|
AMOXICILLIN 400 MG/5 ML ORAL SUSR 100 ML ED PACK (CAMERON)
|
Facility
|
IP
|
$18.90
|
|
|
Service Code
|
NDC 000934161
|
| Hospital Charge Code |
1401000800900
|
|
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 100 ML ED PACK (CAMERON)
|
Facility
|
OP
|
$18.90
|
|
|
Service Code
|
NDC 000934161
|
| Hospital Charge Code |
1401000800900
|
|
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-POT CLAVULANATE 400-57 MG/5 ML ORAL SUSR
|
Facility
|
OP
|
$36.23
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$33.69 |
| Rate for Payer: Aetna Commercial |
$30.57
|
| Rate for Payer: Aetna Medicare |
$11.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.15
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Centivo All Commercial |
$18.47
|
| Rate for Payer: Cigna All Commercial |
$31.26
|
| Rate for Payer: CORVEL All Commercial |
$33.69
|
| Rate for Payer: Coventry All Commercial |
$31.88
|
| Rate for Payer: Encore All Commercial |
$33.35
|
| Rate for Payer: Frontpath All Commercial |
$33.33
|
| Rate for Payer: Humana ChoiceCare |
$31.29
|
| Rate for Payer: Humana Medicare |
$18.47
|
| Rate for Payer: Lucent All Commercial |
$18.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.60
|
| Rate for Payer: PHCS All Commercial |
$27.17
|
| Rate for Payer: PHP All Commercial |
$27.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.13
|
| Rate for Payer: Sagamore Health Network All Products |
$27.97
|
| Rate for Payer: Signature Care EPO |
$30.07
|
| Rate for Payer: Signature Care PPO |
$31.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.79
|
| Rate for Payer: United Healthcare Commercial |
$28.55
|
| Rate for Payer: United Healthcare Medicare |
$11.95
|
|
|
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5 ML ORAL SUSR
|
Facility
|
IP
|
$36.23
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$33.69 |
| Rate for Payer: Aetna Commercial |
$31.30
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Cigna All Commercial |
$31.26
|
| Rate for Payer: CORVEL All Commercial |
$33.69
|
| Rate for Payer: Coventry All Commercial |
$31.88
|
| Rate for Payer: Encore All Commercial |
$33.35
|
| Rate for Payer: Frontpath All Commercial |
$33.33
|
| Rate for Payer: Humana ChoiceCare |
$31.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.60
|
| Rate for Payer: PHCS All Commercial |
$27.17
|
| Rate for Payer: PHP All Commercial |
$27.47
|
| Rate for Payer: Sagamore Health Network All Products |
$27.97
|
| Rate for Payer: Signature Care EPO |
$30.07
|
| Rate for Payer: Signature Care PPO |
$31.88
|
| Rate for Payer: United Healthcare Commercial |
$28.55
|
|
|
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 |
$0.53 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Centivo All Commercial |
$0.82
|
| 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 |
$0.82
|
| Rate for Payer: Lucent All Commercial |
$0.82
|
| 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 |
$0.53
|
|
|
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
|
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 1 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
AMPICILLIN SODIUM 250 MG INJ SOLR
|
Facility
|
OP
|
$28.89
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$26.87 |
| Rate for Payer: Aetna Commercial |
$24.38
|
| Rate for Payer: Aetna Medicare |
$9.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.49
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Centivo All Commercial |
$14.73
|
| Rate for Payer: Cigna All Commercial |
$24.93
|
| Rate for Payer: CORVEL All Commercial |
$26.87
|
| Rate for Payer: Coventry All Commercial |
$25.42
|
| Rate for Payer: Encore All Commercial |
$26.59
|
| Rate for Payer: Frontpath All Commercial |
$26.58
|
| Rate for Payer: Humana ChoiceCare |
$24.95
|
| Rate for Payer: Humana Medicare |
$14.73
|
| Rate for Payer: Lucent All Commercial |
$14.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.00
|
| Rate for Payer: PHCS All Commercial |
$21.67
|
| Rate for Payer: PHP All Commercial |
$21.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.27
|
| Rate for Payer: Sagamore Health Network All Products |
$22.30
|
| Rate for Payer: Signature Care EPO |
$23.98
|
| Rate for Payer: Signature Care PPO |
$25.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.56
|
| Rate for Payer: United Healthcare Commercial |
$22.76
|
| Rate for Payer: United Healthcare Medicare |
$9.53
|
|
|
AMPICILLIN SODIUM 250 MG INJ SOLR
|
Facility
|
IP
|
$28.89
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.67 |
| Max. Negotiated Rate |
$26.87 |
| Rate for Payer: Aetna Commercial |
$24.96
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cigna All Commercial |
$24.93
|
| Rate for Payer: CORVEL All Commercial |
$26.87
|
| Rate for Payer: Coventry All Commercial |
$25.42
|
| Rate for Payer: Encore All Commercial |
$26.59
|
| Rate for Payer: Frontpath All Commercial |
$26.58
|
| Rate for Payer: Humana ChoiceCare |
$24.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.00
|
| Rate for Payer: PHCS All Commercial |
$21.67
|
| Rate for Payer: PHP All Commercial |
$21.91
|
| Rate for Payer: Sagamore Health Network All Products |
$22.30
|
| Rate for Payer: Signature Care EPO |
$23.98
|
| Rate for Payer: Signature Care PPO |
$25.42
|
| Rate for Payer: United Healthcare Commercial |
$22.76
|
|
|
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 |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
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 |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
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
|
OP
|
$22.58
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna Commercial |
$19.05
|
| Rate for Payer: Aetna Medicare |
$7.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.19
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Centivo All Commercial |
$11.51
|
| Rate for Payer: Cigna All Commercial |
$19.48
|
| Rate for Payer: CORVEL All Commercial |
$20.99
|
| Rate for Payer: Coventry All Commercial |
$19.87
|
| Rate for Payer: Encore All Commercial |
$20.78
|
| Rate for Payer: Frontpath All Commercial |
$20.77
|
| Rate for Payer: Humana ChoiceCare |
$19.50
|
| Rate for Payer: Humana Medicare |
$11.51
|
| Rate for Payer: Lucent All Commercial |
$11.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.32
|
| Rate for Payer: PHCS All Commercial |
$16.93
|
| Rate for Payer: PHP All Commercial |
$17.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.80
|
| Rate for Payer: Sagamore Health Network All Products |
$17.43
|
| Rate for Payer: Signature Care EPO |
$18.74
|
| Rate for Payer: Signature Care PPO |
$19.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19.19
|
| Rate for Payer: United Healthcare Commercial |
$17.79
|
| Rate for Payer: United Healthcare Medicare |
$7.45
|
|
|
AMPICILLIN-SULBACTAM 3 G INJ SOLR
|
Facility
|
IP
|
$22.58
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna All Commercial |
$19.48
|
| Rate for Payer: CORVEL All Commercial |
$20.99
|
| Rate for Payer: Coventry All Commercial |
$19.87
|
| Rate for Payer: Encore All Commercial |
$20.78
|
| Rate for Payer: Frontpath All Commercial |
$20.77
|
| Rate for Payer: Humana ChoiceCare |
$19.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.32
|
| Rate for Payer: PHCS All Commercial |
$16.93
|
| Rate for Payer: PHP All Commercial |
$17.12
|
| Rate for Payer: Sagamore Health Network All Products |
$17.43
|
| Rate for Payer: Signature Care EPO |
$18.74
|
| Rate for Payer: Signature Care PPO |
$19.87
|
| Rate for Payer: United Healthcare Commercial |
$17.79
|
|
|
Amputation, toe; metatarsophalangeal joint
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 28820
|
| Hospital Charge Code |
CPT-28820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
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 |
$0.33 |
| Max. Negotiated Rate |
$37.28 |
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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
|
|
|
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
|
|
|
APIXABAN 2.5 MG ORAL TAB
|
Facility
|
OP
|
$49.34
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
162266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$45.88 |
| Rate for Payer: Aetna Commercial |
$41.64
|
| Rate for Payer: Aetna Medicare |
$16.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.91
|
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Centivo All Commercial |
$25.16
|
| Rate for Payer: Cigna All Commercial |
$42.58
|
| Rate for Payer: CORVEL All Commercial |
$45.88
|
| Rate for Payer: Coventry All Commercial |
$43.42
|
| Rate for Payer: Encore All Commercial |
$45.41
|
| Rate for Payer: Frontpath All Commercial |
$45.39
|
| Rate for Payer: Humana ChoiceCare |
$42.61
|
| Rate for Payer: Humana Medicare |
$25.16
|
| Rate for Payer: Lucent All Commercial |
$25.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.40
|
| Rate for Payer: PHCS All Commercial |
$37.00
|
| Rate for Payer: PHP All Commercial |
$37.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.24
|
| Rate for Payer: Sagamore Health Network All Products |
$38.09
|
| Rate for Payer: Signature Care EPO |
$40.95
|
| Rate for Payer: Signature Care PPO |
$43.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.94
|
| Rate for Payer: United Healthcare Commercial |
$38.88
|
| Rate for Payer: United Healthcare Medicare |
$16.28
|
|
|
APIXABAN 2.5 MG ORAL TAB
|
Facility
|
IP
|
$49.34
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
162266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$45.88 |
| Rate for Payer: Aetna Commercial |
$42.63
|
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Cigna All Commercial |
$42.58
|
| Rate for Payer: CORVEL All Commercial |
$45.88
|
| Rate for Payer: Coventry All Commercial |
$43.42
|
| Rate for Payer: Encore All Commercial |
$45.41
|
| Rate for Payer: Frontpath All Commercial |
$45.39
|
| Rate for Payer: Humana ChoiceCare |
$42.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.40
|
| Rate for Payer: PHCS All Commercial |
$37.00
|
| Rate for Payer: PHP All Commercial |
$37.42
|
| Rate for Payer: Sagamore Health Network All Products |
$38.09
|
| Rate for Payer: Signature Care EPO |
$40.95
|
| Rate for Payer: Signature Care PPO |
$43.42
|
| Rate for Payer: United Healthcare Commercial |
$38.88
|
|
|
APRACLONIDINE 0.5 % OPHT DROP
|
Facility
|
OP
|
$280.28
|
|
|
Service Code
|
NDC 17478071610
|
| Hospital Charge Code |
9119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$260.66 |
| Rate for Payer: Aetna Commercial |
$236.56
|
| Rate for Payer: Aetna Medicare |
$92.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$92.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$160.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.74
|
| Rate for Payer: Cash Price |
$173.77
|
| Rate for Payer: Cash Price |
$173.77
|
| Rate for Payer: Centivo All Commercial |
$142.94
|
| Rate for Payer: Cigna All Commercial |
$241.88
|
| Rate for Payer: CORVEL All Commercial |
$260.66
|
| Rate for Payer: Coventry All Commercial |
$246.65
|
| Rate for Payer: Encore All Commercial |
$258.00
|
| Rate for Payer: Frontpath All Commercial |
$257.86
|
| Rate for Payer: Humana ChoiceCare |
$242.08
|
| Rate for Payer: Humana Medicare |
$142.94
|
| Rate for Payer: Lucent All Commercial |
$142.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.25
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$210.21
|
| Rate for Payer: PHP All Commercial |
$212.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.31
|
| Rate for Payer: Sagamore Health Network All Products |
$216.38
|
| Rate for Payer: Signature Care EPO |
$232.63
|
| Rate for Payer: Signature Care PPO |
$246.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$238.24
|
| Rate for Payer: United Healthcare Commercial |
$220.86
|
| Rate for Payer: United Healthcare Medicare |
$92.49
|
|
|
APRACLONIDINE 0.5 % OPHT DROP
|
Facility
|
IP
|
$280.28
|
|
|
Service Code
|
NDC 17478071610
|
| Hospital Charge Code |
9119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.21 |
| Max. Negotiated Rate |
$260.66 |
| Rate for Payer: Aetna Commercial |
$242.16
|
| Rate for Payer: Cash Price |
$173.77
|
| Rate for Payer: Cigna All Commercial |
$241.88
|
| Rate for Payer: CORVEL All Commercial |
$260.66
|
| Rate for Payer: Coventry All Commercial |
$246.65
|
| Rate for Payer: Encore All Commercial |
$258.00
|
| Rate for Payer: Frontpath All Commercial |
$257.86
|
| Rate for Payer: Humana ChoiceCare |
$242.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.25
|
| Rate for Payer: PHCS All Commercial |
$210.21
|
| Rate for Payer: PHP All Commercial |
$212.56
|
| Rate for Payer: Sagamore Health Network All Products |
$216.38
|
| Rate for Payer: Signature Care EPO |
$232.63
|
| Rate for Payer: Signature Care PPO |
$246.65
|
| Rate for Payer: United Healthcare Commercial |
$220.86
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$8.04
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna All Commercial |
$8.03
|
| Rate for Payer: CORVEL All Commercial |
$8.66
|
| Rate for Payer: Coventry All Commercial |
$8.19
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Frontpath All Commercial |
$8.57
|
| Rate for Payer: Humana ChoiceCare |
$8.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.38
|
| Rate for Payer: PHCS All Commercial |
$6.98
|
| Rate for Payer: PHP All Commercial |
$7.06
|
| Rate for Payer: Sagamore Health Network All Products |
$7.19
|
| Rate for Payer: Signature Care EPO |
$7.73
|
| Rate for Payer: Signature Care PPO |
$8.19
|
| Rate for Payer: United Healthcare Commercial |
$7.34
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$7.86
|
| Rate for Payer: Aetna Medicare |
$3.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.38
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Centivo All Commercial |
$4.75
|
| Rate for Payer: Cigna All Commercial |
$8.03
|
| Rate for Payer: CORVEL All Commercial |
$8.66
|
| Rate for Payer: Coventry All Commercial |
$8.19
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Frontpath All Commercial |
$8.57
|
| Rate for Payer: Humana ChoiceCare |
$8.04
|
| Rate for Payer: Humana Medicare |
$4.75
|
| Rate for Payer: Lucent All Commercial |
$4.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.38
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$6.98
|
| Rate for Payer: PHP All Commercial |
$7.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.63
|
| Rate for Payer: Sagamore Health Network All Products |
$7.19
|
| Rate for Payer: Signature Care EPO |
$7.73
|
| Rate for Payer: Signature Care PPO |
$8.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.91
|
| Rate for Payer: United Healthcare Commercial |
$7.34
|
| Rate for Payer: United Healthcare Medicare |
$3.07
|
|
