|
ALLERGY SERUM - VIAL 2
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 99999990054
|
| Hospital Charge Code |
800680
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
ALLERGY SERUM - VIAL 3
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 99999990055
|
| Hospital Charge Code |
800681
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
ALLOPURINOL 100 MG ORAL TAB
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.83
|
| Rate for Payer: Aetna Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Centivo All Commercial |
$1.18
|
| Rate for Payer: Cigna All Commercial |
$1.87
|
| Rate for Payer: CORVEL All Commercial |
$2.02
|
| Rate for Payer: Coventry All Commercial |
$1.91
|
| Rate for Payer: Encore All Commercial |
$2.00
|
| Rate for Payer: Frontpath All Commercial |
$2.00
|
| Rate for Payer: Humana ChoiceCare |
$1.87
|
| Rate for Payer: Humana Medicare |
$0.69
|
| Rate for Payer: Lucent All Commercial |
$1.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.95
|
| Rate for Payer: PHCS All Commercial |
$1.63
|
| Rate for Payer: PHP All Commercial |
$1.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1.68
|
| Rate for Payer: Signature Care EPO |
$1.80
|
| Rate for Payer: Signature Care PPO |
$1.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
| Rate for Payer: United Healthcare Medicare |
$0.69
|
|
|
ALLOPURINOL 100 MG ORAL TAB
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna All Commercial |
$1.87
|
| Rate for Payer: CORVEL All Commercial |
$2.02
|
| Rate for Payer: Coventry All Commercial |
$1.91
|
| Rate for Payer: Encore All Commercial |
$2.00
|
| Rate for Payer: Frontpath All Commercial |
$2.00
|
| Rate for Payer: Humana ChoiceCare |
$1.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.95
|
| Rate for Payer: PHCS All Commercial |
$1.63
|
| Rate for Payer: PHP All Commercial |
$1.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1.68
|
| Rate for Payer: Signature Care EPO |
$1.80
|
| Rate for Payer: Signature Care PPO |
$1.91
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
|
|
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 0.25 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00781106101
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
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 |
$1.24 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| 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 Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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
|
|
|
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
|
|
|
ALTEPLASE 100 MG IV SOLR
|
Facility
|
IP
|
$28,876.05
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21,657.04 |
| Max. Negotiated Rate |
$26,854.73 |
| Rate for Payer: Aetna Commercial |
$24,948.91
|
| Rate for Payer: Cash Price |
$17,903.15
|
| Rate for Payer: Cigna All Commercial |
$24,920.03
|
| Rate for Payer: CORVEL All Commercial |
$26,854.73
|
| Rate for Payer: Coventry All Commercial |
$25,410.92
|
| Rate for Payer: Encore All Commercial |
$26,580.40
|
| Rate for Payer: Frontpath All Commercial |
$26,565.97
|
| Rate for Payer: Humana ChoiceCare |
$24,940.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25,988.44
|
| Rate for Payer: PHCS All Commercial |
$21,657.04
|
| Rate for Payer: PHP All Commercial |
$21,899.60
|
| Rate for Payer: Sagamore Health Network All Products |
$22,292.31
|
| Rate for Payer: Signature Care EPO |
$23,967.12
|
| Rate for Payer: Signature Care PPO |
$25,410.92
|
| Rate for Payer: United Healthcare Commercial |
$22,754.33
|
|
|
ALTEPLASE 100 MG IV SOLR
|
Facility
|
OP
|
$28,876.05
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$26,854.73 |
| Rate for Payer: Aetna Commercial |
$24,371.39
|
| Rate for Payer: Aetna Medicare |
$9,240.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$92.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,951.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16,583.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18,050.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$92.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,626.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10,164.37
|
| Rate for Payer: Cash Price |
$17,903.15
|
| Rate for Payer: Cash Price |
$17,903.15
|
| Rate for Payer: Centivo All Commercial |
$15,708.57
|
| Rate for Payer: Cigna All Commercial |
$24,920.03
|
| Rate for Payer: CORVEL All Commercial |
$26,854.73
|
| Rate for Payer: Coventry All Commercial |
$25,410.92
|
| Rate for Payer: Encore All Commercial |
$26,580.40
|
| Rate for Payer: Frontpath All Commercial |
$26,565.97
|
| Rate for Payer: Humana ChoiceCare |
$24,940.24
|
| Rate for Payer: Humana Medicare |
$9,240.34
|
| Rate for Payer: Lucent All Commercial |
$15,708.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25,988.44
|
| Rate for Payer: Managed Health Services Medicaid |
$92.40
|
| Rate for Payer: MDWise Medicaid |
$92.40
|
| Rate for Payer: PHCS All Commercial |
$21,657.04
|
| Rate for Payer: PHP All Commercial |
$21,899.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11,261.66
|
| Rate for Payer: Sagamore Health Network All Products |
$22,292.31
|
| Rate for Payer: Signature Care EPO |
$23,967.12
|
| Rate for Payer: Signature Care PPO |
$25,410.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24,544.64
|
| Rate for Payer: United Healthcare Commercial |
$22,754.33
|
| Rate for Payer: United Healthcare Medicare |
$9,240.34
|
|
|
ALTEPLASE 2 MG CATH SOLR
|
Facility
|
IP
|
$868.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$651.00 |
| Max. Negotiated Rate |
$807.24 |
| Rate for Payer: Aetna Commercial |
$749.95
|
| Rate for Payer: Cash Price |
$538.16
|
| Rate for Payer: Cigna All Commercial |
$749.08
|
| Rate for Payer: CORVEL All Commercial |
$807.24
|
| Rate for Payer: Coventry All Commercial |
$763.84
|
| Rate for Payer: Encore All Commercial |
$798.99
|
| Rate for Payer: Frontpath All Commercial |
$798.56
|
| Rate for Payer: Humana ChoiceCare |
$749.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$781.20
|
| Rate for Payer: PHCS All Commercial |
$651.00
|
| Rate for Payer: PHP All Commercial |
$658.29
|
| Rate for Payer: Sagamore Health Network All Products |
$670.10
|
| Rate for Payer: Signature Care EPO |
$720.44
|
| Rate for Payer: Signature Care PPO |
$763.84
|
| Rate for Payer: United Healthcare Commercial |
$683.98
|
|
|
ALTEPLASE 2 MG CATH SOLR
|
Facility
|
OP
|
$868.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$807.24 |
| Rate for Payer: Aetna Commercial |
$732.59
|
| Rate for Payer: Aetna Medicare |
$277.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$92.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$269.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$498.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$542.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$92.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$319.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$305.54
|
| Rate for Payer: Cash Price |
$538.16
|
| Rate for Payer: Cash Price |
$538.16
|
| Rate for Payer: Centivo All Commercial |
$472.19
|
| Rate for Payer: Cigna All Commercial |
$749.08
|
| Rate for Payer: CORVEL All Commercial |
$807.24
|
| Rate for Payer: Coventry All Commercial |
$763.84
|
| Rate for Payer: Encore All Commercial |
$798.99
|
| Rate for Payer: Frontpath All Commercial |
$798.56
|
| Rate for Payer: Humana ChoiceCare |
$749.69
|
| Rate for Payer: Humana Medicare |
$277.76
|
| Rate for Payer: Lucent All Commercial |
$472.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$781.20
|
| Rate for Payer: Managed Health Services Medicaid |
$92.40
|
| Rate for Payer: MDWise Medicaid |
$92.40
|
| Rate for Payer: PHCS All Commercial |
$651.00
|
| Rate for Payer: PHP All Commercial |
$658.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$338.52
|
| Rate for Payer: Sagamore Health Network All Products |
$670.10
|
| Rate for Payer: Signature Care EPO |
$720.44
|
| Rate for Payer: Signature Care PPO |
$763.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$737.80
|
| Rate for Payer: United Healthcare Commercial |
$683.98
|
| Rate for Payer: United Healthcare Medicare |
$277.76
|
|
|
ALTEPLASE BOLUS STD DOSE FOR **STROKE** (CAMERON)
|
Facility
|
OP
|
$92.40
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
1401600246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$92.40 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$92.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$92.40
|
| Rate for Payer: Managed Health Services Medicaid |
$92.40
|
| Rate for Payer: MDWise Medicaid |
$92.40
|
|
|
ALTEPLASE INFUSION KIT FOR **STROKE** (CAMERON)
|
Facility
|
OP
|
$29,214.99
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
1401000600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$27,169.94 |
| Rate for Payer: Aetna Commercial |
$24,657.45
|
| Rate for Payer: Aetna Medicare |
$9,348.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$92.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9,056.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16,778.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18,262.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$92.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,751.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10,283.68
|
| Rate for Payer: Cash Price |
$18,113.29
|
| Rate for Payer: Cash Price |
$18,113.29
|
| Rate for Payer: Centivo All Commercial |
$15,892.95
|
| Rate for Payer: Cigna All Commercial |
$25,212.54
|
| Rate for Payer: CORVEL All Commercial |
$27,169.94
|
| Rate for Payer: Coventry All Commercial |
$25,709.19
|
| Rate for Payer: Encore All Commercial |
$26,892.40
|
| Rate for Payer: Frontpath All Commercial |
$26,877.79
|
| Rate for Payer: Humana ChoiceCare |
$25,232.99
|
| Rate for Payer: Humana Medicare |
$9,348.80
|
| Rate for Payer: Lucent All Commercial |
$15,892.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26,293.49
|
| Rate for Payer: Managed Health Services Medicaid |
$92.40
|
| Rate for Payer: MDWise Medicaid |
$92.40
|
| Rate for Payer: PHCS All Commercial |
$21,911.24
|
| Rate for Payer: PHP All Commercial |
$22,156.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11,393.85
|
| Rate for Payer: Sagamore Health Network All Products |
$22,553.97
|
| Rate for Payer: Signature Care EPO |
$24,248.44
|
| Rate for Payer: Signature Care PPO |
$25,709.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24,832.74
|
| Rate for Payer: United Healthcare Commercial |
$23,021.41
|
| Rate for Payer: United Healthcare Medicare |
$9,348.80
|
|
|
ALTEPLASE INFUSION KIT FOR **STROKE** (CAMERON)
|
Facility
|
IP
|
$29,214.99
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
1401000600245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21,911.24 |
| Max. Negotiated Rate |
$27,169.94 |
| Rate for Payer: Aetna Commercial |
$25,241.75
|
| Rate for Payer: Cash Price |
$18,113.29
|
| Rate for Payer: Cigna All Commercial |
$25,212.54
|
| Rate for Payer: CORVEL All Commercial |
$27,169.94
|
| Rate for Payer: Coventry All Commercial |
$25,709.19
|
| Rate for Payer: Encore All Commercial |
$26,892.40
|
| Rate for Payer: Frontpath All Commercial |
$26,877.79
|
| Rate for Payer: Humana ChoiceCare |
$25,232.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26,293.49
|
| Rate for Payer: PHCS All Commercial |
$21,911.24
|
| Rate for Payer: PHP All Commercial |
$22,156.65
|
| Rate for Payer: Sagamore Health Network All Products |
$22,553.97
|
| Rate for Payer: Signature Care EPO |
$24,248.44
|
| Rate for Payer: Signature Care PPO |
$25,709.19
|
| Rate for Payer: United Healthcare Commercial |
$23,021.41
|
|
|
ALUMINUM CHLORIDE 20 % TOP SOLN
|
Facility
|
OP
|
$51.19
|
|
|
Service Code
|
NDC 00096070737
|
| Hospital Charge Code |
9028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$47.60 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Medicare |
$16.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.02
|
| Rate for Payer: Cash Price |
$31.74
|
| Rate for Payer: Centivo All Commercial |
$27.85
|
| Rate for Payer: Cigna All Commercial |
$44.18
|
| Rate for Payer: CORVEL All Commercial |
$47.60
|
| Rate for Payer: Coventry All Commercial |
$45.05
|
| Rate for Payer: Encore All Commercial |
$47.12
|
| Rate for Payer: Frontpath All Commercial |
$47.09
|
| Rate for Payer: Humana ChoiceCare |
$44.21
|
| Rate for Payer: Humana Medicare |
$16.38
|
| Rate for Payer: Lucent All Commercial |
$27.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.07
|
| Rate for Payer: PHCS All Commercial |
$38.39
|
| Rate for Payer: PHP All Commercial |
$38.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.96
|
| Rate for Payer: Sagamore Health Network All Products |
$39.52
|
| Rate for Payer: Signature Care EPO |
$42.49
|
| Rate for Payer: Signature Care PPO |
$45.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.51
|
| Rate for Payer: United Healthcare Commercial |
$40.34
|
| Rate for Payer: United Healthcare Medicare |
$16.38
|
|
|
ALUMINUM CHLORIDE 20 % TOP SOLN
|
Facility
|
IP
|
$51.19
|
|
|
Service Code
|
NDC 00096070737
|
| Hospital Charge Code |
9028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.39 |
| Max. Negotiated Rate |
$47.60 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Cash Price |
$31.74
|
| Rate for Payer: Cigna All Commercial |
$44.18
|
| Rate for Payer: CORVEL All Commercial |
$47.60
|
| Rate for Payer: Coventry All Commercial |
$45.05
|
| Rate for Payer: Encore All Commercial |
$47.12
|
| Rate for Payer: Frontpath All Commercial |
$47.09
|
| Rate for Payer: Humana ChoiceCare |
$44.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.07
|
| Rate for Payer: PHCS All Commercial |
$38.39
|
| Rate for Payer: PHP All Commercial |
$38.82
|
| Rate for Payer: Sagamore Health Network All Products |
$39.52
|
| Rate for Payer: Signature Care EPO |
$42.49
|
| Rate for Payer: Signature Care PPO |
$45.05
|
| Rate for Payer: United Healthcare Commercial |
$40.34
|
|
|
ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
NDC 09045725
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cigna All Commercial |
$1.81
|
| Rate for Payer: CORVEL All Commercial |
$1.95
|
| Rate for Payer: Coventry All Commercial |
$1.85
|
| Rate for Payer: Encore All Commercial |
$1.93
|
| Rate for Payer: Frontpath All Commercial |
$1.93
|
| Rate for Payer: Humana ChoiceCare |
$1.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.89
|
| Rate for Payer: PHCS All Commercial |
$1.57
|
| Rate for Payer: PHP All Commercial |
$1.59
|
| Rate for Payer: Sagamore Health Network All Products |
$1.62
|
| Rate for Payer: Signature Care EPO |
$1.74
|
| Rate for Payer: Signature Care PPO |
$1.85
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
|
|
ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
NDC 09045725
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna Commercial |
$1.77
|
| Rate for Payer: Aetna Medicare |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Centivo All Commercial |
$1.14
|
| Rate for Payer: Cigna All Commercial |
$1.81
|
| Rate for Payer: CORVEL All Commercial |
$1.95
|
| Rate for Payer: Coventry All Commercial |
$1.85
|
| Rate for Payer: Encore All Commercial |
$1.93
|
| Rate for Payer: Frontpath All Commercial |
$1.93
|
| Rate for Payer: Humana ChoiceCare |
$1.81
|
| Rate for Payer: Humana Medicare |
$0.67
|
| Rate for Payer: Lucent All Commercial |
$1.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.89
|
| Rate for Payer: PHCS All Commercial |
$1.57
|
| Rate for Payer: PHP All Commercial |
$1.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.82
|
| Rate for Payer: Sagamore Health Network All Products |
$1.62
|
| Rate for Payer: Signature Care EPO |
$1.74
|
| Rate for Payer: Signature Care PPO |
$1.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
| Rate for Payer: United Healthcare Medicare |
$0.67
|
|
|
AMANTADINE HCL 100 MG ORAL CAP
|
Facility
|
OP
|
$6.82
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$6.34 |
| Rate for Payer: Aetna Commercial |
$5.75
|
| Rate for Payer: Aetna Medicare |
$2.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Centivo All Commercial |
$3.71
|
| Rate for Payer: Cigna All Commercial |
$5.88
|
| Rate for Payer: CORVEL All Commercial |
$6.34
|
| Rate for Payer: Coventry All Commercial |
$6.00
|
| Rate for Payer: Encore All Commercial |
$6.28
|
| Rate for Payer: Frontpath All Commercial |
$6.27
|
| Rate for Payer: Humana ChoiceCare |
$5.89
|
| Rate for Payer: Humana Medicare |
$2.18
|
| Rate for Payer: Lucent All Commercial |
$3.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.14
|
| Rate for Payer: PHCS All Commercial |
$5.11
|
| Rate for Payer: PHP All Commercial |
$5.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.66
|
| Rate for Payer: Sagamore Health Network All Products |
$5.26
|
| Rate for Payer: Signature Care EPO |
$5.66
|
| Rate for Payer: Signature Care PPO |
$6.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.80
|
| Rate for Payer: United Healthcare Commercial |
$5.37
|
| Rate for Payer: United Healthcare Medicare |
$2.18
|
|
|
AMANTADINE HCL 100 MG ORAL CAP
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$6.34 |
| Rate for Payer: Aetna Commercial |
$5.89
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna All Commercial |
$5.88
|
| Rate for Payer: CORVEL All Commercial |
$6.34
|
| Rate for Payer: Coventry All Commercial |
$6.00
|
| Rate for Payer: Encore All Commercial |
$6.28
|
| Rate for Payer: Frontpath All Commercial |
$6.27
|
| Rate for Payer: Humana ChoiceCare |
$5.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.14
|
| Rate for Payer: PHCS All Commercial |
$5.11
|
| Rate for Payer: PHP All Commercial |
$5.17
|
| Rate for Payer: Sagamore Health Network All Products |
$5.26
|
| Rate for Payer: Signature Care EPO |
$5.66
|
| Rate for Payer: Signature Care PPO |
$6.00
|
| Rate for Payer: United Healthcare Commercial |
$5.37
|
|
|
AMIKACIN 500 MG/2 ML INJ SOLN
|
Facility
|
OP
|
$27.43
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
121291
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$25.51 |
| Rate for Payer: Aetna Commercial |
$23.15
|
| Rate for Payer: Aetna Medicare |
$8.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.65
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Centivo All Commercial |
$14.92
|
| Rate for Payer: Cigna All Commercial |
$23.67
|
| Rate for Payer: CORVEL All Commercial |
$25.51
|
| Rate for Payer: Coventry All Commercial |
$24.13
|
| Rate for Payer: Encore All Commercial |
$25.25
|
| Rate for Payer: Frontpath All Commercial |
$25.23
|
| Rate for Payer: Humana ChoiceCare |
$23.69
|
| Rate for Payer: Humana Medicare |
$8.78
|
| Rate for Payer: Lucent All Commercial |
$14.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.68
|
| Rate for Payer: PHCS All Commercial |
$20.57
|
| Rate for Payer: PHP All Commercial |
$20.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.17
|
| Rate for Payer: Signature Care EPO |
$22.76
|
| Rate for Payer: Signature Care PPO |
$24.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.31
|
| Rate for Payer: United Healthcare Commercial |
$21.61
|
| Rate for Payer: United Healthcare Medicare |
$8.78
|
|
|
AMIKACIN 500 MG/2 ML INJ SOLN
|
Facility
|
IP
|
$27.43
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
121291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.57 |
| Max. Negotiated Rate |
$25.51 |
| Rate for Payer: Aetna Commercial |
$23.70
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna All Commercial |
$23.67
|
| Rate for Payer: CORVEL All Commercial |
$25.51
|
| Rate for Payer: Coventry All Commercial |
$24.13
|
| Rate for Payer: Encore All Commercial |
$25.25
|
| Rate for Payer: Frontpath All Commercial |
$25.23
|
| Rate for Payer: Humana ChoiceCare |
$23.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.68
|
| Rate for Payer: PHCS All Commercial |
$20.57
|
| Rate for Payer: PHP All Commercial |
$20.80
|
| Rate for Payer: Sagamore Health Network All Products |
$21.17
|
| Rate for Payer: Signature Care EPO |
$22.76
|
| Rate for Payer: Signature Care PPO |
$24.13
|
| Rate for Payer: United Healthcare Commercial |
$21.61
|
|
|
AMINOPHYLLINE 250 MG/10 ML IV SOLN
|
Facility
|
IP
|
$118.16
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.62 |
| Max. Negotiated Rate |
$109.89 |
| Rate for Payer: Aetna Commercial |
$102.09
|
| Rate for Payer: Cash Price |
$73.26
|
| Rate for Payer: Cigna All Commercial |
$101.97
|
| Rate for Payer: CORVEL All Commercial |
$109.89
|
| Rate for Payer: Coventry All Commercial |
$103.98
|
| Rate for Payer: Encore All Commercial |
$108.77
|
| Rate for Payer: Frontpath All Commercial |
$108.71
|
| Rate for Payer: Humana ChoiceCare |
$102.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.34
|
| Rate for Payer: PHCS All Commercial |
$88.62
|
| Rate for Payer: PHP All Commercial |
$89.61
|
| Rate for Payer: Sagamore Health Network All Products |
$91.22
|
| Rate for Payer: Signature Care EPO |
$98.07
|
| Rate for Payer: Signature Care PPO |
$103.98
|
| Rate for Payer: United Healthcare Commercial |
$93.11
|
|
|
AMINOPHYLLINE 250 MG/10 ML IV SOLN
|
Facility
|
OP
|
$118.16
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.63 |
| Max. Negotiated Rate |
$109.89 |
| Rate for Payer: Aetna Commercial |
$99.73
|
| Rate for Payer: Aetna Medicare |
$37.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$67.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$43.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$41.59
|
| Rate for Payer: Cash Price |
$73.26
|
| Rate for Payer: Centivo All Commercial |
$64.28
|
| Rate for Payer: Cigna All Commercial |
$101.97
|
| Rate for Payer: CORVEL All Commercial |
$109.89
|
| Rate for Payer: Coventry All Commercial |
$103.98
|
| Rate for Payer: Encore All Commercial |
$108.77
|
| Rate for Payer: Frontpath All Commercial |
$108.71
|
| Rate for Payer: Humana ChoiceCare |
$102.05
|
| Rate for Payer: Humana Medicare |
$37.81
|
| Rate for Payer: Lucent All Commercial |
$64.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.34
|
| Rate for Payer: PHCS All Commercial |
$88.62
|
| Rate for Payer: PHP All Commercial |
$89.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.08
|
| Rate for Payer: Sagamore Health Network All Products |
$91.22
|
| Rate for Payer: Signature Care EPO |
$98.07
|
| Rate for Payer: Signature Care PPO |
$103.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$100.44
|
| Rate for Payer: United Healthcare Commercial |
$93.11
|
| Rate for Payer: United Healthcare Medicare |
$37.81
|
|
