|
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 400 MG/5 ML ORAL SUSR
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
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 400 MG/5 ML ORAL SUSR
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
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 400 MG/5 ML ORAL SUSR 100 ML ED PACK (CAMERON)
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 000934161
|
| Hospital Charge Code |
1401000800900
|
|
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 400 MG/5 ML ORAL SUSR 100 ML ED PACK (CAMERON)
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 000934161
|
| Hospital Charge Code |
1401000800900
|
|
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-POT CLAVULANATE 400-57 MG/5 ML ORAL SUSR
|
Facility
|
IP
|
$48.83
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.62 |
| Max. Negotiated Rate |
$45.41 |
| Rate for Payer: Aetna Commercial |
$42.18
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cigna All Commercial |
$42.14
|
| Rate for Payer: CORVEL All Commercial |
$45.41
|
| Rate for Payer: Coventry All Commercial |
$42.97
|
| Rate for Payer: Encore All Commercial |
$44.94
|
| Rate for Payer: Frontpath All Commercial |
$44.92
|
| Rate for Payer: Humana ChoiceCare |
$42.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.94
|
| Rate for Payer: PHCS All Commercial |
$36.62
|
| Rate for Payer: PHP All Commercial |
$37.03
|
| Rate for Payer: Sagamore Health Network All Products |
$37.69
|
| Rate for Payer: Signature Care EPO |
$40.52
|
| Rate for Payer: Signature Care PPO |
$42.97
|
| Rate for Payer: United Healthcare Commercial |
$38.47
|
|
|
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5 ML ORAL SUSR
|
Facility
|
OP
|
$48.83
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$45.41 |
| Rate for Payer: Aetna Commercial |
$41.21
|
| Rate for Payer: Aetna Medicare |
$15.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.19
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Centivo All Commercial |
$26.56
|
| Rate for Payer: Cigna All Commercial |
$42.14
|
| Rate for Payer: CORVEL All Commercial |
$45.41
|
| Rate for Payer: Coventry All Commercial |
$42.97
|
| Rate for Payer: Encore All Commercial |
$44.94
|
| Rate for Payer: Frontpath All Commercial |
$44.92
|
| Rate for Payer: Humana ChoiceCare |
$42.17
|
| Rate for Payer: Humana Medicare |
$15.62
|
| Rate for Payer: Lucent All Commercial |
$26.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.94
|
| Rate for Payer: PHCS All Commercial |
$36.62
|
| Rate for Payer: PHP All Commercial |
$37.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.04
|
| Rate for Payer: Sagamore Health Network All Products |
$37.69
|
| Rate for Payer: Signature Care EPO |
$40.52
|
| Rate for Payer: Signature Care PPO |
$42.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.50
|
| Rate for Payer: United Healthcare Commercial |
$38.47
|
| Rate for Payer: United Healthcare Medicare |
$15.62
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TAB
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Aetna Medicare |
$0.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Centivo All Commercial |
$0.88
|
| Rate for Payer: Cigna All Commercial |
$1.39
|
| Rate for Payer: CORVEL All Commercial |
$1.50
|
| Rate for Payer: Coventry All Commercial |
$1.42
|
| Rate for Payer: Encore All Commercial |
$1.48
|
| Rate for Payer: Frontpath All Commercial |
$1.48
|
| Rate for Payer: Humana ChoiceCare |
$1.39
|
| Rate for Payer: Humana Medicare |
$0.52
|
| Rate for Payer: Lucent All Commercial |
$0.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.45
|
| Rate for Payer: PHCS All Commercial |
$1.21
|
| Rate for Payer: PHP All Commercial |
$1.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1.24
|
| Rate for Payer: Signature Care EPO |
$1.34
|
| Rate for Payer: Signature Care PPO |
$1.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
| Rate for Payer: United Healthcare Medicare |
$0.52
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TAB
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna All Commercial |
$1.39
|
| Rate for Payer: CORVEL All Commercial |
$1.50
|
| Rate for Payer: Coventry All Commercial |
$1.42
|
| Rate for Payer: Encore All Commercial |
$1.48
|
| Rate for Payer: Frontpath All Commercial |
$1.48
|
| Rate for Payer: Humana ChoiceCare |
$1.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.45
|
| Rate for Payer: PHCS All Commercial |
$1.21
|
| Rate for Payer: PHP All Commercial |
$1.22
|
| Rate for Payer: Sagamore Health Network All Products |
$1.24
|
| Rate for Payer: Signature Care EPO |
$1.34
|
| Rate for Payer: Signature Care PPO |
$1.42
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
|
|
AMPICILLIN SODIUM 1 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
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
|
|
|
AMPICILLIN SODIUM 1 G INJ SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
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
|
|
|
AMPICILLIN SODIUM 250 MG INJ SOLR
|
Facility
|
OP
|
$27.63
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Aetna Commercial |
$23.32
|
| Rate for Payer: Aetna Medicare |
$8.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.73
|
| Rate for Payer: Cash Price |
$17.13
|
| Rate for Payer: Centivo All Commercial |
$15.03
|
| Rate for Payer: Cigna All Commercial |
$23.84
|
| Rate for Payer: CORVEL All Commercial |
$25.69
|
| Rate for Payer: Coventry All Commercial |
$24.31
|
| Rate for Payer: Encore All Commercial |
$25.43
|
| Rate for Payer: Frontpath All Commercial |
$25.42
|
| Rate for Payer: Humana ChoiceCare |
$23.86
|
| Rate for Payer: Humana Medicare |
$8.84
|
| Rate for Payer: Lucent All Commercial |
$15.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.87
|
| Rate for Payer: PHCS All Commercial |
$20.72
|
| Rate for Payer: PHP All Commercial |
$20.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.78
|
| Rate for Payer: Sagamore Health Network All Products |
$21.33
|
| Rate for Payer: Signature Care EPO |
$22.93
|
| Rate for Payer: Signature Care PPO |
$24.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.48
|
| Rate for Payer: United Healthcare Commercial |
$21.77
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
|
|
AMPICILLIN SODIUM 250 MG INJ SOLR
|
Facility
|
IP
|
$27.63
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Cash Price |
$17.13
|
| Rate for Payer: Cigna All Commercial |
$23.84
|
| Rate for Payer: CORVEL All Commercial |
$25.69
|
| Rate for Payer: Coventry All Commercial |
$24.31
|
| Rate for Payer: Encore All Commercial |
$25.43
|
| Rate for Payer: Frontpath All Commercial |
$25.42
|
| Rate for Payer: Humana ChoiceCare |
$23.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.87
|
| Rate for Payer: PHCS All Commercial |
$20.72
|
| Rate for Payer: PHP All Commercial |
$20.95
|
| Rate for Payer: Sagamore Health Network All Products |
$21.33
|
| Rate for Payer: Signature Care EPO |
$22.93
|
| Rate for Payer: Signature Care PPO |
$24.31
|
| Rate for Payer: United Healthcare Commercial |
$21.77
|
|
|
AMPICILLIN SODIUM 2 G INJ SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
472
|
|
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
|
|
|
AMPICILLIN SODIUM 2 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
472
|
|
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
|
|
|
AMPICILLIN-SULBACTAM 1.5 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32470
|
|
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
|
|
|
AMPICILLIN-SULBACTAM 1.5 G INJ SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32470
|
|
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
|
|
|
AMPICILLIN-SULBACTAM 3 G INJ SOLR
|
Facility
|
IP
|
$22.32
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.74 |
| Max. Negotiated Rate |
$20.75 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: Cash Price |
$13.84
|
| Rate for Payer: Cigna All Commercial |
$19.26
|
| Rate for Payer: CORVEL All Commercial |
$20.75
|
| Rate for Payer: Coventry All Commercial |
$19.64
|
| Rate for Payer: Encore All Commercial |
$20.54
|
| Rate for Payer: Frontpath All Commercial |
$20.53
|
| Rate for Payer: Humana ChoiceCare |
$19.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.08
|
| Rate for Payer: PHCS All Commercial |
$16.74
|
| Rate for Payer: PHP All Commercial |
$16.92
|
| Rate for Payer: Sagamore Health Network All Products |
$17.23
|
| Rate for Payer: Signature Care EPO |
$18.52
|
| Rate for Payer: Signature Care PPO |
$19.64
|
| Rate for Payer: United Healthcare Commercial |
$17.59
|
|
|
AMPICILLIN-SULBACTAM 3 G INJ SOLR
|
Facility
|
OP
|
$22.32
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$20.75 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Aetna Medicare |
$7.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.86
|
| Rate for Payer: Cash Price |
$13.84
|
| Rate for Payer: Centivo All Commercial |
$12.14
|
| Rate for Payer: Cigna All Commercial |
$19.26
|
| Rate for Payer: CORVEL All Commercial |
$20.75
|
| Rate for Payer: Coventry All Commercial |
$19.64
|
| Rate for Payer: Encore All Commercial |
$20.54
|
| Rate for Payer: Frontpath All Commercial |
$20.53
|
| Rate for Payer: Humana ChoiceCare |
$19.27
|
| Rate for Payer: Humana Medicare |
$7.14
|
| Rate for Payer: Lucent All Commercial |
$12.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.08
|
| Rate for Payer: PHCS All Commercial |
$16.74
|
| Rate for Payer: PHP All Commercial |
$16.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.70
|
| Rate for Payer: Sagamore Health Network All Products |
$17.23
|
| Rate for Payer: Signature Care EPO |
$18.52
|
| Rate for Payer: Signature Care PPO |
$19.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.97
|
| Rate for Payer: United Healthcare Commercial |
$17.59
|
| Rate for Payer: United Healthcare Medicare |
$7.14
|
|
|
AMPUTATION, METATARSAL, WITH TOE, SINGLE
|
Facility
|
OP
|
$443.28
|
|
|
Service Code
|
CPT 28810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$443.28 |
| Max. Negotiated Rate |
$443.28 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$443.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$443.28
|
| Rate for Payer: Managed Health Services Medicaid |
$443.28
|
| Rate for Payer: MDWise Medicaid |
$443.28
|
|
|
AMPUTATION, TOE; INTERPHALANGEAL JOINT
|
Facility
|
OP
|
$443.28
|
|
|
Service Code
|
CPT 28825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$443.28 |
| Max. Negotiated Rate |
$443.28 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$443.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$443.28
|
| Rate for Payer: Managed Health Services Medicaid |
$443.28
|
| Rate for Payer: MDWise Medicaid |
$443.28
|
|
|
AMYL NITRITE 0.3 ML INHL SOLN
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 46414222201
|
| Hospital Charge Code |
479
|
|
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
|
|
|
AMYL NITRITE 0.3 ML INHL SOLN
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 46414222201
|
| Hospital Charge Code |
479
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| 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 Hoosier Healthwise/HIP |
$9.56
|
| 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: 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: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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
|
|
|
ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$318.54
|
|
|
Service Code
|
CPT 46600
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$318.54 |
| Max. Negotiated Rate |
$318.54 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$318.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$318.54
|
| Rate for Payer: Managed Health Services Medicaid |
$318.54
|
| Rate for Payer: MDWise Medicaid |
$318.54
|
|
|
APIXABAN 2.5 MG ORAL TAB
|
Facility
|
OP
|
$49.74
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
162266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.42 |
| Max. Negotiated Rate |
$46.26 |
| Rate for Payer: Aetna Commercial |
$41.98
|
| Rate for Payer: Aetna Medicare |
$15.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.51
|
| Rate for Payer: Cash Price |
$30.84
|
| Rate for Payer: Centivo All Commercial |
$27.06
|
| Rate for Payer: Cigna All Commercial |
$42.93
|
| Rate for Payer: CORVEL All Commercial |
$46.26
|
| Rate for Payer: Coventry All Commercial |
$43.77
|
| Rate for Payer: Encore All Commercial |
$45.79
|
| Rate for Payer: Frontpath All Commercial |
$45.76
|
| Rate for Payer: Humana ChoiceCare |
$42.96
|
| Rate for Payer: Humana Medicare |
$15.92
|
| Rate for Payer: Lucent All Commercial |
$27.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.77
|
| Rate for Payer: PHCS All Commercial |
$37.31
|
| Rate for Payer: PHP All Commercial |
$37.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.40
|
| Rate for Payer: Sagamore Health Network All Products |
$38.40
|
| Rate for Payer: Signature Care EPO |
$41.29
|
| Rate for Payer: Signature Care PPO |
$43.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.28
|
| Rate for Payer: United Healthcare Commercial |
$39.20
|
| Rate for Payer: United Healthcare Medicare |
$15.92
|
|
