|
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU
|
Facility
|
IP
|
$2.98
|
|
|
Service Code
|
NDC 00487990401
|
| Hospital Charge Code |
31578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna All Commercial |
$2.57
|
| Rate for Payer: CORVEL All Commercial |
$2.77
|
| Rate for Payer: Coventry All Commercial |
$2.62
|
| Rate for Payer: Encore All Commercial |
$2.74
|
| Rate for Payer: Frontpath All Commercial |
$2.74
|
| Rate for Payer: Humana ChoiceCare |
$2.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.68
|
| Rate for Payer: PHCS All Commercial |
$2.24
|
| Rate for Payer: PHP All Commercial |
$2.26
|
| Rate for Payer: Sagamore Health Network All Products |
$2.30
|
| Rate for Payer: Signature Care EPO |
$2.48
|
| Rate for Payer: Signature Care PPO |
$2.62
|
| Rate for Payer: United Healthcare Commercial |
$2.35
|
|
|
ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INHL NEBU
|
Facility
|
OP
|
$1.83
|
|
|
Service Code
|
NDC 00487950101
|
| Hospital Charge Code |
250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.54
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| 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 |
$1.10
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Centivo All Commercial |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.58
|
| Rate for Payer: CORVEL All Commercial |
$1.70
|
| Rate for Payer: Coventry All Commercial |
$1.61
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.68
|
| Rate for Payer: Humana ChoiceCare |
$1.58
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.37
|
| Rate for Payer: PHP All Commercial |
$1.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.52
|
| Rate for Payer: Signature Care PPO |
$1.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INHL NEBU
|
Facility
|
IP
|
$1.83
|
|
|
Service Code
|
NDC 00487950101
|
| Hospital Charge Code |
250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna All Commercial |
$1.58
|
| Rate for Payer: CORVEL All Commercial |
$1.70
|
| Rate for Payer: Coventry All Commercial |
$1.61
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.68
|
| Rate for Payer: Humana ChoiceCare |
$1.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.37
|
| Rate for Payer: PHP All Commercial |
$1.39
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.52
|
| Rate for Payer: Signature Care PPO |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
|
OP
|
$182.11
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.45 |
| Max. Negotiated Rate |
$169.36 |
| Rate for Payer: Aetna Commercial |
$153.70
|
| Rate for Payer: Aetna Medicare |
$58.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$56.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$104.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$113.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$67.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$64.10
|
| Rate for Payer: Cash Price |
$109.26
|
| Rate for Payer: Centivo All Commercial |
$99.07
|
| Rate for Payer: Cigna All Commercial |
$157.16
|
| Rate for Payer: CORVEL All Commercial |
$169.36
|
| Rate for Payer: Coventry All Commercial |
$160.25
|
| Rate for Payer: Encore All Commercial |
$167.63
|
| Rate for Payer: Frontpath All Commercial |
$167.54
|
| Rate for Payer: Humana ChoiceCare |
$157.28
|
| Rate for Payer: Humana Medicare |
$58.27
|
| Rate for Payer: Lucent All Commercial |
$99.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$163.89
|
| Rate for Payer: PHCS All Commercial |
$136.58
|
| Rate for Payer: PHP All Commercial |
$138.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$71.02
|
| Rate for Payer: Sagamore Health Network All Products |
$140.59
|
| Rate for Payer: Signature Care EPO |
$151.15
|
| Rate for Payer: Signature Care PPO |
$160.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$154.79
|
| Rate for Payer: United Healthcare Commercial |
$143.50
|
| Rate for Payer: United Healthcare Medicare |
$58.27
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
NDC 70752102
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna Commercial |
$1.62
|
| Rate for Payer: Aetna Medicare |
$0.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Centivo All Commercial |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.66
|
| Rate for Payer: CORVEL All Commercial |
$1.79
|
| Rate for Payer: Coventry All Commercial |
$1.69
|
| Rate for Payer: Encore All Commercial |
$1.77
|
| Rate for Payer: Frontpath All Commercial |
$1.77
|
| Rate for Payer: Humana ChoiceCare |
$1.66
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Lucent All Commercial |
$1.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.73
|
| Rate for Payer: PHCS All Commercial |
$1.44
|
| Rate for Payer: PHP All Commercial |
$1.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.75
|
| Rate for Payer: Sagamore Health Network All Products |
$1.49
|
| Rate for Payer: Signature Care EPO |
$1.60
|
| Rate for Payer: Signature Care PPO |
$1.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
NDC 70752102
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna Commercial |
$1.66
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna All Commercial |
$1.66
|
| Rate for Payer: CORVEL All Commercial |
$1.79
|
| Rate for Payer: Coventry All Commercial |
$1.69
|
| Rate for Payer: Encore All Commercial |
$1.77
|
| Rate for Payer: Frontpath All Commercial |
$1.77
|
| Rate for Payer: Humana ChoiceCare |
$1.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.73
|
| Rate for Payer: PHCS All Commercial |
$1.44
|
| Rate for Payer: PHP All Commercial |
$1.46
|
| Rate for Payer: Sagamore Health Network All Products |
$1.49
|
| Rate for Payer: Signature Care EPO |
$1.60
|
| Rate for Payer: Signature Care PPO |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
|
|
ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRP
|
Facility
|
IP
|
$182.11
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.58 |
| Max. Negotiated Rate |
$169.36 |
| Rate for Payer: Aetna Commercial |
$157.34
|
| Rate for Payer: Cash Price |
$109.26
|
| Rate for Payer: Cigna All Commercial |
$157.16
|
| Rate for Payer: CORVEL All Commercial |
$169.36
|
| Rate for Payer: Coventry All Commercial |
$160.25
|
| Rate for Payer: Encore All Commercial |
$167.63
|
| Rate for Payer: Frontpath All Commercial |
$167.54
|
| Rate for Payer: Humana ChoiceCare |
$157.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$163.89
|
| Rate for Payer: PHCS All Commercial |
$136.58
|
| Rate for Payer: PHP All Commercial |
$138.11
|
| Rate for Payer: Sagamore Health Network All Products |
$140.59
|
| Rate for Payer: Signature Care EPO |
$151.15
|
| Rate for Payer: Signature Care PPO |
$160.25
|
| Rate for Payer: United Healthcare Commercial |
$143.50
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$74.56
|
|
|
Service Code
|
NDC 00173068224
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.92 |
| Max. Negotiated Rate |
$69.34 |
| Rate for Payer: Aetna Commercial |
$64.42
|
| Rate for Payer: Cash Price |
$44.74
|
| Rate for Payer: Cigna All Commercial |
$64.35
|
| Rate for Payer: CORVEL All Commercial |
$69.34
|
| Rate for Payer: Coventry All Commercial |
$65.62
|
| Rate for Payer: Encore All Commercial |
$68.64
|
| Rate for Payer: Frontpath All Commercial |
$68.60
|
| Rate for Payer: Humana ChoiceCare |
$64.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.11
|
| Rate for Payer: PHCS All Commercial |
$55.92
|
| Rate for Payer: PHP All Commercial |
$56.55
|
| Rate for Payer: Sagamore Health Network All Products |
$57.56
|
| Rate for Payer: Signature Care EPO |
$61.89
|
| Rate for Payer: Signature Care PPO |
$65.62
|
| Rate for Payer: United Healthcare Commercial |
$58.76
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$100.37
|
|
|
Service Code
|
NDC 00093317431
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.28 |
| Max. Negotiated Rate |
$93.34 |
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cigna All Commercial |
$86.62
|
| Rate for Payer: CORVEL All Commercial |
$93.34
|
| Rate for Payer: Coventry All Commercial |
$88.32
|
| Rate for Payer: Encore All Commercial |
$92.39
|
| Rate for Payer: Frontpath All Commercial |
$92.34
|
| Rate for Payer: Humana ChoiceCare |
$86.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.33
|
| Rate for Payer: PHCS All Commercial |
$75.28
|
| Rate for Payer: PHP All Commercial |
$76.12
|
| Rate for Payer: Sagamore Health Network All Products |
$77.48
|
| Rate for Payer: Signature Care EPO |
$83.31
|
| Rate for Payer: Signature Care PPO |
$88.32
|
| Rate for Payer: United Healthcare Commercial |
$79.09
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$101.95
|
|
|
Service Code
|
NDC 66993001968
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.61 |
| Max. Negotiated Rate |
$94.82 |
| Rate for Payer: Aetna Commercial |
$86.05
|
| Rate for Payer: Aetna Medicare |
$32.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$58.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.89
|
| Rate for Payer: Cash Price |
$61.17
|
| Rate for Payer: Centivo All Commercial |
$55.46
|
| Rate for Payer: Cigna All Commercial |
$87.98
|
| Rate for Payer: CORVEL All Commercial |
$94.82
|
| Rate for Payer: Coventry All Commercial |
$89.72
|
| Rate for Payer: Encore All Commercial |
$93.85
|
| Rate for Payer: Frontpath All Commercial |
$93.80
|
| Rate for Payer: Humana ChoiceCare |
$88.06
|
| Rate for Payer: Humana Medicare |
$32.62
|
| Rate for Payer: Lucent All Commercial |
$55.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.76
|
| Rate for Payer: PHCS All Commercial |
$76.46
|
| Rate for Payer: PHP All Commercial |
$77.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.76
|
| Rate for Payer: Sagamore Health Network All Products |
$78.71
|
| Rate for Payer: Signature Care EPO |
$84.62
|
| Rate for Payer: Signature Care PPO |
$89.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.66
|
| Rate for Payer: United Healthcare Commercial |
$80.34
|
| Rate for Payer: United Healthcare Medicare |
$32.62
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$74.56
|
|
|
Service Code
|
NDC 00173068224
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.11 |
| Max. Negotiated Rate |
$69.34 |
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: Aetna Medicare |
$23.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$42.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.25
|
| Rate for Payer: Cash Price |
$44.74
|
| Rate for Payer: Centivo All Commercial |
$40.56
|
| Rate for Payer: Cigna All Commercial |
$64.35
|
| Rate for Payer: CORVEL All Commercial |
$69.34
|
| Rate for Payer: Coventry All Commercial |
$65.62
|
| Rate for Payer: Encore All Commercial |
$68.64
|
| Rate for Payer: Frontpath All Commercial |
$68.60
|
| Rate for Payer: Humana ChoiceCare |
$64.40
|
| Rate for Payer: Humana Medicare |
$23.86
|
| Rate for Payer: Lucent All Commercial |
$40.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.11
|
| Rate for Payer: PHCS All Commercial |
$55.92
|
| Rate for Payer: PHP All Commercial |
$56.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.08
|
| Rate for Payer: Sagamore Health Network All Products |
$57.56
|
| Rate for Payer: Signature Care EPO |
$61.89
|
| Rate for Payer: Signature Care PPO |
$65.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$63.38
|
| Rate for Payer: United Healthcare Commercial |
$58.76
|
| Rate for Payer: United Healthcare Medicare |
$23.86
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$101.95
|
|
|
Service Code
|
NDC 66993001968
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.46 |
| Max. Negotiated Rate |
$94.82 |
| Rate for Payer: Aetna Commercial |
$88.09
|
| Rate for Payer: Cash Price |
$61.17
|
| Rate for Payer: Cigna All Commercial |
$87.98
|
| Rate for Payer: CORVEL All Commercial |
$94.82
|
| Rate for Payer: Coventry All Commercial |
$89.72
|
| Rate for Payer: Encore All Commercial |
$93.85
|
| Rate for Payer: Frontpath All Commercial |
$93.80
|
| Rate for Payer: Humana ChoiceCare |
$88.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.76
|
| Rate for Payer: PHCS All Commercial |
$76.46
|
| Rate for Payer: PHP All Commercial |
$77.32
|
| Rate for Payer: Sagamore Health Network All Products |
$78.71
|
| Rate for Payer: Signature Care EPO |
$84.62
|
| Rate for Payer: Signature Care PPO |
$89.72
|
| Rate for Payer: United Healthcare Commercial |
$80.34
|
|
|
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$100.37
|
|
|
Service Code
|
NDC 00093317431
|
| Hospital Charge Code |
17837
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.11 |
| Max. Negotiated Rate |
$93.34 |
| Rate for Payer: Aetna Commercial |
$84.71
|
| Rate for Payer: Aetna Medicare |
$32.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$57.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.33
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Centivo All Commercial |
$54.60
|
| Rate for Payer: Cigna All Commercial |
$86.62
|
| Rate for Payer: CORVEL All Commercial |
$93.34
|
| Rate for Payer: Coventry All Commercial |
$88.32
|
| Rate for Payer: Encore All Commercial |
$92.39
|
| Rate for Payer: Frontpath All Commercial |
$92.34
|
| Rate for Payer: Humana ChoiceCare |
$86.69
|
| Rate for Payer: Humana Medicare |
$32.12
|
| Rate for Payer: Lucent All Commercial |
$54.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.33
|
| Rate for Payer: PHCS All Commercial |
$75.28
|
| Rate for Payer: PHP All Commercial |
$76.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.14
|
| Rate for Payer: Sagamore Health Network All Products |
$77.48
|
| Rate for Payer: Signature Care EPO |
$83.31
|
| Rate for Payer: Signature Care PPO |
$88.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.31
|
| Rate for Payer: United Healthcare Commercial |
$79.09
|
| Rate for Payer: United Healthcare Medicare |
$32.12
|
|
|
ALIROCUMAB 150 MG/ML SUBQ PNIJ
|
Facility
|
IP
|
$1,222.43
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
173401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$916.82 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,056.18
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
|
|
ALIROCUMAB 150 MG/ML SUBQ PNIJ
|
Facility
|
OP
|
$1,222.43
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
173401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$378.95 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,031.73
|
| Rate for Payer: Aetna Medicare |
$391.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$378.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$702.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$764.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$449.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$430.29
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Centivo All Commercial |
$665.00
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Humana Medicare |
$391.18
|
| Rate for Payer: Lucent All Commercial |
$665.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$476.75
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,039.06
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
| Rate for Payer: United Healthcare Medicare |
$391.18
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
|
IP
|
$1,222.43
|
|
|
Service Code
|
NDC 61755002001
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$916.82 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,056.18
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
|
OP
|
$1,222.43
|
|
|
Service Code
|
NDC 61755002001
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,031.73
|
| Rate for Payer: Aetna Medicare |
$391.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$378.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$702.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$764.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$449.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$430.29
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Centivo All Commercial |
$665.00
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Humana Medicare |
$391.18
|
| Rate for Payer: Lucent All Commercial |
$665.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$476.75
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,039.06
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
| Rate for Payer: United Healthcare Medicare |
$391.18
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
|
IP
|
$1,222.43
|
|
|
Service Code
|
NDC 61755002002
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$916.82 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,056.18
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
|
|
ALIROCUMAB 75 MG/ML SUBQ PNIJ
|
Facility
|
OP
|
$1,222.43
|
|
|
Service Code
|
NDC 61755002002
|
| Hospital Charge Code |
173399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,136.86 |
| Rate for Payer: Aetna Commercial |
$1,031.73
|
| Rate for Payer: Aetna Medicare |
$391.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$378.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$702.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$764.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$449.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$430.29
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Cash Price |
$733.46
|
| Rate for Payer: Centivo All Commercial |
$665.00
|
| Rate for Payer: Cigna All Commercial |
$1,054.95
|
| Rate for Payer: CORVEL All Commercial |
$1,136.86
|
| Rate for Payer: Coventry All Commercial |
$1,075.73
|
| Rate for Payer: Encore All Commercial |
$1,125.24
|
| Rate for Payer: Frontpath All Commercial |
$1,124.63
|
| Rate for Payer: Humana ChoiceCare |
$1,055.81
|
| Rate for Payer: Humana Medicare |
$391.18
|
| Rate for Payer: Lucent All Commercial |
$665.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,100.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$916.82
|
| Rate for Payer: PHP All Commercial |
$927.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$476.75
|
| Rate for Payer: Sagamore Health Network All Products |
$943.71
|
| Rate for Payer: Signature Care EPO |
$1,014.61
|
| Rate for Payer: Signature Care PPO |
$1,075.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,039.06
|
| Rate for Payer: United Healthcare Commercial |
$963.27
|
| Rate for Payer: United Healthcare Medicare |
$391.18
|
|
|
ALISKIREN 150 MG ORAL TAB
|
Facility
|
OP
|
$28.86
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
78653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.36
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Centivo All Commercial |
$15.70
|
| Rate for Payer: Cigna All Commercial |
$24.91
|
| Rate for Payer: CORVEL All Commercial |
$26.84
|
| Rate for Payer: Coventry All Commercial |
$25.40
|
| Rate for Payer: Encore All Commercial |
$26.57
|
| Rate for Payer: Frontpath All Commercial |
$26.55
|
| Rate for Payer: Humana ChoiceCare |
$24.93
|
| Rate for Payer: Humana Medicare |
$9.24
|
| Rate for Payer: Lucent All Commercial |
$15.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.97
|
| Rate for Payer: PHCS All Commercial |
$21.65
|
| Rate for Payer: PHP All Commercial |
$21.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.26
|
| Rate for Payer: Sagamore Health Network All Products |
$22.28
|
| Rate for Payer: Signature Care EPO |
$23.95
|
| Rate for Payer: Signature Care PPO |
$25.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.53
|
| Rate for Payer: United Healthcare Commercial |
$22.74
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
|
|
ALISKIREN 150 MG ORAL TAB
|
Facility
|
IP
|
$28.86
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
78653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.65 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.94
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cigna All Commercial |
$24.91
|
| Rate for Payer: CORVEL All Commercial |
$26.84
|
| Rate for Payer: Coventry All Commercial |
$25.40
|
| Rate for Payer: Encore All Commercial |
$26.57
|
| Rate for Payer: Frontpath All Commercial |
$26.55
|
| Rate for Payer: Humana ChoiceCare |
$24.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.97
|
| Rate for Payer: PHCS All Commercial |
$21.65
|
| Rate for Payer: PHP All Commercial |
$21.89
|
| Rate for Payer: Sagamore Health Network All Products |
$22.28
|
| Rate for Payer: Signature Care EPO |
$23.95
|
| Rate for Payer: Signature Care PPO |
$25.40
|
| Rate for Payer: United Healthcare Commercial |
$22.74
|
|
|
ALLERGY SERUM - PATIENT OWN SUPPLY
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 9999990002
|
| Hospital Charge Code |
152266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
ALLERGY SERUM - VIAL 1
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 99999990053
|
| Hospital Charge Code |
800679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
ALLERGY SERUM - VIAL 2
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 99999990054
|
| Hospital Charge Code |
800680
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
ALLERGY SERUM - VIAL 3
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 99999990055
|
| Hospital Charge Code |
800681
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
