|
BIPOLAR DISORDERS
|
Facility
|
IP
|
$4,495.69
|
|
|
Service Code
|
APR-DRG 7533
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,495.69 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BIPOLAR DISORDERS
|
Facility
|
IP
|
$7,824.23
|
|
|
Service Code
|
APR-DRG 7534
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$7,824.23 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BISACODYL 10 MG RECT SUPP
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 00574705012
|
| Hospital Charge Code |
1080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.56
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.67
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.63
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.40
|
| Rate for Payer: Signature Care EPO |
$1.50
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
BISACODYL 10 MG RECT SUPP
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 00574705012
|
| Hospital Charge Code |
1080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.56
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.67
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.63
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.37
|
| Rate for Payer: Sagamore Health Network All Products |
$1.40
|
| Rate for Payer: Signature Care EPO |
$1.50
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
BISACODYL 5 MG ORAL TBEC
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 00904640761
|
| Hospital Charge Code |
1079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Aetna Medicare |
$0.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Centivo All Commercial |
$0.11
|
| Rate for Payer: Cigna All Commercial |
$0.18
|
| Rate for Payer: CORVEL All Commercial |
$0.20
|
| Rate for Payer: Coventry All Commercial |
$0.18
|
| Rate for Payer: Encore All Commercial |
$0.19
|
| Rate for Payer: Frontpath All Commercial |
$0.19
|
| Rate for Payer: Humana ChoiceCare |
$0.18
|
| Rate for Payer: Humana Medicare |
$0.07
|
| Rate for Payer: Lucent All Commercial |
$0.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.19
|
| Rate for Payer: PHCS All Commercial |
$0.16
|
| Rate for Payer: PHP All Commercial |
$0.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.08
|
| Rate for Payer: Sagamore Health Network All Products |
$0.16
|
| Rate for Payer: Signature Care EPO |
$0.17
|
| Rate for Payer: Signature Care PPO |
$0.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
|
|
BISACODYL 5 MG ORAL TBEC
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 00904640761
|
| Hospital Charge Code |
1079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna All Commercial |
$0.18
|
| Rate for Payer: CORVEL All Commercial |
$0.20
|
| Rate for Payer: Coventry All Commercial |
$0.18
|
| Rate for Payer: Encore All Commercial |
$0.19
|
| Rate for Payer: Frontpath All Commercial |
$0.19
|
| Rate for Payer: Humana ChoiceCare |
$0.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.19
|
| Rate for Payer: PHCS All Commercial |
$0.16
|
| Rate for Payer: PHP All Commercial |
$0.16
|
| Rate for Payer: Sagamore Health Network All Products |
$0.16
|
| Rate for Payer: Signature Care EPO |
$0.17
|
| Rate for Payer: Signature Care PPO |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
|
IP
|
$6.97
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$6.02
|
| Rate for Payer: Cash Price |
$4.18
|
| Rate for Payer: Cigna All Commercial |
$6.01
|
| Rate for Payer: CORVEL All Commercial |
$6.48
|
| Rate for Payer: Coventry All Commercial |
$6.13
|
| Rate for Payer: Encore All Commercial |
$6.41
|
| Rate for Payer: Frontpath All Commercial |
$6.41
|
| Rate for Payer: Humana ChoiceCare |
$6.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.27
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Sagamore Health Network All Products |
$5.38
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.13
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
|
OP
|
$6.97
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$5.88
|
| Rate for Payer: Aetna Medicare |
$2.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.45
|
| Rate for Payer: Cash Price |
$4.18
|
| Rate for Payer: Centivo All Commercial |
$3.79
|
| Rate for Payer: Cigna All Commercial |
$6.01
|
| Rate for Payer: CORVEL All Commercial |
$6.48
|
| Rate for Payer: Coventry All Commercial |
$6.13
|
| Rate for Payer: Encore All Commercial |
$6.41
|
| Rate for Payer: Frontpath All Commercial |
$6.41
|
| Rate for Payer: Humana ChoiceCare |
$6.02
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Lucent All Commercial |
$3.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.27
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.72
|
| Rate for Payer: Sagamore Health Network All Products |
$5.38
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.92
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
| Rate for Payer: United Healthcare Medicare |
$2.23
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
|
OP
|
$6.97
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$5.88
|
| Rate for Payer: Aetna Medicare |
$2.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.45
|
| Rate for Payer: Cash Price |
$4.18
|
| Rate for Payer: Centivo All Commercial |
$3.79
|
| Rate for Payer: Cigna All Commercial |
$6.01
|
| Rate for Payer: CORVEL All Commercial |
$6.48
|
| Rate for Payer: Coventry All Commercial |
$6.13
|
| Rate for Payer: Encore All Commercial |
$6.41
|
| Rate for Payer: Frontpath All Commercial |
$6.41
|
| Rate for Payer: Humana ChoiceCare |
$6.02
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Lucent All Commercial |
$3.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.27
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.72
|
| Rate for Payer: Sagamore Health Network All Products |
$5.38
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.92
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
| Rate for Payer: United Healthcare Medicare |
$2.23
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
|
IP
|
$6.97
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$6.02
|
| Rate for Payer: Cash Price |
$4.18
|
| Rate for Payer: Cigna All Commercial |
$6.01
|
| Rate for Payer: CORVEL All Commercial |
$6.48
|
| Rate for Payer: Coventry All Commercial |
$6.13
|
| Rate for Payer: Encore All Commercial |
$6.41
|
| Rate for Payer: Frontpath All Commercial |
$6.41
|
| Rate for Payer: Humana ChoiceCare |
$6.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.27
|
| Rate for Payer: PHCS All Commercial |
$5.22
|
| Rate for Payer: PHP All Commercial |
$5.28
|
| Rate for Payer: Sagamore Health Network All Products |
$5.38
|
| Rate for Payer: Signature Care EPO |
$5.78
|
| Rate for Payer: Signature Care PPO |
$6.13
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
|
|
BRIMONIDINE 0.2 % OPHT DROP
|
Facility
|
OP
|
$20.30
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
17881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Aetna Medicare |
$6.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.15
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Centivo All Commercial |
$11.04
|
| Rate for Payer: Cigna All Commercial |
$17.52
|
| Rate for Payer: CORVEL All Commercial |
$18.88
|
| Rate for Payer: Coventry All Commercial |
$17.86
|
| Rate for Payer: Encore All Commercial |
$18.69
|
| Rate for Payer: Frontpath All Commercial |
$18.68
|
| Rate for Payer: Humana ChoiceCare |
$17.53
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Lucent All Commercial |
$11.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.27
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$15.22
|
| Rate for Payer: PHP All Commercial |
$15.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.92
|
| Rate for Payer: Sagamore Health Network All Products |
$15.67
|
| Rate for Payer: Signature Care EPO |
$16.85
|
| Rate for Payer: Signature Care PPO |
$17.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.25
|
| Rate for Payer: United Healthcare Commercial |
$16.00
|
| Rate for Payer: United Healthcare Medicare |
$6.50
|
|
|
BRIMONIDINE 0.2 % OPHT DROP
|
Facility
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
17881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.22 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Aetna Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cigna All Commercial |
$17.52
|
| Rate for Payer: CORVEL All Commercial |
$18.88
|
| Rate for Payer: Coventry All Commercial |
$17.86
|
| Rate for Payer: Encore All Commercial |
$18.69
|
| Rate for Payer: Frontpath All Commercial |
$18.68
|
| Rate for Payer: Humana ChoiceCare |
$17.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.27
|
| Rate for Payer: PHCS All Commercial |
$15.22
|
| Rate for Payer: PHP All Commercial |
$15.40
|
| Rate for Payer: Sagamore Health Network All Products |
$15.67
|
| Rate for Payer: Signature Care EPO |
$16.85
|
| Rate for Payer: Signature Care PPO |
$17.86
|
| Rate for Payer: United Healthcare Commercial |
$16.00
|
|
|
BUDESONIDE 0.25 MG/2 ML INHL NBSP
|
Facility
|
OP
|
$14.04
|
|
|
Service Code
|
NDC 00093681573
|
| Hospital Charge Code |
28774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$13.06 |
| Rate for Payer: Aetna Commercial |
$11.85
|
| Rate for Payer: Aetna Medicare |
$4.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.94
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Centivo All Commercial |
$7.64
|
| Rate for Payer: Cigna All Commercial |
$12.12
|
| Rate for Payer: CORVEL All Commercial |
$13.06
|
| Rate for Payer: Coventry All Commercial |
$12.36
|
| Rate for Payer: Encore All Commercial |
$12.93
|
| Rate for Payer: Frontpath All Commercial |
$12.92
|
| Rate for Payer: Humana ChoiceCare |
$12.13
|
| Rate for Payer: Humana Medicare |
$4.49
|
| Rate for Payer: Lucent All Commercial |
$7.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$10.53
|
| Rate for Payer: PHP All Commercial |
$10.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.48
|
| Rate for Payer: Sagamore Health Network All Products |
$10.84
|
| Rate for Payer: Signature Care EPO |
$11.65
|
| Rate for Payer: Signature Care PPO |
$12.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.94
|
| Rate for Payer: United Healthcare Commercial |
$11.07
|
| Rate for Payer: United Healthcare Medicare |
$4.49
|
|
|
BUDESONIDE 0.25 MG/2 ML INHL NBSP
|
Facility
|
IP
|
$14.04
|
|
|
Service Code
|
NDC 00093681573
|
| Hospital Charge Code |
28774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$13.06 |
| Rate for Payer: Aetna Commercial |
$12.13
|
| Rate for Payer: Cash Price |
$8.43
|
| Rate for Payer: Cigna All Commercial |
$12.12
|
| Rate for Payer: CORVEL All Commercial |
$13.06
|
| Rate for Payer: Coventry All Commercial |
$12.36
|
| Rate for Payer: Encore All Commercial |
$12.93
|
| Rate for Payer: Frontpath All Commercial |
$12.92
|
| Rate for Payer: Humana ChoiceCare |
$12.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.64
|
| Rate for Payer: PHCS All Commercial |
$10.53
|
| Rate for Payer: PHP All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$10.84
|
| Rate for Payer: Signature Care EPO |
$11.65
|
| Rate for Payer: Signature Care PPO |
$12.36
|
| Rate for Payer: United Healthcare Commercial |
$11.07
|
|
|
BUDESONIDE 0.5 MG/2 ML INHL NBSP
|
Facility
|
OP
|
$20.75
|
|
|
Service Code
|
NDC 00093681655
|
| Hospital Charge Code |
28775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.51
|
| Rate for Payer: Aetna Medicare |
$6.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.30
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Centivo All Commercial |
$11.29
|
| Rate for Payer: Cigna All Commercial |
$17.91
|
| Rate for Payer: CORVEL All Commercial |
$19.30
|
| Rate for Payer: Coventry All Commercial |
$18.26
|
| Rate for Payer: Encore All Commercial |
$19.10
|
| Rate for Payer: Frontpath All Commercial |
$19.09
|
| Rate for Payer: Humana ChoiceCare |
$17.92
|
| Rate for Payer: Humana Medicare |
$6.64
|
| Rate for Payer: Lucent All Commercial |
$11.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.67
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$15.56
|
| Rate for Payer: PHP All Commercial |
$15.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.09
|
| Rate for Payer: Sagamore Health Network All Products |
$16.02
|
| Rate for Payer: Signature Care EPO |
$17.22
|
| Rate for Payer: Signature Care PPO |
$18.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.64
|
| Rate for Payer: United Healthcare Commercial |
$16.35
|
| Rate for Payer: United Healthcare Medicare |
$6.64
|
|
|
BUDESONIDE 0.5 MG/2 ML INHL NBSP
|
Facility
|
IP
|
$20.75
|
|
|
Service Code
|
NDC 00093681655
|
| Hospital Charge Code |
28775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.93
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cigna All Commercial |
$17.91
|
| Rate for Payer: CORVEL All Commercial |
$19.30
|
| Rate for Payer: Coventry All Commercial |
$18.26
|
| Rate for Payer: Encore All Commercial |
$19.10
|
| Rate for Payer: Frontpath All Commercial |
$19.09
|
| Rate for Payer: Humana ChoiceCare |
$17.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.67
|
| Rate for Payer: PHCS All Commercial |
$15.56
|
| Rate for Payer: PHP All Commercial |
$15.74
|
| Rate for Payer: Sagamore Health Network All Products |
$16.02
|
| Rate for Payer: Signature Care EPO |
$17.22
|
| Rate for Payer: Signature Care PPO |
$18.26
|
| Rate for Payer: United Healthcare Commercial |
$16.35
|
|
|
BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
NDC 00186037028
|
| Hospital Charge Code |
81454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$132.99 |
| Rate for Payer: Aetna Commercial |
$123.55
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna All Commercial |
$123.40
|
| Rate for Payer: CORVEL All Commercial |
$132.99
|
| Rate for Payer: Coventry All Commercial |
$125.84
|
| Rate for Payer: Encore All Commercial |
$131.63
|
| Rate for Payer: Frontpath All Commercial |
$131.56
|
| Rate for Payer: Humana ChoiceCare |
$123.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.70
|
| Rate for Payer: PHCS All Commercial |
$107.25
|
| Rate for Payer: PHP All Commercial |
$108.45
|
| Rate for Payer: Sagamore Health Network All Products |
$110.39
|
| Rate for Payer: Signature Care EPO |
$118.69
|
| Rate for Payer: Signature Care PPO |
$125.84
|
| Rate for Payer: United Healthcare Commercial |
$112.68
|
|
|
BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
NDC 00186037028
|
| Hospital Charge Code |
81454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.33 |
| Max. Negotiated Rate |
$132.99 |
| Rate for Payer: Aetna Commercial |
$120.69
|
| Rate for Payer: Aetna Medicare |
$45.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.33
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Centivo All Commercial |
$77.79
|
| Rate for Payer: Cigna All Commercial |
$123.40
|
| Rate for Payer: CORVEL All Commercial |
$132.99
|
| Rate for Payer: Coventry All Commercial |
$125.84
|
| Rate for Payer: Encore All Commercial |
$131.63
|
| Rate for Payer: Frontpath All Commercial |
$131.56
|
| Rate for Payer: Humana ChoiceCare |
$123.50
|
| Rate for Payer: Humana Medicare |
$45.76
|
| Rate for Payer: Lucent All Commercial |
$77.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.70
|
| Rate for Payer: PHCS All Commercial |
$107.25
|
| Rate for Payer: PHP All Commercial |
$108.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.77
|
| Rate for Payer: Sagamore Health Network All Products |
$110.39
|
| Rate for Payer: Signature Care EPO |
$118.69
|
| Rate for Payer: Signature Care PPO |
$125.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.55
|
| Rate for Payer: United Healthcare Commercial |
$112.68
|
| Rate for Payer: United Healthcare Medicare |
$45.76
|
|
|
BUDESONIDE-FORMOTEROL 80-4.5 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
NDC 00186037228
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.33 |
| Max. Negotiated Rate |
$132.99 |
| Rate for Payer: Aetna Commercial |
$120.69
|
| Rate for Payer: Aetna Medicare |
$45.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.34
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Centivo All Commercial |
$77.79
|
| Rate for Payer: Cigna All Commercial |
$123.41
|
| Rate for Payer: CORVEL All Commercial |
$132.99
|
| Rate for Payer: Coventry All Commercial |
$125.84
|
| Rate for Payer: Encore All Commercial |
$131.63
|
| Rate for Payer: Frontpath All Commercial |
$131.56
|
| Rate for Payer: Humana ChoiceCare |
$123.51
|
| Rate for Payer: Humana Medicare |
$45.76
|
| Rate for Payer: Lucent All Commercial |
$77.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.70
|
| Rate for Payer: PHCS All Commercial |
$107.25
|
| Rate for Payer: PHP All Commercial |
$108.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.77
|
| Rate for Payer: Sagamore Health Network All Products |
$110.40
|
| Rate for Payer: Signature Care EPO |
$118.69
|
| Rate for Payer: Signature Care PPO |
$125.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.55
|
| Rate for Payer: United Healthcare Commercial |
$112.69
|
| Rate for Payer: United Healthcare Medicare |
$45.76
|
|
|
BUDESONIDE-FORMOTEROL 80-4.5 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
NDC 00186037228
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$132.99 |
| Rate for Payer: Aetna Commercial |
$123.55
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna All Commercial |
$123.41
|
| Rate for Payer: CORVEL All Commercial |
$132.99
|
| Rate for Payer: Coventry All Commercial |
$125.84
|
| Rate for Payer: Encore All Commercial |
$131.63
|
| Rate for Payer: Frontpath All Commercial |
$131.56
|
| Rate for Payer: Humana ChoiceCare |
$123.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.70
|
| Rate for Payer: PHCS All Commercial |
$107.25
|
| Rate for Payer: PHP All Commercial |
$108.45
|
| Rate for Payer: Sagamore Health Network All Products |
$110.40
|
| Rate for Payer: Signature Care EPO |
$118.69
|
| Rate for Payer: Signature Care PPO |
$125.84
|
| Rate for Payer: United Healthcare Commercial |
$112.69
|
|
|
BUMETANIDE 0.25 MG/ML INJ SOLN
|
Facility
|
IP
|
$19.63
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
9308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Aetna Commercial |
$16.96
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna All Commercial |
$16.94
|
| Rate for Payer: CORVEL All Commercial |
$18.25
|
| Rate for Payer: Coventry All Commercial |
$17.27
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.72
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Sagamore Health Network All Products |
$15.15
|
| Rate for Payer: Signature Care EPO |
$16.29
|
| Rate for Payer: Signature Care PPO |
$17.27
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
|
|
BUMETANIDE 0.25 MG/ML INJ SOLN
|
Facility
|
OP
|
$19.63
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
9308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Medicare |
$6.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.91
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Centivo All Commercial |
$10.68
|
| Rate for Payer: Cigna All Commercial |
$16.94
|
| Rate for Payer: CORVEL All Commercial |
$18.25
|
| Rate for Payer: Coventry All Commercial |
$17.27
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.95
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Lucent All Commercial |
$10.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.72
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.65
|
| Rate for Payer: Sagamore Health Network All Products |
$15.15
|
| Rate for Payer: Signature Care EPO |
$16.29
|
| Rate for Payer: Signature Care PPO |
$17.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.68
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$6.28
|
|
|
BUMETANIDE 1 MG ORAL TAB
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 60687038401
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Aetna Commercial |
$5.74
|
| Rate for Payer: Aetna Medicare |
$2.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.39
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Centivo All Commercial |
$3.70
|
| Rate for Payer: Cigna All Commercial |
$5.87
|
| Rate for Payer: CORVEL All Commercial |
$6.32
|
| Rate for Payer: Coventry All Commercial |
$5.98
|
| Rate for Payer: Encore All Commercial |
$6.26
|
| Rate for Payer: Frontpath All Commercial |
$6.25
|
| Rate for Payer: Humana ChoiceCare |
$5.87
|
| Rate for Payer: Humana Medicare |
$2.18
|
| Rate for Payer: Lucent All Commercial |
$3.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.12
|
| Rate for Payer: PHCS All Commercial |
$5.10
|
| Rate for Payer: PHP All Commercial |
$5.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.65
|
| Rate for Payer: Sagamore Health Network All Products |
$5.25
|
| Rate for Payer: Signature Care EPO |
$5.64
|
| Rate for Payer: Signature Care PPO |
$5.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.78
|
| Rate for Payer: United Healthcare Commercial |
$5.36
|
| Rate for Payer: United Healthcare Medicare |
$2.18
|
|
|
BUMETANIDE 1 MG ORAL TAB
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 60687038401
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Aetna Commercial |
$5.87
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Cigna All Commercial |
$5.87
|
| Rate for Payer: CORVEL All Commercial |
$6.32
|
| Rate for Payer: Coventry All Commercial |
$5.98
|
| Rate for Payer: Encore All Commercial |
$6.26
|
| Rate for Payer: Frontpath All Commercial |
$6.25
|
| Rate for Payer: Humana ChoiceCare |
$5.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.12
|
| Rate for Payer: PHCS All Commercial |
$5.10
|
| Rate for Payer: PHP All Commercial |
$5.15
|
| Rate for Payer: Sagamore Health Network All Products |
$5.25
|
| Rate for Payer: Signature Care EPO |
$5.64
|
| Rate for Payer: Signature Care PPO |
$5.98
|
| Rate for Payer: United Healthcare Commercial |
$5.36
|
|
|
BUPIVACAINE-DEXTROSE-WATER(PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
9316
|
|
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 |
$10.80
|
| 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
|
|
