|
IMMUNE GLOBUL G-GLY-IGA AVG 46 10 GRAM/100 ML (10 %) INJ SOLN
|
Facility
|
IP
|
$4,034.45
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107753
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,025.84 |
| Max. Negotiated Rate |
$3,752.04 |
| Rate for Payer: Aetna Commercial |
$3,485.76
|
| Rate for Payer: Cash Price |
$2,420.67
|
| Rate for Payer: Cigna All Commercial |
$3,481.73
|
| Rate for Payer: CORVEL All Commercial |
$3,752.04
|
| Rate for Payer: Coventry All Commercial |
$3,550.32
|
| Rate for Payer: Encore All Commercial |
$3,713.71
|
| Rate for Payer: Frontpath All Commercial |
$3,711.69
|
| Rate for Payer: Humana ChoiceCare |
$3,484.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,631.01
|
| Rate for Payer: PHCS All Commercial |
$3,025.84
|
| Rate for Payer: PHP All Commercial |
$3,059.73
|
| Rate for Payer: Sagamore Health Network All Products |
$3,114.60
|
| Rate for Payer: Signature Care EPO |
$3,348.59
|
| Rate for Payer: Signature Care PPO |
$3,550.32
|
| Rate for Payer: United Healthcare Commercial |
$3,179.15
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 10 GRAM/100 ML (10 %) INJ SOLN
|
Facility
|
OP
|
$4,034.45
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107753
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$3,752.04 |
| Rate for Payer: Aetna Commercial |
$3,405.08
|
| Rate for Payer: Aetna Medicare |
$1,291.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$76.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,250.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,316.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,521.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$76.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,484.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,420.13
|
| Rate for Payer: Cash Price |
$2,420.67
|
| Rate for Payer: Cash Price |
$2,420.67
|
| Rate for Payer: Centivo All Commercial |
$2,194.74
|
| Rate for Payer: Cigna All Commercial |
$3,481.73
|
| Rate for Payer: CORVEL All Commercial |
$3,752.04
|
| Rate for Payer: Coventry All Commercial |
$3,550.32
|
| Rate for Payer: Encore All Commercial |
$3,713.71
|
| Rate for Payer: Frontpath All Commercial |
$3,711.69
|
| Rate for Payer: Humana ChoiceCare |
$3,484.55
|
| Rate for Payer: Humana Medicare |
$1,291.02
|
| Rate for Payer: Lucent All Commercial |
$2,194.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,631.01
|
| Rate for Payer: Managed Health Services Medicaid |
$76.65
|
| Rate for Payer: MDWise Medicaid |
$76.65
|
| Rate for Payer: PHCS All Commercial |
$3,025.84
|
| Rate for Payer: PHP All Commercial |
$3,059.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,573.44
|
| Rate for Payer: Sagamore Health Network All Products |
$3,114.60
|
| Rate for Payer: Signature Care EPO |
$3,348.59
|
| Rate for Payer: Signature Care PPO |
$3,550.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,429.28
|
| Rate for Payer: United Healthcare Commercial |
$3,179.15
|
| Rate for Payer: United Healthcare Medicare |
$1,291.02
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 20 GRAM/200 ML (10 %) INJ SOLN
|
Facility
|
IP
|
$8,068.90
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,051.68 |
| Max. Negotiated Rate |
$7,504.08 |
| Rate for Payer: Aetna Commercial |
$6,971.53
|
| Rate for Payer: Cash Price |
$4,841.34
|
| Rate for Payer: Cigna All Commercial |
$6,963.46
|
| Rate for Payer: CORVEL All Commercial |
$7,504.08
|
| Rate for Payer: Coventry All Commercial |
$7,100.63
|
| Rate for Payer: Encore All Commercial |
$7,427.42
|
| Rate for Payer: Frontpath All Commercial |
$7,423.39
|
| Rate for Payer: Humana ChoiceCare |
$6,969.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,262.01
|
| Rate for Payer: PHCS All Commercial |
$6,051.68
|
| Rate for Payer: PHP All Commercial |
$6,119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$6,229.19
|
| Rate for Payer: Signature Care EPO |
$6,697.19
|
| Rate for Payer: Signature Care PPO |
$7,100.63
|
| Rate for Payer: United Healthcare Commercial |
$6,358.29
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 20 GRAM/200 ML (10 %) INJ SOLN
|
Facility
|
OP
|
$8,068.90
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$7,504.08 |
| Rate for Payer: Aetna Commercial |
$6,810.15
|
| Rate for Payer: Aetna Medicare |
$2,582.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$76.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,501.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,633.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,043.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$76.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,969.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,840.25
|
| Rate for Payer: Cash Price |
$4,841.34
|
| Rate for Payer: Cash Price |
$4,841.34
|
| Rate for Payer: Centivo All Commercial |
$4,389.48
|
| Rate for Payer: Cigna All Commercial |
$6,963.46
|
| Rate for Payer: CORVEL All Commercial |
$7,504.08
|
| Rate for Payer: Coventry All Commercial |
$7,100.63
|
| Rate for Payer: Encore All Commercial |
$7,427.42
|
| Rate for Payer: Frontpath All Commercial |
$7,423.39
|
| Rate for Payer: Humana ChoiceCare |
$6,969.11
|
| Rate for Payer: Humana Medicare |
$2,582.05
|
| Rate for Payer: Lucent All Commercial |
$4,389.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,262.01
|
| Rate for Payer: Managed Health Services Medicaid |
$76.65
|
| Rate for Payer: MDWise Medicaid |
$76.65
|
| Rate for Payer: PHCS All Commercial |
$6,051.68
|
| Rate for Payer: PHP All Commercial |
$6,119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,146.87
|
| Rate for Payer: Sagamore Health Network All Products |
$6,229.19
|
| Rate for Payer: Signature Care EPO |
$6,697.19
|
| Rate for Payer: Signature Care PPO |
$7,100.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,858.56
|
| Rate for Payer: United Healthcare Commercial |
$6,358.29
|
| Rate for Payer: United Healthcare Medicare |
$2,582.05
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 40 GRAM/400 ML (10 %) INJ SOLN
|
Facility
|
IP
|
$16,137.80
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
170495
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,103.35 |
| Max. Negotiated Rate |
$15,008.15 |
| Rate for Payer: Aetna Commercial |
$13,943.06
|
| Rate for Payer: Cash Price |
$9,682.68
|
| Rate for Payer: Cigna All Commercial |
$13,926.92
|
| Rate for Payer: CORVEL All Commercial |
$15,008.15
|
| Rate for Payer: Coventry All Commercial |
$14,201.26
|
| Rate for Payer: Encore All Commercial |
$14,854.84
|
| Rate for Payer: Frontpath All Commercial |
$14,846.78
|
| Rate for Payer: Humana ChoiceCare |
$13,938.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,524.02
|
| Rate for Payer: PHCS All Commercial |
$12,103.35
|
| Rate for Payer: PHP All Commercial |
$12,238.91
|
| Rate for Payer: Sagamore Health Network All Products |
$12,458.38
|
| Rate for Payer: Signature Care EPO |
$13,394.37
|
| Rate for Payer: Signature Care PPO |
$14,201.26
|
| Rate for Payer: United Healthcare Commercial |
$12,716.59
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 40 GRAM/400 ML (10 %) INJ SOLN
|
Facility
|
OP
|
$16,137.80
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
170495
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$15,008.15 |
| Rate for Payer: Aetna Commercial |
$13,620.30
|
| Rate for Payer: Aetna Medicare |
$5,164.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$76.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,002.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9,267.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,087.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$76.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,938.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,680.51
|
| Rate for Payer: Cash Price |
$9,682.68
|
| Rate for Payer: Cash Price |
$9,682.68
|
| Rate for Payer: Centivo All Commercial |
$8,778.96
|
| Rate for Payer: Cigna All Commercial |
$13,926.92
|
| Rate for Payer: CORVEL All Commercial |
$15,008.15
|
| Rate for Payer: Coventry All Commercial |
$14,201.26
|
| Rate for Payer: Encore All Commercial |
$14,854.84
|
| Rate for Payer: Frontpath All Commercial |
$14,846.78
|
| Rate for Payer: Humana ChoiceCare |
$13,938.22
|
| Rate for Payer: Humana Medicare |
$5,164.10
|
| Rate for Payer: Lucent All Commercial |
$8,778.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,524.02
|
| Rate for Payer: Managed Health Services Medicaid |
$76.65
|
| Rate for Payer: MDWise Medicaid |
$76.65
|
| Rate for Payer: PHCS All Commercial |
$12,103.35
|
| Rate for Payer: PHP All Commercial |
$12,238.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,293.74
|
| Rate for Payer: Sagamore Health Network All Products |
$12,458.38
|
| Rate for Payer: Signature Care EPO |
$13,394.37
|
| Rate for Payer: Signature Care PPO |
$14,201.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,717.13
|
| Rate for Payer: United Healthcare Commercial |
$12,716.59
|
| Rate for Payer: United Healthcare Medicare |
$5,164.10
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) INJ SOLN
|
Facility
|
OP
|
$2,305.40
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107752
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$2,144.02 |
| Rate for Payer: Aetna Commercial |
$1,945.76
|
| Rate for Payer: Aetna Medicare |
$737.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$76.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$714.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,323.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,441.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$76.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$848.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$811.50
|
| Rate for Payer: Cash Price |
$1,383.24
|
| Rate for Payer: Cash Price |
$1,383.24
|
| Rate for Payer: Centivo All Commercial |
$1,254.14
|
| Rate for Payer: Cigna All Commercial |
$1,989.56
|
| Rate for Payer: CORVEL All Commercial |
$2,144.02
|
| Rate for Payer: Coventry All Commercial |
$2,028.75
|
| Rate for Payer: Encore All Commercial |
$2,122.12
|
| Rate for Payer: Frontpath All Commercial |
$2,120.97
|
| Rate for Payer: Humana ChoiceCare |
$1,991.17
|
| Rate for Payer: Humana Medicare |
$737.73
|
| Rate for Payer: Lucent All Commercial |
$1,254.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,074.86
|
| Rate for Payer: Managed Health Services Medicaid |
$76.65
|
| Rate for Payer: MDWise Medicaid |
$76.65
|
| Rate for Payer: PHCS All Commercial |
$1,729.05
|
| Rate for Payer: PHP All Commercial |
$1,748.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$899.11
|
| Rate for Payer: Sagamore Health Network All Products |
$1,779.77
|
| Rate for Payer: Signature Care EPO |
$1,913.48
|
| Rate for Payer: Signature Care PPO |
$2,028.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,959.59
|
| Rate for Payer: United Healthcare Commercial |
$1,816.66
|
| Rate for Payer: United Healthcare Medicare |
$737.73
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) INJ SOLN
|
Facility
|
IP
|
$2,305.40
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,729.05 |
| Max. Negotiated Rate |
$2,144.02 |
| Rate for Payer: Aetna Commercial |
$1,991.87
|
| Rate for Payer: Cash Price |
$1,383.24
|
| Rate for Payer: Cigna All Commercial |
$1,989.56
|
| Rate for Payer: CORVEL All Commercial |
$2,144.02
|
| Rate for Payer: Coventry All Commercial |
$2,028.75
|
| Rate for Payer: Encore All Commercial |
$2,122.12
|
| Rate for Payer: Frontpath All Commercial |
$2,120.97
|
| Rate for Payer: Humana ChoiceCare |
$1,991.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,074.86
|
| Rate for Payer: PHCS All Commercial |
$1,729.05
|
| Rate for Payer: PHP All Commercial |
$1,748.42
|
| Rate for Payer: Sagamore Health Network All Products |
$1,779.77
|
| Rate for Payer: Signature Care EPO |
$1,913.48
|
| Rate for Payer: Signature Care PPO |
$2,028.75
|
| Rate for Payer: United Healthcare Commercial |
$1,816.66
|
|
|
IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % INJ SOLN
|
Facility
|
IP
|
$3,929.80
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
172845
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,947.35 |
| Max. Negotiated Rate |
$3,654.71 |
| Rate for Payer: Aetna Commercial |
$3,395.35
|
| Rate for Payer: Cash Price |
$2,357.88
|
| Rate for Payer: Cigna All Commercial |
$3,391.42
|
| Rate for Payer: CORVEL All Commercial |
$3,654.71
|
| Rate for Payer: Coventry All Commercial |
$3,458.22
|
| Rate for Payer: Encore All Commercial |
$3,617.38
|
| Rate for Payer: Frontpath All Commercial |
$3,615.42
|
| Rate for Payer: Humana ChoiceCare |
$3,394.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,536.82
|
| Rate for Payer: PHCS All Commercial |
$2,947.35
|
| Rate for Payer: PHP All Commercial |
$2,980.36
|
| Rate for Payer: Sagamore Health Network All Products |
$3,033.81
|
| Rate for Payer: Signature Care EPO |
$3,261.73
|
| Rate for Payer: Signature Care PPO |
$3,458.22
|
| Rate for Payer: United Healthcare Commercial |
$3,096.68
|
|
|
IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % INJ SOLN
|
Facility
|
OP
|
$3,929.80
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
172845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.67 |
| Max. Negotiated Rate |
$3,654.71 |
| Rate for Payer: Aetna Commercial |
$3,316.75
|
| Rate for Payer: Aetna Medicare |
$1,257.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$91.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,218.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,256.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,456.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$91.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,446.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,383.29
|
| Rate for Payer: Cash Price |
$2,357.88
|
| Rate for Payer: Cash Price |
$2,357.88
|
| Rate for Payer: Centivo All Commercial |
$2,137.81
|
| Rate for Payer: Cigna All Commercial |
$3,391.42
|
| Rate for Payer: CORVEL All Commercial |
$3,654.71
|
| Rate for Payer: Coventry All Commercial |
$3,458.22
|
| Rate for Payer: Encore All Commercial |
$3,617.38
|
| Rate for Payer: Frontpath All Commercial |
$3,615.42
|
| Rate for Payer: Humana ChoiceCare |
$3,394.17
|
| Rate for Payer: Humana Medicare |
$1,257.54
|
| Rate for Payer: Lucent All Commercial |
$2,137.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,536.82
|
| Rate for Payer: Managed Health Services Medicaid |
$91.67
|
| Rate for Payer: MDWise Medicaid |
$91.67
|
| Rate for Payer: PHCS All Commercial |
$2,947.35
|
| Rate for Payer: PHP All Commercial |
$2,980.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,532.62
|
| Rate for Payer: Sagamore Health Network All Products |
$3,033.81
|
| Rate for Payer: Signature Care EPO |
$3,261.73
|
| Rate for Payer: Signature Care PPO |
$3,458.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,340.33
|
| Rate for Payer: United Healthcare Commercial |
$3,096.68
|
| Rate for Payer: United Healthcare Medicare |
$1,257.54
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
|
OP
|
$3,995.60
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
172846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.85 |
| Max. Negotiated Rate |
$3,715.91 |
| Rate for Payer: Aetna Commercial |
$3,372.29
|
| Rate for Payer: Aetna Medicare |
$1,278.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$98.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,238.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,294.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,497.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$98.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,470.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,406.45
|
| Rate for Payer: Cash Price |
$2,397.36
|
| Rate for Payer: Cash Price |
$2,397.36
|
| Rate for Payer: Centivo All Commercial |
$2,173.61
|
| Rate for Payer: Cigna All Commercial |
$3,448.20
|
| Rate for Payer: CORVEL All Commercial |
$3,715.91
|
| Rate for Payer: Coventry All Commercial |
$3,516.13
|
| Rate for Payer: Encore All Commercial |
$3,677.95
|
| Rate for Payer: Frontpath All Commercial |
$3,675.95
|
| Rate for Payer: Humana ChoiceCare |
$3,451.00
|
| Rate for Payer: Humana Medicare |
$1,278.59
|
| Rate for Payer: Lucent All Commercial |
$2,173.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,596.04
|
| Rate for Payer: Managed Health Services Medicaid |
$98.85
|
| Rate for Payer: MDWise Medicaid |
$98.85
|
| Rate for Payer: PHCS All Commercial |
$2,996.70
|
| Rate for Payer: PHP All Commercial |
$3,030.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,558.28
|
| Rate for Payer: Sagamore Health Network All Products |
$3,084.60
|
| Rate for Payer: Signature Care EPO |
$3,316.35
|
| Rate for Payer: Signature Care PPO |
$3,516.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,396.26
|
| Rate for Payer: United Healthcare Commercial |
$3,148.53
|
| Rate for Payer: United Healthcare Medicare |
$1,278.59
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
|
IP
|
$3,995.60
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
172846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,996.70 |
| Max. Negotiated Rate |
$3,715.91 |
| Rate for Payer: Aetna Commercial |
$3,452.20
|
| Rate for Payer: Cash Price |
$2,397.36
|
| Rate for Payer: Cigna All Commercial |
$3,448.20
|
| Rate for Payer: CORVEL All Commercial |
$3,715.91
|
| Rate for Payer: Coventry All Commercial |
$3,516.13
|
| Rate for Payer: Encore All Commercial |
$3,677.95
|
| Rate for Payer: Frontpath All Commercial |
$3,675.95
|
| Rate for Payer: Humana ChoiceCare |
$3,451.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,596.04
|
| Rate for Payer: PHCS All Commercial |
$2,996.70
|
| Rate for Payer: PHP All Commercial |
$3,030.26
|
| Rate for Payer: Sagamore Health Network All Products |
$3,084.60
|
| Rate for Payer: Signature Care EPO |
$3,316.35
|
| Rate for Payer: Signature Care PPO |
$3,516.13
|
| Rate for Payer: United Healthcare Commercial |
$3,148.53
|
|
|
INDAPAMIDE 2.5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
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
|
|
|
INDAPAMIDE 2.5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
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
|
|
|
INDIUM IN-111 OXYQUINOLINE 1 MCI/ML (37 MBQ/ML)(1 ML) IV SOLN
|
Facility
|
IP
|
$12,225.05
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
153809
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$9,168.78 |
| Max. Negotiated Rate |
$11,369.29 |
| Rate for Payer: Aetna Commercial |
$10,562.44
|
| Rate for Payer: Cash Price |
$7,335.03
|
| Rate for Payer: Cigna All Commercial |
$10,550.21
|
| Rate for Payer: CORVEL All Commercial |
$11,369.29
|
| Rate for Payer: Coventry All Commercial |
$10,758.04
|
| Rate for Payer: Encore All Commercial |
$11,253.15
|
| Rate for Payer: Frontpath All Commercial |
$11,247.04
|
| Rate for Payer: Humana ChoiceCare |
$10,558.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,002.54
|
| Rate for Payer: PHCS All Commercial |
$9,168.78
|
| Rate for Payer: PHP All Commercial |
$9,271.47
|
| Rate for Payer: Sagamore Health Network All Products |
$9,437.73
|
| Rate for Payer: Signature Care EPO |
$10,146.79
|
| Rate for Payer: Signature Care PPO |
$10,758.04
|
| Rate for Payer: United Healthcare Commercial |
$9,633.34
|
|
|
INDIUM IN-111 OXYQUINOLINE 1 MCI/ML (37 MBQ/ML)(1 ML) IV SOLN
|
Facility
|
OP
|
$12,225.05
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
153809
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,789.76 |
| Max. Negotiated Rate |
$11,369.29 |
| Rate for Payer: Aetna Commercial |
$10,317.94
|
| Rate for Payer: Aetna Medicare |
$3,912.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,789.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7,020.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,641.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,498.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,303.22
|
| Rate for Payer: Cash Price |
$7,335.03
|
| Rate for Payer: Centivo All Commercial |
$6,650.42
|
| Rate for Payer: Cigna All Commercial |
$10,550.21
|
| Rate for Payer: CORVEL All Commercial |
$11,369.29
|
| Rate for Payer: Coventry All Commercial |
$10,758.04
|
| Rate for Payer: Encore All Commercial |
$11,253.15
|
| Rate for Payer: Frontpath All Commercial |
$11,247.04
|
| Rate for Payer: Humana ChoiceCare |
$10,558.77
|
| Rate for Payer: Humana Medicare |
$3,912.01
|
| Rate for Payer: Lucent All Commercial |
$6,650.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,002.54
|
| Rate for Payer: PHCS All Commercial |
$9,168.78
|
| Rate for Payer: PHP All Commercial |
$9,271.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,767.77
|
| Rate for Payer: Sagamore Health Network All Products |
$9,437.73
|
| Rate for Payer: Signature Care EPO |
$10,146.79
|
| Rate for Payer: Signature Care PPO |
$10,758.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,391.29
|
| Rate for Payer: United Healthcare Commercial |
$9,633.34
|
| Rate for Payer: United Healthcare Medicare |
$3,912.01
|
|
|
INDOCYANINE GREEN 25 MG INJ SOLR
|
Facility
|
OP
|
$999.20
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$929.26 |
| Rate for Payer: Aetna Commercial |
$843.32
|
| Rate for Payer: Aetna Medicare |
$319.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$309.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$573.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$624.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$367.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$351.72
|
| Rate for Payer: Cash Price |
$599.52
|
| Rate for Payer: Cash Price |
$599.52
|
| Rate for Payer: Centivo All Commercial |
$543.56
|
| Rate for Payer: Cigna All Commercial |
$862.31
|
| Rate for Payer: CORVEL All Commercial |
$929.26
|
| Rate for Payer: Coventry All Commercial |
$879.30
|
| Rate for Payer: Encore All Commercial |
$919.76
|
| Rate for Payer: Frontpath All Commercial |
$919.26
|
| Rate for Payer: Humana ChoiceCare |
$863.01
|
| Rate for Payer: Humana Medicare |
$319.74
|
| Rate for Payer: Lucent All Commercial |
$543.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$899.28
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$749.40
|
| Rate for Payer: PHP All Commercial |
$757.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$389.69
|
| Rate for Payer: Sagamore Health Network All Products |
$771.38
|
| Rate for Payer: Signature Care EPO |
$829.34
|
| Rate for Payer: Signature Care PPO |
$879.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$849.32
|
| Rate for Payer: United Healthcare Commercial |
$787.37
|
| Rate for Payer: United Healthcare Medicare |
$319.74
|
|
|
INDOCYANINE GREEN 25 MG INJ SOLR
|
Facility
|
IP
|
$999.20
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$749.40 |
| Max. Negotiated Rate |
$929.26 |
| Rate for Payer: Aetna Commercial |
$863.31
|
| Rate for Payer: Cash Price |
$599.52
|
| Rate for Payer: Cigna All Commercial |
$862.31
|
| Rate for Payer: CORVEL All Commercial |
$929.26
|
| Rate for Payer: Coventry All Commercial |
$879.30
|
| Rate for Payer: Encore All Commercial |
$919.76
|
| Rate for Payer: Frontpath All Commercial |
$919.26
|
| Rate for Payer: Humana ChoiceCare |
$863.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$899.28
|
| Rate for Payer: PHCS All Commercial |
$749.40
|
| Rate for Payer: PHP All Commercial |
$757.79
|
| Rate for Payer: Sagamore Health Network All Products |
$771.38
|
| Rate for Payer: Signature Care EPO |
$829.34
|
| Rate for Payer: Signature Care PPO |
$879.30
|
| Rate for Payer: United Healthcare Commercial |
$787.37
|
|
|
INDOMETHACIN 25 MG ORAL CAP
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna All Commercial |
$1.51
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.54
|
| Rate for Payer: Encore All Commercial |
$1.61
|
| Rate for Payer: Frontpath All Commercial |
$1.61
|
| Rate for Payer: Humana ChoiceCare |
$1.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| Rate for Payer: Signature Care PPO |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
INDOMETHACIN 25 MG ORAL CAP
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Centivo All Commercial |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.51
|
| Rate for Payer: CORVEL All Commercial |
$1.63
|
| Rate for Payer: Coventry All Commercial |
$1.54
|
| Rate for Payer: Encore All Commercial |
$1.61
|
| Rate for Payer: Frontpath All Commercial |
$1.61
|
| Rate for Payer: Humana ChoiceCare |
$1.51
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.31
|
| Rate for Payer: PHP All Commercial |
$1.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.35
|
| Rate for Payer: Signature Care EPO |
$1.45
|
| Rate for Payer: Signature Care PPO |
$1.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.49
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
INFLIXIMAB 100 MG IV SOLR
|
Facility
|
IP
|
$1,851.56
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,388.67 |
| Max. Negotiated Rate |
$1,721.95 |
| Rate for Payer: Aetna Commercial |
$1,599.75
|
| Rate for Payer: Cash Price |
$1,110.94
|
| Rate for Payer: Cigna All Commercial |
$1,597.90
|
| Rate for Payer: CORVEL All Commercial |
$1,721.95
|
| Rate for Payer: Coventry All Commercial |
$1,629.37
|
| Rate for Payer: Encore All Commercial |
$1,704.36
|
| Rate for Payer: Frontpath All Commercial |
$1,703.44
|
| Rate for Payer: Humana ChoiceCare |
$1,599.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,666.40
|
| Rate for Payer: PHCS All Commercial |
$1,388.67
|
| Rate for Payer: PHP All Commercial |
$1,404.22
|
| Rate for Payer: Sagamore Health Network All Products |
$1,429.40
|
| Rate for Payer: Signature Care EPO |
$1,536.79
|
| Rate for Payer: Signature Care PPO |
$1,629.37
|
| Rate for Payer: United Healthcare Commercial |
$1,459.03
|
|
|
INFLIXIMAB 100 MG IV SOLR
|
Facility
|
OP
|
$1,851.56
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.88 |
| Max. Negotiated Rate |
$1,721.95 |
| Rate for Payer: Aetna Commercial |
$1,562.72
|
| Rate for Payer: Aetna Medicare |
$592.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$49.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$573.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,063.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,157.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$49.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$681.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$651.75
|
| Rate for Payer: Cash Price |
$1,110.94
|
| Rate for Payer: Cash Price |
$1,110.94
|
| Rate for Payer: Centivo All Commercial |
$1,007.25
|
| Rate for Payer: Cigna All Commercial |
$1,597.90
|
| Rate for Payer: CORVEL All Commercial |
$1,721.95
|
| Rate for Payer: Coventry All Commercial |
$1,629.37
|
| Rate for Payer: Encore All Commercial |
$1,704.36
|
| Rate for Payer: Frontpath All Commercial |
$1,703.44
|
| Rate for Payer: Humana ChoiceCare |
$1,599.19
|
| Rate for Payer: Humana Medicare |
$592.50
|
| Rate for Payer: Lucent All Commercial |
$1,007.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,666.40
|
| Rate for Payer: Managed Health Services Medicaid |
$49.88
|
| Rate for Payer: MDWise Medicaid |
$49.88
|
| Rate for Payer: PHCS All Commercial |
$1,388.67
|
| Rate for Payer: PHP All Commercial |
$1,404.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$722.11
|
| Rate for Payer: Sagamore Health Network All Products |
$1,429.40
|
| Rate for Payer: Signature Care EPO |
$1,536.79
|
| Rate for Payer: Signature Care PPO |
$1,629.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,573.83
|
| Rate for Payer: United Healthcare Commercial |
$1,459.03
|
| Rate for Payer: United Healthcare Medicare |
$592.50
|
|
|
INFLIXIMAB-AXXQ 100 MG IV SOLR
|
Facility
|
IP
|
$1,911.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
191220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,433.25 |
| Max. Negotiated Rate |
$1,777.23 |
| Rate for Payer: Aetna Commercial |
$1,651.10
|
| Rate for Payer: Cash Price |
$1,146.60
|
| Rate for Payer: Cigna All Commercial |
$1,649.19
|
| Rate for Payer: CORVEL All Commercial |
$1,777.23
|
| Rate for Payer: Coventry All Commercial |
$1,681.68
|
| Rate for Payer: Encore All Commercial |
$1,759.08
|
| Rate for Payer: Frontpath All Commercial |
$1,758.12
|
| Rate for Payer: Humana ChoiceCare |
$1,650.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,719.90
|
| Rate for Payer: PHCS All Commercial |
$1,433.25
|
| Rate for Payer: PHP All Commercial |
$1,449.30
|
| Rate for Payer: Sagamore Health Network All Products |
$1,475.29
|
| Rate for Payer: Signature Care EPO |
$1,586.13
|
| Rate for Payer: Signature Care PPO |
$1,681.68
|
| Rate for Payer: United Healthcare Commercial |
$1,505.87
|
|
|
INFLIXIMAB-AXXQ 100 MG IV SOLR
|
Facility
|
OP
|
$1,911.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
191220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$1,777.23 |
| Rate for Payer: Aetna Commercial |
$1,612.88
|
| Rate for Payer: Aetna Medicare |
$611.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$52.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$592.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,097.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,194.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$52.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$703.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$672.67
|
| Rate for Payer: Cash Price |
$1,146.60
|
| Rate for Payer: Cash Price |
$1,146.60
|
| Rate for Payer: Centivo All Commercial |
$1,039.58
|
| Rate for Payer: Cigna All Commercial |
$1,649.19
|
| Rate for Payer: CORVEL All Commercial |
$1,777.23
|
| Rate for Payer: Coventry All Commercial |
$1,681.68
|
| Rate for Payer: Encore All Commercial |
$1,759.08
|
| Rate for Payer: Frontpath All Commercial |
$1,758.12
|
| Rate for Payer: Humana ChoiceCare |
$1,650.53
|
| Rate for Payer: Humana Medicare |
$611.52
|
| Rate for Payer: Lucent All Commercial |
$1,039.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,719.90
|
| Rate for Payer: Managed Health Services Medicaid |
$52.50
|
| Rate for Payer: MDWise Medicaid |
$52.50
|
| Rate for Payer: PHCS All Commercial |
$1,433.25
|
| Rate for Payer: PHP All Commercial |
$1,449.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$745.29
|
| Rate for Payer: Sagamore Health Network All Products |
$1,475.29
|
| Rate for Payer: Signature Care EPO |
$1,586.13
|
| Rate for Payer: Signature Care PPO |
$1,681.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,624.35
|
| Rate for Payer: United Healthcare Commercial |
$1,505.87
|
| Rate for Payer: United Healthcare Medicare |
$611.52
|
|
|
INFLIXIMAB-DYYB 100 MG IV SOLR
|
Facility
|
IP
|
$3,690.48
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
179180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,767.86 |
| Max. Negotiated Rate |
$3,432.15 |
| Rate for Payer: Aetna Commercial |
$3,188.57
|
| Rate for Payer: Cash Price |
$2,214.29
|
| Rate for Payer: Cigna All Commercial |
$3,184.88
|
| Rate for Payer: CORVEL All Commercial |
$3,432.15
|
| Rate for Payer: Coventry All Commercial |
$3,247.62
|
| Rate for Payer: Encore All Commercial |
$3,397.09
|
| Rate for Payer: Frontpath All Commercial |
$3,395.24
|
| Rate for Payer: Humana ChoiceCare |
$3,187.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,321.43
|
| Rate for Payer: PHCS All Commercial |
$2,767.86
|
| Rate for Payer: PHP All Commercial |
$2,798.86
|
| Rate for Payer: Sagamore Health Network All Products |
$2,849.05
|
| Rate for Payer: Signature Care EPO |
$3,063.10
|
| Rate for Payer: Signature Care PPO |
$3,247.62
|
| Rate for Payer: United Healthcare Commercial |
$2,908.10
|
|
