|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
IP
|
$1,850.00
|
|
|
Service Code
|
NDC 13533033512
|
| Hospital Charge Code |
173186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$1,720.50 |
| Rate for Payer: Aetna Commercial |
$1,598.40
|
| Rate for Payer: Cash Price |
$1,147.00
|
| Rate for Payer: Cigna All Commercial |
$1,596.55
|
| Rate for Payer: CORVEL All Commercial |
$1,720.50
|
| Rate for Payer: Coventry All Commercial |
$1,628.00
|
| Rate for Payer: Encore All Commercial |
$1,702.92
|
| Rate for Payer: Frontpath All Commercial |
$1,702.00
|
| Rate for Payer: Humana ChoiceCare |
$1,597.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,665.00
|
| Rate for Payer: PHCS All Commercial |
$1,387.50
|
| Rate for Payer: PHP All Commercial |
$1,403.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1,428.20
|
| Rate for Payer: Signature Care EPO |
$1,535.50
|
| Rate for Payer: Signature Care PPO |
$1,628.00
|
| Rate for Payer: United Healthcare Commercial |
$1,457.80
|
|
|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
OP
|
$1,850.00
|
|
|
Service Code
|
NDC 13533033512
|
| Hospital Charge Code |
173186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$610.50 |
| Max. Negotiated Rate |
$1,720.50 |
| Rate for Payer: Aetna Commercial |
$1,561.40
|
| Rate for Payer: Aetna Medicare |
$610.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$610.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,062.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,156.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$702.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$671.55
|
| Rate for Payer: Cash Price |
$1,147.00
|
| Rate for Payer: Centivo All Commercial |
$943.50
|
| Rate for Payer: Cigna All Commercial |
$1,596.55
|
| Rate for Payer: CORVEL All Commercial |
$1,720.50
|
| Rate for Payer: Coventry All Commercial |
$1,628.00
|
| Rate for Payer: Encore All Commercial |
$1,702.92
|
| Rate for Payer: Frontpath All Commercial |
$1,702.00
|
| Rate for Payer: Humana ChoiceCare |
$1,597.84
|
| Rate for Payer: Humana Medicare |
$943.50
|
| Rate for Payer: Lucent All Commercial |
$943.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,665.00
|
| Rate for Payer: PHCS All Commercial |
$1,387.50
|
| Rate for Payer: PHP All Commercial |
$1,403.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$721.50
|
| Rate for Payer: Sagamore Health Network All Products |
$1,428.20
|
| Rate for Payer: Signature Care EPO |
$1,535.50
|
| Rate for Payer: Signature Care PPO |
$1,628.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,572.50
|
| Rate for Payer: United Healthcare Commercial |
$1,457.80
|
| Rate for Payer: United Healthcare Medicare |
$610.50
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 10 GRAM/100 ML (10 %) INJ SOLN
|
Facility
IP
|
$3,916.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107753
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,937.64 |
| Max. Negotiated Rate |
$3,642.67 |
| Rate for Payer: Aetna Commercial |
$3,384.16
|
| Rate for Payer: Cash Price |
$2,428.45
|
| Rate for Payer: Cigna All Commercial |
$3,380.24
|
| Rate for Payer: CORVEL All Commercial |
$3,642.67
|
| Rate for Payer: Coventry All Commercial |
$3,446.83
|
| Rate for Payer: Encore All Commercial |
$3,605.46
|
| Rate for Payer: Frontpath All Commercial |
$3,603.50
|
| Rate for Payer: Humana ChoiceCare |
$3,382.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,525.16
|
| Rate for Payer: PHCS All Commercial |
$2,937.64
|
| Rate for Payer: PHP All Commercial |
$2,970.54
|
| Rate for Payer: Sagamore Health Network All Products |
$3,023.81
|
| Rate for Payer: Signature Care EPO |
$3,250.99
|
| Rate for Payer: Signature Care PPO |
$3,446.83
|
| Rate for Payer: United Healthcare Commercial |
$3,086.48
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 10 GRAM/100 ML (10 %) INJ SOLN
|
Facility
OP
|
$3,916.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107753
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.88 |
| Max. Negotiated Rate |
$3,642.67 |
| Rate for Payer: Aetna Commercial |
$3,305.82
|
| Rate for Payer: Aetna Medicare |
$1,292.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,292.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,249.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,448.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$71.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,486.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,421.82
|
| Rate for Payer: Cash Price |
$2,428.45
|
| Rate for Payer: Cash Price |
$2,428.45
|
| Rate for Payer: Centivo All Commercial |
$1,997.59
|
| Rate for Payer: Cigna All Commercial |
$3,380.24
|
| Rate for Payer: CORVEL All Commercial |
$3,642.67
|
| Rate for Payer: Coventry All Commercial |
$3,446.83
|
| Rate for Payer: Encore All Commercial |
$3,605.46
|
| Rate for Payer: Frontpath All Commercial |
$3,603.50
|
| Rate for Payer: Humana ChoiceCare |
$3,382.98
|
| Rate for Payer: Humana Medicare |
$1,997.59
|
| Rate for Payer: Lucent All Commercial |
$1,997.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,525.16
|
| Rate for Payer: Managed Health Services Medicaid |
$71.88
|
| Rate for Payer: MDWise Medicaid |
$71.88
|
| Rate for Payer: PHCS All Commercial |
$2,937.64
|
| Rate for Payer: PHP All Commercial |
$2,970.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,527.57
|
| Rate for Payer: Sagamore Health Network All Products |
$3,023.81
|
| Rate for Payer: Signature Care EPO |
$3,250.99
|
| Rate for Payer: Signature Care PPO |
$3,446.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,329.32
|
| Rate for Payer: United Healthcare Commercial |
$3,086.48
|
| Rate for Payer: United Healthcare Medicare |
$1,292.56
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 20 GRAM/200 ML (10 %) INJ SOLN
|
Facility
IP
|
$7,833.70
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,875.28 |
| Max. Negotiated Rate |
$7,285.34 |
| Rate for Payer: Aetna Commercial |
$6,768.32
|
| Rate for Payer: Cash Price |
$4,856.89
|
| Rate for Payer: Cigna All Commercial |
$6,760.48
|
| Rate for Payer: CORVEL All Commercial |
$7,285.34
|
| Rate for Payer: Coventry All Commercial |
$6,893.66
|
| Rate for Payer: Encore All Commercial |
$7,210.92
|
| Rate for Payer: Frontpath All Commercial |
$7,207.00
|
| Rate for Payer: Humana ChoiceCare |
$6,765.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,050.33
|
| Rate for Payer: PHCS All Commercial |
$5,875.28
|
| Rate for Payer: PHP All Commercial |
$5,941.08
|
| Rate for Payer: Sagamore Health Network All Products |
$6,047.62
|
| Rate for Payer: Signature Care EPO |
$6,501.97
|
| Rate for Payer: Signature Care PPO |
$6,893.66
|
| Rate for Payer: United Healthcare Commercial |
$6,172.96
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 20 GRAM/200 ML (10 %) INJ SOLN
|
Facility
OP
|
$7,833.70
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.88 |
| Max. Negotiated Rate |
$7,285.34 |
| Rate for Payer: Aetna Commercial |
$6,611.64
|
| Rate for Payer: Aetna Medicare |
$2,585.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,585.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,498.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,896.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$71.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,972.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,843.63
|
| Rate for Payer: Cash Price |
$4,856.89
|
| Rate for Payer: Cash Price |
$4,856.89
|
| Rate for Payer: Centivo All Commercial |
$3,995.19
|
| Rate for Payer: Cigna All Commercial |
$6,760.48
|
| Rate for Payer: CORVEL All Commercial |
$7,285.34
|
| Rate for Payer: Coventry All Commercial |
$6,893.66
|
| Rate for Payer: Encore All Commercial |
$7,210.92
|
| Rate for Payer: Frontpath All Commercial |
$7,207.00
|
| Rate for Payer: Humana ChoiceCare |
$6,765.97
|
| Rate for Payer: Humana Medicare |
$3,995.19
|
| Rate for Payer: Lucent All Commercial |
$3,995.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,050.33
|
| Rate for Payer: Managed Health Services Medicaid |
$71.88
|
| Rate for Payer: MDWise Medicaid |
$71.88
|
| Rate for Payer: PHCS All Commercial |
$5,875.28
|
| Rate for Payer: PHP All Commercial |
$5,941.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,055.14
|
| Rate for Payer: Sagamore Health Network All Products |
$6,047.62
|
| Rate for Payer: Signature Care EPO |
$6,501.97
|
| Rate for Payer: Signature Care PPO |
$6,893.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,658.64
|
| Rate for Payer: United Healthcare Commercial |
$6,172.96
|
| Rate for Payer: United Healthcare Medicare |
$2,585.12
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 40 GRAM/400 ML (10 %) INJ SOLN
|
Facility
IP
|
$15,667.40
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
170495
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,750.55 |
| Max. Negotiated Rate |
$14,570.68 |
| Rate for Payer: Aetna Commercial |
$13,536.63
|
| Rate for Payer: Cash Price |
$9,713.79
|
| Rate for Payer: Cigna All Commercial |
$13,520.97
|
| Rate for Payer: CORVEL All Commercial |
$14,570.68
|
| Rate for Payer: Coventry All Commercial |
$13,787.31
|
| Rate for Payer: Encore All Commercial |
$14,421.84
|
| Rate for Payer: Frontpath All Commercial |
$14,414.01
|
| Rate for Payer: Humana ChoiceCare |
$13,531.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,100.66
|
| Rate for Payer: PHCS All Commercial |
$11,750.55
|
| Rate for Payer: PHP All Commercial |
$11,882.16
|
| Rate for Payer: Sagamore Health Network All Products |
$12,095.23
|
| Rate for Payer: Signature Care EPO |
$13,003.94
|
| Rate for Payer: Signature Care PPO |
$13,787.31
|
| Rate for Payer: United Healthcare Commercial |
$12,345.91
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 40 GRAM/400 ML (10 %) INJ SOLN
|
Facility
OP
|
$15,667.40
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
170495
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.88 |
| Max. Negotiated Rate |
$14,570.68 |
| Rate for Payer: Aetna Commercial |
$13,223.29
|
| Rate for Payer: Aetna Medicare |
$5,170.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,170.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8,997.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,793.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$71.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,945.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,687.27
|
| Rate for Payer: Cash Price |
$9,713.79
|
| Rate for Payer: Cash Price |
$9,713.79
|
| Rate for Payer: Centivo All Commercial |
$7,990.37
|
| Rate for Payer: Cigna All Commercial |
$13,520.97
|
| Rate for Payer: CORVEL All Commercial |
$14,570.68
|
| Rate for Payer: Coventry All Commercial |
$13,787.31
|
| Rate for Payer: Encore All Commercial |
$14,421.84
|
| Rate for Payer: Frontpath All Commercial |
$14,414.01
|
| Rate for Payer: Humana ChoiceCare |
$13,531.93
|
| Rate for Payer: Humana Medicare |
$7,990.37
|
| Rate for Payer: Lucent All Commercial |
$7,990.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,100.66
|
| Rate for Payer: Managed Health Services Medicaid |
$71.88
|
| Rate for Payer: MDWise Medicaid |
$71.88
|
| Rate for Payer: PHCS All Commercial |
$11,750.55
|
| Rate for Payer: PHP All Commercial |
$11,882.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,110.29
|
| Rate for Payer: Sagamore Health Network All Products |
$12,095.23
|
| Rate for Payer: Signature Care EPO |
$13,003.94
|
| Rate for Payer: Signature Care PPO |
$13,787.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,317.29
|
| Rate for Payer: United Healthcare Commercial |
$12,345.91
|
| Rate for Payer: United Healthcare Medicare |
$5,170.24
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) INJ SOLN
|
Facility
OP
|
$2,238.20
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107752
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.88 |
| Max. Negotiated Rate |
$2,081.53 |
| Rate for Payer: Aetna Commercial |
$1,889.04
|
| Rate for Payer: Aetna Medicare |
$738.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$738.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,285.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,399.10
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$71.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$849.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$812.47
|
| Rate for Payer: Cash Price |
$1,387.68
|
| Rate for Payer: Cash Price |
$1,387.68
|
| Rate for Payer: Centivo All Commercial |
$1,141.48
|
| Rate for Payer: Cigna All Commercial |
$1,931.57
|
| Rate for Payer: CORVEL All Commercial |
$2,081.53
|
| Rate for Payer: Coventry All Commercial |
$1,969.62
|
| Rate for Payer: Encore All Commercial |
$2,060.26
|
| Rate for Payer: Frontpath All Commercial |
$2,059.14
|
| Rate for Payer: Humana ChoiceCare |
$1,933.13
|
| Rate for Payer: Humana Medicare |
$1,141.48
|
| Rate for Payer: Lucent All Commercial |
$1,141.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,014.38
|
| Rate for Payer: Managed Health Services Medicaid |
$71.88
|
| Rate for Payer: MDWise Medicaid |
$71.88
|
| Rate for Payer: PHCS All Commercial |
$1,678.65
|
| Rate for Payer: PHP All Commercial |
$1,697.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$872.90
|
| Rate for Payer: Sagamore Health Network All Products |
$1,727.89
|
| Rate for Payer: Signature Care EPO |
$1,857.71
|
| Rate for Payer: Signature Care PPO |
$1,969.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,902.47
|
| Rate for Payer: United Healthcare Commercial |
$1,763.70
|
| Rate for Payer: United Healthcare Medicare |
$738.61
|
|
|
IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) INJ SOLN
|
Facility
IP
|
$2,238.20
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,678.65 |
| Max. Negotiated Rate |
$2,081.53 |
| Rate for Payer: Aetna Commercial |
$1,933.80
|
| Rate for Payer: Cash Price |
$1,387.68
|
| Rate for Payer: Cigna All Commercial |
$1,931.57
|
| Rate for Payer: CORVEL All Commercial |
$2,081.53
|
| Rate for Payer: Coventry All Commercial |
$1,969.62
|
| Rate for Payer: Encore All Commercial |
$2,060.26
|
| Rate for Payer: Frontpath All Commercial |
$2,059.14
|
| Rate for Payer: Humana ChoiceCare |
$1,933.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,014.38
|
| Rate for Payer: PHCS All Commercial |
$1,678.65
|
| Rate for Payer: PHP All Commercial |
$1,697.45
|
| Rate for Payer: Sagamore Health Network All Products |
$1,727.89
|
| Rate for Payer: Signature Care EPO |
$1,857.71
|
| Rate for Payer: Signature Care PPO |
$1,969.62
|
| Rate for Payer: United Healthcare Commercial |
$1,763.70
|
|
|
IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % INJ SOLN
|
Facility
IP
|
$3,815.35
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
172845
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,861.51 |
| Max. Negotiated Rate |
$3,548.28 |
| Rate for Payer: Aetna Commercial |
$3,296.46
|
| Rate for Payer: Cash Price |
$2,365.52
|
| Rate for Payer: Cigna All Commercial |
$3,292.65
|
| Rate for Payer: CORVEL All Commercial |
$3,548.28
|
| Rate for Payer: Coventry All Commercial |
$3,357.51
|
| Rate for Payer: Encore All Commercial |
$3,512.03
|
| Rate for Payer: Frontpath All Commercial |
$3,510.12
|
| Rate for Payer: Humana ChoiceCare |
$3,295.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,433.82
|
| Rate for Payer: PHCS All Commercial |
$2,861.51
|
| Rate for Payer: PHP All Commercial |
$2,893.56
|
| Rate for Payer: Sagamore Health Network All Products |
$2,945.45
|
| Rate for Payer: Signature Care EPO |
$3,166.74
|
| Rate for Payer: Signature Care PPO |
$3,357.51
|
| Rate for Payer: United Healthcare Commercial |
$3,006.50
|
|
|
IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % INJ SOLN
|
Facility
OP
|
$3,815.35
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
172845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.76 |
| Max. Negotiated Rate |
$3,548.28 |
| Rate for Payer: Aetna Commercial |
$3,220.16
|
| Rate for Payer: Aetna Medicare |
$1,259.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,259.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,191.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,384.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$84.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,447.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,384.97
|
| Rate for Payer: Cash Price |
$2,365.52
|
| Rate for Payer: Cash Price |
$2,365.52
|
| Rate for Payer: Centivo All Commercial |
$1,945.83
|
| Rate for Payer: Cigna All Commercial |
$3,292.65
|
| Rate for Payer: CORVEL All Commercial |
$3,548.28
|
| Rate for Payer: Coventry All Commercial |
$3,357.51
|
| Rate for Payer: Encore All Commercial |
$3,512.03
|
| Rate for Payer: Frontpath All Commercial |
$3,510.12
|
| Rate for Payer: Humana ChoiceCare |
$3,295.32
|
| Rate for Payer: Humana Medicare |
$1,945.83
|
| Rate for Payer: Lucent All Commercial |
$1,945.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,433.82
|
| Rate for Payer: Managed Health Services Medicaid |
$84.76
|
| Rate for Payer: MDWise Medicaid |
$84.76
|
| Rate for Payer: PHCS All Commercial |
$2,861.51
|
| Rate for Payer: PHP All Commercial |
$2,893.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,487.99
|
| Rate for Payer: Sagamore Health Network All Products |
$2,945.45
|
| Rate for Payer: Signature Care EPO |
$3,166.74
|
| Rate for Payer: Signature Care PPO |
$3,357.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,243.05
|
| Rate for Payer: United Healthcare Commercial |
$3,006.50
|
| Rate for Payer: United Healthcare Medicare |
$1,259.07
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
OP
|
$3,841.95
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
172846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.68 |
| Max. Negotiated Rate |
$3,573.01 |
| Rate for Payer: Aetna Commercial |
$3,242.61
|
| Rate for Payer: Aetna Medicare |
$1,267.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,267.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,206.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,401.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$89.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,458.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,394.63
|
| Rate for Payer: Cash Price |
$2,382.01
|
| Rate for Payer: Cash Price |
$2,382.01
|
| Rate for Payer: Centivo All Commercial |
$1,959.39
|
| Rate for Payer: Cigna All Commercial |
$3,315.60
|
| Rate for Payer: CORVEL All Commercial |
$3,573.01
|
| Rate for Payer: Coventry All Commercial |
$3,380.92
|
| Rate for Payer: Encore All Commercial |
$3,536.51
|
| Rate for Payer: Frontpath All Commercial |
$3,534.59
|
| Rate for Payer: Humana ChoiceCare |
$3,318.29
|
| Rate for Payer: Humana Medicare |
$1,959.39
|
| Rate for Payer: Lucent All Commercial |
$1,959.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,457.76
|
| Rate for Payer: Managed Health Services Medicaid |
$89.68
|
| Rate for Payer: MDWise Medicaid |
$89.68
|
| Rate for Payer: PHCS All Commercial |
$2,881.46
|
| Rate for Payer: PHP All Commercial |
$2,913.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,498.36
|
| Rate for Payer: Sagamore Health Network All Products |
$2,965.99
|
| Rate for Payer: Signature Care EPO |
$3,188.82
|
| Rate for Payer: Signature Care PPO |
$3,380.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,265.66
|
| Rate for Payer: United Healthcare Commercial |
$3,027.46
|
| Rate for Payer: United Healthcare Medicare |
$1,267.84
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
IP
|
$3,841.95
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
172846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,881.46 |
| Max. Negotiated Rate |
$3,573.01 |
| Rate for Payer: Aetna Commercial |
$3,319.44
|
| Rate for Payer: Cash Price |
$2,382.01
|
| Rate for Payer: Cigna All Commercial |
$3,315.60
|
| Rate for Payer: CORVEL All Commercial |
$3,573.01
|
| Rate for Payer: Coventry All Commercial |
$3,380.92
|
| Rate for Payer: Encore All Commercial |
$3,536.51
|
| Rate for Payer: Frontpath All Commercial |
$3,534.59
|
| Rate for Payer: Humana ChoiceCare |
$3,318.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,457.76
|
| Rate for Payer: PHCS All Commercial |
$2,881.46
|
| Rate for Payer: PHP All Commercial |
$2,913.73
|
| Rate for Payer: Sagamore Health Network All Products |
$2,965.99
|
| Rate for Payer: Signature Care EPO |
$3,188.82
|
| Rate for Payer: Signature Care PPO |
$3,380.92
|
| Rate for Payer: United Healthcare Commercial |
$3,027.46
|
|
|
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
|
Facility
OP
|
$381.15
|
|
|
Service Code
|
CPT 10060
|
| Hospital Charge Code |
CPT-10060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$381.15
|
| Rate for Payer: Managed Health Services Medicaid |
$381.15
|
| Rate for Payer: MDWise Medicaid |
$381.15
|
|
|
Incision and drainage of pilonidal cyst; simple
|
Facility
OP
|
$381.15
|
|
|
Service Code
|
CPT 10080
|
| Hospital Charge Code |
CPT-10080
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$381.15
|
| Rate for Payer: Managed Health Services Medicaid |
$381.15
|
| Rate for Payer: MDWise Medicaid |
$381.15
|
|
|
Incision and drainage, perianal abscess, superficial
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 46050
|
| Hospital Charge Code |
CPT-46050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Incision of thrombosed hemorrhoid, external
|
Facility
OP
|
$648.18
|
|
|
Service Code
|
CPT 46083
|
| Hospital Charge Code |
CPT-46083
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$648.18 |
| Max. Negotiated Rate |
$648.18 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$648.18
|
| Rate for Payer: Managed Health Services Medicaid |
$648.18
|
| Rate for Payer: MDWise Medicaid |
$648.18
|
|
|
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 |
$0.33 |
| 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
|
|
|
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 |
$0.62
|
| 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
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJ SOLN
|
Facility
IP
|
$744.63
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
110901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$558.47 |
| Max. Negotiated Rate |
$692.50 |
| Rate for Payer: Aetna Commercial |
$643.36
|
| Rate for Payer: Cash Price |
$461.67
|
| Rate for Payer: Cigna All Commercial |
$642.61
|
| Rate for Payer: CORVEL All Commercial |
$692.50
|
| Rate for Payer: Coventry All Commercial |
$655.27
|
| Rate for Payer: Encore All Commercial |
$685.43
|
| Rate for Payer: Frontpath All Commercial |
$685.06
|
| Rate for Payer: Humana ChoiceCare |
$643.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$670.16
|
| Rate for Payer: PHCS All Commercial |
$558.47
|
| Rate for Payer: PHP All Commercial |
$564.72
|
| Rate for Payer: Sagamore Health Network All Products |
$574.85
|
| Rate for Payer: Signature Care EPO |
$618.04
|
| Rate for Payer: Signature Care PPO |
$655.27
|
| Rate for Payer: United Healthcare Commercial |
$586.76
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJ SOLN
|
Facility
OP
|
$744.63
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
110901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$692.50 |
| Rate for Payer: Aetna Commercial |
$628.46
|
| Rate for Payer: Aetna Medicare |
$245.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$245.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$427.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$465.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$282.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$270.30
|
| Rate for Payer: Cash Price |
$461.67
|
| Rate for Payer: Cash Price |
$461.67
|
| Rate for Payer: Centivo All Commercial |
$379.76
|
| Rate for Payer: Cigna All Commercial |
$642.61
|
| Rate for Payer: CORVEL All Commercial |
$692.50
|
| Rate for Payer: Coventry All Commercial |
$655.27
|
| Rate for Payer: Encore All Commercial |
$685.43
|
| Rate for Payer: Frontpath All Commercial |
$685.06
|
| Rate for Payer: Humana ChoiceCare |
$643.13
|
| Rate for Payer: Humana Medicare |
$379.76
|
| Rate for Payer: Lucent All Commercial |
$379.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$670.16
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$558.47
|
| Rate for Payer: PHP All Commercial |
$564.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$290.40
|
| Rate for Payer: Sagamore Health Network All Products |
$574.85
|
| Rate for Payer: Signature Care EPO |
$618.04
|
| Rate for Payer: Signature Care PPO |
$655.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$632.93
|
| Rate for Payer: United Healthcare Commercial |
$586.76
|
| Rate for Payer: United Healthcare Medicare |
$245.73
|
|
|
INDIUM IN-111 OXYQUINOLINE 1 MCI/ML (37 MBQ/ML)(1 ML) IV SOLN
|
Facility
IP
|
$24.66
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
153809
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$22.93 |
| Rate for Payer: Aetna Commercial |
$21.31
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Cigna All Commercial |
$21.28
|
| Rate for Payer: CORVEL All Commercial |
$22.93
|
| Rate for Payer: Coventry All Commercial |
$21.70
|
| Rate for Payer: Encore All Commercial |
$22.70
|
| Rate for Payer: Frontpath All Commercial |
$22.69
|
| Rate for Payer: Humana ChoiceCare |
$21.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.19
|
| Rate for Payer: PHCS All Commercial |
$18.50
|
| Rate for Payer: PHP All Commercial |
$18.70
|
| Rate for Payer: Sagamore Health Network All Products |
$19.04
|
| Rate for Payer: Signature Care EPO |
$20.47
|
| Rate for Payer: Signature Care PPO |
$21.70
|
| Rate for Payer: United Healthcare Commercial |
$19.43
|
|
|
INDIUM IN-111 OXYQUINOLINE 1 MCI/ML (37 MBQ/ML)(1 ML) IV SOLN
|
Facility
OP
|
$24.66
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
153809
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$22.93 |
| Rate for Payer: Aetna Commercial |
$20.81
|
| Rate for Payer: Aetna Medicare |
$8.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.95
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Centivo All Commercial |
$12.58
|
| Rate for Payer: Cigna All Commercial |
$21.28
|
| Rate for Payer: CORVEL All Commercial |
$22.93
|
| Rate for Payer: Coventry All Commercial |
$21.70
|
| Rate for Payer: Encore All Commercial |
$22.70
|
| Rate for Payer: Frontpath All Commercial |
$22.69
|
| Rate for Payer: Humana ChoiceCare |
$21.30
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Lucent All Commercial |
$12.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.19
|
| Rate for Payer: PHCS All Commercial |
$18.50
|
| Rate for Payer: PHP All Commercial |
$18.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.62
|
| Rate for Payer: Sagamore Health Network All Products |
$19.04
|
| Rate for Payer: Signature Care EPO |
$20.47
|
| Rate for Payer: Signature Care PPO |
$21.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.96
|
| Rate for Payer: United Healthcare Commercial |
$19.43
|
| Rate for Payer: United Healthcare Medicare |
$8.14
|
|
|
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 |
$619.50
|
| 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
|
|
