020.85
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
| Rate for Payer: United Healthcare Medicare |
$396.33
|
|
|
ALIROCUMAB 150 MG/ML SUBQ PNIJ
|
Facility
IP
|
$1,201.00
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
173401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$900.75 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,037.66
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
IP
|
$1,201.00
|
|
|
Service Code
|
NDC 61755002002
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$900.75 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,037.66
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
IP
|
$1,201.00
|
|
|
Service Code
|
NDC 61755002001
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$900.75 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,037.66
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
OP
|
$1,201.00
|
|
|
Service Code
|
NDC 61755002001
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,013.64
|
| Rate for Payer: Aetna Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$689.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$750.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$455.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$435.96
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Centivo All Commercial |
$612.51
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Humana Medicare |
$612.51
|
| Rate for Payer: Lucent All Commercial |
$612.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$468.39
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,020.85
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
| Rate for Payer: United Healthcare Medicare |
$396.33
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
OP
|
$1,201.00
|
|
|
Service Code
|
NDC 61755002002
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,116.93 |
| Rate for Payer: Aetna Commercial |
$1,013.64
|
| Rate for Payer: Aetna Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$396.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$689.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$750.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$455.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$435.96
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Cash Price |
$744.62
|
| Rate for Payer: Centivo All Commercial |
$612.51
|
| Rate for Payer: Cigna All Commercial |
$1,036.46
|
| Rate for Payer: CORVEL All Commercial |
$1,116.93
|
| Rate for Payer: Coventry All Commercial |
$1,056.88
|
| Rate for Payer: Encore All Commercial |
$1,105.52
|
| Rate for Payer: Frontpath All Commercial |
$1,104.92
|
| Rate for Payer: Humana ChoiceCare |
$1,037.30
|
| Rate for Payer: Humana Medicare |
$612.51
|
| Rate for Payer: Lucent All Commercial |
$612.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.90
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$900.75
|
| Rate for Payer: PHP All Commercial |
$910.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$468.39
|
| Rate for Payer: Sagamore Health Network All Products |
$927.17
|
| Rate for Payer: Signature Care EPO |
$996.83
|
| Rate for Payer: Signature Care PPO |
$1,056.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,020.85
|
| Rate for Payer: United Healthcare Commercial |
$946.39
|
| Rate for Payer: United Healthcare Medicare |
$396.33
|
|
|
ALISKIREN 150 MG ORAL TAB
|
Facility
OP
|
$29.20
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
78653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Aetna Commercial |
$24.65
|
| Rate for Payer: Aetna Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.60
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Centivo All Commercial |
$14.89
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Humana Medicare |
$14.89
|
| Rate for Payer: Lucent All Commercial |
$14.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.39
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
|
|
ALISKIREN 150 MG ORAL TAB
|
Facility
IP
|
$29.20
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
78653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Aetna Commercial |
$25.23
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
|
|
ALLOPURINOL 100 MG ORAL TAB
|
Facility
IP
|
$2.05
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cigna All Commercial |
$1.77
|
| Rate for Payer: CORVEL All Commercial |
$1.91
|
| Rate for Payer: Coventry All Commercial |
$1.80
|
| Rate for Payer: Encore All Commercial |
$1.89
|
| Rate for Payer: Frontpath All Commercial |
$1.89
|
| Rate for Payer: Humana ChoiceCare |
$1.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.85
|
| Rate for Payer: PHCS All Commercial |
$1.54
|
| Rate for Payer: PHP All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$1.58
|
| Rate for Payer: Signature Care EPO |
$1.70
|
| Rate for Payer: Signature Care PPO |
$1.80
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
|
|
ALLOPURINOL 100 MG ORAL TAB
|
Facility
OP
|
$2.05
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna Medicare |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Centivo All Commercial |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.77
|
| Rate for Payer: CORVEL All Commercial |
$1.91
|
| Rate for Payer: Coventry All Commercial |
$1.80
|
| Rate for Payer: Encore All Commercial |
$1.89
|
| Rate for Payer: Frontpath All Commercial |
$1.89
|
| Rate for Payer: Humana ChoiceCare |
$1.77
|
| Rate for Payer: Humana Medicare |
$1.05
|
| Rate for Payer: Lucent All Commercial |
$1.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.85
|
| Rate for Payer: PHCS All Commercial |
$1.54
|
| Rate for Payer: PHP All Commercial |
$1.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.80
|
| Rate for Payer: Sagamore Health Network All Products |
$1.58
|
| Rate for Payer: Signature Care EPO |
$1.70
|
| Rate for Payer: Signature Care PPO |
$1.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$0.68
|
|
|
ALPRAZOLAM 0.25 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 00781106101
|
| Hospital Charge Code |
324
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG ORAL TAB
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 00781106101
|
| Hospital Charge Code |
324
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$37.28 |
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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
|
|
|
ALPRAZOLAM 0.5 MG ORAL TAB
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
| Hospital Charge Code |
325
|
|
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
|
|
