|
HYLAN G-F 20 48 MG/6 ML IATC SYRG
|
Facility
|
OP
|
$4,494.06
|
|
|
Service Code
|
HCPCS j7325
|
| Hospital Charge Code |
120298
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,393.16 |
| Max. Negotiated Rate |
$4,179.48 |
| Rate for Payer: Aetna Commercial |
$3,792.99
|
| Rate for Payer: Aetna Medicare |
$1,438.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,393.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,580.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,809.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,653.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,581.91
|
| Rate for Payer: Cash Price |
$2,696.44
|
| Rate for Payer: Centivo All Commercial |
$2,444.77
|
| Rate for Payer: Cigna All Commercial |
$3,878.38
|
| Rate for Payer: CORVEL All Commercial |
$4,179.48
|
| Rate for Payer: Coventry All Commercial |
$3,954.78
|
| Rate for Payer: Encore All Commercial |
$4,136.78
|
| Rate for Payer: Frontpath All Commercial |
$4,134.54
|
| Rate for Payer: Humana ChoiceCare |
$3,881.52
|
| Rate for Payer: Humana Medicare |
$1,438.10
|
| Rate for Payer: Lucent All Commercial |
$2,444.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,044.66
|
| Rate for Payer: PHCS All Commercial |
$3,370.55
|
| Rate for Payer: PHP All Commercial |
$3,408.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,752.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3,469.42
|
| Rate for Payer: Signature Care EPO |
$3,730.07
|
| Rate for Payer: Signature Care PPO |
$3,954.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,819.95
|
| Rate for Payer: United Healthcare Commercial |
$3,541.32
|
| Rate for Payer: United Healthcare Medicare |
$1,438.10
|
|
|
HYOSCYAMINE SULFATE 0.125 MG SL SUBL
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: 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: 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: United Healthcare Commercial |
$0.79
|
|
|
HYOSCYAMINE SULFATE 0.125 MG SL SUBL
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
IBANDRONATE 150 MG ORAL TAB
|
Facility
|
OP
|
$120.96
|
|
|
Service Code
|
NDC 55111057503
|
| Hospital Charge Code |
41063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$112.49 |
| Rate for Payer: Aetna Commercial |
$102.09
|
| Rate for Payer: Aetna Medicare |
$38.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$69.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.58
|
| Rate for Payer: Cash Price |
$72.58
|
| Rate for Payer: Centivo All Commercial |
$65.80
|
| Rate for Payer: Cigna All Commercial |
$104.39
|
| Rate for Payer: CORVEL All Commercial |
$112.49
|
| Rate for Payer: Coventry All Commercial |
$106.44
|
| Rate for Payer: Encore All Commercial |
$111.34
|
| Rate for Payer: Frontpath All Commercial |
$111.28
|
| Rate for Payer: Humana ChoiceCare |
$104.47
|
| Rate for Payer: Humana Medicare |
$38.71
|
| Rate for Payer: Lucent All Commercial |
$65.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.86
|
| Rate for Payer: PHCS All Commercial |
$90.72
|
| Rate for Payer: PHP All Commercial |
$91.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.17
|
| Rate for Payer: Sagamore Health Network All Products |
$93.38
|
| Rate for Payer: Signature Care EPO |
$100.40
|
| Rate for Payer: Signature Care PPO |
$106.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$102.82
|
| Rate for Payer: United Healthcare Commercial |
$95.32
|
| Rate for Payer: United Healthcare Medicare |
$38.71
|
|
|
IBANDRONATE 150 MG ORAL TAB
|
Facility
|
IP
|
$120.96
|
|
|
Service Code
|
NDC 55111057503
|
| Hospital Charge Code |
41063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.72 |
| Max. Negotiated Rate |
$112.49 |
| Rate for Payer: Aetna Commercial |
$104.51
|
| Rate for Payer: Cash Price |
$72.58
|
| Rate for Payer: Cigna All Commercial |
$104.39
|
| Rate for Payer: CORVEL All Commercial |
$112.49
|
| Rate for Payer: Coventry All Commercial |
$106.44
|
| Rate for Payer: Encore All Commercial |
$111.34
|
| Rate for Payer: Frontpath All Commercial |
$111.28
|
| Rate for Payer: Humana ChoiceCare |
$104.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.86
|
| Rate for Payer: PHCS All Commercial |
$90.72
|
| Rate for Payer: PHP All Commercial |
$91.74
|
| Rate for Payer: Sagamore Health Network All Products |
$93.38
|
| Rate for Payer: Signature Care EPO |
$100.40
|
| Rate for Payer: Signature Care PPO |
$106.44
|
| Rate for Payer: United Healthcare Commercial |
$95.32
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$59.64
|
|
|
Service Code
|
NDC 50580060121
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.73 |
| Max. Negotiated Rate |
$55.47 |
| Rate for Payer: Aetna Commercial |
$51.53
|
| Rate for Payer: Cash Price |
$35.78
|
| Rate for Payer: Cigna All Commercial |
$51.47
|
| Rate for Payer: CORVEL All Commercial |
$55.47
|
| Rate for Payer: Coventry All Commercial |
$52.48
|
| Rate for Payer: Encore All Commercial |
$54.90
|
| Rate for Payer: Frontpath All Commercial |
$54.87
|
| Rate for Payer: Humana ChoiceCare |
$51.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.68
|
| Rate for Payer: PHCS All Commercial |
$44.73
|
| Rate for Payer: PHP All Commercial |
$45.23
|
| Rate for Payer: Sagamore Health Network All Products |
$46.04
|
| Rate for Payer: Signature Care EPO |
$49.50
|
| Rate for Payer: Signature Care PPO |
$52.48
|
| Rate for Payer: United Healthcare Commercial |
$47.00
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$59.64
|
|
|
Service Code
|
NDC 50580060121
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$55.47 |
| Rate for Payer: Aetna Commercial |
$50.34
|
| Rate for Payer: Aetna Medicare |
$19.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$34.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.99
|
| Rate for Payer: Cash Price |
$35.78
|
| Rate for Payer: Centivo All Commercial |
$32.44
|
| Rate for Payer: Cigna All Commercial |
$51.47
|
| Rate for Payer: CORVEL All Commercial |
$55.47
|
| Rate for Payer: Coventry All Commercial |
$52.48
|
| Rate for Payer: Encore All Commercial |
$54.90
|
| Rate for Payer: Frontpath All Commercial |
$54.87
|
| Rate for Payer: Humana ChoiceCare |
$51.51
|
| Rate for Payer: Humana Medicare |
$19.08
|
| Rate for Payer: Lucent All Commercial |
$32.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.68
|
| Rate for Payer: PHCS All Commercial |
$44.73
|
| Rate for Payer: PHP All Commercial |
$45.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.26
|
| Rate for Payer: Sagamore Health Network All Products |
$46.04
|
| Rate for Payer: Signature Care EPO |
$49.50
|
| Rate for Payer: Signature Care PPO |
$52.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.69
|
| Rate for Payer: United Healthcare Commercial |
$47.00
|
| Rate for Payer: United Healthcare Medicare |
$19.08
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 00121091400
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna All Commercial |
$3.69
|
| Rate for Payer: CORVEL All Commercial |
$3.97
|
| Rate for Payer: Coventry All Commercial |
$3.76
|
| Rate for Payer: Encore All Commercial |
$3.93
|
| Rate for Payer: Frontpath All Commercial |
$3.93
|
| Rate for Payer: Humana ChoiceCare |
$3.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.84
|
| Rate for Payer: PHCS All Commercial |
$3.20
|
| Rate for Payer: PHP All Commercial |
$3.24
|
| Rate for Payer: Sagamore Health Network All Products |
$3.30
|
| Rate for Payer: Signature Care EPO |
$3.54
|
| Rate for Payer: Signature Care PPO |
$3.76
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 00121091405
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna All Commercial |
$3.69
|
| Rate for Payer: CORVEL All Commercial |
$3.97
|
| Rate for Payer: Coventry All Commercial |
$3.76
|
| Rate for Payer: Encore All Commercial |
$3.93
|
| Rate for Payer: Frontpath All Commercial |
$3.93
|
| Rate for Payer: Humana ChoiceCare |
$3.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.84
|
| Rate for Payer: PHCS All Commercial |
$3.20
|
| Rate for Payer: PHP All Commercial |
$3.24
|
| Rate for Payer: Sagamore Health Network All Products |
$3.30
|
| Rate for Payer: Signature Care EPO |
$3.54
|
| Rate for Payer: Signature Care PPO |
$3.76
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 00121091405
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Centivo All Commercial |
$2.32
|
| Rate for Payer: Cigna All Commercial |
$3.69
|
| Rate for Payer: CORVEL All Commercial |
$3.97
|
| Rate for Payer: Coventry All Commercial |
$3.76
|
| Rate for Payer: Encore All Commercial |
$3.93
|
| Rate for Payer: Frontpath All Commercial |
$3.93
|
| Rate for Payer: Humana ChoiceCare |
$3.69
|
| Rate for Payer: Humana Medicare |
$1.37
|
| Rate for Payer: Lucent All Commercial |
$2.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.84
|
| Rate for Payer: PHCS All Commercial |
$3.20
|
| Rate for Payer: PHP All Commercial |
$3.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.67
|
| Rate for Payer: Sagamore Health Network All Products |
$3.30
|
| Rate for Payer: Signature Care EPO |
$3.54
|
| Rate for Payer: Signature Care PPO |
$3.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
| Rate for Payer: United Healthcare Medicare |
$1.37
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 00121091400
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Centivo All Commercial |
$2.32
|
| Rate for Payer: Cigna All Commercial |
$3.69
|
| Rate for Payer: CORVEL All Commercial |
$3.97
|
| Rate for Payer: Coventry All Commercial |
$3.76
|
| Rate for Payer: Encore All Commercial |
$3.93
|
| Rate for Payer: Frontpath All Commercial |
$3.93
|
| Rate for Payer: Humana ChoiceCare |
$3.69
|
| Rate for Payer: Humana Medicare |
$1.37
|
| Rate for Payer: Lucent All Commercial |
$2.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.84
|
| Rate for Payer: PHCS All Commercial |
$3.20
|
| Rate for Payer: PHP All Commercial |
$3.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.67
|
| Rate for Payer: Sagamore Health Network All Products |
$3.30
|
| Rate for Payer: Signature Care EPO |
$3.54
|
| Rate for Payer: Signature Care PPO |
$3.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
| Rate for Payer: United Healthcare Medicare |
$1.37
|
|
|
IBUPROFEN 200 MG ORAL TAB
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 00904791461
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Centivo All Commercial |
$0.22
|
| Rate for Payer: Cigna All Commercial |
$0.34
|
| Rate for Payer: CORVEL All Commercial |
$0.37
|
| Rate for Payer: Coventry All Commercial |
$0.35
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.34
|
| Rate for Payer: Humana Medicare |
$0.13
|
| Rate for Payer: Lucent All Commercial |
$0.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.36
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.16
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.33
|
| Rate for Payer: Signature Care PPO |
$0.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
|
|
IBUPROFEN 200 MG ORAL TAB
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 00904791461
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna All Commercial |
$0.34
|
| Rate for Payer: CORVEL All Commercial |
$0.37
|
| Rate for Payer: Coventry All Commercial |
$0.35
|
| Rate for Payer: Encore All Commercial |
$0.37
|
| Rate for Payer: Frontpath All Commercial |
$0.37
|
| Rate for Payer: Humana ChoiceCare |
$0.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.36
|
| Rate for Payer: PHCS All Commercial |
$0.30
|
| Rate for Payer: PHP All Commercial |
$0.30
|
| Rate for Payer: Sagamore Health Network All Products |
$0.31
|
| Rate for Payer: Signature Care EPO |
$0.33
|
| Rate for Payer: Signature Care PPO |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
|
|
IBUPROFEN 600 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904585461
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: 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: 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: United Healthcare Commercial |
$0.79
|
|
|
IBUPROFEN 600 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904585461
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
IBUPROFEN 800 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904585561
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| 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: 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: 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: United Healthcare Commercial |
$0.79
|
|
|
IBUPROFEN 800 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904585561
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN
|
Facility
|
IP
|
$1,073.56
|
|
|
Service Code
|
HCPCS J1742
|
| Hospital Charge Code |
16156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$805.17 |
| Max. Negotiated Rate |
$998.41 |
| Rate for Payer: Aetna Commercial |
$927.56
|
| Rate for Payer: Cash Price |
$644.14
|
| Rate for Payer: Cigna All Commercial |
$926.48
|
| Rate for Payer: CORVEL All Commercial |
$998.41
|
| Rate for Payer: Coventry All Commercial |
$944.73
|
| Rate for Payer: Encore All Commercial |
$988.21
|
| Rate for Payer: Frontpath All Commercial |
$987.68
|
| Rate for Payer: Humana ChoiceCare |
$927.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$966.20
|
| Rate for Payer: PHCS All Commercial |
$805.17
|
| Rate for Payer: PHP All Commercial |
$814.19
|
| Rate for Payer: Sagamore Health Network All Products |
$828.79
|
| Rate for Payer: Signature Care EPO |
$891.05
|
| Rate for Payer: Signature Care PPO |
$944.73
|
| Rate for Payer: United Healthcare Commercial |
$845.97
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN
|
Facility
|
OP
|
$1,073.56
|
|
|
Service Code
|
HCPCS J1742
|
| Hospital Charge Code |
16156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.57 |
| Max. Negotiated Rate |
$998.41 |
| Rate for Payer: Aetna Commercial |
$906.08
|
| Rate for Payer: Aetna Medicare |
$343.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$98.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$332.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$616.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$671.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$98.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$395.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$377.89
|
| Rate for Payer: Cash Price |
$644.14
|
| Rate for Payer: Cash Price |
$644.14
|
| Rate for Payer: Centivo All Commercial |
$584.02
|
| Rate for Payer: Cigna All Commercial |
$926.48
|
| Rate for Payer: CORVEL All Commercial |
$998.41
|
| Rate for Payer: Coventry All Commercial |
$944.73
|
| Rate for Payer: Encore All Commercial |
$988.21
|
| Rate for Payer: Frontpath All Commercial |
$987.68
|
| Rate for Payer: Humana ChoiceCare |
$927.23
|
| Rate for Payer: Humana Medicare |
$343.54
|
| Rate for Payer: Lucent All Commercial |
$584.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$966.20
|
| Rate for Payer: Managed Health Services Medicaid |
$98.57
|
| Rate for Payer: MDWise Medicaid |
$98.57
|
| Rate for Payer: PHCS All Commercial |
$805.17
|
| Rate for Payer: PHP All Commercial |
$814.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$418.69
|
| Rate for Payer: Sagamore Health Network All Products |
$828.79
|
| Rate for Payer: Signature Care EPO |
$891.05
|
| Rate for Payer: Signature Care PPO |
$944.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$912.53
|
| Rate for Payer: United Healthcare Commercial |
$845.97
|
| Rate for Payer: United Healthcare Medicare |
$343.54
|
|
|
IMM GLOB G (IGG)-SORB-IGA 0-50 5 % IV SOLN
|
Facility
|
OP
|
$3,636.00
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
172840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.59 |
| Max. Negotiated Rate |
$3,381.48 |
| Rate for Payer: Aetna Commercial |
$3,068.78
|
| Rate for Payer: Aetna Medicare |
$1,163.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$55.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,127.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,088.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,272.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$55.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,338.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,279.87
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Centivo All Commercial |
$1,977.98
|
| Rate for Payer: Cigna All Commercial |
$3,137.87
|
| Rate for Payer: CORVEL All Commercial |
$3,381.48
|
| Rate for Payer: Coventry All Commercial |
$3,199.68
|
| Rate for Payer: Encore All Commercial |
$3,346.94
|
| Rate for Payer: Frontpath All Commercial |
$3,345.12
|
| Rate for Payer: Humana ChoiceCare |
$3,140.41
|
| Rate for Payer: Humana Medicare |
$1,163.52
|
| Rate for Payer: Lucent All Commercial |
$1,977.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,272.40
|
| Rate for Payer: Managed Health Services Medicaid |
$55.59
|
| Rate for Payer: MDWise Medicaid |
$55.59
|
| Rate for Payer: PHCS All Commercial |
$2,727.00
|
| Rate for Payer: PHP All Commercial |
$2,757.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,418.04
|
| Rate for Payer: Sagamore Health Network All Products |
$2,806.99
|
| Rate for Payer: Signature Care EPO |
$3,017.88
|
| Rate for Payer: Signature Care PPO |
$3,199.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,090.60
|
| Rate for Payer: United Healthcare Commercial |
$2,865.17
|
| Rate for Payer: United Healthcare Medicare |
$1,163.52
|
|
|
IMM GLOB G (IGG)-SORB-IGA 0-50 5 % IV SOLN
|
Facility
|
IP
|
$6,363.00
|
|
|
Service Code
|
NDC 61953000405
|
| Hospital Charge Code |
172840
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,772.25 |
| Max. Negotiated Rate |
$5,917.59 |
| Rate for Payer: Aetna Commercial |
$5,497.63
|
| Rate for Payer: Cash Price |
$3,817.80
|
| Rate for Payer: Cigna All Commercial |
$5,491.27
|
| Rate for Payer: CORVEL All Commercial |
$5,917.59
|
| Rate for Payer: Coventry All Commercial |
$5,599.44
|
| Rate for Payer: Encore All Commercial |
$5,857.14
|
| Rate for Payer: Frontpath All Commercial |
$5,853.96
|
| Rate for Payer: Humana ChoiceCare |
$5,495.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,726.70
|
| Rate for Payer: PHCS All Commercial |
$4,772.25
|
| Rate for Payer: PHP All Commercial |
$4,825.70
|
| Rate for Payer: Sagamore Health Network All Products |
$4,912.24
|
| Rate for Payer: Signature Care EPO |
$5,281.29
|
| Rate for Payer: Signature Care PPO |
$5,599.44
|
| Rate for Payer: United Healthcare Commercial |
$5,014.04
|
|
|
IMM GLOB G (IGG)-SORB-IGA 0-50 5 % IV SOLN
|
Facility
|
IP
|
$3,636.00
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
172840
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,727.00 |
| Max. Negotiated Rate |
$3,381.48 |
| Rate for Payer: Aetna Commercial |
$3,141.50
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cigna All Commercial |
$3,137.87
|
| Rate for Payer: CORVEL All Commercial |
$3,381.48
|
| Rate for Payer: Coventry All Commercial |
$3,199.68
|
| Rate for Payer: Encore All Commercial |
$3,346.94
|
| Rate for Payer: Frontpath All Commercial |
$3,345.12
|
| Rate for Payer: Humana ChoiceCare |
$3,140.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,272.40
|
| Rate for Payer: PHCS All Commercial |
$2,727.00
|
| Rate for Payer: PHP All Commercial |
$2,757.54
|
| Rate for Payer: Sagamore Health Network All Products |
$2,806.99
|
| Rate for Payer: Signature Care EPO |
$3,017.88
|
| Rate for Payer: Signature Care PPO |
$3,199.68
|
| Rate for Payer: United Healthcare Commercial |
$2,865.17
|
|
|
IMM GLOB G (IGG)-SORB-IGA 0-50 5 % IV SOLN
|
Facility
|
OP
|
$6,363.00
|
|
|
Service Code
|
NDC 61953000405
|
| Hospital Charge Code |
172840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,972.53 |
| Max. Negotiated Rate |
$5,917.59 |
| Rate for Payer: Aetna Commercial |
$5,370.37
|
| Rate for Payer: Aetna Medicare |
$2,036.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,972.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,654.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,977.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,341.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,239.78
|
| Rate for Payer: Cash Price |
$3,817.80
|
| Rate for Payer: Centivo All Commercial |
$3,461.47
|
| Rate for Payer: Cigna All Commercial |
$5,491.27
|
| Rate for Payer: CORVEL All Commercial |
$5,917.59
|
| Rate for Payer: Coventry All Commercial |
$5,599.44
|
| Rate for Payer: Encore All Commercial |
$5,857.14
|
| Rate for Payer: Frontpath All Commercial |
$5,853.96
|
| Rate for Payer: Humana ChoiceCare |
$5,495.72
|
| Rate for Payer: Humana Medicare |
$2,036.16
|
| Rate for Payer: Lucent All Commercial |
$3,461.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,726.70
|
| Rate for Payer: PHCS All Commercial |
$4,772.25
|
| Rate for Payer: PHP All Commercial |
$4,825.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,481.57
|
| Rate for Payer: Sagamore Health Network All Products |
$4,912.24
|
| Rate for Payer: Signature Care EPO |
$5,281.29
|
| Rate for Payer: Signature Care PPO |
$5,599.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,408.55
|
| Rate for Payer: United Healthcare Commercial |
$5,014.04
|
| Rate for Payer: United Healthcare Medicare |
$2,036.16
|
|
|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS J1560
|
| Hospital Charge Code |
173186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$1,720.50 |
| Rate for Payer: Aetna Commercial |
$1,598.40
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cigna All Commercial |
$1,596.55
|
| Rate for Payer: CORVEL All Commercial |
$1,720.50
|
| Rate for Payer: Coventry All Commercial |
$1,628.00
|
| Rate for Payer: Encore All Commercial |
$1,702.92
|
| Rate for Payer: Frontpath All Commercial |
$1,702.00
|
| Rate for Payer: Humana ChoiceCare |
$1,597.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,665.00
|
| Rate for Payer: PHCS All Commercial |
$1,387.50
|
| Rate for Payer: PHP All Commercial |
$1,403.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1,428.20
|
| Rate for Payer: Signature Care EPO |
$1,535.50
|
| Rate for Payer: Signature Care PPO |
$1,628.00
|
| Rate for Payer: United Healthcare Commercial |
$1,457.80
|
|
|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS J1560
|
| Hospital Charge Code |
173186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$499.16 |
| Max. Negotiated Rate |
$1,720.50 |
| Rate for Payer: Aetna Commercial |
$1,561.40
|
| Rate for Payer: Aetna Medicare |
$592.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$499.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$573.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,062.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,156.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$499.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$680.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$651.20
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Centivo All Commercial |
$1,006.40
|
| Rate for Payer: Cigna All Commercial |
$1,596.55
|
| Rate for Payer: CORVEL All Commercial |
$1,720.50
|
| Rate for Payer: Coventry All Commercial |
$1,628.00
|
| Rate for Payer: Encore All Commercial |
$1,702.92
|
| Rate for Payer: Frontpath All Commercial |
$1,702.00
|
| Rate for Payer: Humana ChoiceCare |
$1,597.85
|
| Rate for Payer: Humana Medicare |
$592.00
|
| Rate for Payer: Lucent All Commercial |
$1,006.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,665.00
|
| Rate for Payer: Managed Health Services Medicaid |
$499.16
|
| Rate for Payer: MDWise Medicaid |
$499.16
|
| Rate for Payer: PHCS All Commercial |
$1,387.50
|
| Rate for Payer: PHP All Commercial |
$1,403.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$721.50
|
| Rate for Payer: Sagamore Health Network All Products |
$1,428.20
|
| Rate for Payer: Signature Care EPO |
$1,535.50
|
| Rate for Payer: Signature Care PPO |
$1,628.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,572.50
|
| Rate for Payer: United Healthcare Commercial |
$1,457.80
|
| Rate for Payer: United Healthcare Medicare |
$592.00
|
|
