|
Hysteroscopy, surgical; with removal of leiomyomata
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 58561
|
| Hospital Charge Code |
CPT-58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 58558
|
| Hospital Charge Code |
CPT-58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
IBANDRONATE 150 MG ORAL TAB
|
Facility
OP
|
$120.96
|
|
|
Service Code
|
NDC 55111057503
|
| Hospital Charge Code |
41063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.92 |
| Max. Negotiated Rate |
$112.49 |
| Rate for Payer: Aetna Commercial |
$102.09
|
| Rate for Payer: Aetna Medicare |
$39.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$69.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$45.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$43.91
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Centivo All Commercial |
$61.69
|
| 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 |
$61.69
|
| Rate for Payer: Lucent All Commercial |
$61.69
|
| 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 |
$39.92
|
|
|
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 |
$75.00
|
| 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
OP
|
$49.56
|
|
|
Service Code
|
NDC 50580060121
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$46.09 |
| Rate for Payer: Aetna Commercial |
$41.83
|
| Rate for Payer: Aetna Medicare |
$16.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.99
|
| Rate for Payer: Cash Price |
$30.73
|
| Rate for Payer: Centivo All Commercial |
$25.28
|
| Rate for Payer: Cigna All Commercial |
$42.77
|
| Rate for Payer: CORVEL All Commercial |
$46.09
|
| Rate for Payer: Coventry All Commercial |
$43.61
|
| Rate for Payer: Encore All Commercial |
$45.62
|
| Rate for Payer: Frontpath All Commercial |
$45.60
|
| Rate for Payer: Humana ChoiceCare |
$42.80
|
| Rate for Payer: Humana Medicare |
$25.28
|
| Rate for Payer: Lucent All Commercial |
$25.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.60
|
| Rate for Payer: PHCS All Commercial |
$37.17
|
| Rate for Payer: PHP All Commercial |
$37.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.33
|
| Rate for Payer: Sagamore Health Network All Products |
$38.26
|
| Rate for Payer: Signature Care EPO |
$41.13
|
| Rate for Payer: Signature Care PPO |
$43.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.13
|
| Rate for Payer: United Healthcare Commercial |
$39.05
|
| Rate for Payer: United Healthcare Medicare |
$16.35
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 00121091400
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Centivo All Commercial |
$1.96
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.58
|
| Rate for Payer: Coventry All Commercial |
$3.39
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.33
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Lucent All Commercial |
$1.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.89
|
| Rate for Payer: PHP All Commercial |
$2.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.50
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.20
|
| Rate for Payer: Signature Care PPO |
$3.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.27
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
IP
|
$49.56
|
|
|
Service Code
|
NDC 50580060121
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.17 |
| Max. Negotiated Rate |
$46.09 |
| Rate for Payer: Aetna Commercial |
$42.82
|
| Rate for Payer: Cash Price |
$30.73
|
| Rate for Payer: Cigna All Commercial |
$42.77
|
| Rate for Payer: CORVEL All Commercial |
$46.09
|
| Rate for Payer: Coventry All Commercial |
$43.61
|
| Rate for Payer: Encore All Commercial |
$45.62
|
| Rate for Payer: Frontpath All Commercial |
$45.60
|
| Rate for Payer: Humana ChoiceCare |
$42.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.60
|
| Rate for Payer: PHCS All Commercial |
$37.17
|
| Rate for Payer: PHP All Commercial |
$37.59
|
| Rate for Payer: Sagamore Health Network All Products |
$38.26
|
| Rate for Payer: Signature Care EPO |
$41.13
|
| Rate for Payer: Signature Care PPO |
$43.61
|
| Rate for Payer: United Healthcare Commercial |
$39.05
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 00121091405
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.58
|
| Rate for Payer: Coventry All Commercial |
$3.39
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.89
|
| Rate for Payer: PHP All Commercial |
$2.92
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.20
|
| Rate for Payer: Signature Care PPO |
$3.39
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 00121091405
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Centivo All Commercial |
$1.96
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.58
|
| Rate for Payer: Coventry All Commercial |
$3.39
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.33
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Lucent All Commercial |
$1.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.89
|
| Rate for Payer: PHP All Commercial |
$2.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.50
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.20
|
| Rate for Payer: Signature Care PPO |
$3.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.27
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSP
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 00121091400
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna All Commercial |
$3.32
|
| Rate for Payer: CORVEL All Commercial |
$3.58
|
| Rate for Payer: Coventry All Commercial |
$3.39
|
| Rate for Payer: Encore All Commercial |
$3.54
|
| Rate for Payer: Frontpath All Commercial |
$3.54
|
| Rate for Payer: Humana ChoiceCare |
$3.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.46
|
| Rate for Payer: PHCS All Commercial |
$2.89
|
| Rate for Payer: PHP All Commercial |
$2.92
|
| Rate for Payer: Sagamore Health Network All Products |
$2.97
|
| Rate for Payer: Signature Care EPO |
$3.20
|
| Rate for Payer: Signature Care PPO |
$3.39
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
|
|
IBUPROFEN 200 MG ORAL TAB
|
Facility
IP
|
$0.39
|
|
|
Service Code
|
NDC 00904791461
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna All Commercial |
$0.33
|
| Rate for Payer: CORVEL All Commercial |
$0.36
|
| Rate for Payer: Coventry All Commercial |
$0.34
|
| Rate for Payer: Encore All Commercial |
$0.35
|
| Rate for Payer: Frontpath All Commercial |
$0.35
|
| Rate for Payer: Humana ChoiceCare |
$0.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.35
|
| Rate for Payer: PHCS All Commercial |
$0.29
|
| Rate for Payer: PHP All Commercial |
$0.29
|
| Rate for Payer: Sagamore Health Network All Products |
$0.30
|
| Rate for Payer: Signature Care EPO |
$0.32
|
| Rate for Payer: Signature Care PPO |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
|
|
IBUPROFEN 200 MG ORAL TAB
|
Facility
OP
|
$0.39
|
|
|
Service Code
|
NDC 00904791461
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.24
|
| 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 |
$0.20
|
| Rate for Payer: Cigna All Commercial |
$0.33
|
| Rate for Payer: CORVEL All Commercial |
$0.36
|
| Rate for Payer: Coventry All Commercial |
$0.34
|
| Rate for Payer: Encore All Commercial |
$0.35
|
| Rate for Payer: Frontpath All Commercial |
$0.35
|
| Rate for Payer: Humana ChoiceCare |
$0.33
|
| Rate for Payer: Humana Medicare |
$0.20
|
| Rate for Payer: Lucent All Commercial |
$0.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.35
|
| Rate for Payer: PHCS All Commercial |
$0.29
|
| Rate for Payer: PHP All Commercial |
$0.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.15
|
| Rate for Payer: Sagamore Health Network All Products |
$0.30
|
| Rate for Payer: Signature Care EPO |
$0.32
|
| Rate for Payer: Signature Care PPO |
$0.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
|
|
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 |
$0.62
|
| 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 |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
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 |
$0.62
|
| 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 |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN
|
Facility
OP
|
$1,064.88
|
|
|
Service Code
|
HCPCS J1742
|
| Hospital Charge Code |
16156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$313.22 |
| Max. Negotiated Rate |
$990.34 |
| Rate for Payer: Aetna Commercial |
$898.76
|
| Rate for Payer: Aetna Medicare |
$351.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$351.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$611.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$665.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$313.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$404.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$386.55
|
| Rate for Payer: Cash Price |
$660.23
|
| Rate for Payer: Cash Price |
$660.23
|
| Rate for Payer: Centivo All Commercial |
$543.09
|
| Rate for Payer: Cigna All Commercial |
$918.99
|
| Rate for Payer: CORVEL All Commercial |
$990.34
|
| Rate for Payer: Coventry All Commercial |
$937.09
|
| Rate for Payer: Encore All Commercial |
$980.22
|
| Rate for Payer: Frontpath All Commercial |
$979.69
|
| Rate for Payer: Humana ChoiceCare |
$919.74
|
| Rate for Payer: Humana Medicare |
$543.09
|
| Rate for Payer: Lucent All Commercial |
$543.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$958.39
|
| Rate for Payer: Managed Health Services Medicaid |
$313.22
|
| Rate for Payer: MDWise Medicaid |
$313.22
|
| Rate for Payer: PHCS All Commercial |
$798.66
|
| Rate for Payer: PHP All Commercial |
$807.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$415.30
|
| Rate for Payer: Sagamore Health Network All Products |
$822.09
|
| Rate for Payer: Signature Care EPO |
$883.85
|
| Rate for Payer: Signature Care PPO |
$937.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$905.15
|
| Rate for Payer: United Healthcare Commercial |
$839.13
|
| Rate for Payer: United Healthcare Medicare |
$351.41
|
|
|
IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN
|
Facility
IP
|
$1,064.88
|
|
|
Service Code
|
HCPCS J1742
|
| Hospital Charge Code |
16156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$798.66 |
| Max. Negotiated Rate |
$990.34 |
| Rate for Payer: Aetna Commercial |
$920.06
|
| Rate for Payer: Cash Price |
$660.23
|
| Rate for Payer: Cigna All Commercial |
$918.99
|
| Rate for Payer: CORVEL All Commercial |
$990.34
|
| Rate for Payer: Coventry All Commercial |
$937.09
|
| Rate for Payer: Encore All Commercial |
$980.22
|
| Rate for Payer: Frontpath All Commercial |
$979.69
|
| Rate for Payer: Humana ChoiceCare |
$919.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$958.39
|
| Rate for Payer: PHCS All Commercial |
$798.66
|
| Rate for Payer: PHP All Commercial |
$807.60
|
| Rate for Payer: Sagamore Health Network All Products |
$822.09
|
| Rate for Payer: Signature Care EPO |
$883.85
|
| Rate for Payer: Signature Care PPO |
$937.09
|
| Rate for Payer: United Healthcare Commercial |
$839.13
|
|
|
Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 10030
|
| Hospital Charge Code |
CPT-10030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
IMDEVIMAB (REGN10987) 120 MG/ML IV SOLN
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0244
|
| Hospital Charge Code |
193082
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
IMDEVIMAB (REGN10987) 120 MG/ML IV SOLN
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0244
|
| Hospital Charge Code |
193082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
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 |
$3,945.06
|
| 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
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 |
$1,199.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,199.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,088.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,272.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$55.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,379.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,319.87
|
| Rate for Payer: Cash Price |
$2,254.32
|
| Rate for Payer: Cash Price |
$2,254.32
|
| Rate for Payer: Centivo All Commercial |
$1,854.36
|
| 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 |
$1,854.36
|
| Rate for Payer: Lucent All Commercial |
$1,854.36
|
| 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 |
$1,199.88
|
|
|
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 |
$2,099.79 |
| Max. Negotiated Rate |
$5,917.59 |
| Rate for Payer: Aetna Commercial |
$5,370.37
|
| Rate for Payer: Aetna Medicare |
$2,099.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,099.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$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 |
$2,414.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,309.77
|
| Rate for Payer: Cash Price |
$3,945.06
|
| Rate for Payer: Centivo All Commercial |
$3,245.13
|
| 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 |
$3,245.13
|
| Rate for Payer: Lucent All Commercial |
$3,245.13
|
| 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 |
$2,099.79
|
|
|
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 |
$2,254.32
|
| 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
|
|
