|
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
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
IP
|
$306.60
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.95 |
| Max. Negotiated Rate |
$285.14 |
| Rate for Payer: Aetna Commercial |
$264.90
|
| Rate for Payer: Cash Price |
$190.09
|
| Rate for Payer: Cigna All Commercial |
$264.60
|
| Rate for Payer: CORVEL All Commercial |
$285.14
|
| Rate for Payer: Coventry All Commercial |
$269.81
|
| Rate for Payer: Encore All Commercial |
$282.23
|
| Rate for Payer: Frontpath All Commercial |
$282.07
|
| Rate for Payer: Humana ChoiceCare |
$264.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$275.94
|
| Rate for Payer: PHCS All Commercial |
$229.95
|
| Rate for Payer: PHP All Commercial |
$232.53
|
| Rate for Payer: Sagamore Health Network All Products |
$236.70
|
| Rate for Payer: Signature Care EPO |
$254.48
|
| Rate for Payer: Signature Care PPO |
$269.81
|
| Rate for Payer: United Healthcare Commercial |
$241.60
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
OP
|
$306.60
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.18 |
| Max. Negotiated Rate |
$285.14 |
| Rate for Payer: Aetna Commercial |
$258.77
|
| Rate for Payer: Aetna Medicare |
$101.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$101.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$176.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$191.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$116.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$111.30
|
| Rate for Payer: Cash Price |
$190.09
|
| Rate for Payer: Centivo All Commercial |
$156.37
|
| Rate for Payer: Cigna All Commercial |
$264.60
|
| Rate for Payer: CORVEL All Commercial |
$285.14
|
| Rate for Payer: Coventry All Commercial |
$269.81
|
| Rate for Payer: Encore All Commercial |
$282.23
|
| Rate for Payer: Frontpath All Commercial |
$282.07
|
| Rate for Payer: Humana ChoiceCare |
$264.81
|
| Rate for Payer: Humana Medicare |
$156.37
|
| Rate for Payer: Lucent All Commercial |
$156.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$275.94
|
| Rate for Payer: PHCS All Commercial |
$229.95
|
| Rate for Payer: PHP All Commercial |
$232.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$119.57
|
| Rate for Payer: Sagamore Health Network All Products |
$236.70
|
| Rate for Payer: Signature Care EPO |
$254.48
|
| Rate for Payer: Signature Care PPO |
$269.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$260.61
|
| Rate for Payer: United Healthcare Commercial |
$241.60
|
| Rate for Payer: United Healthcare Medicare |
$101.18
|
|
|
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 |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
IP
|
$1.69
|
|
|
Service Code
|
NDC 00904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna Commercial |
$1.46
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.46
|
| Rate for Payer: CORVEL All Commercial |
$1.57
|
| Rate for Payer: Coventry All Commercial |
$1.48
|
| Rate for Payer: Encore All Commercial |
$1.55
|
| Rate for Payer: Frontpath All Commercial |
$1.55
|
| Rate for Payer: Humana ChoiceCare |
$1.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.52
|
| Rate for Payer: PHCS All Commercial |
$1.27
|
| Rate for Payer: PHP All Commercial |
$1.28
|
| Rate for Payer: Sagamore Health Network All Products |
$1.30
|
| Rate for Payer: Signature Care EPO |
$1.40
|
| Rate for Payer: Signature Care PPO |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
|
|
AMITRIPTYLINE 25 MG ORAL TAB
|
Facility
OP
|
$1.69
|
|
|
Service Code
|
NDC 00904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna Commercial |
$1.42
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Centivo All Commercial |
$0.86
|
| Rate for Payer: Cigna All Commercial |
$1.46
|
| Rate for Payer: CORVEL All Commercial |
$1.57
|
| Rate for Payer: Coventry All Commercial |
$1.48
|
| Rate for Payer: Encore All Commercial |
$1.55
|
| Rate for Payer: Frontpath All Commercial |
$1.55
|
| Rate for Payer: Humana ChoiceCare |
$1.46
|
| Rate for Payer: Humana Medicare |
$0.86
|
| Rate for Payer: Lucent All Commercial |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.52
|
| Rate for Payer: PHCS All Commercial |
$1.27
|
| Rate for Payer: PHP All Commercial |
$1.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.66
|
| Rate for Payer: Sagamore Health Network All Products |
$1.30
|
| Rate for Payer: Signature Care EPO |
$1.40
|
| Rate for Payer: Signature Care PPO |
$1.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
AMLODIPINE 10 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904637161
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
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 |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
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
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
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
|
|
|
AMMONIA AROMATIC 15 % (W/V) INHL SOLN
|
Facility
OP
|
$2.47
|
|
|
Service Code
|
NDC 39822990002
|
| Hospital Charge Code |
439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$2.09
|
| Rate for Payer: Aetna Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Centivo All Commercial |
$1.26
|
| Rate for Payer: Cigna All Commercial |
$2.13
|
| Rate for Payer: CORVEL All Commercial |
$2.30
|
| Rate for Payer: Coventry All Commercial |
$2.17
|
| Rate for Payer: Encore All Commercial |
$2.27
|
| Rate for Payer: Frontpath All Commercial |
$2.27
|
| Rate for Payer: Humana ChoiceCare |
$2.13
|
| Rate for Payer: Humana Medicare |
$1.26
|
| Rate for Payer: Lucent All Commercial |
$1.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.22
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.85
|
| Rate for Payer: PHP All Commercial |
$1.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.96
|
| Rate for Payer: Sagamore Health Network All Products |
$1.91
|
| Rate for Payer: Signature Care EPO |
$2.05
|
| Rate for Payer: Signature Care PPO |
$2.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.10
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Medicare |
$0.82
|
|
|
AMMONIA AROMATIC 15 % (W/V) INHL SOLN
|
Facility
IP
|
$2.47
|
|
|
Service Code
|
NDC 39822990002
|
| Hospital Charge Code |
439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.13
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna All Commercial |
$2.13
|
| Rate for Payer: CORVEL All Commercial |
$2.30
|
| Rate for Payer: Coventry All Commercial |
$2.17
|
| Rate for Payer: Encore All Commercial |
$2.27
|
| Rate for Payer: Frontpath All Commercial |
$2.27
|
| Rate for Payer: Humana ChoiceCare |
$2.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.22
|
| Rate for Payer: PHCS All Commercial |
$1.85
|
| Rate for Payer: PHP All Commercial |
$1.87
|
| Rate for Payer: Sagamore Health Network All Products |
$1.91
|
| Rate for Payer: Signature Care EPO |
$2.05
|
| Rate for Payer: Signature Care PPO |
$2.17
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
|
|
AMMONIUM LACTATE 12 % TOP LOTN
|
Facility
OP
|
$36.39
|
|
|
Service Code
|
NDC 00904598426
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$33.84 |
| Rate for Payer: Aetna Commercial |
$30.71
|
| Rate for Payer: Aetna Medicare |
$12.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.21
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Centivo All Commercial |
$18.56
|
| 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: Humana Medicare |
$18.56
|
| Rate for Payer: Lucent All Commercial |
$18.56
|
| 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 |
$12.01
|
|
|
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
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSR
|
Facility
IP
|
$18.90
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$16.33
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSR
|
Facility
OP
|
$18.90
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$15.95
|
| Rate for Payer: Aetna Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.86
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Centivo All Commercial |
$9.64
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Humana Medicare |
$9.64
|
| Rate for Payer: Lucent All Commercial |
$9.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.37
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.06
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
|
|
AMOXICILLIN 250 MG/5 ML SUSP 100 ML ED PACK (CAMERON)
|
Facility
IP
|
$18.90
|
|
|
Service Code
|
NDC 007816041
|
| Hospital Charge Code |
1401000800174
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$16.33
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
|
|
AMOXICILLIN 250 MG/5 ML SUSP 100 ML ED PACK (CAMERON)
|
Facility
OP
|
$18.90
|
|
|
Service Code
|
NDC 007816041
|
| Hospital Charge Code |
1401000800174
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$15.95
|
| Rate for Payer: Aetna Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.86
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Centivo All Commercial |
$9.64
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Humana Medicare |
$9.64
|
| Rate for Payer: Lucent All Commercial |
$9.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.37
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.06
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
|
|
AMOXICILLIN 250 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
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
|
|
|
AMOXICILLIN 250 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSR
|
Facility
IP
|
$18.90
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$16.33
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSR
|
Facility
OP
|
$18.90
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$15.95
|
| Rate for Payer: Aetna Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.86
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Centivo All Commercial |
$9.64
|
| Rate for Payer: Cigna All Commercial |
$16.31
|
| Rate for Payer: CORVEL All Commercial |
$17.58
|
| Rate for Payer: Coventry All Commercial |
$16.63
|
| Rate for Payer: Encore All Commercial |
$17.40
|
| Rate for Payer: Frontpath All Commercial |
$17.39
|
| Rate for Payer: Humana ChoiceCare |
$16.32
|
| Rate for Payer: Humana Medicare |
$9.64
|
| Rate for Payer: Lucent All Commercial |
$9.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.01
|
| Rate for Payer: PHCS All Commercial |
$14.18
|
| Rate for Payer: PHP All Commercial |
$14.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.37
|
| Rate for Payer: Sagamore Health Network All Products |
$14.59
|
| Rate for Payer: Signature Care EPO |
$15.69
|
| Rate for Payer: Signature Care PPO |
$16.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.06
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
|
