|
MORPHINE 4 MG/ML IV SOLN
|
Facility
IP
|
$16.51
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
174484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna Commercial |
$14.27
|
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: Cigna All Commercial |
$14.25
|
| Rate for Payer: CORVEL All Commercial |
$15.36
|
| Rate for Payer: Coventry All Commercial |
$14.53
|
| Rate for Payer: Encore All Commercial |
$15.20
|
| Rate for Payer: Frontpath All Commercial |
$15.19
|
| Rate for Payer: Humana ChoiceCare |
$14.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.86
|
| Rate for Payer: PHCS All Commercial |
$12.38
|
| Rate for Payer: PHP All Commercial |
$12.52
|
| Rate for Payer: Sagamore Health Network All Products |
$12.75
|
| Rate for Payer: Signature Care EPO |
$13.71
|
| Rate for Payer: Signature Care PPO |
$14.53
|
| Rate for Payer: United Healthcare Commercial |
$13.01
|
|
|
MORPHINE 4 MG/ML IV SOLN
|
Facility
OP
|
$16.51
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
174484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna Commercial |
$13.94
|
| Rate for Payer: Aetna Medicare |
$5.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.99
|
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: Centivo All Commercial |
$8.42
|
| Rate for Payer: Cigna All Commercial |
$14.25
|
| Rate for Payer: CORVEL All Commercial |
$15.36
|
| Rate for Payer: Coventry All Commercial |
$14.53
|
| Rate for Payer: Encore All Commercial |
$15.20
|
| Rate for Payer: Frontpath All Commercial |
$15.19
|
| Rate for Payer: Humana ChoiceCare |
$14.26
|
| Rate for Payer: Humana Medicare |
$8.42
|
| Rate for Payer: Lucent All Commercial |
$8.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.86
|
| Rate for Payer: PHCS All Commercial |
$12.38
|
| Rate for Payer: PHP All Commercial |
$12.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.44
|
| Rate for Payer: Sagamore Health Network All Products |
$12.75
|
| Rate for Payer: Signature Care EPO |
$13.71
|
| Rate for Payer: Signature Care PPO |
$14.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14.04
|
| Rate for Payer: United Healthcare Commercial |
$13.01
|
| Rate for Payer: United Healthcare Medicare |
$5.45
|
|
|
MORPHINE 4 MG/ML IV SYRG
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
167700
|
|
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
|
|
|
MORPHINE 4 MG/ML IV SYRG
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
167700
|
|
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
|
|
|
MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRG
|
Facility
OP
|
$19.95
|
|
|
Service Code
|
NDC 68094004558
|
| Hospital Charge Code |
187373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$16.84
|
| Rate for Payer: Aetna Medicare |
$6.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.24
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: Centivo All Commercial |
$10.17
|
| Rate for Payer: Cigna All Commercial |
$17.22
|
| Rate for Payer: CORVEL All Commercial |
$18.55
|
| Rate for Payer: Coventry All Commercial |
$17.56
|
| Rate for Payer: Encore All Commercial |
$18.36
|
| Rate for Payer: Frontpath All Commercial |
$18.35
|
| Rate for Payer: Humana ChoiceCare |
$17.23
|
| Rate for Payer: Humana Medicare |
$10.17
|
| Rate for Payer: Lucent All Commercial |
$10.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.96
|
| Rate for Payer: PHCS All Commercial |
$14.96
|
| Rate for Payer: PHP All Commercial |
$15.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.78
|
| Rate for Payer: Sagamore Health Network All Products |
$15.40
|
| Rate for Payer: Signature Care EPO |
$16.56
|
| Rate for Payer: Signature Care PPO |
$17.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.96
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Medicare |
$6.58
|
|
|
MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRG
|
Facility
IP
|
$19.95
|
|
|
Service Code
|
NDC 68094004501
|
| Hospital Charge Code |
187373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$17.24
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: Cigna All Commercial |
$17.22
|
| Rate for Payer: CORVEL All Commercial |
$18.55
|
| Rate for Payer: Coventry All Commercial |
$17.56
|
| Rate for Payer: Encore All Commercial |
$18.36
|
| Rate for Payer: Frontpath All Commercial |
$18.35
|
| Rate for Payer: Humana ChoiceCare |
$17.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.96
|
| Rate for Payer: PHCS All Commercial |
$14.96
|
| Rate for Payer: PHP All Commercial |
$15.13
|
| Rate for Payer: Sagamore Health Network All Products |
$15.40
|
| Rate for Payer: Signature Care EPO |
$16.56
|
| Rate for Payer: Signature Care PPO |
$17.56
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
|
|
MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRG
|
Facility
IP
|
$19.95
|
|
|
Service Code
|
NDC 68094004558
|
| Hospital Charge Code |
187373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$17.24
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: Cigna All Commercial |
$17.22
|
| Rate for Payer: CORVEL All Commercial |
$18.55
|
| Rate for Payer: Coventry All Commercial |
$17.56
|
| Rate for Payer: Encore All Commercial |
$18.36
|
| Rate for Payer: Frontpath All Commercial |
$18.35
|
| Rate for Payer: Humana ChoiceCare |
$17.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.96
|
| Rate for Payer: PHCS All Commercial |
$14.96
|
| Rate for Payer: PHP All Commercial |
$15.13
|
| Rate for Payer: Sagamore Health Network All Products |
$15.40
|
| Rate for Payer: Signature Care EPO |
$16.56
|
| Rate for Payer: Signature Care PPO |
$17.56
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
|
|
MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRG
|
Facility
OP
|
$19.95
|
|
|
Service Code
|
NDC 68094004501
|
| Hospital Charge Code |
187373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$16.84
|
| Rate for Payer: Aetna Medicare |
$6.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.24
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: Centivo All Commercial |
$10.17
|
| Rate for Payer: Cigna All Commercial |
$17.22
|
| Rate for Payer: CORVEL All Commercial |
$18.55
|
| Rate for Payer: Coventry All Commercial |
$17.56
|
| Rate for Payer: Encore All Commercial |
$18.36
|
| Rate for Payer: Frontpath All Commercial |
$18.35
|
| Rate for Payer: Humana ChoiceCare |
$17.23
|
| Rate for Payer: Humana Medicare |
$10.17
|
| Rate for Payer: Lucent All Commercial |
$10.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.96
|
| Rate for Payer: PHCS All Commercial |
$14.96
|
| Rate for Payer: PHP All Commercial |
$15.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.78
|
| Rate for Payer: Sagamore Health Network All Products |
$15.40
|
| Rate for Payer: Signature Care EPO |
$16.56
|
| Rate for Payer: Signature Care PPO |
$17.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.96
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Medicare |
$6.58
|
|
|
MORPHINE (PF) 1 MG/ML INJ SOLN
|
Facility
OP
|
$49.35
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
15852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: Aetna Medicare |
$16.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.91
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Centivo All Commercial |
$25.17
|
| Rate for Payer: Cigna All Commercial |
$42.59
|
| Rate for Payer: CORVEL All Commercial |
$45.90
|
| Rate for Payer: Coventry All Commercial |
$43.43
|
| Rate for Payer: Encore All Commercial |
$45.43
|
| Rate for Payer: Frontpath All Commercial |
$45.40
|
| Rate for Payer: Humana ChoiceCare |
$42.62
|
| Rate for Payer: Humana Medicare |
$25.17
|
| Rate for Payer: Lucent All Commercial |
$25.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.42
|
| Rate for Payer: PHCS All Commercial |
$37.01
|
| Rate for Payer: PHP All Commercial |
$37.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.25
|
| Rate for Payer: Sagamore Health Network All Products |
$38.10
|
| Rate for Payer: Signature Care EPO |
$40.96
|
| Rate for Payer: Signature Care PPO |
$43.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.95
|
| Rate for Payer: United Healthcare Commercial |
$38.89
|
| Rate for Payer: United Healthcare Medicare |
$16.29
|
|
|
MORPHINE (PF) 1 MG/ML INJ SOLN
|
Facility
IP
|
$49.35
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
15852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$42.64
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna All Commercial |
$42.59
|
| Rate for Payer: CORVEL All Commercial |
$45.90
|
| Rate for Payer: Coventry All Commercial |
$43.43
|
| Rate for Payer: Encore All Commercial |
$45.43
|
| Rate for Payer: Frontpath All Commercial |
$45.40
|
| Rate for Payer: Humana ChoiceCare |
$42.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.42
|
| Rate for Payer: PHCS All Commercial |
$37.01
|
| Rate for Payer: PHP All Commercial |
$37.43
|
| Rate for Payer: Sagamore Health Network All Products |
$38.10
|
| Rate for Payer: Signature Care EPO |
$40.96
|
| Rate for Payer: Signature Care PPO |
$43.43
|
| Rate for Payer: United Healthcare Commercial |
$38.89
|
|
|
MORPHINE (PF) 30 MG/30 ML (1 MG/ML) IV PCAS
|
Facility
IP
|
$66.36
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
119818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.77 |
| Max. Negotiated Rate |
$61.71 |
| Rate for Payer: Aetna Commercial |
$57.34
|
| Rate for Payer: Cash Price |
$41.14
|
| Rate for Payer: Cigna All Commercial |
$57.27
|
| Rate for Payer: CORVEL All Commercial |
$61.71
|
| Rate for Payer: Coventry All Commercial |
$58.40
|
| Rate for Payer: Encore All Commercial |
$61.08
|
| Rate for Payer: Frontpath All Commercial |
$61.05
|
| Rate for Payer: Humana ChoiceCare |
$57.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.72
|
| Rate for Payer: PHCS All Commercial |
$49.77
|
| Rate for Payer: PHP All Commercial |
$50.33
|
| Rate for Payer: Sagamore Health Network All Products |
$51.23
|
| Rate for Payer: Signature Care EPO |
$55.08
|
| Rate for Payer: Signature Care PPO |
$58.40
|
| Rate for Payer: United Healthcare Commercial |
$52.29
|
|
|
MORPHINE (PF) 30 MG/30 ML (1 MG/ML) IV PCAS
|
Facility
OP
|
$66.36
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
119818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$61.71 |
| Rate for Payer: Aetna Commercial |
$56.01
|
| Rate for Payer: Aetna Medicare |
$21.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$38.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.09
|
| Rate for Payer: Cash Price |
$41.14
|
| Rate for Payer: Centivo All Commercial |
$33.84
|
| Rate for Payer: Cigna All Commercial |
$57.27
|
| Rate for Payer: CORVEL All Commercial |
$61.71
|
| Rate for Payer: Coventry All Commercial |
$58.40
|
| Rate for Payer: Encore All Commercial |
$61.08
|
| Rate for Payer: Frontpath All Commercial |
$61.05
|
| Rate for Payer: Humana ChoiceCare |
$57.32
|
| Rate for Payer: Humana Medicare |
$33.84
|
| Rate for Payer: Lucent All Commercial |
$33.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.72
|
| Rate for Payer: PHCS All Commercial |
$49.77
|
| Rate for Payer: PHP All Commercial |
$50.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.88
|
| Rate for Payer: Sagamore Health Network All Products |
$51.23
|
| Rate for Payer: Signature Care EPO |
$55.08
|
| Rate for Payer: Signature Care PPO |
$58.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56.41
|
| Rate for Payer: United Healthcare Commercial |
$52.29
|
| Rate for Payer: United Healthcare Medicare |
$21.90
|
|
|
MOXIFLOXACIN 0.5 % OPHT DROP
|
Facility
IP
|
$217.92
|
|
|
Service Code
|
NDC 65862084003
|
| Hospital Charge Code |
35699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$202.66 |
| Rate for Payer: Aetna Commercial |
$188.28
|
| Rate for Payer: Cash Price |
$135.11
|
| Rate for Payer: Cigna All Commercial |
$188.06
|
| Rate for Payer: CORVEL All Commercial |
$202.66
|
| Rate for Payer: Coventry All Commercial |
$191.77
|
| Rate for Payer: Encore All Commercial |
$200.59
|
| Rate for Payer: Frontpath All Commercial |
$200.48
|
| Rate for Payer: Humana ChoiceCare |
$188.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$196.13
|
| Rate for Payer: PHCS All Commercial |
$163.44
|
| Rate for Payer: PHP All Commercial |
$165.27
|
| Rate for Payer: Sagamore Health Network All Products |
$168.23
|
| Rate for Payer: Signature Care EPO |
$180.87
|
| Rate for Payer: Signature Care PPO |
$191.77
|
| Rate for Payer: United Healthcare Commercial |
$171.72
|
|
|
MOXIFLOXACIN 0.5 % OPHT DROP
|
Facility
OP
|
$217.92
|
|
|
Service Code
|
NDC 65862084003
|
| Hospital Charge Code |
35699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$202.66 |
| Rate for Payer: Aetna Commercial |
$183.92
|
| Rate for Payer: Aetna Medicare |
$71.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$71.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$125.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$136.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$82.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$79.10
|
| Rate for Payer: Cash Price |
$135.11
|
| Rate for Payer: Cash Price |
$135.11
|
| Rate for Payer: Centivo All Commercial |
$111.14
|
| Rate for Payer: Cigna All Commercial |
$188.06
|
| Rate for Payer: CORVEL All Commercial |
$202.66
|
| Rate for Payer: Coventry All Commercial |
$191.77
|
| Rate for Payer: Encore All Commercial |
$200.59
|
| Rate for Payer: Frontpath All Commercial |
$200.48
|
| Rate for Payer: Humana ChoiceCare |
$188.21
|
| Rate for Payer: Humana Medicare |
$111.14
|
| Rate for Payer: Lucent All Commercial |
$111.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$196.13
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$163.44
|
| Rate for Payer: PHP All Commercial |
$165.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$84.99
|
| Rate for Payer: Sagamore Health Network All Products |
$168.23
|
| Rate for Payer: Signature Care EPO |
$180.87
|
| Rate for Payer: Signature Care PPO |
$191.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$185.23
|
| Rate for Payer: United Healthcare Commercial |
$171.72
|
| Rate for Payer: United Healthcare Medicare |
$71.91
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
IP
|
$0.37
|
|
|
Service Code
|
NDC 00904549261
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna All Commercial |
$0.32
|
| Rate for Payer: CORVEL All Commercial |
$0.35
|
| Rate for Payer: Coventry All Commercial |
$0.33
|
| Rate for Payer: Encore All Commercial |
$0.34
|
| Rate for Payer: Frontpath All Commercial |
$0.34
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.33
|
| Rate for Payer: PHCS All Commercial |
$0.28
|
| Rate for Payer: PHP All Commercial |
$0.28
|
| Rate for Payer: Sagamore Health Network All Products |
$0.29
|
| Rate for Payer: Signature Care EPO |
$0.31
|
| Rate for Payer: Signature Care PPO |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
OP
|
$0.37
|
|
|
Service Code
|
NDC 00904549261
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna Commercial |
$0.31
|
| Rate for Payer: Aetna Medicare |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Centivo All Commercial |
$0.19
|
| Rate for Payer: Cigna All Commercial |
$0.32
|
| Rate for Payer: CORVEL All Commercial |
$0.35
|
| Rate for Payer: Coventry All Commercial |
$0.33
|
| Rate for Payer: Encore All Commercial |
$0.34
|
| Rate for Payer: Frontpath All Commercial |
$0.34
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare |
$0.19
|
| Rate for Payer: Lucent All Commercial |
$0.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.33
|
| Rate for Payer: PHCS All Commercial |
$0.28
|
| Rate for Payer: PHP All Commercial |
$0.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.14
|
| Rate for Payer: Sagamore Health Network All Products |
$0.29
|
| Rate for Payer: Signature Care EPO |
$0.31
|
| Rate for Payer: Signature Care PPO |
$0.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
|
|
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQD
|
Facility
OP
|
$54.52
|
|
|
Service Code
|
NDC 00005434462
|
| Hospital Charge Code |
121122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.99 |
| Max. Negotiated Rate |
$50.70 |
| Rate for Payer: Aetna Commercial |
$46.01
|
| Rate for Payer: Aetna Medicare |
$17.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$31.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$34.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.79
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Centivo All Commercial |
$27.80
|
| Rate for Payer: Cigna All Commercial |
$47.05
|
| Rate for Payer: CORVEL All Commercial |
$50.70
|
| Rate for Payer: Coventry All Commercial |
$47.97
|
| Rate for Payer: Encore All Commercial |
$50.18
|
| Rate for Payer: Frontpath All Commercial |
$50.15
|
| Rate for Payer: Humana ChoiceCare |
$47.09
|
| Rate for Payer: Humana Medicare |
$27.80
|
| Rate for Payer: Lucent All Commercial |
$27.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.06
|
| Rate for Payer: PHCS All Commercial |
$40.89
|
| Rate for Payer: PHP All Commercial |
$41.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.26
|
| Rate for Payer: Sagamore Health Network All Products |
$42.09
|
| Rate for Payer: Signature Care EPO |
$45.25
|
| Rate for Payer: Signature Care PPO |
$47.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.34
|
| Rate for Payer: United Healthcare Commercial |
$42.96
|
| Rate for Payer: United Healthcare Medicare |
$17.99
|
|
|
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQD
|
Facility
IP
|
$54.52
|
|
|
Service Code
|
NDC 00005434462
|
| Hospital Charge Code |
121122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.89 |
| Max. Negotiated Rate |
$50.70 |
| Rate for Payer: Aetna Commercial |
$47.10
|
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Cigna All Commercial |
$47.05
|
| Rate for Payer: CORVEL All Commercial |
$50.70
|
| Rate for Payer: Coventry All Commercial |
$47.97
|
| Rate for Payer: Encore All Commercial |
$50.18
|
| Rate for Payer: Frontpath All Commercial |
$50.15
|
| Rate for Payer: Humana ChoiceCare |
$47.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.06
|
| Rate for Payer: PHCS All Commercial |
$40.89
|
| Rate for Payer: PHP All Commercial |
$41.34
|
| Rate for Payer: Sagamore Health Network All Products |
$42.09
|
| Rate for Payer: Signature Care EPO |
$45.25
|
| Rate for Payer: Signature Care PPO |
$47.97
|
| Rate for Payer: United Healthcare Commercial |
$42.96
|
|
|
MUPIROCIN 2 % TOP OINT
|
Facility
IP
|
$31.57
|
|
|
Service Code
|
NDC 51672131200
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$29.36 |
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Cigna All Commercial |
$27.24
|
| Rate for Payer: CORVEL All Commercial |
$29.36
|
| Rate for Payer: Coventry All Commercial |
$27.78
|
| Rate for Payer: Encore All Commercial |
$29.06
|
| Rate for Payer: Frontpath All Commercial |
$29.04
|
| Rate for Payer: Humana ChoiceCare |
$27.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.41
|
| Rate for Payer: PHCS All Commercial |
$23.68
|
| Rate for Payer: PHP All Commercial |
$23.94
|
| Rate for Payer: Sagamore Health Network All Products |
$24.37
|
| Rate for Payer: Signature Care EPO |
$26.20
|
| Rate for Payer: Signature Care PPO |
$27.78
|
| Rate for Payer: United Healthcare Commercial |
$24.88
|
|
|
MUPIROCIN 2 % TOP OINT
|
Facility
OP
|
$31.57
|
|
|
Service Code
|
NDC 51672131200
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.42 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Aetna Medicare |
$10.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.46
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Centivo All Commercial |
$16.10
|
| Rate for Payer: Cigna All Commercial |
$27.24
|
| Rate for Payer: CORVEL All Commercial |
$29.36
|
| Rate for Payer: Coventry All Commercial |
$27.78
|
| Rate for Payer: Encore All Commercial |
$29.06
|
| Rate for Payer: Frontpath All Commercial |
$29.04
|
| Rate for Payer: Humana ChoiceCare |
$27.27
|
| Rate for Payer: Humana Medicare |
$16.10
|
| Rate for Payer: Lucent All Commercial |
$16.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.41
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$23.68
|
| Rate for Payer: PHP All Commercial |
$23.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.31
|
| Rate for Payer: Sagamore Health Network All Products |
$24.37
|
| Rate for Payer: Signature Care EPO |
$26.20
|
| Rate for Payer: Signature Care PPO |
$27.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.83
|
| Rate for Payer: United Healthcare Commercial |
$24.88
|
| Rate for Payer: United Healthcare Medicare |
$10.42
|
|
|
MUPIROCIN CALCIUM 2 % TOP CREA
|
Facility
OP
|
$1,225.73
|
|
|
Service Code
|
NDC 68462056417
|
| Hospital Charge Code |
22251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$404.49 |
| Max. Negotiated Rate |
$1,139.92 |
| Rate for Payer: Aetna Commercial |
$1,034.51
|
| Rate for Payer: Aetna Medicare |
$404.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$404.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$703.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$766.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$465.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$444.94
|
| Rate for Payer: Cash Price |
$759.95
|
| Rate for Payer: Centivo All Commercial |
$625.12
|
| Rate for Payer: Cigna All Commercial |
$1,057.80
|
| Rate for Payer: CORVEL All Commercial |
$1,139.92
|
| Rate for Payer: Coventry All Commercial |
$1,078.64
|
| Rate for Payer: Encore All Commercial |
$1,128.28
|
| Rate for Payer: Frontpath All Commercial |
$1,127.67
|
| Rate for Payer: Humana ChoiceCare |
$1,058.66
|
| Rate for Payer: Humana Medicare |
$625.12
|
| Rate for Payer: Lucent All Commercial |
$625.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,103.15
|
| Rate for Payer: PHCS All Commercial |
$919.29
|
| Rate for Payer: PHP All Commercial |
$929.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$478.03
|
| Rate for Payer: Sagamore Health Network All Products |
$946.26
|
| Rate for Payer: Signature Care EPO |
$1,017.35
|
| Rate for Payer: Signature Care PPO |
$1,078.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,041.87
|
| Rate for Payer: United Healthcare Commercial |
$965.87
|
| Rate for Payer: United Healthcare Medicare |
$404.49
|
|
|
MUPIROCIN CALCIUM 2 % TOP CREA
|
Facility
IP
|
$1,225.73
|
|
|
Service Code
|
NDC 68462056417
|
| Hospital Charge Code |
22251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$919.29 |
| Max. Negotiated Rate |
$1,139.92 |
| Rate for Payer: Aetna Commercial |
$1,059.03
|
| Rate for Payer: Cash Price |
$759.95
|
| Rate for Payer: Cigna All Commercial |
$1,057.80
|
| Rate for Payer: CORVEL All Commercial |
$1,139.92
|
| Rate for Payer: Coventry All Commercial |
$1,078.64
|
| Rate for Payer: Encore All Commercial |
$1,128.28
|
| Rate for Payer: Frontpath All Commercial |
$1,127.67
|
| Rate for Payer: Humana ChoiceCare |
$1,058.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,103.15
|
| Rate for Payer: PHCS All Commercial |
$919.29
|
| Rate for Payer: PHP All Commercial |
$929.59
|
| Rate for Payer: Sagamore Health Network All Products |
$946.26
|
| Rate for Payer: Signature Care EPO |
$1,017.35
|
| Rate for Payer: Signature Care PPO |
$1,078.64
|
| Rate for Payer: United Healthcare Commercial |
$965.87
|
|
|
MVI, ADULT NO.4, VIT K, 1 OF 2 3,300 UNIT- 150 MCG/5 ML IV SOLN
|
Facility
IP
|
$33.71
|
|
|
Service Code
|
NDC 54643786208
|
| Hospital Charge Code |
182456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.12
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
|
|
MVI, ADULT NO.4, VIT K, 1 OF 2 3,300 UNIT- 150 MCG/5 ML IV SOLN
|
Facility
OP
|
$33.71
|
|
|
Service Code
|
NDC 54643786208
|
| Hospital Charge Code |
182456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.23
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Centivo All Commercial |
$17.19
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Humana Medicare |
$17.19
|
| Rate for Payer: Lucent All Commercial |
$17.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.14
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.65
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
|
|
MVI, ADULT NO.4, VIT K, 2 OF 2 600 MCG-60 MCG- 5 MCG/5 ML IV SOLN
|
Facility
IP
|
$33.71
|
|
|
Service Code
|
NDC 54643786209
|
| Hospital Charge Code |
182457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.12
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
|
