|
BETHANECHOL CHLORIDE 5 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00832051000
|
| Hospital Charge Code |
1045
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
Biopsy or excision of lymph node(s); open, deep axillary node(s)
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 38525
|
| Hospital Charge Code |
CPT-38525
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
Biopsy or excision of lymph node(s); open, deep cervical node(s)
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 38510
|
| Hospital Charge Code |
CPT-38510
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
|
Facility
OP
|
$8,683.74
|
|
|
Service Code
|
CPT 38531
|
| Hospital Charge Code |
CPT-38531
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,683.74 |
| Max. Negotiated Rate |
$8,683.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8,683.74
|
| Rate for Payer: Managed Health Services Medicaid |
$8,683.74
|
| Rate for Payer: MDWise Medicaid |
$8,683.74
|
|
|
BISACODYL 10 MG RECT SUPP
|
Facility
OP
|
$1.81
|
|
|
Service Code
|
NDC 00574705012
|
| Hospital Charge Code |
1080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Aetna Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Centivo All Commercial |
$0.92
|
| 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 |
$0.92
|
| Rate for Payer: Lucent All Commercial |
$0.92
|
| 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 |
$0.60
|
|
|
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 |
$1.12
|
| 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/Exchange |
$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 |
$0.08
|
| 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 |
$0.11
|
| 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
OP
|
$6.94
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$6.45 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Centivo All Commercial |
$3.54
|
| Rate for Payer: Cigna All Commercial |
$5.99
|
| Rate for Payer: CORVEL All Commercial |
$6.45
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.39
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Humana Medicare |
$3.54
|
| Rate for Payer: Lucent All Commercial |
$3.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.71
|
| Rate for Payer: Sagamore Health Network All Products |
$5.36
|
| Rate for Payer: Signature Care EPO |
$5.76
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.90
|
| Rate for Payer: United Healthcare Commercial |
$5.47
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
OP
|
$6.94
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$6.45 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Centivo All Commercial |
$3.54
|
| Rate for Payer: Cigna All Commercial |
$5.99
|
| Rate for Payer: CORVEL All Commercial |
$6.45
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.39
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Humana Medicare |
$3.54
|
| Rate for Payer: Lucent All Commercial |
$3.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.71
|
| Rate for Payer: Sagamore Health Network All Products |
$5.36
|
| Rate for Payer: Signature Care EPO |
$5.76
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.90
|
| Rate for Payer: United Healthcare Commercial |
$5.47
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
IP
|
$6.94
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$6.45 |
| Rate for Payer: Aetna Commercial |
$5.99
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Cigna All Commercial |
$5.99
|
| Rate for Payer: CORVEL All Commercial |
$6.45
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.39
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Sagamore Health Network All Products |
$5.36
|
| Rate for Payer: Signature Care EPO |
$5.76
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: United Healthcare Commercial |
$5.47
|
|
|
BISOPROLOL FUMARATE 5 MG ORAL TAB
|
Facility
IP
|
$6.94
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$6.45 |
| Rate for Payer: Aetna Commercial |
$5.99
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Cigna All Commercial |
$5.99
|
| Rate for Payer: CORVEL All Commercial |
$6.45
|
| Rate for Payer: Coventry All Commercial |
$6.10
|
| Rate for Payer: Encore All Commercial |
$6.39
|
| Rate for Payer: Frontpath All Commercial |
$6.38
|
| Rate for Payer: Humana ChoiceCare |
$5.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.24
|
| Rate for Payer: PHCS All Commercial |
$5.20
|
| Rate for Payer: PHP All Commercial |
$5.26
|
| Rate for Payer: Sagamore Health Network All Products |
$5.36
|
| Rate for Payer: Signature Care EPO |
$5.76
|
| Rate for Payer: Signature Care PPO |
$6.10
|
| Rate for Payer: United Healthcare Commercial |
$5.47
|
|
|
Blepharoplasty, upper eyelid; with excessive skin weighting down lid
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 15823
|
| Hospital Charge Code |
CPT-15823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
BREXANOLONE 5 MG/ML IV SOLN
|
Facility
OP
|
$26,075.00
|
|
|
Service Code
|
HCPCS J1632
|
| Hospital Charge Code |
188512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.23 |
| Max. Negotiated Rate |
$24,249.75 |
| Rate for Payer: Aetna Commercial |
$22,007.30
|
| Rate for Payer: Aetna Medicare |
$8,604.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,604.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14,974.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,299.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$78.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9,895.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,465.22
|
| Rate for Payer: Cash Price |
$16,166.50
|
| Rate for Payer: Cash Price |
$16,166.50
|
| Rate for Payer: Centivo All Commercial |
$13,298.25
|
| Rate for Payer: Cigna All Commercial |
$22,502.72
|
| Rate for Payer: CORVEL All Commercial |
$24,249.75
|
| Rate for Payer: Coventry All Commercial |
$22,946.00
|
| Rate for Payer: Encore All Commercial |
$24,002.04
|
| Rate for Payer: Frontpath All Commercial |
$23,989.00
|
| Rate for Payer: Humana ChoiceCare |
$22,520.98
|
| Rate for Payer: Humana Medicare |
$13,298.25
|
| Rate for Payer: Lucent All Commercial |
$13,298.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,467.50
|
| Rate for Payer: Managed Health Services Medicaid |
$78.23
|
| Rate for Payer: MDWise Medicaid |
$78.23
|
| Rate for Payer: PHCS All Commercial |
$19,556.25
|
| Rate for Payer: PHP All Commercial |
$19,775.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,169.25
|
| Rate for Payer: Sagamore Health Network All Products |
$20,129.90
|
| Rate for Payer: Signature Care EPO |
$21,642.25
|
| Rate for Payer: Signature Care PPO |
$22,946.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22,163.75
|
| Rate for Payer: United Healthcare Commercial |
$20,547.10
|
| Rate for Payer: United Healthcare Medicare |
$8,604.75
|
|
|
BREXANOLONE 5 MG/ML IV SOLN
|
Facility
IP
|
$26,075.00
|
|
|
Service Code
|
HCPCS J1632
|
| Hospital Charge Code |
188512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19,556.25 |
| Max. Negotiated Rate |
$24,249.75 |
| Rate for Payer: Aetna Commercial |
$22,528.80
|
| Rate for Payer: Cash Price |
$16,166.50
|
| Rate for Payer: Cigna All Commercial |
$22,502.72
|
| Rate for Payer: CORVEL All Commercial |
$24,249.75
|
| Rate for Payer: Coventry All Commercial |
$22,946.00
|
| Rate for Payer: Encore All Commercial |
$24,002.04
|
| Rate for Payer: Frontpath All Commercial |
$23,989.00
|
| Rate for Payer: Humana ChoiceCare |
$22,520.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,467.50
|
| Rate for Payer: PHCS All Commercial |
$19,556.25
|
| Rate for Payer: PHP All Commercial |
$19,775.28
|
| Rate for Payer: Sagamore Health Network All Products |
$20,129.90
|
| Rate for Payer: Signature Care EPO |
$21,642.25
|
| Rate for Payer: Signature Care PPO |
$22,946.00
|
| Rate for Payer: United Healthcare Commercial |
$20,547.10
|
|
|
BRIMONIDINE 0.2 % OPHT DROP
|
Facility
IP
|
$20.51
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
17881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.38 |
| Max. Negotiated Rate |
$19.07 |
| Rate for Payer: Aetna Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Cigna All Commercial |
$17.70
|
| Rate for Payer: CORVEL All Commercial |
$19.07
|
| Rate for Payer: Coventry All Commercial |
$18.05
|
| Rate for Payer: Encore All Commercial |
$18.88
|
| Rate for Payer: Frontpath All Commercial |
$18.87
|
| Rate for Payer: Humana ChoiceCare |
$17.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.46
|
| Rate for Payer: PHCS All Commercial |
$15.38
|
| Rate for Payer: PHP All Commercial |
$15.55
|
| Rate for Payer: Sagamore Health Network All Products |
$15.83
|
| Rate for Payer: Signature Care EPO |
$17.02
|
| Rate for Payer: Signature Care PPO |
$18.05
|
| Rate for Payer: United Healthcare Commercial |
$16.16
|
|
|
BRIMONIDINE 0.2 % OPHT DROP
|
Facility
OP
|
$20.51
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
17881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$17.31
|
| Rate for Payer: Aetna Medicare |
$6.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.45
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Centivo All Commercial |
$10.46
|
| Rate for Payer: Cigna All Commercial |
$17.70
|
| Rate for Payer: CORVEL All Commercial |
$19.07
|
| Rate for Payer: Coventry All Commercial |
$18.05
|
| Rate for Payer: Encore All Commercial |
$18.88
|
| Rate for Payer: Frontpath All Commercial |
$18.87
|
| Rate for Payer: Humana ChoiceCare |
$17.71
|
| Rate for Payer: Humana Medicare |
$10.46
|
| Rate for Payer: Lucent All Commercial |
$10.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.46
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$15.38
|
| Rate for Payer: PHP All Commercial |
$15.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.00
|
| Rate for Payer: Sagamore Health Network All Products |
$15.83
|
| Rate for Payer: Signature Care EPO |
$17.02
|
| Rate for Payer: Signature Care PPO |
$18.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$16.16
|
| Rate for Payer: United Healthcare Medicare |
$6.77
|
|
|
BUDESONIDE 0.25 MG/2 ML INHL NBSP
|
Facility
IP
|
$13.08
|
|
|
Service Code
|
NDC 00093681573
|
| Hospital Charge Code |
28774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Aetna Commercial |
$11.30
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Cigna All Commercial |
$11.28
|
| Rate for Payer: CORVEL All Commercial |
$12.16
|
| Rate for Payer: Coventry All Commercial |
$11.51
|
| Rate for Payer: Encore All Commercial |
$12.04
|
| Rate for Payer: Frontpath All Commercial |
$12.03
|
| Rate for Payer: Humana ChoiceCare |
$11.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.77
|
| Rate for Payer: PHCS All Commercial |
$9.81
|
| Rate for Payer: PHP All Commercial |
$9.92
|
| Rate for Payer: Sagamore Health Network All Products |
$10.09
|
| Rate for Payer: Signature Care EPO |
$10.85
|
| Rate for Payer: Signature Care PPO |
$11.51
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
|
|
BUDESONIDE 0.25 MG/2 ML INHL NBSP
|
Facility
OP
|
$13.08
|
|
|
Service Code
|
NDC 00093681573
|
| Hospital Charge Code |
28774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$11.04
|
| Rate for Payer: Aetna Medicare |
$4.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.17
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.75
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Centivo All Commercial |
$6.67
|
| Rate for Payer: Cigna All Commercial |
$11.28
|
| Rate for Payer: CORVEL All Commercial |
$12.16
|
| Rate for Payer: Coventry All Commercial |
$11.51
|
| Rate for Payer: Encore All Commercial |
$12.04
|
| Rate for Payer: Frontpath All Commercial |
$12.03
|
| Rate for Payer: Humana ChoiceCare |
$11.29
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Lucent All Commercial |
$6.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.77
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$9.81
|
| Rate for Payer: PHP All Commercial |
$9.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.10
|
| Rate for Payer: Sagamore Health Network All Products |
$10.09
|
| Rate for Payer: Signature Care EPO |
$10.85
|
| Rate for Payer: Signature Care PPO |
$11.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.11
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
| Rate for Payer: United Healthcare Medicare |
$4.32
|
|
|
BUDESONIDE 0.5 MG/2 ML INHL NBSP
|
Facility
OP
|
$20.99
|
|
|
Service Code
|
NDC 00093681655
|
| Hospital Charge Code |
28775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Aetna Medicare |
$6.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.62
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Centivo All Commercial |
$10.70
|
| Rate for Payer: Cigna All Commercial |
$18.11
|
| Rate for Payer: CORVEL All Commercial |
$19.52
|
| Rate for Payer: Coventry All Commercial |
$18.47
|
| Rate for Payer: Encore All Commercial |
$19.32
|
| Rate for Payer: Frontpath All Commercial |
$19.31
|
| Rate for Payer: Humana ChoiceCare |
$18.13
|
| Rate for Payer: Humana Medicare |
$10.70
|
| Rate for Payer: Lucent All Commercial |
$10.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.89
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$15.74
|
| Rate for Payer: PHP All Commercial |
$15.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.18
|
| Rate for Payer: Sagamore Health Network All Products |
$16.20
|
| Rate for Payer: Signature Care EPO |
$17.42
|
| Rate for Payer: Signature Care PPO |
$18.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.84
|
| Rate for Payer: United Healthcare Commercial |
$16.54
|
| Rate for Payer: United Healthcare Medicare |
$6.93
|
|
|
BUDESONIDE 0.5 MG/2 ML INHL NBSP
|
Facility
IP
|
$20.99
|
|
|
Service Code
|
NDC 00093681655
|
| Hospital Charge Code |
28775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.74 |
| Max. Negotiated Rate |
$19.52 |
| Rate for Payer: Aetna Commercial |
$18.13
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cigna All Commercial |
$18.11
|
| Rate for Payer: CORVEL All Commercial |
$19.52
|
| Rate for Payer: Coventry All Commercial |
$18.47
|
| Rate for Payer: Encore All Commercial |
$19.32
|
| Rate for Payer: Frontpath All Commercial |
$19.31
|
| Rate for Payer: Humana ChoiceCare |
$18.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.89
|
| Rate for Payer: PHCS All Commercial |
$15.74
|
| Rate for Payer: PHP All Commercial |
$15.92
|
| Rate for Payer: Sagamore Health Network All Products |
$16.20
|
| Rate for Payer: Signature Care EPO |
$17.42
|
| Rate for Payer: Signature Care PPO |
$18.47
|
| Rate for Payer: United Healthcare Commercial |
$16.54
|
|
|
BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION INHL HFAA
|
Facility
IP
|
$144.68
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
81454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.51 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna Commercial |
$125.00
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cigna All Commercial |
$124.85
|
| Rate for Payer: CORVEL All Commercial |
$134.55
|
| Rate for Payer: Coventry All Commercial |
$127.31
|
| Rate for Payer: Encore All Commercial |
$133.17
|
| Rate for Payer: Frontpath All Commercial |
$133.10
|
| Rate for Payer: Humana ChoiceCare |
$124.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$130.21
|
| Rate for Payer: PHCS All Commercial |
$108.51
|
| Rate for Payer: PHP All Commercial |
$109.72
|
| Rate for Payer: Sagamore Health Network All Products |
$111.69
|
| Rate for Payer: Signature Care EPO |
$120.08
|
| Rate for Payer: Signature Care PPO |
$127.31
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
|
|
BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION INHL HFAA
|
Facility
OP
|
$144.68
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
81454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.74 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna Commercial |
$122.11
|
| Rate for Payer: Aetna Medicare |
$47.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$83.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$90.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.52
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Centivo All Commercial |
$73.78
|
| Rate for Payer: Cigna All Commercial |
$124.85
|
| Rate for Payer: CORVEL All Commercial |
$134.55
|
| Rate for Payer: Coventry All Commercial |
$127.31
|
| Rate for Payer: Encore All Commercial |
$133.17
|
| Rate for Payer: Frontpath All Commercial |
$133.10
|
| Rate for Payer: Humana ChoiceCare |
$124.96
|
| Rate for Payer: Humana Medicare |
$73.78
|
| Rate for Payer: Lucent All Commercial |
$73.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$130.21
|
| Rate for Payer: PHCS All Commercial |
$108.51
|
| Rate for Payer: PHP All Commercial |
$109.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.42
|
| Rate for Payer: Sagamore Health Network All Products |
$111.69
|
| Rate for Payer: Signature Care EPO |
$120.08
|
| Rate for Payer: Signature Care PPO |
$127.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$122.97
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
| Rate for Payer: United Healthcare Medicare |
$47.74
|
|
|
BUDESONIDE-FORMOTEROL 80-4.5 MCG/ACTUATION INHL HFAA
|
Facility
OP
|
$144.68
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.74 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna Commercial |
$122.11
|
| Rate for Payer: Aetna Medicare |
$47.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$83.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$90.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.52
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Centivo All Commercial |
$73.78
|
| Rate for Payer: Cigna All Commercial |
$124.86
|
| Rate for Payer: CORVEL All Commercial |
$134.55
|
| Rate for Payer: Coventry All Commercial |
$127.31
|
| Rate for Payer: Encore All Commercial |
$133.17
|
| Rate for Payer: Frontpath All Commercial |
$133.10
|
| Rate for Payer: Humana ChoiceCare |
$124.96
|
| Rate for Payer: Humana Medicare |
$73.78
|
| Rate for Payer: Lucent All Commercial |
$73.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$130.21
|
| Rate for Payer: PHCS All Commercial |
$108.51
|
| Rate for Payer: PHP All Commercial |
$109.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.42
|
| Rate for Payer: Sagamore Health Network All Products |
$111.69
|
| Rate for Payer: Signature Care EPO |
$120.08
|
| Rate for Payer: Signature Care PPO |
$127.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$122.97
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
| Rate for Payer: United Healthcare Medicare |
$47.74
|
|
|
BUDESONIDE-FORMOTEROL 80-4.5 MCG/ACTUATION INHL HFAA
|
Facility
IP
|
$144.68
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.51 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna Commercial |
$125.00
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cigna All Commercial |
$124.86
|
| Rate for Payer: CORVEL All Commercial |
$134.55
|
| Rate for Payer: Coventry All Commercial |
$127.31
|
| Rate for Payer: Encore All Commercial |
$133.17
|
| Rate for Payer: Frontpath All Commercial |
$133.10
|
| Rate for Payer: Humana ChoiceCare |
$124.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$130.21
|
| Rate for Payer: PHCS All Commercial |
$108.51
|
| Rate for Payer: PHP All Commercial |
$109.72
|
| Rate for Payer: Sagamore Health Network All Products |
$111.69
|
| Rate for Payer: Signature Care EPO |
$120.08
|
| Rate for Payer: Signature Care PPO |
$127.31
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
|
