|
AMIODARONE 200 MG ORAL TAB
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
NDC 00904699361
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Aetna Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Centivo All Commercial |
$0.86
|
| Rate for Payer: Cigna All Commercial |
$1.37
|
| Rate for Payer: CORVEL All Commercial |
$1.48
|
| Rate for Payer: Coventry All Commercial |
$1.40
|
| Rate for Payer: Encore All Commercial |
$1.46
|
| Rate for Payer: Frontpath All Commercial |
$1.46
|
| Rate for Payer: Humana ChoiceCare |
$1.37
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.43
|
| Rate for Payer: PHCS All Commercial |
$1.19
|
| Rate for Payer: PHP All Commercial |
$1.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.62
|
| Rate for Payer: Sagamore Health Network All Products |
$1.23
|
| Rate for Payer: Signature Care EPO |
$1.32
|
| Rate for Payer: Signature Care PPO |
$1.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.25
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
|
|
AMIODARONE 200 MG ORAL TAB
|
Facility
|
IP
|
$1.59
|
|
|
Service Code
|
NDC 00904699361
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.37
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.37
|
| Rate for Payer: CORVEL All Commercial |
$1.48
|
| Rate for Payer: Coventry All Commercial |
$1.40
|
| Rate for Payer: Encore All Commercial |
$1.46
|
| Rate for Payer: Frontpath All Commercial |
$1.46
|
| Rate for Payer: Humana ChoiceCare |
$1.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.43
|
| Rate for Payer: PHCS All Commercial |
$1.19
|
| Rate for Payer: PHP All Commercial |
$1.21
|
| Rate for Payer: Sagamore Health Network All Products |
$1.23
|
| Rate for Payer: Signature Care EPO |
$1.32
|
| Rate for Payer: Signature Care PPO |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.25
|
|
|
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 |
$5.58 |
| 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 |
$11.16
|
| 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
|
|
|
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
|
$227.50
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.62 |
| Max. Negotiated Rate |
$211.57 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Cash Price |
$141.05
|
| Rate for Payer: Cigna All Commercial |
$196.33
|
| Rate for Payer: CORVEL All Commercial |
$211.57
|
| Rate for Payer: Coventry All Commercial |
$200.20
|
| Rate for Payer: Encore All Commercial |
$209.41
|
| Rate for Payer: Frontpath All Commercial |
$209.30
|
| Rate for Payer: Humana ChoiceCare |
$196.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.75
|
| Rate for Payer: PHCS All Commercial |
$170.62
|
| Rate for Payer: PHP All Commercial |
$172.54
|
| Rate for Payer: Sagamore Health Network All Products |
$175.63
|
| Rate for Payer: Signature Care EPO |
$188.82
|
| Rate for Payer: Signature Care PPO |
$200.20
|
| Rate for Payer: United Healthcare Commercial |
$179.27
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN
|
Facility
|
OP
|
$227.50
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152382
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.53 |
| Max. Negotiated Rate |
$211.57 |
| Rate for Payer: Aetna Commercial |
$192.01
|
| Rate for Payer: Aetna Medicare |
$72.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$70.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$130.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$142.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$83.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$80.08
|
| Rate for Payer: Cash Price |
$141.05
|
| Rate for Payer: Centivo All Commercial |
$123.76
|
| Rate for Payer: Cigna All Commercial |
$196.33
|
| Rate for Payer: CORVEL All Commercial |
$211.57
|
| Rate for Payer: Coventry All Commercial |
$200.20
|
| Rate for Payer: Encore All Commercial |
$209.41
|
| Rate for Payer: Frontpath All Commercial |
$209.30
|
| Rate for Payer: Humana ChoiceCare |
$196.49
|
| Rate for Payer: Humana Medicare |
$72.80
|
| Rate for Payer: Lucent All Commercial |
$123.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.75
|
| Rate for Payer: PHCS All Commercial |
$170.62
|
| Rate for Payer: PHP All Commercial |
$172.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$88.72
|
| Rate for Payer: Sagamore Health Network All Products |
$175.63
|
| Rate for Payer: Signature Care EPO |
$188.82
|
| Rate for Payer: Signature Care PPO |
$200.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$193.38
|
| Rate for Payer: United Healthcare Commercial |
$179.27
|
| Rate for Payer: United Healthcare Medicare |
$72.80
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
|
IP
|
$302.40
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$226.80 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$261.27
|
| Rate for Payer: Cash Price |
$187.49
|
| Rate for Payer: Cigna All Commercial |
$260.97
|
| Rate for Payer: CORVEL All Commercial |
$281.23
|
| Rate for Payer: Coventry All Commercial |
$266.11
|
| Rate for Payer: Encore All Commercial |
$278.36
|
| Rate for Payer: Frontpath All Commercial |
$278.21
|
| Rate for Payer: Humana ChoiceCare |
$261.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.16
|
| Rate for Payer: PHCS All Commercial |
$226.80
|
| Rate for Payer: PHP All Commercial |
$229.34
|
| Rate for Payer: Sagamore Health Network All Products |
$233.45
|
| Rate for Payer: Signature Care EPO |
$250.99
|
| Rate for Payer: Signature Care PPO |
$266.11
|
| Rate for Payer: United Healthcare Commercial |
$238.29
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
|
OP
|
$302.40
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.74 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$255.23
|
| Rate for Payer: Aetna Medicare |
$96.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$173.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$189.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$111.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$106.44
|
| Rate for Payer: Cash Price |
$187.49
|
| Rate for Payer: Centivo All Commercial |
$164.51
|
| Rate for Payer: Cigna All Commercial |
$260.97
|
| Rate for Payer: CORVEL All Commercial |
$281.23
|
| Rate for Payer: Coventry All Commercial |
$266.11
|
| Rate for Payer: Encore All Commercial |
$278.36
|
| Rate for Payer: Frontpath All Commercial |
$278.21
|
| Rate for Payer: Humana ChoiceCare |
$261.18
|
| Rate for Payer: Humana Medicare |
$96.77
|
| Rate for Payer: Lucent All Commercial |
$164.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.16
|
| Rate for Payer: PHCS All Commercial |
$226.80
|
| Rate for Payer: PHP All Commercial |
$229.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$117.94
|
| Rate for Payer: Sagamore Health Network All Products |
$233.45
|
| Rate for Payer: Signature Care EPO |
$250.99
|
| Rate for Payer: Signature Care PPO |
$266.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$257.04
|
| Rate for Payer: United Healthcare Commercial |
$238.29
|
| Rate for Payer: United Healthcare Medicare |
$96.77
|
|
|
AMITRIPTYLINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
AMITRIPTYLINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.89
|
| Rate for Payer: Aetna Medicare |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Centivo All Commercial |
$1.22
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Humana Medicare |
$0.72
|
| Rate for Payer: Lucent All Commercial |
$1.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
| Rate for Payer: United Healthcare Medicare |
$0.72
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna Commercial |
$1.89
|
| Rate for Payer: Aetna Medicare |
$0.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Centivo All Commercial |
$1.22
|
| Rate for Payer: Cigna All Commercial |
$1.93
|
| Rate for Payer: CORVEL All Commercial |
$2.08
|
| Rate for Payer: Coventry All Commercial |
$1.97
|
| Rate for Payer: Encore All Commercial |
$2.06
|
| Rate for Payer: Frontpath All Commercial |
$2.06
|
| Rate for Payer: Humana ChoiceCare |
$1.93
|
| Rate for Payer: Humana Medicare |
$0.72
|
| Rate for Payer: Lucent All Commercial |
$1.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.02
|
| Rate for Payer: PHCS All Commercial |
$1.68
|
| Rate for Payer: PHP All Commercial |
$1.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$1.73
|
| Rate for Payer: Signature Care EPO |
$1.86
|
| Rate for Payer: Signature Care PPO |
$1.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$1.77
|
| Rate for Payer: United Healthcare Medicare |
$0.72
|
|
|
AMLODIPINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904637161
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
AMLODIPINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904637161
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
AMLODIPINE 2.5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904636961
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
AMLODIPINE 2.5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904636961
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
AMLODIPINE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
AMLODIPINE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
AMMONIUM LACTATE 12 % TOP LOTN
|
Facility
|
IP
|
$36.39
|
|
|
Service Code
|
NDC 00904598426
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.29 |
| Max. Negotiated Rate |
$33.84 |
| Rate for Payer: Aetna Commercial |
$31.44
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cigna All Commercial |
$31.40
|
| Rate for Payer: CORVEL All Commercial |
$33.84
|
| Rate for Payer: Coventry All Commercial |
$32.02
|
| Rate for Payer: Encore All Commercial |
$33.49
|
| Rate for Payer: Frontpath All Commercial |
$33.48
|
| Rate for Payer: Humana ChoiceCare |
$31.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.75
|
| Rate for Payer: PHCS All Commercial |
$27.29
|
| Rate for Payer: PHP All Commercial |
$27.60
|
| Rate for Payer: Sagamore Health Network All Products |
$28.09
|
| Rate for Payer: Signature Care EPO |
$30.20
|
| Rate for Payer: Signature Care PPO |
$32.02
|
| Rate for Payer: United Healthcare Commercial |
$28.67
|
|
|
AMMONIUM LACTATE 12 % TOP LOTN
|
Facility
|
OP
|
$36.39
|
|
|
Service Code
|
NDC 00904598426
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$33.84 |
| Rate for Payer: Aetna Commercial |
$30.71
|
| Rate for Payer: Aetna Medicare |
$11.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.81
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Centivo All Commercial |
$19.79
|
| Rate for Payer: Cigna All Commercial |
$31.40
|
| Rate for Payer: CORVEL All Commercial |
$33.84
|
| Rate for Payer: Coventry All Commercial |
$32.02
|
| Rate for Payer: Encore All Commercial |
$33.49
|
| Rate for Payer: Frontpath All Commercial |
$33.48
|
| Rate for Payer: Humana ChoiceCare |
$31.43
|
| Rate for Payer: Humana Medicare |
$11.64
|
| Rate for Payer: Lucent All Commercial |
$19.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.75
|
| Rate for Payer: PHCS All Commercial |
$27.29
|
| Rate for Payer: PHP All Commercial |
$27.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.19
|
| Rate for Payer: Sagamore Health Network All Products |
$28.09
|
| Rate for Payer: Signature Care EPO |
$30.20
|
| Rate for Payer: Signature Care PPO |
$32.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.93
|
| Rate for Payer: United Healthcare Commercial |
$28.67
|
| Rate for Payer: United Healthcare Medicare |
$11.64
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSR
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$19.53 |
| Rate for Payer: Aetna Commercial |
$17.72
|
| Rate for Payer: Aetna Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.39
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Centivo All Commercial |
$11.42
|
| Rate for Payer: Cigna All Commercial |
$18.12
|
| Rate for Payer: CORVEL All Commercial |
$19.53
|
| Rate for Payer: Coventry All Commercial |
$18.48
|
| Rate for Payer: Encore All Commercial |
$19.33
|
| Rate for Payer: Frontpath All Commercial |
$19.32
|
| Rate for Payer: Humana ChoiceCare |
$18.14
|
| Rate for Payer: Humana Medicare |
$6.72
|
| Rate for Payer: Lucent All Commercial |
$11.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.90
|
| Rate for Payer: PHCS All Commercial |
$15.75
|
| Rate for Payer: PHP All Commercial |
$15.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.19
|
| Rate for Payer: Sagamore Health Network All Products |
$16.21
|
| Rate for Payer: Signature Care EPO |
$17.43
|
| Rate for Payer: Signature Care PPO |
$18.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.85
|
| Rate for Payer: United Healthcare Commercial |
$16.55
|
| Rate for Payer: United Healthcare Medicare |
$6.72
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSR
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$19.53 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Cigna All Commercial |
$18.12
|
| Rate for Payer: CORVEL All Commercial |
$19.53
|
| Rate for Payer: Coventry All Commercial |
$18.48
|
| Rate for Payer: Encore All Commercial |
$19.33
|
| Rate for Payer: Frontpath All Commercial |
$19.32
|
| Rate for Payer: Humana ChoiceCare |
$18.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.90
|
| Rate for Payer: PHCS All Commercial |
$15.75
|
| Rate for Payer: PHP All Commercial |
$15.93
|
| Rate for Payer: Sagamore Health Network All Products |
$16.21
|
| Rate for Payer: Signature Care EPO |
$17.43
|
| Rate for Payer: Signature Care PPO |
$18.48
|
| Rate for Payer: United Healthcare Commercial |
$16.55
|
|
|
AMOXICILLIN 250 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
