|
IOPAMIDOL 76 % IV SOLN 50 ML BTL
|
Facility
|
OP
|
$78.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$72.91 |
| Rate for Payer: Aetna Commercial |
$66.17
|
| Rate for Payer: Aetna Medicare |
$25.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.60
|
| Rate for Payer: Cash Price |
$47.04
|
| Rate for Payer: Centivo All Commercial |
$42.65
|
| Rate for Payer: Cigna All Commercial |
$67.66
|
| Rate for Payer: CORVEL All Commercial |
$72.91
|
| Rate for Payer: Coventry All Commercial |
$68.99
|
| Rate for Payer: Encore All Commercial |
$72.17
|
| Rate for Payer: Frontpath All Commercial |
$72.13
|
| Rate for Payer: Humana ChoiceCare |
$67.71
|
| Rate for Payer: Humana Medicare |
$25.09
|
| Rate for Payer: Lucent All Commercial |
$42.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.56
|
| Rate for Payer: PHCS All Commercial |
$58.80
|
| Rate for Payer: PHP All Commercial |
$59.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.58
|
| Rate for Payer: Sagamore Health Network All Products |
$60.52
|
| Rate for Payer: Signature Care EPO |
$65.07
|
| Rate for Payer: Signature Care PPO |
$68.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$66.64
|
| Rate for Payer: United Healthcare Commercial |
$61.78
|
| Rate for Payer: United Healthcare Medicare |
$25.09
|
|
|
IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHL NEBU
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 00487020101
|
| Hospital Charge Code |
30510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna Commercial |
$1.69
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna All Commercial |
$1.69
|
| Rate for Payer: CORVEL All Commercial |
$1.82
|
| Rate for Payer: Coventry All Commercial |
$1.72
|
| Rate for Payer: Encore All Commercial |
$1.80
|
| Rate for Payer: Frontpath All Commercial |
$1.80
|
| Rate for Payer: Humana ChoiceCare |
$1.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.76
|
| Rate for Payer: PHCS All Commercial |
$1.46
|
| Rate for Payer: PHP All Commercial |
$1.48
|
| Rate for Payer: Sagamore Health Network All Products |
$1.51
|
| Rate for Payer: Signature Care EPO |
$1.62
|
| Rate for Payer: Signature Care PPO |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
|
|
IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHL NEBU
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 00487020101
|
| Hospital Charge Code |
30510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.65
|
| Rate for Payer: Aetna Medicare |
$0.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Centivo All Commercial |
$1.06
|
| Rate for Payer: Cigna All Commercial |
$1.69
|
| Rate for Payer: CORVEL All Commercial |
$1.82
|
| Rate for Payer: Coventry All Commercial |
$1.72
|
| Rate for Payer: Encore All Commercial |
$1.80
|
| Rate for Payer: Frontpath All Commercial |
$1.80
|
| Rate for Payer: Humana ChoiceCare |
$1.69
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Lucent All Commercial |
$1.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.76
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.46
|
| Rate for Payer: PHP All Commercial |
$1.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$1.51
|
| Rate for Payer: Signature Care EPO |
$1.62
|
| Rate for Payer: Signature Care PPO |
$1.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
|
|
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST
|
Facility
|
OP
|
$1,039.54
|
|
|
Service Code
|
NDC 00597002402
|
| Hospital Charge Code |
170346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$322.26 |
| Max. Negotiated Rate |
$966.78 |
| Rate for Payer: Aetna Commercial |
$877.38
|
| Rate for Payer: Aetna Medicare |
$332.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$322.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$597.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$649.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$382.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$365.92
|
| Rate for Payer: Cash Price |
$623.73
|
| Rate for Payer: Centivo All Commercial |
$565.51
|
| Rate for Payer: Cigna All Commercial |
$897.13
|
| Rate for Payer: CORVEL All Commercial |
$966.78
|
| Rate for Payer: Coventry All Commercial |
$914.80
|
| Rate for Payer: Encore All Commercial |
$956.90
|
| Rate for Payer: Frontpath All Commercial |
$956.38
|
| Rate for Payer: Humana ChoiceCare |
$897.85
|
| Rate for Payer: Humana Medicare |
$332.65
|
| Rate for Payer: Lucent All Commercial |
$565.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$935.59
|
| Rate for Payer: PHCS All Commercial |
$779.66
|
| Rate for Payer: PHP All Commercial |
$788.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$405.42
|
| Rate for Payer: Sagamore Health Network All Products |
$802.53
|
| Rate for Payer: Signature Care EPO |
$862.82
|
| Rate for Payer: Signature Care PPO |
$914.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$883.61
|
| Rate for Payer: United Healthcare Commercial |
$819.16
|
| Rate for Payer: United Healthcare Medicare |
$332.65
|
|
|
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST
|
Facility
|
IP
|
$1,039.54
|
|
|
Service Code
|
NDC 00597002402
|
| Hospital Charge Code |
170346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$779.66 |
| Max. Negotiated Rate |
$966.78 |
| Rate for Payer: Aetna Commercial |
$898.17
|
| Rate for Payer: Cash Price |
$623.73
|
| Rate for Payer: Cigna All Commercial |
$897.13
|
| Rate for Payer: CORVEL All Commercial |
$966.78
|
| Rate for Payer: Coventry All Commercial |
$914.80
|
| Rate for Payer: Encore All Commercial |
$956.90
|
| Rate for Payer: Frontpath All Commercial |
$956.38
|
| Rate for Payer: Humana ChoiceCare |
$897.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$935.59
|
| Rate for Payer: PHCS All Commercial |
$779.66
|
| Rate for Payer: PHP All Commercial |
$788.39
|
| Rate for Payer: Sagamore Health Network All Products |
$802.53
|
| Rate for Payer: Signature Care EPO |
$862.82
|
| Rate for Payer: Signature Care PPO |
$914.80
|
| Rate for Payer: United Healthcare Commercial |
$819.16
|
|
|
IPRATROPIUM BROMIDE 0.02 % INHL SOLN
|
Facility
|
IP
|
$1.82
|
|
|
Service Code
|
NDC 00487980101
|
| Hospital Charge Code |
12580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
IPRATROPIUM BROMIDE 0.02 % INHL SOLN
|
Facility
|
OP
|
$1.82
|
|
|
Service Code
|
NDC 00487980101
|
| Hospital Charge Code |
12580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$0.56
|
| 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 |
$1.09
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Centivo All Commercial |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| 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 |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL HFAA
|
Facility
|
OP
|
$632.85
|
|
|
Service Code
|
NDC 00597008717
|
| Hospital Charge Code |
41142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.18 |
| Max. Negotiated Rate |
$588.55 |
| Rate for Payer: Aetna Commercial |
$534.12
|
| Rate for Payer: Aetna Medicare |
$202.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$196.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$363.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$395.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$232.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$222.76
|
| Rate for Payer: Cash Price |
$379.71
|
| Rate for Payer: Centivo All Commercial |
$344.27
|
| Rate for Payer: Cigna All Commercial |
$546.15
|
| Rate for Payer: CORVEL All Commercial |
$588.55
|
| Rate for Payer: Coventry All Commercial |
$556.90
|
| Rate for Payer: Encore All Commercial |
$582.53
|
| Rate for Payer: Frontpath All Commercial |
$582.22
|
| Rate for Payer: Humana ChoiceCare |
$546.59
|
| Rate for Payer: Humana Medicare |
$202.51
|
| Rate for Payer: Lucent All Commercial |
$344.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$569.56
|
| Rate for Payer: PHCS All Commercial |
$474.63
|
| Rate for Payer: PHP All Commercial |
$479.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$246.81
|
| Rate for Payer: Sagamore Health Network All Products |
$488.56
|
| Rate for Payer: Signature Care EPO |
$525.26
|
| Rate for Payer: Signature Care PPO |
$556.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$537.92
|
| Rate for Payer: United Healthcare Commercial |
$498.68
|
| Rate for Payer: United Healthcare Medicare |
$202.51
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL HFAA
|
Facility
|
IP
|
$632.85
|
|
|
Service Code
|
NDC 00597008717
|
| Hospital Charge Code |
41142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$474.63 |
| Max. Negotiated Rate |
$588.55 |
| Rate for Payer: Aetna Commercial |
$546.78
|
| Rate for Payer: Cash Price |
$379.71
|
| Rate for Payer: Cigna All Commercial |
$546.15
|
| Rate for Payer: CORVEL All Commercial |
$588.55
|
| Rate for Payer: Coventry All Commercial |
$556.90
|
| Rate for Payer: Encore All Commercial |
$582.53
|
| Rate for Payer: Frontpath All Commercial |
$582.22
|
| Rate for Payer: Humana ChoiceCare |
$546.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$569.56
|
| Rate for Payer: PHCS All Commercial |
$474.63
|
| Rate for Payer: PHP All Commercial |
$479.95
|
| Rate for Payer: Sagamore Health Network All Products |
$488.56
|
| Rate for Payer: Signature Care EPO |
$525.26
|
| Rate for Payer: Signature Care PPO |
$556.90
|
| Rate for Payer: United Healthcare Commercial |
$498.68
|
|
|
IRON DEXTRAN 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$244.55
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
184397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$183.41 |
| Max. Negotiated Rate |
$227.43 |
| Rate for Payer: Aetna Commercial |
$211.29
|
| Rate for Payer: Cash Price |
$146.73
|
| Rate for Payer: Cigna All Commercial |
$211.05
|
| Rate for Payer: CORVEL All Commercial |
$227.43
|
| Rate for Payer: Coventry All Commercial |
$215.21
|
| Rate for Payer: Encore All Commercial |
$225.11
|
| Rate for Payer: Frontpath All Commercial |
$224.99
|
| Rate for Payer: Humana ChoiceCare |
$211.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$220.10
|
| Rate for Payer: PHCS All Commercial |
$183.41
|
| Rate for Payer: PHP All Commercial |
$185.47
|
| Rate for Payer: Sagamore Health Network All Products |
$188.79
|
| Rate for Payer: Signature Care EPO |
$202.98
|
| Rate for Payer: Signature Care PPO |
$215.21
|
| Rate for Payer: United Healthcare Commercial |
$192.71
|
|
|
IRON DEXTRAN 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$244.55
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
184397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.81 |
| Max. Negotiated Rate |
$227.43 |
| Rate for Payer: Aetna Commercial |
$206.40
|
| Rate for Payer: Aetna Medicare |
$78.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$75.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$140.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$152.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.08
|
| Rate for Payer: Cash Price |
$146.73
|
| Rate for Payer: Centivo All Commercial |
$133.04
|
| Rate for Payer: Cigna All Commercial |
$211.05
|
| Rate for Payer: CORVEL All Commercial |
$227.43
|
| Rate for Payer: Coventry All Commercial |
$215.21
|
| Rate for Payer: Encore All Commercial |
$225.11
|
| Rate for Payer: Frontpath All Commercial |
$224.99
|
| Rate for Payer: Humana ChoiceCare |
$211.22
|
| Rate for Payer: Humana Medicare |
$78.26
|
| Rate for Payer: Lucent All Commercial |
$133.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$220.10
|
| Rate for Payer: PHCS All Commercial |
$183.41
|
| Rate for Payer: PHP All Commercial |
$185.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$95.38
|
| Rate for Payer: Sagamore Health Network All Products |
$188.79
|
| Rate for Payer: Signature Care EPO |
$202.98
|
| Rate for Payer: Signature Care PPO |
$215.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$207.87
|
| Rate for Payer: United Healthcare Commercial |
$192.71
|
| Rate for Payer: United Healthcare Medicare |
$78.26
|
|
|
IRON SUCROSE 100 MG IRON/5 ML IV SOLN
|
Facility
|
IP
|
$271.29
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.46 |
| Max. Negotiated Rate |
$252.30 |
| Rate for Payer: Aetna Commercial |
$234.39
|
| Rate for Payer: Cash Price |
$162.77
|
| Rate for Payer: Cigna All Commercial |
$234.12
|
| Rate for Payer: CORVEL All Commercial |
$252.30
|
| Rate for Payer: Coventry All Commercial |
$238.73
|
| Rate for Payer: Encore All Commercial |
$249.72
|
| Rate for Payer: Frontpath All Commercial |
$249.58
|
| Rate for Payer: Humana ChoiceCare |
$234.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$244.16
|
| Rate for Payer: PHCS All Commercial |
$203.46
|
| Rate for Payer: PHP All Commercial |
$205.74
|
| Rate for Payer: Sagamore Health Network All Products |
$209.43
|
| Rate for Payer: Signature Care EPO |
$225.17
|
| Rate for Payer: Signature Care PPO |
$238.73
|
| Rate for Payer: United Healthcare Commercial |
$213.77
|
|
|
IRON SUCROSE 100 MG IRON/5 ML IV SOLN
|
Facility
|
OP
|
$271.29
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$252.30 |
| Rate for Payer: Aetna Commercial |
$228.96
|
| Rate for Payer: Aetna Medicare |
$86.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$84.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$155.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$169.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$99.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$95.49
|
| Rate for Payer: Cash Price |
$162.77
|
| Rate for Payer: Cash Price |
$162.77
|
| Rate for Payer: Centivo All Commercial |
$147.58
|
| Rate for Payer: Cigna All Commercial |
$234.12
|
| Rate for Payer: CORVEL All Commercial |
$252.30
|
| Rate for Payer: Coventry All Commercial |
$238.73
|
| Rate for Payer: Encore All Commercial |
$249.72
|
| Rate for Payer: Frontpath All Commercial |
$249.58
|
| Rate for Payer: Humana ChoiceCare |
$234.31
|
| Rate for Payer: Humana Medicare |
$86.81
|
| Rate for Payer: Lucent All Commercial |
$147.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$244.16
|
| Rate for Payer: Managed Health Services Medicaid |
$0.38
|
| Rate for Payer: MDWise Medicaid |
$0.38
|
| Rate for Payer: PHCS All Commercial |
$203.46
|
| Rate for Payer: PHP All Commercial |
$205.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$105.80
|
| Rate for Payer: Sagamore Health Network All Products |
$209.43
|
| Rate for Payer: Signature Care EPO |
$225.17
|
| Rate for Payer: Signature Care PPO |
$238.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$230.59
|
| Rate for Payer: United Healthcare Commercial |
$213.77
|
| Rate for Payer: United Healthcare Medicare |
$86.81
|
|
|
ISONIAZID 300 MG ORAL TAB
|
Facility
|
OP
|
$7.94
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Aetna Commercial |
$6.70
|
| Rate for Payer: Aetna Medicare |
$2.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Centivo All Commercial |
$4.32
|
| Rate for Payer: Cigna All Commercial |
$6.85
|
| Rate for Payer: CORVEL All Commercial |
$7.38
|
| Rate for Payer: Coventry All Commercial |
$6.99
|
| Rate for Payer: Encore All Commercial |
$7.31
|
| Rate for Payer: Frontpath All Commercial |
$7.30
|
| Rate for Payer: Humana ChoiceCare |
$6.86
|
| Rate for Payer: Humana Medicare |
$2.54
|
| Rate for Payer: Lucent All Commercial |
$4.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$5.95
|
| Rate for Payer: PHP All Commercial |
$6.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.10
|
| Rate for Payer: Sagamore Health Network All Products |
$6.13
|
| Rate for Payer: Signature Care EPO |
$6.59
|
| Rate for Payer: Signature Care PPO |
$6.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.75
|
| Rate for Payer: United Healthcare Commercial |
$6.26
|
| Rate for Payer: United Healthcare Medicare |
$2.54
|
|
|
ISONIAZID 300 MG ORAL TAB
|
Facility
|
IP
|
$7.94
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Aetna Commercial |
$6.86
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cigna All Commercial |
$6.85
|
| Rate for Payer: CORVEL All Commercial |
$7.38
|
| Rate for Payer: Coventry All Commercial |
$6.99
|
| Rate for Payer: Encore All Commercial |
$7.31
|
| Rate for Payer: Frontpath All Commercial |
$7.30
|
| Rate for Payer: Humana ChoiceCare |
$6.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$5.95
|
| Rate for Payer: PHP All Commercial |
$6.02
|
| Rate for Payer: Sagamore Health Network All Products |
$6.13
|
| Rate for Payer: Signature Care EPO |
$6.59
|
| Rate for Payer: Signature Care PPO |
$6.99
|
| Rate for Payer: United Healthcare Commercial |
$6.26
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 50268044815
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Centivo All Commercial |
$2.24
|
| Rate for Payer: Cigna All Commercial |
$3.56
|
| Rate for Payer: CORVEL All Commercial |
$3.83
|
| Rate for Payer: Coventry All Commercial |
$3.63
|
| Rate for Payer: Encore All Commercial |
$3.80
|
| Rate for Payer: Frontpath All Commercial |
$3.79
|
| Rate for Payer: Humana ChoiceCare |
$3.56
|
| Rate for Payer: Humana Medicare |
$1.32
|
| Rate for Payer: Lucent All Commercial |
$2.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.71
|
| Rate for Payer: PHCS All Commercial |
$3.09
|
| Rate for Payer: PHP All Commercial |
$3.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.61
|
| Rate for Payer: Sagamore Health Network All Products |
$3.18
|
| Rate for Payer: Signature Care EPO |
$3.42
|
| Rate for Payer: Signature Care PPO |
$3.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.50
|
| Rate for Payer: United Healthcare Commercial |
$3.25
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 50268044811
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna All Commercial |
$3.56
|
| Rate for Payer: CORVEL All Commercial |
$3.83
|
| Rate for Payer: Coventry All Commercial |
$3.63
|
| Rate for Payer: Encore All Commercial |
$3.80
|
| Rate for Payer: Frontpath All Commercial |
$3.79
|
| Rate for Payer: Humana ChoiceCare |
$3.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.71
|
| Rate for Payer: PHCS All Commercial |
$3.09
|
| Rate for Payer: PHP All Commercial |
$3.13
|
| Rate for Payer: Sagamore Health Network All Products |
$3.18
|
| Rate for Payer: Signature Care EPO |
$3.42
|
| Rate for Payer: Signature Care PPO |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$3.25
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 50268044811
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Centivo All Commercial |
$2.24
|
| Rate for Payer: Cigna All Commercial |
$3.56
|
| Rate for Payer: CORVEL All Commercial |
$3.83
|
| Rate for Payer: Coventry All Commercial |
$3.63
|
| Rate for Payer: Encore All Commercial |
$3.80
|
| Rate for Payer: Frontpath All Commercial |
$3.79
|
| Rate for Payer: Humana ChoiceCare |
$3.56
|
| Rate for Payer: Humana Medicare |
$1.32
|
| Rate for Payer: Lucent All Commercial |
$2.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.71
|
| Rate for Payer: PHCS All Commercial |
$3.09
|
| Rate for Payer: PHP All Commercial |
$3.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.61
|
| Rate for Payer: Sagamore Health Network All Products |
$3.18
|
| Rate for Payer: Signature Care EPO |
$3.42
|
| Rate for Payer: Signature Care PPO |
$3.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.50
|
| Rate for Payer: United Healthcare Commercial |
$3.25
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 50268044815
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna All Commercial |
$3.56
|
| Rate for Payer: CORVEL All Commercial |
$3.83
|
| Rate for Payer: Coventry All Commercial |
$3.63
|
| Rate for Payer: Encore All Commercial |
$3.80
|
| Rate for Payer: Frontpath All Commercial |
$3.79
|
| Rate for Payer: Humana ChoiceCare |
$3.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.71
|
| Rate for Payer: PHCS All Commercial |
$3.09
|
| Rate for Payer: PHP All Commercial |
$3.13
|
| Rate for Payer: Sagamore Health Network All Products |
$3.18
|
| Rate for Payer: Signature Care EPO |
$3.42
|
| Rate for Payer: Signature Care PPO |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$3.25
|
|
|
ISOSORBIDE MONONITRATE 30 MG ORAL TB24
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 00904644961
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.23
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.51
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Centivo All Commercial |
$0.79
|
| Rate for Payer: Cigna All Commercial |
$1.26
|
| Rate for Payer: CORVEL All Commercial |
$1.35
|
| Rate for Payer: Coventry All Commercial |
$1.28
|
| Rate for Payer: Encore All Commercial |
$1.34
|
| Rate for Payer: Frontpath All Commercial |
$1.34
|
| Rate for Payer: Humana ChoiceCare |
$1.26
|
| Rate for Payer: Humana Medicare |
$0.47
|
| Rate for Payer: Lucent All Commercial |
$0.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.31
|
| Rate for Payer: PHCS All Commercial |
$1.09
|
| Rate for Payer: PHP All Commercial |
$1.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.57
|
| Rate for Payer: Sagamore Health Network All Products |
$1.12
|
| Rate for Payer: Signature Care EPO |
$1.21
|
| Rate for Payer: Signature Care PPO |
$1.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
|
|
ISOSORBIDE MONONITRATE 30 MG ORAL TB24
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 00904644961
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.26
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna All Commercial |
$1.26
|
| Rate for Payer: CORVEL All Commercial |
$1.35
|
| Rate for Payer: Coventry All Commercial |
$1.28
|
| Rate for Payer: Encore All Commercial |
$1.34
|
| Rate for Payer: Frontpath All Commercial |
$1.34
|
| Rate for Payer: Humana ChoiceCare |
$1.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.31
|
| Rate for Payer: PHCS All Commercial |
$1.09
|
| Rate for Payer: PHP All Commercial |
$1.10
|
| Rate for Payer: Sagamore Health Network All Products |
$1.12
|
| Rate for Payer: Signature Care EPO |
$1.21
|
| Rate for Payer: Signature Care PPO |
$1.28
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYRG
|
Facility
|
OP
|
$282.10
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
152711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$262.35 |
| Rate for Payer: Aetna Commercial |
$238.09
|
| Rate for Payer: Aetna Medicare |
$90.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$162.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$176.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.30
|
| Rate for Payer: Cash Price |
$169.26
|
| Rate for Payer: Cash Price |
$169.26
|
| Rate for Payer: Centivo All Commercial |
$153.46
|
| Rate for Payer: Cigna All Commercial |
$243.45
|
| Rate for Payer: CORVEL All Commercial |
$262.35
|
| Rate for Payer: Coventry All Commercial |
$248.25
|
| Rate for Payer: Encore All Commercial |
$259.67
|
| Rate for Payer: Frontpath All Commercial |
$259.53
|
| Rate for Payer: Humana ChoiceCare |
$243.65
|
| Rate for Payer: Humana Medicare |
$90.27
|
| Rate for Payer: Lucent All Commercial |
$153.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.89
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$211.57
|
| Rate for Payer: PHP All Commercial |
$213.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.02
|
| Rate for Payer: Sagamore Health Network All Products |
$217.78
|
| Rate for Payer: Signature Care EPO |
$234.14
|
| Rate for Payer: Signature Care PPO |
$248.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$239.78
|
| Rate for Payer: United Healthcare Commercial |
$222.29
|
| Rate for Payer: United Healthcare Medicare |
$90.27
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYRG
|
Facility
|
IP
|
$282.10
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
152711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$211.57 |
| Max. Negotiated Rate |
$262.35 |
| Rate for Payer: Aetna Commercial |
$243.73
|
| Rate for Payer: Cash Price |
$169.26
|
| Rate for Payer: Cigna All Commercial |
$243.45
|
| Rate for Payer: CORVEL All Commercial |
$262.35
|
| Rate for Payer: Coventry All Commercial |
$248.25
|
| Rate for Payer: Encore All Commercial |
$259.67
|
| Rate for Payer: Frontpath All Commercial |
$259.53
|
| Rate for Payer: Humana ChoiceCare |
$243.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.89
|
| Rate for Payer: PHCS All Commercial |
$211.57
|
| Rate for Payer: PHP All Commercial |
$213.94
|
| Rate for Payer: Sagamore Health Network All Products |
$217.78
|
| Rate for Payer: Signature Care EPO |
$234.14
|
| Rate for Payer: Signature Care PPO |
$248.25
|
| Rate for Payer: United Healthcare Commercial |
$222.29
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$19.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$18.10 |
| Rate for Payer: Aetna Commercial |
$16.42
|
| Rate for Payer: Aetna Medicare |
$6.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.85
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Centivo All Commercial |
$10.59
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Humana Medicare |
$6.23
|
| Rate for Payer: Lucent All Commercial |
$10.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.59
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.54
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
| Rate for Payer: United Healthcare Medicare |
$6.23
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$19.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$18.10 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
|
