|
ALTEPLASE 100 MG IV SOLR
|
Facility
OP
|
$29,214.85
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.17 |
| Max. Negotiated Rate |
$27,169.81 |
| Rate for Payer: Aetna Commercial |
$24,657.33
|
| Rate for Payer: Aetna Medicare |
$9,640.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9,640.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16,778.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18,262.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$88.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11,087.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10,604.99
|
| Rate for Payer: Cash Price |
$18,113.21
|
| Rate for Payer: Cash Price |
$18,113.21
|
| Rate for Payer: Centivo All Commercial |
$14,899.57
|
| Rate for Payer: Cigna All Commercial |
$25,212.42
|
| Rate for Payer: CORVEL All Commercial |
$27,169.81
|
| Rate for Payer: Coventry All Commercial |
$25,709.07
|
| Rate for Payer: Encore All Commercial |
$26,892.27
|
| Rate for Payer: Frontpath All Commercial |
$26,877.66
|
| Rate for Payer: Humana ChoiceCare |
$25,232.87
|
| Rate for Payer: Humana Medicare |
$14,899.57
|
| Rate for Payer: Lucent All Commercial |
$14,899.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26,293.36
|
| Rate for Payer: Managed Health Services Medicaid |
$88.17
|
| Rate for Payer: MDWise Medicaid |
$88.17
|
| Rate for Payer: PHCS All Commercial |
$21,911.14
|
| Rate for Payer: PHP All Commercial |
$22,156.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11,393.79
|
| Rate for Payer: Sagamore Health Network All Products |
$22,553.86
|
| Rate for Payer: Signature Care EPO |
$24,248.33
|
| Rate for Payer: Signature Care PPO |
$25,709.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24,832.62
|
| Rate for Payer: United Healthcare Commercial |
$23,021.30
|
| Rate for Payer: United Healthcare Medicare |
$9,640.90
|
|
|
ALTEPLASE 100 MG IV SOLR
|
Facility
IP
|
$29,214.85
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21,911.14 |
| Max. Negotiated Rate |
$27,169.81 |
| Rate for Payer: Aetna Commercial |
$25,241.63
|
| Rate for Payer: Cash Price |
$18,113.21
|
| Rate for Payer: Cigna All Commercial |
$25,212.42
|
| Rate for Payer: CORVEL All Commercial |
$27,169.81
|
| Rate for Payer: Coventry All Commercial |
$25,709.07
|
| Rate for Payer: Encore All Commercial |
$26,892.27
|
| Rate for Payer: Frontpath All Commercial |
$26,877.66
|
| Rate for Payer: Humana ChoiceCare |
$25,232.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26,293.36
|
| Rate for Payer: PHCS All Commercial |
$21,911.14
|
| Rate for Payer: PHP All Commercial |
$22,156.54
|
| Rate for Payer: Sagamore Health Network All Products |
$22,553.86
|
| Rate for Payer: Signature Care EPO |
$24,248.33
|
| Rate for Payer: Signature Care PPO |
$25,709.07
|
| Rate for Payer: United Healthcare Commercial |
$23,021.30
|
|
|
ALTEPLASE 2 MG CATH SOLR
|
Facility
IP
|
$836.35
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$627.26 |
| Max. Negotiated Rate |
$777.81 |
| Rate for Payer: Aetna Commercial |
$722.61
|
| Rate for Payer: Cash Price |
$518.54
|
| Rate for Payer: Cigna All Commercial |
$721.77
|
| Rate for Payer: CORVEL All Commercial |
$777.81
|
| Rate for Payer: Coventry All Commercial |
$735.99
|
| Rate for Payer: Encore All Commercial |
$769.86
|
| Rate for Payer: Frontpath All Commercial |
$769.44
|
| Rate for Payer: Humana ChoiceCare |
$722.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$752.72
|
| Rate for Payer: PHCS All Commercial |
$627.26
|
| Rate for Payer: PHP All Commercial |
$634.29
|
| Rate for Payer: Sagamore Health Network All Products |
$645.66
|
| Rate for Payer: Signature Care EPO |
$694.17
|
| Rate for Payer: Signature Care PPO |
$735.99
|
| Rate for Payer: United Healthcare Commercial |
$659.04
|
|
|
ALTEPLASE 2 MG CATH SOLR
|
Facility
OP
|
$836.35
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.17 |
| Max. Negotiated Rate |
$777.81 |
| Rate for Payer: Aetna Commercial |
$705.88
|
| Rate for Payer: Aetna Medicare |
$276.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$276.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$480.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$522.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$88.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$317.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$303.60
|
| Rate for Payer: Cash Price |
$518.54
|
| Rate for Payer: Cash Price |
$518.54
|
| Rate for Payer: Centivo All Commercial |
$426.54
|
| Rate for Payer: Cigna All Commercial |
$721.77
|
| Rate for Payer: CORVEL All Commercial |
$777.81
|
| Rate for Payer: Coventry All Commercial |
$735.99
|
| Rate for Payer: Encore All Commercial |
$769.86
|
| Rate for Payer: Frontpath All Commercial |
$769.44
|
| Rate for Payer: Humana ChoiceCare |
$722.36
|
| Rate for Payer: Humana Medicare |
$426.54
|
| Rate for Payer: Lucent All Commercial |
$426.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$752.72
|
| Rate for Payer: Managed Health Services Medicaid |
$88.17
|
| Rate for Payer: MDWise Medicaid |
$88.17
|
| Rate for Payer: PHCS All Commercial |
$627.26
|
| Rate for Payer: PHP All Commercial |
$634.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$326.18
|
| Rate for Payer: Sagamore Health Network All Products |
$645.66
|
| Rate for Payer: Signature Care EPO |
$694.17
|
| Rate for Payer: Signature Care PPO |
$735.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$710.90
|
| Rate for Payer: United Healthcare Commercial |
$659.04
|
| Rate for Payer: United Healthcare Medicare |
$276.00
|
|
|
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
|
|
|
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 |
$88.17 |
| Max. Negotiated Rate |
$27,169.94 |
| Rate for Payer: Aetna Commercial |
$24,657.45
|
| Rate for Payer: Aetna Medicare |
$9,640.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9,640.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16,778.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18,262.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$88.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11,087.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10,605.04
|
| Rate for Payer: Cash Price |
$18,113.29
|
| Rate for Payer: Cash Price |
$18,113.29
|
| Rate for Payer: Centivo All Commercial |
$14,899.64
|
| 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 |
$14,899.64
|
| Rate for Payer: Lucent All Commercial |
$14,899.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26,293.49
|
| Rate for Payer: Managed Health Services Medicaid |
$88.17
|
| Rate for Payer: MDWise Medicaid |
$88.17
|
| 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 |
$9,640.95
|
|
|
ALUMINUM CHLORIDE 20 % TOP SOLN
|
Facility
IP
|
$51.98
|
|
|
Service Code
|
NDC 00096070737
|
| Hospital Charge Code |
9028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.98 |
| Max. Negotiated Rate |
$48.34 |
| Rate for Payer: Aetna Commercial |
$44.91
|
| Rate for Payer: Cash Price |
$32.22
|
| Rate for Payer: Cigna All Commercial |
$44.85
|
| Rate for Payer: CORVEL All Commercial |
$48.34
|
| Rate for Payer: Coventry All Commercial |
$45.74
|
| Rate for Payer: Encore All Commercial |
$47.84
|
| Rate for Payer: Frontpath All Commercial |
$47.82
|
| Rate for Payer: Humana ChoiceCare |
$44.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.78
|
| Rate for Payer: PHCS All Commercial |
$38.98
|
| Rate for Payer: PHP All Commercial |
$39.42
|
| Rate for Payer: Sagamore Health Network All Products |
$40.12
|
| Rate for Payer: Signature Care EPO |
$43.14
|
| Rate for Payer: Signature Care PPO |
$45.74
|
| Rate for Payer: United Healthcare Commercial |
$40.96
|
|
|
ALUMINUM CHLORIDE 20 % TOP SOLN
|
Facility
OP
|
$51.98
|
|
|
Service Code
|
NDC 00096070737
|
| Hospital Charge Code |
9028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$48.34 |
| Rate for Payer: Aetna Commercial |
$43.87
|
| Rate for Payer: Aetna Medicare |
$17.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.87
|
| Rate for Payer: Cash Price |
$32.22
|
| Rate for Payer: Centivo All Commercial |
$26.51
|
| Rate for Payer: Cigna All Commercial |
$44.85
|
| Rate for Payer: CORVEL All Commercial |
$48.34
|
| Rate for Payer: Coventry All Commercial |
$45.74
|
| Rate for Payer: Encore All Commercial |
$47.84
|
| Rate for Payer: Frontpath All Commercial |
$47.82
|
| Rate for Payer: Humana ChoiceCare |
$44.89
|
| Rate for Payer: Humana Medicare |
$26.51
|
| Rate for Payer: Lucent All Commercial |
$26.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.78
|
| Rate for Payer: PHCS All Commercial |
$38.98
|
| Rate for Payer: PHP All Commercial |
$39.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.27
|
| Rate for Payer: Sagamore Health Network All Products |
$40.12
|
| Rate for Payer: Signature Care EPO |
$43.14
|
| Rate for Payer: Signature Care PPO |
$45.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44.18
|
| Rate for Payer: United Healthcare Commercial |
$40.96
|
| Rate for Payer: United Healthcare Medicare |
$17.15
|
|
|
ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML ORAL SUSP
|
Facility
OP
|
$2.31
|
|
|
Service Code
|
NDC 09045725
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$1.95
|
| Rate for Payer: Aetna Medicare |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Centivo All Commercial |
$1.18
|
| Rate for Payer: Cigna All Commercial |
$1.99
|
| Rate for Payer: CORVEL All Commercial |
$2.15
|
| Rate for Payer: Coventry All Commercial |
$2.03
|
| Rate for Payer: Encore All Commercial |
$2.13
|
| Rate for Payer: Frontpath All Commercial |
$2.13
|
| Rate for Payer: Humana ChoiceCare |
$2.00
|
| Rate for Payer: Humana Medicare |
$1.18
|
| Rate for Payer: Lucent All Commercial |
$1.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.08
|
| Rate for Payer: PHCS All Commercial |
$1.73
|
| Rate for Payer: PHP All Commercial |
$1.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.90
|
| Rate for Payer: Sagamore Health Network All Products |
$1.78
|
| Rate for Payer: Signature Care EPO |
$1.92
|
| Rate for Payer: Signature Care PPO |
$2.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.96
|
| Rate for Payer: United Healthcare Commercial |
$1.82
|
| Rate for Payer: United Healthcare Medicare |
$0.76
|
|
|
ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML ORAL SUSP
|
Facility
IP
|
$2.31
|
|
|
Service Code
|
NDC 09045725
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Encore All Commercial |
$2.13
|
| Rate for Payer: Aetna Commercial |
$2.00
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna All Commercial |
$1.99
|
| Rate for Payer: CORVEL All Commercial |
$2.15
|
| Rate for Payer: Coventry All Commercial |
$2.03
|
| Rate for Payer: Frontpath All Commercial |
$2.13
|
| Rate for Payer: Humana ChoiceCare |
$2.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.08
|
| Rate for Payer: PHCS All Commercial |
$1.73
|
| Rate for Payer: PHP All Commercial |
$1.75
|
| Rate for Payer: Sagamore Health Network All Products |
$1.78
|
| Rate for Payer: Signature Care EPO |
$1.92
|
| Rate for Payer: Signature Care PPO |
$2.03
|
| Rate for Payer: United Healthcare Commercial |
$1.82
|
|
|
AMANTADINE HCL 100 MG ORAL CAP
|
Facility
OP
|
$6.44
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: Aetna Medicare |
$2.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Centivo All Commercial |
$3.28
|
| Rate for Payer: Cigna All Commercial |
$5.56
|
| Rate for Payer: CORVEL All Commercial |
$5.99
|
| Rate for Payer: Coventry All Commercial |
$5.67
|
| Rate for Payer: Encore All Commercial |
$5.93
|
| Rate for Payer: Frontpath All Commercial |
$5.92
|
| Rate for Payer: Humana ChoiceCare |
$5.56
|
| Rate for Payer: Humana Medicare |
$3.28
|
| Rate for Payer: Lucent All Commercial |
$3.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.80
|
| Rate for Payer: PHCS All Commercial |
$4.83
|
| Rate for Payer: PHP All Commercial |
$4.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.51
|
| Rate for Payer: Sagamore Health Network All Products |
$4.97
|
| Rate for Payer: Signature Care EPO |
$5.35
|
| Rate for Payer: Signature Care PPO |
$5.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.47
|
| Rate for Payer: United Healthcare Commercial |
$5.07
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
|
|
AMANTADINE HCL 100 MG ORAL CAP
|
Facility
IP
|
$6.44
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Aetna Commercial |
$5.56
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna All Commercial |
$5.56
|
| Rate for Payer: CORVEL All Commercial |
$5.99
|
| Rate for Payer: Coventry All Commercial |
$5.67
|
| Rate for Payer: Encore All Commercial |
$5.93
|
| Rate for Payer: Frontpath All Commercial |
$5.92
|
| Rate for Payer: Humana ChoiceCare |
$5.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.80
|
| Rate for Payer: PHCS All Commercial |
$4.83
|
| Rate for Payer: PHP All Commercial |
$4.88
|
| Rate for Payer: Sagamore Health Network All Products |
$4.97
|
| Rate for Payer: Signature Care EPO |
$5.35
|
| Rate for Payer: Signature Care PPO |
$5.67
|
| Rate for Payer: United Healthcare Commercial |
$5.07
|
|
|
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
|
|
|
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 |
$9.05 |
| Max. Negotiated Rate |
$25.51 |
| Rate for Payer: Aetna Commercial |
$23.15
|
| Rate for Payer: Aetna Medicare |
$9.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Centivo All Commercial |
$13.99
|
| 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 |
$13.99
|
| Rate for Payer: Lucent All Commercial |
$13.99
|
| 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 |
$9.05
|
|
|
AMINO ACID 4.25 % IN D5W 4.25 % IV SOLP
|
Facility
IP
|
$468.00
|
|
|
Service Code
|
NDC 00338108904
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$435.24 |
| Rate for Payer: Aetna Commercial |
$404.35
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Cigna All Commercial |
$403.88
|
| Rate for Payer: CORVEL All Commercial |
$435.24
|
| Rate for Payer: Coventry All Commercial |
$411.84
|
| Rate for Payer: Encore All Commercial |
$430.79
|
| Rate for Payer: Frontpath All Commercial |
$430.56
|
| Rate for Payer: Humana ChoiceCare |
$404.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$421.20
|
| Rate for Payer: PHCS All Commercial |
$351.00
|
| Rate for Payer: PHP All Commercial |
$354.93
|
| Rate for Payer: Sagamore Health Network All Products |
$361.30
|
| Rate for Payer: Signature Care EPO |
$388.44
|
| Rate for Payer: Signature Care PPO |
$411.84
|
| Rate for Payer: United Healthcare Commercial |
$368.78
|
|
|
AMINO ACID 4.25 % IN D5W 4.25 % IV SOLP
|
Facility
OP
|
$468.00
|
|
|
Service Code
|
NDC 00338108904
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$74.57 |
| Max. Negotiated Rate |
$435.24 |
| Rate for Payer: Aetna Commercial |
$394.99
|
| Rate for Payer: Aetna Medicare |
$154.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$154.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$268.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$292.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$177.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$169.88
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Cash Price |
$290.16
|
| Rate for Payer: Centivo All Commercial |
$238.68
|
| Rate for Payer: Cigna All Commercial |
$403.88
|
| Rate for Payer: CORVEL All Commercial |
$435.24
|
| Rate for Payer: Coventry All Commercial |
$411.84
|
| Rate for Payer: Encore All Commercial |
$430.79
|
| Rate for Payer: Frontpath All Commercial |
$430.56
|
| Rate for Payer: Humana ChoiceCare |
$404.21
|
| Rate for Payer: Humana Medicare |
$238.68
|
| Rate for Payer: Lucent All Commercial |
$238.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$421.20
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| Rate for Payer: PHCS All Commercial |
$351.00
|
| Rate for Payer: PHP All Commercial |
$354.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$182.52
|
| Rate for Payer: Sagamore Health Network All Products |
$361.30
|
| Rate for Payer: Signature Care EPO |
$388.44
|
| Rate for Payer: Signature Care PPO |
$411.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$397.80
|
| Rate for Payer: United Healthcare Commercial |
$368.78
|
| Rate for Payer: United Healthcare Medicare |
$154.44
|
|
|
AMINO ACID 4.25 % IN D5W 4.25 % IV SOLP
|
Facility
OP
|
$287.00
|
|
|
Service Code
|
NDC 00338113303
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$74.57 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$242.23
|
| Rate for Payer: Aetna Medicare |
$94.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$94.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$164.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$179.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$108.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$104.18
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Centivo All Commercial |
$146.37
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Humana Medicare |
$146.37
|
| Rate for Payer: Lucent All Commercial |
$146.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$111.93
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$243.95
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
|
|
AMINO ACID 4.25 % IN D5W 4.25 % IV SOLP
|
Facility
IP
|
$287.00
|
|
|
Service Code
|
NDC 00338113303
|
| Hospital Charge Code |
27927
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$215.25 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial |
$247.97
|
| Rate for Payer: Cash Price |
$177.94
|
| Rate for Payer: Cigna All Commercial |
$247.68
|
| Rate for Payer: CORVEL All Commercial |
$266.91
|
| Rate for Payer: Coventry All Commercial |
$252.56
|
| Rate for Payer: Encore All Commercial |
$264.18
|
| Rate for Payer: Frontpath All Commercial |
$264.04
|
| Rate for Payer: Humana ChoiceCare |
$247.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$258.30
|
| Rate for Payer: PHCS All Commercial |
$215.25
|
| Rate for Payer: PHP All Commercial |
$217.66
|
| Rate for Payer: Sagamore Health Network All Products |
$221.56
|
| Rate for Payer: Signature Care EPO |
$238.21
|
| Rate for Payer: Signature Care PPO |
$252.56
|
| Rate for Payer: United Healthcare Commercial |
$226.16
|
|
|
AMINOPHYLLINE 250 MG/10 ML IV SOLN
|
Facility
OP
|
$98.70
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$91.79 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Medicare |
$32.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$56.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$61.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.83
|
| Rate for Payer: Cash Price |
$61.19
|
| Rate for Payer: Centivo All Commercial |
$50.34
|
| Rate for Payer: Cigna All Commercial |
$85.18
|
| Rate for Payer: CORVEL All Commercial |
$91.79
|
| Rate for Payer: Coventry All Commercial |
$86.86
|
| Rate for Payer: Encore All Commercial |
$90.85
|
| Rate for Payer: Frontpath All Commercial |
$90.80
|
| Rate for Payer: Humana ChoiceCare |
$85.25
|
| Rate for Payer: Humana Medicare |
$50.34
|
| Rate for Payer: Lucent All Commercial |
$50.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.83
|
| Rate for Payer: PHCS All Commercial |
$74.02
|
| Rate for Payer: PHP All Commercial |
$74.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.49
|
| Rate for Payer: Sagamore Health Network All Products |
$76.20
|
| Rate for Payer: Signature Care EPO |
$81.92
|
| Rate for Payer: Signature Care PPO |
$86.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$83.90
|
| Rate for Payer: United Healthcare Commercial |
$77.78
|
| Rate for Payer: United Healthcare Medicare |
$32.57
|
|
|
AMINOPHYLLINE 250 MG/10 ML IV SOLN
|
Facility
IP
|
$98.70
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.02 |
| Max. Negotiated Rate |
$91.79 |
| Rate for Payer: Aetna Commercial |
$85.28
|
| Rate for Payer: Cash Price |
$61.19
|
| Rate for Payer: Cigna All Commercial |
$85.18
|
| Rate for Payer: CORVEL All Commercial |
$91.79
|
| Rate for Payer: Coventry All Commercial |
$86.86
|
| Rate for Payer: Encore All Commercial |
$90.85
|
| Rate for Payer: Frontpath All Commercial |
$90.80
|
| Rate for Payer: Humana ChoiceCare |
$85.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$88.83
|
| Rate for Payer: PHCS All Commercial |
$74.02
|
| Rate for Payer: PHP All Commercial |
$74.85
|
| Rate for Payer: Sagamore Health Network All Products |
$76.20
|
| Rate for Payer: Signature Care EPO |
$81.92
|
| Rate for Payer: Signature Care PPO |
$86.86
|
| Rate for Payer: United Healthcare Commercial |
$77.78
|
|
|
AMIODARONE 200 MG ORAL TAB
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 00904699361
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.07
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.06
|
| Rate for Payer: Frontpath All Commercial |
$1.06
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.04
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Sagamore Health Network All Products |
$0.89
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
|
|
AMIODARONE 200 MG ORAL TAB
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 00904699361
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Centivo All Commercial |
$0.59
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.07
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.06
|
| Rate for Payer: Frontpath All Commercial |
$1.06
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Humana Medicare |
$0.59
|
| Rate for Payer: Lucent All Commercial |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.04
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.89
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
AMIODARONE 50 MG/ML IV SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
93084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
AMIODARONE 50 MG/ML IV SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
93084
|
|
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 |
$11.16
|
| 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
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN
|
Facility
IP
|
$230.30
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
152382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$172.72 |
| Max. Negotiated Rate |
$214.18 |
| Rate for Payer: Aetna Commercial |
$198.98
|
| Rate for Payer: Cash Price |
$142.79
|
| Rate for Payer: Cigna All Commercial |
$198.75
|
| Rate for Payer: CORVEL All Commercial |
$214.18
|
| Rate for Payer: Coventry All Commercial |
$202.66
|
| Rate for Payer: Encore All Commercial |
$211.99
|
| Rate for Payer: Frontpath All Commercial |
$211.88
|
| Rate for Payer: Humana ChoiceCare |
$198.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$207.27
|
| Rate for Payer: PHCS All Commercial |
$172.72
|
| Rate for Payer: PHP All Commercial |
$174.66
|
| Rate for Payer: Sagamore Health Network All Products |
$177.79
|
| Rate for Payer: Signature Care EPO |
$191.15
|
| Rate for Payer: Signature Care PPO |
$202.66
|
| Rate for Payer: United Healthcare Commercial |
$181.48
|
|
