|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP
|
Facility
IP
|
$781.25
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$585.94 |
| Max. Negotiated Rate |
$726.56 |
| Rate for Payer: Aetna Commercial |
$675.00
|
| Rate for Payer: Cash Price |
$484.38
|
| Rate for Payer: Cigna All Commercial |
$674.22
|
| Rate for Payer: CORVEL All Commercial |
$726.56
|
| Rate for Payer: Coventry All Commercial |
$687.50
|
| Rate for Payer: Encore All Commercial |
$719.14
|
| Rate for Payer: Frontpath All Commercial |
$718.75
|
| Rate for Payer: Humana ChoiceCare |
$674.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.12
|
| Rate for Payer: PHCS All Commercial |
$585.94
|
| Rate for Payer: PHP All Commercial |
$592.50
|
| Rate for Payer: Sagamore Health Network All Products |
$603.12
|
| Rate for Payer: Signature Care EPO |
$648.44
|
| Rate for Payer: Signature Care PPO |
$687.50
|
| Rate for Payer: United Healthcare Commercial |
$615.62
|
|
|
PERMETHRIN 1 % TOP LIQD
|
Facility
IP
|
$59.06
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$54.92 |
| Rate for Payer: Aetna Commercial |
$51.03
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Cigna All Commercial |
$50.97
|
| Rate for Payer: CORVEL All Commercial |
$54.92
|
| Rate for Payer: Coventry All Commercial |
$51.97
|
| Rate for Payer: Encore All Commercial |
$54.36
|
| Rate for Payer: Frontpath All Commercial |
$54.33
|
| Rate for Payer: Humana ChoiceCare |
$51.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.15
|
| Rate for Payer: PHCS All Commercial |
$44.29
|
| Rate for Payer: PHP All Commercial |
$44.79
|
| Rate for Payer: Sagamore Health Network All Products |
$45.59
|
| Rate for Payer: Signature Care EPO |
$49.02
|
| Rate for Payer: Signature Care PPO |
$51.97
|
| Rate for Payer: United Healthcare Commercial |
$46.54
|
|
|
PERMETHRIN 1 % TOP LIQD
|
Facility
OP
|
$59.06
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.49 |
| Max. Negotiated Rate |
$54.92 |
| Rate for Payer: Aetna Commercial |
$49.85
|
| Rate for Payer: Aetna Medicare |
$19.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$33.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.44
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Centivo All Commercial |
$30.12
|
| Rate for Payer: Cigna All Commercial |
$50.97
|
| Rate for Payer: CORVEL All Commercial |
$54.92
|
| Rate for Payer: Coventry All Commercial |
$51.97
|
| Rate for Payer: Encore All Commercial |
$54.36
|
| Rate for Payer: Frontpath All Commercial |
$54.33
|
| Rate for Payer: Humana ChoiceCare |
$51.01
|
| Rate for Payer: Humana Medicare |
$30.12
|
| Rate for Payer: Lucent All Commercial |
$30.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.15
|
| Rate for Payer: PHCS All Commercial |
$44.29
|
| Rate for Payer: PHP All Commercial |
$44.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.03
|
| Rate for Payer: Sagamore Health Network All Products |
$45.59
|
| Rate for Payer: Signature Care EPO |
$49.02
|
| Rate for Payer: Signature Care PPO |
$51.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.20
|
| Rate for Payer: United Healthcare Commercial |
$46.54
|
| Rate for Payer: United Healthcare Medicare |
$19.49
|
|
|
PHENAZOPYRIDINE 100 MG ORAL TAB
|
Facility
OP
|
$1.49
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna Commercial |
$1.26
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.76
|
| Rate for Payer: Cigna All Commercial |
$1.29
|
| Rate for Payer: CORVEL All Commercial |
$1.39
|
| Rate for Payer: Coventry All Commercial |
$1.31
|
| Rate for Payer: Encore All Commercial |
$1.37
|
| Rate for Payer: Frontpath All Commercial |
$1.37
|
| Rate for Payer: Humana ChoiceCare |
$1.29
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Lucent All Commercial |
$0.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.34
|
| Rate for Payer: PHCS All Commercial |
$1.12
|
| Rate for Payer: PHP All Commercial |
$1.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.15
|
| Rate for Payer: Signature Care EPO |
$1.24
|
| Rate for Payer: Signature Care PPO |
$1.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
PHENAZOPYRIDINE 100 MG ORAL TAB
|
Facility
IP
|
$1.49
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.29
|
| Rate for Payer: CORVEL All Commercial |
$1.39
|
| Rate for Payer: Coventry All Commercial |
$1.31
|
| Rate for Payer: Encore All Commercial |
$1.37
|
| Rate for Payer: Frontpath All Commercial |
$1.37
|
| Rate for Payer: Humana ChoiceCare |
$1.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.34
|
| Rate for Payer: PHCS All Commercial |
$1.12
|
| Rate for Payer: PHP All Commercial |
$1.13
|
| Rate for Payer: Sagamore Health Network All Products |
$1.15
|
| Rate for Payer: Signature Care EPO |
$1.24
|
| Rate for Payer: Signature Care PPO |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
|
|
PHENOBARBITAL 32.4 MG ORAL TAB
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
PHENOBARBITAL 32.4 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLN
|
Facility
IP
|
$107.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.25 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$92.44
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna All Commercial |
$92.34
|
| Rate for Payer: CORVEL All Commercial |
$99.51
|
| Rate for Payer: Coventry All Commercial |
$94.16
|
| Rate for Payer: Encore All Commercial |
$98.49
|
| Rate for Payer: Frontpath All Commercial |
$98.44
|
| Rate for Payer: Humana ChoiceCare |
$92.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.30
|
| Rate for Payer: PHCS All Commercial |
$80.25
|
| Rate for Payer: PHP All Commercial |
$81.15
|
| Rate for Payer: Sagamore Health Network All Products |
$82.60
|
| Rate for Payer: Signature Care EPO |
$88.81
|
| Rate for Payer: Signature Care PPO |
$94.16
|
| Rate for Payer: United Healthcare Commercial |
$84.31
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLN
|
Facility
OP
|
$107.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.31 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$90.30
|
| Rate for Payer: Aetna Medicare |
$35.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.84
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Centivo All Commercial |
$54.57
|
| Rate for Payer: Cigna All Commercial |
$92.34
|
| Rate for Payer: CORVEL All Commercial |
$99.51
|
| Rate for Payer: Coventry All Commercial |
$94.16
|
| Rate for Payer: Encore All Commercial |
$98.49
|
| Rate for Payer: Frontpath All Commercial |
$98.44
|
| Rate for Payer: Humana ChoiceCare |
$92.41
|
| Rate for Payer: Humana Medicare |
$54.57
|
| Rate for Payer: Lucent All Commercial |
$54.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.30
|
| Rate for Payer: PHCS All Commercial |
$80.25
|
| Rate for Payer: PHP All Commercial |
$81.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.73
|
| Rate for Payer: Sagamore Health Network All Products |
$82.60
|
| Rate for Payer: Signature Care EPO |
$88.81
|
| Rate for Payer: Signature Care PPO |
$94.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.95
|
| Rate for Payer: United Healthcare Commercial |
$84.31
|
| Rate for Payer: United Healthcare Medicare |
$35.31
|
|
|
PHENOL 1.4 % MM SPRA
|
Facility
OP
|
$13.58
|
|
|
Service Code
|
NDC 78112069480
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$12.63 |
| Rate for Payer: Aetna Commercial |
$11.46
|
| Rate for Payer: Aetna Medicare |
$4.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.93
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Centivo All Commercial |
$6.93
|
| Rate for Payer: Cigna All Commercial |
$11.72
|
| Rate for Payer: CORVEL All Commercial |
$12.63
|
| Rate for Payer: Coventry All Commercial |
$11.95
|
| Rate for Payer: Encore All Commercial |
$12.50
|
| Rate for Payer: Frontpath All Commercial |
$12.49
|
| Rate for Payer: Humana ChoiceCare |
$11.73
|
| Rate for Payer: Humana Medicare |
$6.93
|
| Rate for Payer: Lucent All Commercial |
$6.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.22
|
| Rate for Payer: PHCS All Commercial |
$10.18
|
| Rate for Payer: PHP All Commercial |
$10.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.30
|
| Rate for Payer: Sagamore Health Network All Products |
$10.48
|
| Rate for Payer: Signature Care EPO |
$11.27
|
| Rate for Payer: Signature Care PPO |
$11.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.54
|
| Rate for Payer: United Healthcare Commercial |
$10.70
|
| Rate for Payer: United Healthcare Medicare |
$4.48
|
|
|
PHENOL 1.4 % MM SPRA
|
Facility
IP
|
$13.58
|
|
|
Service Code
|
NDC 78112069480
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$12.63 |
| Rate for Payer: Aetna Commercial |
$11.73
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Cigna All Commercial |
$11.72
|
| Rate for Payer: CORVEL All Commercial |
$12.63
|
| Rate for Payer: Coventry All Commercial |
$11.95
|
| Rate for Payer: Encore All Commercial |
$12.50
|
| Rate for Payer: Frontpath All Commercial |
$12.49
|
| Rate for Payer: Humana ChoiceCare |
$11.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.22
|
| Rate for Payer: PHCS All Commercial |
$10.18
|
| Rate for Payer: PHP All Commercial |
$10.30
|
| Rate for Payer: Sagamore Health Network All Products |
$10.48
|
| Rate for Payer: Signature Care EPO |
$11.27
|
| Rate for Payer: Signature Care PPO |
$11.95
|
| Rate for Payer: United Healthcare Commercial |
$10.70
|
|
|
PHENTOLAMINE 5 MG INJ SOLR
|
Facility
OP
|
$1,766.00
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$438.90 |
| Max. Negotiated Rate |
$1,642.38 |
| Rate for Payer: Aetna Commercial |
$1,490.50
|
| Rate for Payer: Aetna Medicare |
$582.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$582.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,014.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,103.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$438.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$670.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$641.06
|
| Rate for Payer: Cash Price |
$1,094.92
|
| Rate for Payer: Cash Price |
$1,094.92
|
| Rate for Payer: Centivo All Commercial |
$900.66
|
| Rate for Payer: Cigna All Commercial |
$1,524.06
|
| Rate for Payer: CORVEL All Commercial |
$1,642.38
|
| Rate for Payer: Coventry All Commercial |
$1,554.08
|
| Rate for Payer: Encore All Commercial |
$1,625.60
|
| Rate for Payer: Frontpath All Commercial |
$1,624.72
|
| Rate for Payer: Humana ChoiceCare |
$1,525.29
|
| Rate for Payer: Humana Medicare |
$900.66
|
| Rate for Payer: Lucent All Commercial |
$900.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,589.40
|
| Rate for Payer: Managed Health Services Medicaid |
$438.90
|
| Rate for Payer: MDWise Medicaid |
$438.90
|
| Rate for Payer: PHCS All Commercial |
$1,324.50
|
| Rate for Payer: PHP All Commercial |
$1,339.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$688.74
|
| Rate for Payer: Sagamore Health Network All Products |
$1,363.35
|
| Rate for Payer: Signature Care EPO |
$1,465.78
|
| Rate for Payer: Signature Care PPO |
$1,554.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,501.10
|
| Rate for Payer: United Healthcare Commercial |
$1,391.61
|
| Rate for Payer: United Healthcare Medicare |
$582.78
|
|
|
PHENTOLAMINE 5 MG INJ SOLR
|
Facility
IP
|
$1,766.00
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,324.50 |
| Max. Negotiated Rate |
$1,642.38 |
| Rate for Payer: Aetna Commercial |
$1,525.82
|
| Rate for Payer: Cash Price |
$1,094.92
|
| Rate for Payer: Cigna All Commercial |
$1,524.06
|
| Rate for Payer: CORVEL All Commercial |
$1,642.38
|
| Rate for Payer: Coventry All Commercial |
$1,554.08
|
| Rate for Payer: Encore All Commercial |
$1,625.60
|
| Rate for Payer: Frontpath All Commercial |
$1,624.72
|
| Rate for Payer: Humana ChoiceCare |
$1,525.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,589.40
|
| Rate for Payer: PHCS All Commercial |
$1,324.50
|
| Rate for Payer: PHP All Commercial |
$1,339.33
|
| Rate for Payer: Sagamore Health Network All Products |
$1,363.35
|
| Rate for Payer: Signature Care EPO |
$1,465.78
|
| Rate for Payer: Signature Care PPO |
$1,554.08
|
| Rate for Payer: United Healthcare Commercial |
$1,391.61
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY
|
Facility
IP
|
$25.73
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$22.23
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Cigna All Commercial |
$22.20
|
| Rate for Payer: CORVEL All Commercial |
$23.92
|
| Rate for Payer: Coventry All Commercial |
$22.64
|
| Rate for Payer: Encore All Commercial |
$23.68
|
| Rate for Payer: Frontpath All Commercial |
$23.67
|
| Rate for Payer: Humana ChoiceCare |
$22.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.15
|
| Rate for Payer: PHCS All Commercial |
$19.29
|
| Rate for Payer: PHP All Commercial |
$19.51
|
| Rate for Payer: Sagamore Health Network All Products |
$19.86
|
| Rate for Payer: Signature Care EPO |
$21.35
|
| Rate for Payer: Signature Care PPO |
$22.64
|
| Rate for Payer: United Healthcare Commercial |
$20.27
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY
|
Facility
OP
|
$25.73
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$21.71
|
| Rate for Payer: Aetna Medicare |
$8.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.34
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Centivo All Commercial |
$13.12
|
| Rate for Payer: Cigna All Commercial |
$22.20
|
| Rate for Payer: CORVEL All Commercial |
$23.92
|
| Rate for Payer: Coventry All Commercial |
$22.64
|
| Rate for Payer: Encore All Commercial |
$23.68
|
| Rate for Payer: Frontpath All Commercial |
$23.67
|
| Rate for Payer: Humana ChoiceCare |
$22.22
|
| Rate for Payer: Humana Medicare |
$13.12
|
| Rate for Payer: Lucent All Commercial |
$13.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.15
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$19.29
|
| Rate for Payer: PHP All Commercial |
$19.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.03
|
| Rate for Payer: Sagamore Health Network All Products |
$19.86
|
| Rate for Payer: Signature Care EPO |
$21.35
|
| Rate for Payer: Signature Care PPO |
$22.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.87
|
| Rate for Payer: United Healthcare Commercial |
$20.27
|
| Rate for Payer: United Healthcare Medicare |
$8.49
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY FOR ENT USE (CAMERON)
|
Facility
OP
|
$94.08
|
|
|
Service Code
|
NDC 02250805
|
| Hospital Charge Code |
14010006244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$87.49 |
| Rate for Payer: Aetna Commercial |
$79.40
|
| Rate for Payer: Aetna Medicare |
$31.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$54.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$58.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.15
|
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: Centivo All Commercial |
$47.98
|
| Rate for Payer: Cigna All Commercial |
$81.19
|
| Rate for Payer: CORVEL All Commercial |
$87.49
|
| Rate for Payer: Coventry All Commercial |
$82.79
|
| Rate for Payer: Encore All Commercial |
$86.60
|
| Rate for Payer: Frontpath All Commercial |
$86.55
|
| Rate for Payer: Humana ChoiceCare |
$81.26
|
| Rate for Payer: Humana Medicare |
$47.98
|
| Rate for Payer: Lucent All Commercial |
$47.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$84.67
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$70.56
|
| Rate for Payer: PHP All Commercial |
$71.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$36.69
|
| Rate for Payer: Sagamore Health Network All Products |
$72.63
|
| Rate for Payer: Signature Care EPO |
$78.09
|
| Rate for Payer: Signature Care PPO |
$82.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$79.97
|
| Rate for Payer: United Healthcare Commercial |
$74.14
|
| Rate for Payer: United Healthcare Medicare |
$31.05
|
|
|
PHENYLEPHRINE HCL 0.5 % NASL SPRY FOR ENT USE (CAMERON)
|
Facility
IP
|
$94.08
|
|
|
Service Code
|
NDC 02250805
|
| Hospital Charge Code |
14010006244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$87.49 |
| Rate for Payer: Aetna Commercial |
$81.29
|
| Rate for Payer: Cash Price |
$58.33
|
| Rate for Payer: Cigna All Commercial |
$81.19
|
| Rate for Payer: CORVEL All Commercial |
$87.49
|
| Rate for Payer: Coventry All Commercial |
$82.79
|
| Rate for Payer: Encore All Commercial |
$86.60
|
| Rate for Payer: Frontpath All Commercial |
$86.55
|
| Rate for Payer: Humana ChoiceCare |
$81.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$84.67
|
| Rate for Payer: PHCS All Commercial |
$70.56
|
| Rate for Payer: PHP All Commercial |
$71.35
|
| Rate for Payer: Sagamore Health Network All Products |
$72.63
|
| Rate for Payer: Signature Care EPO |
$78.09
|
| Rate for Payer: Signature Care PPO |
$82.79
|
| Rate for Payer: United Healthcare Commercial |
$74.14
|
|
|
PHENYLEPHRINE HCL 10 MG/ML INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
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
|
|
|
PHENYLEPHRINE HCL 10 MG/ML INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
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
|
|
|
PHENYLEPHRINE HCL 2.5 % OPHT DROP
|
Facility
IP
|
$173.39
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.04 |
| Max. Negotiated Rate |
$161.25 |
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna All Commercial |
$149.64
|
| Rate for Payer: CORVEL All Commercial |
$161.25
|
| Rate for Payer: Coventry All Commercial |
$152.58
|
| Rate for Payer: Encore All Commercial |
$159.61
|
| Rate for Payer: Frontpath All Commercial |
$159.52
|
| Rate for Payer: Humana ChoiceCare |
$149.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$156.05
|
| Rate for Payer: PHCS All Commercial |
$130.04
|
| Rate for Payer: PHP All Commercial |
$131.50
|
| Rate for Payer: Sagamore Health Network All Products |
$133.86
|
| Rate for Payer: Signature Care EPO |
$143.91
|
| Rate for Payer: Signature Care PPO |
$152.58
|
| Rate for Payer: United Healthcare Commercial |
$136.63
|
|
|
PHENYLEPHRINE HCL 2.5 % OPHT DROP
|
Facility
OP
|
$173.39
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$161.25 |
| Rate for Payer: Aetna Commercial |
$146.34
|
| Rate for Payer: Aetna Medicare |
$57.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$99.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$108.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$65.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$62.94
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Centivo All Commercial |
$88.43
|
| Rate for Payer: Cigna All Commercial |
$149.64
|
| Rate for Payer: CORVEL All Commercial |
$161.25
|
| Rate for Payer: Coventry All Commercial |
$152.58
|
| Rate for Payer: Encore All Commercial |
$159.61
|
| Rate for Payer: Frontpath All Commercial |
$159.52
|
| Rate for Payer: Humana ChoiceCare |
$149.76
|
| Rate for Payer: Humana Medicare |
$88.43
|
| Rate for Payer: Lucent All Commercial |
$88.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$156.05
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$130.04
|
| Rate for Payer: PHP All Commercial |
$131.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$67.62
|
| Rate for Payer: Sagamore Health Network All Products |
$133.86
|
| Rate for Payer: Signature Care EPO |
$143.91
|
| Rate for Payer: Signature Care PPO |
$152.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$147.38
|
| Rate for Payer: United Healthcare Commercial |
$136.63
|
| Rate for Payer: United Healthcare Medicare |
$57.22
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SOLN
|
Facility
IP
|
$26.95
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
191797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$25.06 |
| Rate for Payer: Aetna Commercial |
$23.28
|
| Rate for Payer: Cash Price |
$16.71
|
| Rate for Payer: Cigna All Commercial |
$23.26
|
| Rate for Payer: CORVEL All Commercial |
$25.06
|
| Rate for Payer: Coventry All Commercial |
$23.72
|
| Rate for Payer: Encore All Commercial |
$24.81
|
| Rate for Payer: Frontpath All Commercial |
$24.79
|
| Rate for Payer: Humana ChoiceCare |
$23.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.26
|
| Rate for Payer: PHCS All Commercial |
$20.21
|
| Rate for Payer: PHP All Commercial |
$20.44
|
| Rate for Payer: Sagamore Health Network All Products |
$20.81
|
| Rate for Payer: Signature Care EPO |
$22.37
|
| Rate for Payer: Signature Care PPO |
$23.72
|
| Rate for Payer: United Healthcare Commercial |
$21.24
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SOLN
|
Facility
OP
|
$26.95
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
191797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$25.06 |
| Rate for Payer: Aetna Commercial |
$22.75
|
| Rate for Payer: Aetna Medicare |
$8.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.78
|
| Rate for Payer: Cash Price |
$16.71
|
| Rate for Payer: Centivo All Commercial |
$13.74
|
| Rate for Payer: Cigna All Commercial |
$23.26
|
| Rate for Payer: CORVEL All Commercial |
$25.06
|
| Rate for Payer: Coventry All Commercial |
$23.72
|
| Rate for Payer: Encore All Commercial |
$24.81
|
| Rate for Payer: Frontpath All Commercial |
$24.79
|
| Rate for Payer: Humana ChoiceCare |
$23.28
|
| Rate for Payer: Humana Medicare |
$13.74
|
| Rate for Payer: Lucent All Commercial |
$13.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.26
|
| Rate for Payer: PHCS All Commercial |
$20.21
|
| Rate for Payer: PHP All Commercial |
$20.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.51
|
| Rate for Payer: Sagamore Health Network All Products |
$20.81
|
| Rate for Payer: Signature Care EPO |
$22.37
|
| Rate for Payer: Signature Care PPO |
$23.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.91
|
| Rate for Payer: United Healthcare Commercial |
$21.24
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG
|
Facility
IP
|
$116.41
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
121306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.31 |
| Max. Negotiated Rate |
$108.26 |
| Rate for Payer: Aetna Commercial |
$100.58
|
| Rate for Payer: Cash Price |
$72.17
|
| Rate for Payer: Cigna All Commercial |
$100.46
|
| Rate for Payer: CORVEL All Commercial |
$108.26
|
| Rate for Payer: Coventry All Commercial |
$102.44
|
| Rate for Payer: Encore All Commercial |
$107.16
|
| Rate for Payer: Frontpath All Commercial |
$107.10
|
| Rate for Payer: Humana ChoiceCare |
$100.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.77
|
| Rate for Payer: PHCS All Commercial |
$87.31
|
| Rate for Payer: PHP All Commercial |
$88.29
|
| Rate for Payer: Sagamore Health Network All Products |
$89.87
|
| Rate for Payer: Signature Care EPO |
$96.62
|
| Rate for Payer: Signature Care PPO |
$102.44
|
| Rate for Payer: United Healthcare Commercial |
$91.73
|
|
|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG
|
Facility
OP
|
$116.41
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
121306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.42 |
| Max. Negotiated Rate |
$108.26 |
| Rate for Payer: Aetna Commercial |
$98.25
|
| Rate for Payer: Aetna Medicare |
$38.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$38.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$66.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.26
|
| Rate for Payer: Cash Price |
$72.17
|
| Rate for Payer: Centivo All Commercial |
$59.37
|
| Rate for Payer: Cigna All Commercial |
$100.46
|
| Rate for Payer: CORVEL All Commercial |
$108.26
|
| Rate for Payer: Coventry All Commercial |
$102.44
|
| Rate for Payer: Encore All Commercial |
$107.16
|
| Rate for Payer: Frontpath All Commercial |
$107.10
|
| Rate for Payer: Humana ChoiceCare |
$100.54
|
| Rate for Payer: Humana Medicare |
$59.37
|
| Rate for Payer: Lucent All Commercial |
$59.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.77
|
| Rate for Payer: PHCS All Commercial |
$87.31
|
| Rate for Payer: PHP All Commercial |
$88.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.40
|
| Rate for Payer: Sagamore Health Network All Products |
$89.87
|
| Rate for Payer: Signature Care EPO |
$96.62
|
| Rate for Payer: Signature Care PPO |
$102.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$91.73
|
| Rate for Payer: United Healthcare Medicare |
$38.42
|
|
