|
PERMETHRIN 1 % TOP LIQD
|
Facility
|
IP
|
$59.06
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$54.92 |
| Rate for Payer: Aetna Commercial |
$51.03
|
| Rate for Payer: Cash Price |
$35.44
|
| Rate for Payer: Cigna All Commercial |
$50.97
|
| Rate for Payer: CORVEL All Commercial |
$54.92
|
| Rate for Payer: Coventry All Commercial |
$51.97
|
| Rate for Payer: Encore All Commercial |
$54.36
|
| Rate for Payer: Frontpath All Commercial |
$54.33
|
| Rate for Payer: Humana ChoiceCare |
$51.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.15
|
| Rate for Payer: PHCS All Commercial |
$44.29
|
| Rate for Payer: PHP All Commercial |
$44.79
|
| Rate for Payer: Sagamore Health Network All Products |
$45.59
|
| Rate for Payer: Signature Care EPO |
$49.02
|
| Rate for Payer: Signature Care PPO |
$51.97
|
| Rate for Payer: United Healthcare Commercial |
$46.54
|
|
|
PERMETHRIN 1 % TOP LIQD
|
Facility
|
OP
|
$59.06
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.31 |
| Max. Negotiated Rate |
$54.92 |
| Rate for Payer: Aetna Commercial |
$49.85
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.79
|
| Rate for Payer: Cash Price |
$35.44
|
| Rate for Payer: Centivo All Commercial |
$32.13
|
| Rate for Payer: Cigna All Commercial |
$50.97
|
| Rate for Payer: CORVEL All Commercial |
$54.92
|
| Rate for Payer: Coventry All Commercial |
$51.97
|
| Rate for Payer: Encore All Commercial |
$54.36
|
| Rate for Payer: Frontpath All Commercial |
$54.33
|
| Rate for Payer: Humana ChoiceCare |
$51.01
|
| Rate for Payer: Humana Medicare |
$18.90
|
| Rate for Payer: Lucent All Commercial |
$32.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.15
|
| Rate for Payer: PHCS All Commercial |
$44.29
|
| Rate for Payer: PHP All Commercial |
$44.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.03
|
| Rate for Payer: Sagamore Health Network All Products |
$45.59
|
| Rate for Payer: Signature Care EPO |
$49.02
|
| Rate for Payer: Signature Care PPO |
$51.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.20
|
| Rate for Payer: United Healthcare Commercial |
$46.54
|
| Rate for Payer: United Healthcare Medicare |
$18.90
|
|
|
PHENAZOPYRIDINE 100 MG ORAL TAB
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.24
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Centivo All Commercial |
$0.80
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.29
|
| Rate for Payer: Encore All Commercial |
$1.35
|
| Rate for Payer: Frontpath All Commercial |
$1.35
|
| Rate for Payer: Humana ChoiceCare |
$1.27
|
| Rate for Payer: Humana Medicare |
$0.47
|
| Rate for Payer: Lucent All Commercial |
$0.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.32
|
| Rate for Payer: PHCS All Commercial |
$1.10
|
| Rate for Payer: PHP All Commercial |
$1.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.57
|
| Rate for Payer: Sagamore Health Network All Products |
$1.13
|
| Rate for Payer: Signature Care EPO |
$1.22
|
| Rate for Payer: Signature Care PPO |
$1.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
|
|
PHENAZOPYRIDINE 100 MG ORAL TAB
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.29
|
| Rate for Payer: Encore All Commercial |
$1.35
|
| Rate for Payer: Frontpath All Commercial |
$1.35
|
| Rate for Payer: Humana ChoiceCare |
$1.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.32
|
| Rate for Payer: PHCS All Commercial |
$1.10
|
| Rate for Payer: PHP All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$1.13
|
| Rate for Payer: Signature Care EPO |
$1.22
|
| Rate for Payer: Signature Care PPO |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
PHENOBARBITAL 32.4 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
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 |
$2.40
|
| 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
|
|
|
PHENOBARBITAL 32.4 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
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 |
$2.40
|
| 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
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLN
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.25 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$92.44
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna All Commercial |
$92.34
|
| Rate for Payer: CORVEL All Commercial |
$99.51
|
| Rate for Payer: Coventry All Commercial |
$94.16
|
| Rate for Payer: Encore All Commercial |
$98.49
|
| Rate for Payer: Frontpath All Commercial |
$98.44
|
| Rate for Payer: Humana ChoiceCare |
$92.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.30
|
| Rate for Payer: PHCS All Commercial |
$80.25
|
| Rate for Payer: PHP All Commercial |
$81.15
|
| Rate for Payer: Sagamore Health Network All Products |
$82.60
|
| Rate for Payer: Signature Care EPO |
$88.81
|
| Rate for Payer: Signature Care PPO |
$94.16
|
| Rate for Payer: United Healthcare Commercial |
$84.31
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLN
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.17 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$90.30
|
| Rate for Payer: Aetna Medicare |
$34.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$61.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.66
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Centivo All Commercial |
$58.21
|
| Rate for Payer: Cigna All Commercial |
$92.34
|
| Rate for Payer: CORVEL All Commercial |
$99.51
|
| Rate for Payer: Coventry All Commercial |
$94.16
|
| Rate for Payer: Encore All Commercial |
$98.49
|
| Rate for Payer: Frontpath All Commercial |
$98.44
|
| Rate for Payer: Humana ChoiceCare |
$92.41
|
| Rate for Payer: Humana Medicare |
$34.24
|
| Rate for Payer: Lucent All Commercial |
$58.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.30
|
| Rate for Payer: PHCS All Commercial |
$80.25
|
| Rate for Payer: PHP All Commercial |
$81.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.73
|
| Rate for Payer: Sagamore Health Network All Products |
$82.60
|
| Rate for Payer: Signature Care EPO |
$88.81
|
| Rate for Payer: Signature Care PPO |
$94.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.95
|
| Rate for Payer: United Healthcare Commercial |
$84.31
|
| Rate for Payer: United Healthcare Medicare |
$34.24
|
|
|
PHENOL 1.4 % MM SPRA
|
Facility
|
OP
|
$32.21
|
|
|
Service Code
|
NDC 78112001104
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$29.96 |
| Rate for Payer: Aetna Commercial |
$27.19
|
| Rate for Payer: Aetna Medicare |
$10.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.34
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Centivo All Commercial |
$17.52
|
| Rate for Payer: Cigna All Commercial |
$27.80
|
| Rate for Payer: CORVEL All Commercial |
$29.96
|
| Rate for Payer: Coventry All Commercial |
$28.35
|
| Rate for Payer: Encore All Commercial |
$29.65
|
| Rate for Payer: Frontpath All Commercial |
$29.64
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Humana Medicare |
$10.31
|
| Rate for Payer: Lucent All Commercial |
$17.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.99
|
| Rate for Payer: PHCS All Commercial |
$24.16
|
| Rate for Payer: PHP All Commercial |
$24.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.56
|
| Rate for Payer: Sagamore Health Network All Products |
$24.87
|
| Rate for Payer: Signature Care EPO |
$26.74
|
| Rate for Payer: Signature Care PPO |
$28.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.38
|
| Rate for Payer: United Healthcare Commercial |
$25.38
|
| Rate for Payer: United Healthcare Medicare |
$10.31
|
|
|
PHENOL 1.4 % MM SPRA
|
Facility
|
IP
|
$32.21
|
|
|
Service Code
|
NDC 78112001104
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.16 |
| Max. Negotiated Rate |
$29.96 |
| Rate for Payer: Aetna Commercial |
$27.83
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cigna All Commercial |
$27.80
|
| Rate for Payer: CORVEL All Commercial |
$29.96
|
| Rate for Payer: Coventry All Commercial |
$28.35
|
| Rate for Payer: Encore All Commercial |
$29.65
|
| Rate for Payer: Frontpath All Commercial |
$29.64
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.99
|
| Rate for Payer: PHCS All Commercial |
$24.16
|
| Rate for Payer: PHP All Commercial |
$24.43
|
| Rate for Payer: Sagamore Health Network All Products |
$24.87
|
| Rate for Payer: Signature Care EPO |
$26.74
|
| Rate for Payer: Signature Care PPO |
$28.35
|
| Rate for Payer: United Healthcare Commercial |
$25.38
|
|
|
PHENTOLAMINE 5 MG INJ SOLR
|
Facility
|
OP
|
$1,745.52
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$438.90 |
| Max. Negotiated Rate |
$1,623.33 |
| Rate for Payer: Aetna Commercial |
$1,473.22
|
| Rate for Payer: Aetna Medicare |
$558.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$438.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$541.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,002.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,091.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$438.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$642.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$614.42
|
| Rate for Payer: Cash Price |
$1,047.31
|
| Rate for Payer: Cash Price |
$1,047.31
|
| Rate for Payer: Centivo All Commercial |
$949.56
|
| Rate for Payer: Cigna All Commercial |
$1,506.38
|
| Rate for Payer: CORVEL All Commercial |
$1,623.33
|
| Rate for Payer: Coventry All Commercial |
$1,536.06
|
| Rate for Payer: Encore All Commercial |
$1,606.75
|
| Rate for Payer: Frontpath All Commercial |
$1,605.88
|
| Rate for Payer: Humana ChoiceCare |
$1,507.61
|
| Rate for Payer: Humana Medicare |
$558.57
|
| Rate for Payer: Lucent All Commercial |
$949.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,570.97
|
| Rate for Payer: Managed Health Services Medicaid |
$438.90
|
| Rate for Payer: MDWise Medicaid |
$438.90
|
| Rate for Payer: PHCS All Commercial |
$1,309.14
|
| Rate for Payer: PHP All Commercial |
$1,323.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$680.75
|
| Rate for Payer: Sagamore Health Network All Products |
$1,347.54
|
| Rate for Payer: Signature Care EPO |
$1,448.78
|
| Rate for Payer: Signature Care PPO |
$1,536.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,483.69
|
| Rate for Payer: United Healthcare Commercial |
$1,375.47
|
| Rate for Payer: United Healthcare Medicare |
$558.57
|
|
|
PHENTOLAMINE 5 MG INJ SOLR
|
Facility
|
IP
|
$1,745.52
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,309.14 |
| Max. Negotiated Rate |
$1,623.33 |
| Rate for Payer: Aetna Commercial |
$1,508.13
|
| Rate for Payer: Cash Price |
$1,047.31
|
| Rate for Payer: Cigna All Commercial |
$1,506.38
|
| Rate for Payer: CORVEL All Commercial |
$1,623.33
|
| Rate for Payer: Coventry All Commercial |
$1,536.06
|
| Rate for Payer: Encore All Commercial |
$1,606.75
|
| Rate for Payer: Frontpath All Commercial |
$1,605.88
|
| Rate for Payer: Humana ChoiceCare |
$1,507.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,570.97
|
| Rate for Payer: PHCS All Commercial |
$1,309.14
|
| Rate for Payer: PHP All Commercial |
$1,323.80
|
| Rate for Payer: Sagamore Health Network All Products |
$1,347.54
|
| Rate for Payer: Signature Care EPO |
$1,448.78
|
| Rate for Payer: Signature Care PPO |
$1,536.06
|
| Rate for Payer: United Healthcare Commercial |
$1,375.47
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY
|
Facility
|
IP
|
$30.77
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.07 |
| Max. Negotiated Rate |
$28.61 |
| Rate for Payer: Aetna Commercial |
$26.58
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cigna All Commercial |
$26.55
|
| Rate for Payer: CORVEL All Commercial |
$28.61
|
| Rate for Payer: Coventry All Commercial |
$27.07
|
| Rate for Payer: Encore All Commercial |
$28.32
|
| Rate for Payer: Frontpath All Commercial |
$28.30
|
| Rate for Payer: Humana ChoiceCare |
$26.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.69
|
| Rate for Payer: PHCS All Commercial |
$23.07
|
| Rate for Payer: PHP All Commercial |
$23.33
|
| Rate for Payer: Sagamore Health Network All Products |
$23.75
|
| Rate for Payer: Signature Care EPO |
$25.53
|
| Rate for Payer: Signature Care PPO |
$27.07
|
| Rate for Payer: United Healthcare Commercial |
$24.24
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY
|
Facility
|
OP
|
$30.77
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$28.61 |
| Rate for Payer: Aetna Commercial |
$25.97
|
| Rate for Payer: Aetna Medicare |
$9.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.23
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.83
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Centivo All Commercial |
$16.74
|
| Rate for Payer: Cigna All Commercial |
$26.55
|
| Rate for Payer: CORVEL All Commercial |
$28.61
|
| Rate for Payer: Coventry All Commercial |
$27.07
|
| Rate for Payer: Encore All Commercial |
$28.32
|
| Rate for Payer: Frontpath All Commercial |
$28.30
|
| Rate for Payer: Humana ChoiceCare |
$26.57
|
| Rate for Payer: Humana Medicare |
$9.84
|
| Rate for Payer: Lucent All Commercial |
$16.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.69
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$23.07
|
| Rate for Payer: PHP All Commercial |
$23.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.00
|
| Rate for Payer: Sagamore Health Network All Products |
$23.75
|
| Rate for Payer: Signature Care EPO |
$25.53
|
| Rate for Payer: Signature Care PPO |
$27.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.15
|
| Rate for Payer: United Healthcare Commercial |
$24.24
|
| Rate for Payer: United Healthcare Medicare |
$9.84
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY FOR ENT USE (CAMERON)
|
Facility
|
OP
|
$94.08
|
|
|
Service Code
|
NDC 02250805
|
| Hospital Charge Code |
14010006244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$87.49 |
| Rate for Payer: Aetna Commercial |
$79.40
|
| Rate for Payer: Aetna Medicare |
$30.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$54.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$58.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$34.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.12
|
| Rate for Payer: Cash Price |
$56.45
|
| Rate for Payer: Cash Price |
$56.45
|
| Rate for Payer: Centivo All Commercial |
$51.18
|
| Rate for Payer: Cigna All Commercial |
$81.19
|
| Rate for Payer: CORVEL All Commercial |
$87.49
|
| Rate for Payer: Coventry All Commercial |
$82.79
|
| Rate for Payer: Encore All Commercial |
$86.60
|
| Rate for Payer: Frontpath All Commercial |
$86.55
|
| Rate for Payer: Humana ChoiceCare |
$81.26
|
| Rate for Payer: Humana Medicare |
$30.11
|
| Rate for Payer: Lucent All Commercial |
$51.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$84.67
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$70.56
|
| Rate for Payer: PHP All Commercial |
$71.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$36.69
|
| Rate for Payer: Sagamore Health Network All Products |
$72.63
|
| Rate for Payer: Signature Care EPO |
$78.09
|
| Rate for Payer: Signature Care PPO |
$82.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$79.97
|
| Rate for Payer: United Healthcare Commercial |
$74.14
|
| Rate for Payer: United Healthcare Medicare |
$30.11
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY FOR ENT USE (CAMERON)
|
Facility
|
IP
|
$94.08
|
|
|
Service Code
|
NDC 02250805
|
| Hospital Charge Code |
14010006244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$87.49 |
| Rate for Payer: Aetna Commercial |
$81.29
|
| Rate for Payer: Cash Price |
$56.45
|
| Rate for Payer: Cigna All Commercial |
$81.19
|
| Rate for Payer: CORVEL All Commercial |
$87.49
|
| Rate for Payer: Coventry All Commercial |
$82.79
|
| Rate for Payer: Encore All Commercial |
$86.60
|
| Rate for Payer: Frontpath All Commercial |
$86.55
|
| Rate for Payer: Humana ChoiceCare |
$81.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$84.67
|
| Rate for Payer: PHCS All Commercial |
$70.56
|
| Rate for Payer: PHP All Commercial |
$71.35
|
| Rate for Payer: Sagamore Health Network All Products |
$72.63
|
| Rate for Payer: Signature Care EPO |
$78.09
|
| Rate for Payer: Signature Care PPO |
$82.79
|
| Rate for Payer: United Healthcare Commercial |
$74.14
|
|
|
PHENYLEPHRINE HCL 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
|
PHENYLEPHRINE HCL 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| 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: 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: 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: United Healthcare Commercial |
$14.18
|
|
|
PHENYLEPHRINE HCL 10 % OPHT DROP
|
Facility
|
IP
|
$143.85
|
|
|
Service Code
|
NDC 69315032405
|
| Hospital Charge Code |
19636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.89 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: Aetna Commercial |
$124.29
|
| Rate for Payer: Cash Price |
$86.31
|
| Rate for Payer: Cigna All Commercial |
$124.14
|
| Rate for Payer: CORVEL All Commercial |
$133.78
|
| Rate for Payer: Coventry All Commercial |
$126.59
|
| Rate for Payer: Encore All Commercial |
$132.41
|
| Rate for Payer: Frontpath All Commercial |
$132.34
|
| Rate for Payer: Humana ChoiceCare |
$124.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.47
|
| Rate for Payer: PHCS All Commercial |
$107.89
|
| Rate for Payer: PHP All Commercial |
$109.10
|
| Rate for Payer: Sagamore Health Network All Products |
$111.05
|
| Rate for Payer: Signature Care EPO |
$119.40
|
| Rate for Payer: Signature Care PPO |
$126.59
|
| Rate for Payer: United Healthcare Commercial |
$113.35
|
|
|
PHENYLEPHRINE HCL 10 % OPHT DROP
|
Facility
|
OP
|
$143.85
|
|
|
Service Code
|
NDC 69315032405
|
| Hospital Charge Code |
19636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: Aetna Commercial |
$121.41
|
| Rate for Payer: Aetna Medicare |
$46.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.64
|
| Rate for Payer: Cash Price |
$86.31
|
| Rate for Payer: Cash Price |
$86.31
|
| Rate for Payer: Centivo All Commercial |
$78.25
|
| Rate for Payer: Cigna All Commercial |
$124.14
|
| Rate for Payer: CORVEL All Commercial |
$133.78
|
| Rate for Payer: Coventry All Commercial |
$126.59
|
| Rate for Payer: Encore All Commercial |
$132.41
|
| Rate for Payer: Frontpath All Commercial |
$132.34
|
| Rate for Payer: Humana ChoiceCare |
$124.24
|
| Rate for Payer: Humana Medicare |
$46.03
|
| Rate for Payer: Lucent All Commercial |
$78.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.47
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$107.89
|
| Rate for Payer: PHP All Commercial |
$109.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.10
|
| Rate for Payer: Sagamore Health Network All Products |
$111.05
|
| Rate for Payer: Signature Care EPO |
$119.40
|
| Rate for Payer: Signature Care PPO |
$126.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$122.27
|
| Rate for Payer: United Healthcare Commercial |
$113.35
|
| Rate for Payer: United Healthcare Medicare |
$46.03
|
|
|
PHENYLEPHRINE HCL 2.5 % OPHT DROP
|
Facility
|
IP
|
$117.32
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.99 |
| Max. Negotiated Rate |
$109.11 |
| Rate for Payer: Aetna Commercial |
$101.36
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cigna All Commercial |
$101.25
|
| Rate for Payer: CORVEL All Commercial |
$109.11
|
| Rate for Payer: Coventry All Commercial |
$103.24
|
| Rate for Payer: Encore All Commercial |
$107.99
|
| Rate for Payer: Frontpath All Commercial |
$107.93
|
| Rate for Payer: Humana ChoiceCare |
$101.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$105.59
|
| Rate for Payer: PHCS All Commercial |
$87.99
|
| Rate for Payer: PHP All Commercial |
$88.98
|
| Rate for Payer: Sagamore Health Network All Products |
$90.57
|
| Rate for Payer: Signature Care EPO |
$97.38
|
| Rate for Payer: Signature Care PPO |
$103.24
|
| Rate for Payer: United Healthcare Commercial |
$92.45
|
|
|
PHENYLEPHRINE HCL 2.5 % OPHT DROP
|
Facility
|
OP
|
$117.32
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$109.11 |
| Rate for Payer: Aetna Commercial |
$99.02
|
| Rate for Payer: Aetna Medicare |
$37.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$67.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$43.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$41.30
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Centivo All Commercial |
$63.82
|
| Rate for Payer: Cigna All Commercial |
$101.25
|
| Rate for Payer: CORVEL All Commercial |
$109.11
|
| Rate for Payer: Coventry All Commercial |
$103.24
|
| Rate for Payer: Encore All Commercial |
$107.99
|
| Rate for Payer: Frontpath All Commercial |
$107.93
|
| Rate for Payer: Humana ChoiceCare |
$101.33
|
| Rate for Payer: Humana Medicare |
$37.54
|
| Rate for Payer: Lucent All Commercial |
$63.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$105.59
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$87.99
|
| Rate for Payer: PHP All Commercial |
$88.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.75
|
| Rate for Payer: Sagamore Health Network All Products |
$90.57
|
| Rate for Payer: Signature Care EPO |
$97.38
|
| Rate for Payer: Signature Care PPO |
$103.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$99.72
|
| Rate for Payer: United Healthcare Commercial |
$92.45
|
| Rate for Payer: United Healthcare Medicare |
$37.54
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SOLN
|
Facility
|
OP
|
$26.95
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
191797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.35 |
| Max. Negotiated Rate |
$25.06 |
| Rate for Payer: Aetna Commercial |
$22.75
|
| Rate for Payer: Aetna Medicare |
$8.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.49
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Centivo All Commercial |
$14.66
|
| Rate for Payer: Cigna All Commercial |
$23.26
|
| Rate for Payer: CORVEL All Commercial |
$25.06
|
| Rate for Payer: Coventry All Commercial |
$23.72
|
| Rate for Payer: Encore All Commercial |
$24.81
|
| Rate for Payer: Frontpath All Commercial |
$24.79
|
| Rate for Payer: Humana ChoiceCare |
$23.28
|
| Rate for Payer: Humana Medicare |
$8.62
|
| Rate for Payer: Lucent All Commercial |
$14.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.25
|
| Rate for Payer: PHCS All Commercial |
$20.21
|
| Rate for Payer: PHP All Commercial |
$20.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.51
|
| Rate for Payer: Sagamore Health Network All Products |
$20.81
|
| Rate for Payer: Signature Care EPO |
$22.37
|
| Rate for Payer: Signature Care PPO |
$23.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.91
|
| Rate for Payer: United Healthcare Commercial |
$21.24
|
| Rate for Payer: United Healthcare Medicare |
$8.62
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SOLN
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
191797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$25.06 |
| Rate for Payer: Aetna Commercial |
$23.28
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cigna All Commercial |
$23.26
|
| Rate for Payer: CORVEL All Commercial |
$25.06
|
| Rate for Payer: Coventry All Commercial |
$23.72
|
| Rate for Payer: Encore All Commercial |
$24.81
|
| Rate for Payer: Frontpath All Commercial |
$24.79
|
| Rate for Payer: Humana ChoiceCare |
$23.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.25
|
| Rate for Payer: PHCS All Commercial |
$20.21
|
| Rate for Payer: PHP All Commercial |
$20.44
|
| Rate for Payer: Sagamore Health Network All Products |
$20.81
|
| Rate for Payer: Signature Care EPO |
$22.37
|
| Rate for Payer: Signature Care PPO |
$23.72
|
| Rate for Payer: United Healthcare Commercial |
$21.24
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG
|
Facility
|
IP
|
$50.54
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
121306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.91 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$43.67
|
| Rate for Payer: Cash Price |
$30.32
|
| Rate for Payer: Cigna All Commercial |
$43.62
|
| Rate for Payer: CORVEL All Commercial |
$47.00
|
| Rate for Payer: Coventry All Commercial |
$44.48
|
| Rate for Payer: Encore All Commercial |
$46.52
|
| Rate for Payer: Frontpath All Commercial |
$46.50
|
| Rate for Payer: Humana ChoiceCare |
$43.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.49
|
| Rate for Payer: PHCS All Commercial |
$37.91
|
| Rate for Payer: PHP All Commercial |
$38.33
|
| Rate for Payer: Sagamore Health Network All Products |
$39.02
|
| Rate for Payer: Signature Care EPO |
$41.95
|
| Rate for Payer: Signature Care PPO |
$44.48
|
| Rate for Payer: United Healthcare Commercial |
$39.83
|
|
