|
INSULIN REGULAR HUMAN 100 UNITS/ML INJ SOLN
|
Facility
OP
|
$49.67
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
10289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$46.19 |
| Rate for Payer: Aetna Commercial |
$41.92
|
| Rate for Payer: Aetna Commercial |
$13.53
|
| Rate for Payer: Aetna Medicare |
$16.39
|
| Rate for Payer: Aetna Medicare |
$5.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.82
|
| Rate for Payer: Cash Price |
$30.79
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Centivo All Commercial |
$25.33
|
| Rate for Payer: Centivo All Commercial |
$8.18
|
| Rate for Payer: Cigna All Commercial |
$42.86
|
| Rate for Payer: Cigna All Commercial |
$13.84
|
| Rate for Payer: CORVEL All Commercial |
$14.91
|
| Rate for Payer: CORVEL All Commercial |
$46.19
|
| Rate for Payer: Coventry All Commercial |
$43.71
|
| Rate for Payer: Coventry All Commercial |
$14.11
|
| Rate for Payer: Encore All Commercial |
$45.72
|
| Rate for Payer: Encore All Commercial |
$14.76
|
| Rate for Payer: Frontpath All Commercial |
$14.75
|
| Rate for Payer: Frontpath All Commercial |
$45.69
|
| Rate for Payer: Humana ChoiceCare |
$13.85
|
| Rate for Payer: Humana ChoiceCare |
$42.90
|
| Rate for Payer: Humana Medicare |
$8.18
|
| Rate for Payer: Humana Medicare |
$25.33
|
| Rate for Payer: Lucent All Commercial |
$25.33
|
| Rate for Payer: Lucent All Commercial |
$8.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.70
|
| Rate for Payer: PHCS All Commercial |
$37.25
|
| Rate for Payer: PHCS All Commercial |
$12.03
|
| Rate for Payer: PHP All Commercial |
$37.67
|
| Rate for Payer: PHP All Commercial |
$12.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.37
|
| Rate for Payer: Sagamore Health Network All Products |
$12.38
|
| Rate for Payer: Sagamore Health Network All Products |
$38.34
|
| Rate for Payer: Signature Care EPO |
$13.31
|
| Rate for Payer: Signature Care EPO |
$41.22
|
| Rate for Payer: Signature Care PPO |
$14.11
|
| Rate for Payer: Signature Care PPO |
$43.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.63
|
| Rate for Payer: United Healthcare Commercial |
$12.63
|
| Rate for Payer: United Healthcare Commercial |
$39.14
|
| Rate for Payer: United Healthcare Medicare |
$5.29
|
| Rate for Payer: United Healthcare Medicare |
$16.39
|
|
|
INSULIN REGULAR HUMAN 100 UNITS/ML INJ SOLN
|
Facility
IP
|
$49.67
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
10289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.25 |
| Max. Negotiated Rate |
$46.19 |
| Rate for Payer: Aetna Commercial |
$42.91
|
| Rate for Payer: Aetna Commercial |
$13.85
|
| Rate for Payer: Cash Price |
$30.79
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cigna All Commercial |
$13.84
|
| Rate for Payer: Cigna All Commercial |
$42.86
|
| Rate for Payer: CORVEL All Commercial |
$46.19
|
| Rate for Payer: CORVEL All Commercial |
$14.91
|
| Rate for Payer: Coventry All Commercial |
$43.71
|
| Rate for Payer: Coventry All Commercial |
$14.11
|
| Rate for Payer: Encore All Commercial |
$45.72
|
| Rate for Payer: Encore All Commercial |
$14.76
|
| Rate for Payer: Frontpath All Commercial |
$14.75
|
| Rate for Payer: Frontpath All Commercial |
$45.69
|
| Rate for Payer: Humana ChoiceCare |
$13.85
|
| Rate for Payer: Humana ChoiceCare |
$42.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.43
|
| Rate for Payer: PHCS All Commercial |
$12.03
|
| Rate for Payer: PHCS All Commercial |
$37.25
|
| Rate for Payer: PHP All Commercial |
$37.67
|
| Rate for Payer: PHP All Commercial |
$12.16
|
| Rate for Payer: Sagamore Health Network All Products |
$12.38
|
| Rate for Payer: Sagamore Health Network All Products |
$38.34
|
| Rate for Payer: Signature Care EPO |
$13.31
|
| Rate for Payer: Signature Care EPO |
$41.22
|
| Rate for Payer: Signature Care PPO |
$43.71
|
| Rate for Payer: Signature Care PPO |
$14.11
|
| Rate for Payer: United Healthcare Commercial |
$12.63
|
| Rate for Payer: United Healthcare Commercial |
$39.14
|
|
|
INSULIN REGULAR IN 0.9 % NACL 100 UNIT/100 ML (1 UNIT/ML) IV SOLN
|
Facility
OP
|
$245.00
|
|
|
Service Code
|
NDC 00338012612
|
| Hospital Charge Code |
188890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.85 |
| Max. Negotiated Rate |
$227.85 |
| Rate for Payer: Aetna Commercial |
$206.78
|
| Rate for Payer: Aetna Medicare |
$80.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$80.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$140.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$153.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$92.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$88.94
|
| Rate for Payer: Cash Price |
$151.90
|
| Rate for Payer: Centivo All Commercial |
$124.95
|
| Rate for Payer: Cigna All Commercial |
$211.44
|
| Rate for Payer: CORVEL All Commercial |
$227.85
|
| Rate for Payer: Coventry All Commercial |
$215.60
|
| Rate for Payer: Encore All Commercial |
$225.52
|
| Rate for Payer: Frontpath All Commercial |
$225.40
|
| Rate for Payer: Humana ChoiceCare |
$211.61
|
| Rate for Payer: Humana Medicare |
$124.95
|
| Rate for Payer: Lucent All Commercial |
$124.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$220.50
|
| Rate for Payer: PHCS All Commercial |
$183.75
|
| Rate for Payer: PHP All Commercial |
$185.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$95.55
|
| Rate for Payer: Sagamore Health Network All Products |
$189.14
|
| Rate for Payer: Signature Care EPO |
$203.35
|
| Rate for Payer: Signature Care PPO |
$215.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$208.25
|
| Rate for Payer: United Healthcare Commercial |
$193.06
|
| Rate for Payer: United Healthcare Medicare |
$80.85
|
|
|
INSULIN REGULAR IN 0.9 % NACL 100 UNIT/100 ML (1 UNIT/ML) IV SOLN
|
Facility
IP
|
$245.00
|
|
|
Service Code
|
NDC 00338012612
|
| Hospital Charge Code |
188890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$183.75 |
| Max. Negotiated Rate |
$227.85 |
| Rate for Payer: Aetna Commercial |
$211.68
|
| Rate for Payer: Cash Price |
$151.90
|
| Rate for Payer: Cigna All Commercial |
$211.44
|
| Rate for Payer: CORVEL All Commercial |
$227.85
|
| Rate for Payer: Coventry All Commercial |
$215.60
|
| Rate for Payer: Encore All Commercial |
$225.52
|
| Rate for Payer: Frontpath All Commercial |
$225.40
|
| Rate for Payer: Humana ChoiceCare |
$211.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$220.50
|
| Rate for Payer: PHCS All Commercial |
$183.75
|
| Rate for Payer: PHP All Commercial |
$185.81
|
| Rate for Payer: Sagamore Health Network All Products |
$189.14
|
| Rate for Payer: Signature Care EPO |
$203.35
|
| Rate for Payer: Signature Care PPO |
$215.60
|
| Rate for Payer: United Healthcare Commercial |
$193.06
|
|
|
Intubation, endotracheal, emergency procedure
|
Facility
OP
|
$381.15
|
|
|
Service Code
|
CPT 31500
|
| Hospital Charge Code |
CPT-31500
|
|
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
|
|
|
INV CASIRIVIMAB-IMDEVIMAB 1200 MG IVPB (SIMPLE)
|
Facility
OP
|
$19.25
|
|
|
Service Code
|
NDC 9999999838
|
| Hospital Charge Code |
140100019530601
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna Commercial |
$16.25
|
| Rate for Payer: Aetna Medicare |
$6.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.03
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.99
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Centivo All Commercial |
$9.82
|
| Rate for Payer: Cigna All Commercial |
$16.61
|
| Rate for Payer: CORVEL All Commercial |
$17.90
|
| Rate for Payer: Coventry All Commercial |
$16.94
|
| Rate for Payer: Encore All Commercial |
$17.72
|
| Rate for Payer: Frontpath All Commercial |
$17.71
|
| Rate for Payer: Humana ChoiceCare |
$16.63
|
| Rate for Payer: Humana Medicare |
$9.82
|
| Rate for Payer: Lucent All Commercial |
$9.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.32
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| Rate for Payer: PHCS All Commercial |
$14.44
|
| Rate for Payer: PHP All Commercial |
$14.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.51
|
| Rate for Payer: Sagamore Health Network All Products |
$14.86
|
| Rate for Payer: Signature Care EPO |
$15.98
|
| Rate for Payer: Signature Care PPO |
$16.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.36
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
| Rate for Payer: United Healthcare Medicare |
$6.35
|
|
|
INV CASIRIVIMAB-IMDEVIMAB 1200 MG IVPB (SIMPLE)
|
Facility
IP
|
$19.25
|
|
|
Service Code
|
NDC 9999999838
|
| Hospital Charge Code |
140100019530601
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$17.90 |
| Rate for Payer: Aetna Commercial |
$16.63
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Cigna All Commercial |
$16.61
|
| Rate for Payer: CORVEL All Commercial |
$17.90
|
| Rate for Payer: Coventry All Commercial |
$16.94
|
| Rate for Payer: Encore All Commercial |
$17.72
|
| Rate for Payer: Frontpath All Commercial |
$17.71
|
| Rate for Payer: Humana ChoiceCare |
$16.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.32
|
| Rate for Payer: PHCS All Commercial |
$14.44
|
| Rate for Payer: PHP All Commercial |
$14.60
|
| Rate for Payer: Sagamore Health Network All Products |
$14.86
|
| Rate for Payer: Signature Care EPO |
$15.98
|
| Rate for Payer: Signature Care PPO |
$16.94
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
|
|
IODINE-POTASSIUM IODIDE 5-10 % TOP SOLN
|
Facility
OP
|
$57.12
|
|
|
Service Code
|
NDC 10481011108
|
| Hospital Charge Code |
3961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$53.12 |
| Rate for Payer: Aetna Commercial |
$48.21
|
| Rate for Payer: Aetna Medicare |
$18.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$32.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.73
|
| Rate for Payer: Cash Price |
$35.41
|
| Rate for Payer: Cash Price |
$35.41
|
| Rate for Payer: Centivo All Commercial |
$29.13
|
| Rate for Payer: Cigna All Commercial |
$49.29
|
| Rate for Payer: CORVEL All Commercial |
$53.12
|
| Rate for Payer: Coventry All Commercial |
$50.27
|
| Rate for Payer: Encore All Commercial |
$52.58
|
| Rate for Payer: Frontpath All Commercial |
$52.55
|
| Rate for Payer: Humana ChoiceCare |
$49.33
|
| Rate for Payer: Humana Medicare |
$29.13
|
| Rate for Payer: Lucent All Commercial |
$29.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.41
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$42.84
|
| Rate for Payer: PHP All Commercial |
$43.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.28
|
| Rate for Payer: Sagamore Health Network All Products |
$44.10
|
| Rate for Payer: Signature Care EPO |
$47.41
|
| Rate for Payer: Signature Care PPO |
$50.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.55
|
| Rate for Payer: United Healthcare Commercial |
$45.01
|
| Rate for Payer: United Healthcare Medicare |
$18.85
|
|
|
IODINE-POTASSIUM IODIDE 5-10 % TOP SOLN
|
Facility
IP
|
$57.12
|
|
|
Service Code
|
NDC 10481011108
|
| Hospital Charge Code |
3961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$53.12 |
| Rate for Payer: Aetna Commercial |
$49.35
|
| Rate for Payer: Cash Price |
$35.41
|
| Rate for Payer: Cigna All Commercial |
$49.29
|
| Rate for Payer: CORVEL All Commercial |
$53.12
|
| Rate for Payer: Coventry All Commercial |
$50.27
|
| Rate for Payer: Encore All Commercial |
$52.58
|
| Rate for Payer: Frontpath All Commercial |
$52.55
|
| Rate for Payer: Humana ChoiceCare |
$49.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.41
|
| Rate for Payer: PHCS All Commercial |
$42.84
|
| Rate for Payer: PHP All Commercial |
$43.32
|
| Rate for Payer: Sagamore Health Network All Products |
$44.10
|
| Rate for Payer: Signature Care EPO |
$47.41
|
| Rate for Payer: Signature Care PPO |
$50.27
|
| Rate for Payer: United Healthcare Commercial |
$45.01
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLN
|
Facility
OP
|
$289.20
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
110362
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.44 |
| Max. Negotiated Rate |
$268.95 |
| Rate for Payer: Aetna Commercial |
$244.08
|
| Rate for Payer: Aetna Medicare |
$95.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$166.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$109.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$104.98
|
| Rate for Payer: Cash Price |
$179.30
|
| Rate for Payer: Centivo All Commercial |
$147.49
|
| Rate for Payer: Cigna All Commercial |
$249.58
|
| Rate for Payer: CORVEL All Commercial |
$268.95
|
| Rate for Payer: Coventry All Commercial |
$254.49
|
| Rate for Payer: Encore All Commercial |
$266.21
|
| Rate for Payer: Frontpath All Commercial |
$266.06
|
| Rate for Payer: Humana ChoiceCare |
$249.78
|
| Rate for Payer: Humana Medicare |
$147.49
|
| Rate for Payer: Lucent All Commercial |
$147.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$260.28
|
| Rate for Payer: PHCS All Commercial |
$216.90
|
| Rate for Payer: PHP All Commercial |
$219.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.79
|
| Rate for Payer: Sagamore Health Network All Products |
$223.26
|
| Rate for Payer: Signature Care EPO |
$240.03
|
| Rate for Payer: Signature Care PPO |
$254.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$245.82
|
| Rate for Payer: United Healthcare Commercial |
$227.89
|
| Rate for Payer: United Healthcare Medicare |
$95.44
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLN
|
Facility
IP
|
$289.20
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
110362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$216.90 |
| Max. Negotiated Rate |
$268.95 |
| Rate for Payer: Aetna Commercial |
$249.87
|
| Rate for Payer: Cash Price |
$179.30
|
| Rate for Payer: Cigna All Commercial |
$249.58
|
| Rate for Payer: CORVEL All Commercial |
$268.95
|
| Rate for Payer: Coventry All Commercial |
$254.49
|
| Rate for Payer: Encore All Commercial |
$266.21
|
| Rate for Payer: Frontpath All Commercial |
$266.06
|
| Rate for Payer: Humana ChoiceCare |
$249.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$260.28
|
| Rate for Payer: PHCS All Commercial |
$216.90
|
| Rate for Payer: PHP All Commercial |
$219.33
|
| Rate for Payer: Sagamore Health Network All Products |
$223.26
|
| Rate for Payer: Signature Care EPO |
$240.03
|
| Rate for Payer: Signature Care PPO |
$254.49
|
| Rate for Payer: United Healthcare Commercial |
$227.89
|
|
|
IODIXANOL 320 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
OP
|
$176.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408175951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.21 |
| Max. Negotiated Rate |
$164.05 |
| Rate for Payer: Aetna Commercial |
$148.88
|
| Rate for Payer: Aetna Medicare |
$58.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$58.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$101.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$66.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$64.03
|
| Rate for Payer: Cash Price |
$109.37
|
| Rate for Payer: Centivo All Commercial |
$89.96
|
| Rate for Payer: Cigna All Commercial |
$152.23
|
| Rate for Payer: CORVEL All Commercial |
$164.05
|
| Rate for Payer: Coventry All Commercial |
$155.23
|
| Rate for Payer: Encore All Commercial |
$162.38
|
| Rate for Payer: Frontpath All Commercial |
$162.29
|
| Rate for Payer: Humana ChoiceCare |
$152.36
|
| Rate for Payer: Humana Medicare |
$89.96
|
| Rate for Payer: Lucent All Commercial |
$89.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.76
|
| Rate for Payer: PHCS All Commercial |
$132.30
|
| Rate for Payer: PHP All Commercial |
$133.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$68.80
|
| Rate for Payer: Sagamore Health Network All Products |
$136.18
|
| Rate for Payer: Signature Care EPO |
$146.41
|
| Rate for Payer: Signature Care PPO |
$155.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$149.94
|
| Rate for Payer: United Healthcare Commercial |
$139.00
|
| Rate for Payer: United Healthcare Medicare |
$58.21
|
|
|
IODIXANOL 320 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
IP
|
$176.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408175951
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$164.05 |
| Rate for Payer: Aetna Commercial |
$152.41
|
| Rate for Payer: Cash Price |
$109.37
|
| Rate for Payer: Cigna All Commercial |
$152.23
|
| Rate for Payer: CORVEL All Commercial |
$164.05
|
| Rate for Payer: Coventry All Commercial |
$155.23
|
| Rate for Payer: Encore All Commercial |
$162.38
|
| Rate for Payer: Frontpath All Commercial |
$162.29
|
| Rate for Payer: Humana ChoiceCare |
$152.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.76
|
| Rate for Payer: PHCS All Commercial |
$132.30
|
| Rate for Payer: PHP All Commercial |
$133.78
|
| Rate for Payer: Sagamore Health Network All Products |
$136.18
|
| Rate for Payer: Signature Care EPO |
$146.41
|
| Rate for Payer: Signature Care PPO |
$155.23
|
| Rate for Payer: United Healthcare Commercial |
$139.00
|
|
|
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN
|
Facility
IP
|
$7,875.00
|
|
|
Service Code
|
HCPCS A9584
|
| Hospital Charge Code |
108781
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5,906.25 |
| Max. Negotiated Rate |
$7,323.75 |
| Rate for Payer: Aetna Commercial |
$6,804.00
|
| Rate for Payer: Cash Price |
$4,882.50
|
| Rate for Payer: Cigna All Commercial |
$6,796.12
|
| Rate for Payer: CORVEL All Commercial |
$7,323.75
|
| Rate for Payer: Coventry All Commercial |
$6,930.00
|
| Rate for Payer: Encore All Commercial |
$7,248.94
|
| Rate for Payer: Frontpath All Commercial |
$7,245.00
|
| Rate for Payer: Humana ChoiceCare |
$6,801.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,087.50
|
| Rate for Payer: PHCS All Commercial |
$5,906.25
|
| Rate for Payer: PHP All Commercial |
$5,972.40
|
| Rate for Payer: Sagamore Health Network All Products |
$6,079.50
|
| Rate for Payer: Signature Care EPO |
$6,536.25
|
| Rate for Payer: Signature Care PPO |
$6,930.00
|
| Rate for Payer: United Healthcare Commercial |
$6,205.50
|
|
|
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN
|
Facility
OP
|
$7,875.00
|
|
|
Service Code
|
HCPCS A9584
|
| Hospital Charge Code |
108781
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,598.75 |
| Max. Negotiated Rate |
$7,323.75 |
| Rate for Payer: Aetna Commercial |
$6,646.50
|
| Rate for Payer: Aetna Medicare |
$2,598.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,598.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,522.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,922.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,988.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,858.62
|
| Rate for Payer: Cash Price |
$4,882.50
|
| Rate for Payer: Centivo All Commercial |
$4,016.25
|
| Rate for Payer: Cigna All Commercial |
$6,796.12
|
| Rate for Payer: CORVEL All Commercial |
$7,323.75
|
| Rate for Payer: Coventry All Commercial |
$6,930.00
|
| Rate for Payer: Encore All Commercial |
$7,248.94
|
| Rate for Payer: Frontpath All Commercial |
$7,245.00
|
| Rate for Payer: Humana ChoiceCare |
$6,801.64
|
| Rate for Payer: Humana Medicare |
$4,016.25
|
| Rate for Payer: Lucent All Commercial |
$4,016.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,087.50
|
| Rate for Payer: PHCS All Commercial |
$5,906.25
|
| Rate for Payer: PHP All Commercial |
$5,972.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,071.25
|
| Rate for Payer: Sagamore Health Network All Products |
$6,079.50
|
| Rate for Payer: Signature Care EPO |
$6,536.25
|
| Rate for Payer: Signature Care PPO |
$6,930.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,693.75
|
| Rate for Payer: United Healthcare Commercial |
$6,205.50
|
| Rate for Payer: United Healthcare Medicare |
$2,598.75
|
|
|
IOHEXOL 180 MG IODINE/ML IT SOLN 10 ML VIAL
|
Facility
OP
|
$265.86
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
10319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.73 |
| Max. Negotiated Rate |
$247.25 |
| Rate for Payer: Aetna Commercial |
$224.39
|
| Rate for Payer: Aetna Medicare |
$87.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$152.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$166.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$100.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$96.51
|
| Rate for Payer: Cash Price |
$164.83
|
| Rate for Payer: Centivo All Commercial |
$135.59
|
| Rate for Payer: Cigna All Commercial |
$229.44
|
| Rate for Payer: CORVEL All Commercial |
$247.25
|
| Rate for Payer: Coventry All Commercial |
$233.96
|
| Rate for Payer: Encore All Commercial |
$244.72
|
| Rate for Payer: Frontpath All Commercial |
$244.59
|
| Rate for Payer: Humana ChoiceCare |
$229.62
|
| Rate for Payer: Humana Medicare |
$135.59
|
| Rate for Payer: Lucent All Commercial |
$135.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.27
|
| Rate for Payer: PHCS All Commercial |
$199.40
|
| Rate for Payer: PHP All Commercial |
$201.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.69
|
| Rate for Payer: Sagamore Health Network All Products |
$205.24
|
| Rate for Payer: Signature Care EPO |
$220.66
|
| Rate for Payer: Signature Care PPO |
$233.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$225.98
|
| Rate for Payer: United Healthcare Commercial |
$209.50
|
| Rate for Payer: United Healthcare Medicare |
$87.73
|
|
|
IOHEXOL 180 MG IODINE/ML IT SOLN 10 ML VIAL
|
Facility
IP
|
$265.86
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
10319
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$199.40 |
| Max. Negotiated Rate |
$247.25 |
| Rate for Payer: Aetna Commercial |
$229.70
|
| Rate for Payer: Cash Price |
$164.83
|
| Rate for Payer: Cigna All Commercial |
$229.44
|
| Rate for Payer: CORVEL All Commercial |
$247.25
|
| Rate for Payer: Coventry All Commercial |
$233.96
|
| Rate for Payer: Encore All Commercial |
$244.72
|
| Rate for Payer: Frontpath All Commercial |
$244.59
|
| Rate for Payer: Humana ChoiceCare |
$229.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.27
|
| Rate for Payer: PHCS All Commercial |
$199.40
|
| Rate for Payer: PHP All Commercial |
$201.63
|
| Rate for Payer: Sagamore Health Network All Products |
$205.24
|
| Rate for Payer: Signature Care EPO |
$220.66
|
| Rate for Payer: Signature Care PPO |
$233.96
|
| Rate for Payer: United Healthcare Commercial |
$209.50
|
|
|
IOHEXOL 180 MG IODINE/ML IT SOLN 20 ML VIAL
|
Facility
IP
|
$156.66
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
40810319
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$117.50 |
| Max. Negotiated Rate |
$145.69 |
| Rate for Payer: Aetna Commercial |
$135.35
|
| Rate for Payer: Cash Price |
$97.13
|
| Rate for Payer: Cigna All Commercial |
$135.20
|
| Rate for Payer: CORVEL All Commercial |
$145.69
|
| Rate for Payer: Coventry All Commercial |
$137.86
|
| Rate for Payer: Encore All Commercial |
$144.21
|
| Rate for Payer: Frontpath All Commercial |
$144.13
|
| Rate for Payer: Humana ChoiceCare |
$135.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$140.99
|
| Rate for Payer: PHCS All Commercial |
$117.50
|
| Rate for Payer: PHP All Commercial |
$118.81
|
| Rate for Payer: Sagamore Health Network All Products |
$120.94
|
| Rate for Payer: Signature Care EPO |
$130.03
|
| Rate for Payer: Signature Care PPO |
$137.86
|
| Rate for Payer: United Healthcare Commercial |
$123.45
|
|
|
IOHEXOL 180 MG IODINE/ML IT SOLN 20 ML VIAL
|
Facility
OP
|
$156.66
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
40810319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.70 |
| Max. Negotiated Rate |
$145.69 |
| Rate for Payer: Aetna Commercial |
$132.22
|
| Rate for Payer: Aetna Medicare |
$51.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$89.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$97.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$56.87
|
| Rate for Payer: Cash Price |
$97.13
|
| Rate for Payer: Centivo All Commercial |
$79.90
|
| Rate for Payer: Cigna All Commercial |
$135.20
|
| Rate for Payer: CORVEL All Commercial |
$145.69
|
| Rate for Payer: Coventry All Commercial |
$137.86
|
| Rate for Payer: Encore All Commercial |
$144.21
|
| Rate for Payer: Frontpath All Commercial |
$144.13
|
| Rate for Payer: Humana ChoiceCare |
$135.31
|
| Rate for Payer: Humana Medicare |
$79.90
|
| Rate for Payer: Lucent All Commercial |
$79.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$140.99
|
| Rate for Payer: PHCS All Commercial |
$117.50
|
| Rate for Payer: PHP All Commercial |
$118.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.10
|
| Rate for Payer: Sagamore Health Network All Products |
$120.94
|
| Rate for Payer: Signature Care EPO |
$130.03
|
| Rate for Payer: Signature Care PPO |
$137.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.16
|
| Rate for Payer: United Healthcare Commercial |
$123.45
|
| Rate for Payer: United Healthcare Medicare |
$51.70
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 10 ML VIAL
|
Facility
OP
|
$266.91
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.08 |
| Max. Negotiated Rate |
$248.23 |
| Rate for Payer: Aetna Commercial |
$225.27
|
| Rate for Payer: Aetna Medicare |
$88.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$153.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$166.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$101.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$96.89
|
| Rate for Payer: Cash Price |
$165.48
|
| Rate for Payer: Centivo All Commercial |
$136.12
|
| Rate for Payer: Cigna All Commercial |
$230.34
|
| Rate for Payer: CORVEL All Commercial |
$248.23
|
| Rate for Payer: Coventry All Commercial |
$234.88
|
| Rate for Payer: Encore All Commercial |
$245.69
|
| Rate for Payer: Frontpath All Commercial |
$245.56
|
| Rate for Payer: Humana ChoiceCare |
$230.53
|
| Rate for Payer: Humana Medicare |
$136.12
|
| Rate for Payer: Lucent All Commercial |
$136.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$240.22
|
| Rate for Payer: PHCS All Commercial |
$200.18
|
| Rate for Payer: PHP All Commercial |
$202.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.09
|
| Rate for Payer: Sagamore Health Network All Products |
$206.05
|
| Rate for Payer: Signature Care EPO |
$221.54
|
| Rate for Payer: Signature Care PPO |
$234.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$226.87
|
| Rate for Payer: United Healthcare Commercial |
$210.33
|
| Rate for Payer: United Healthcare Medicare |
$88.08
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 10 ML VIAL
|
Facility
IP
|
$266.91
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$200.18 |
| Max. Negotiated Rate |
$248.23 |
| Rate for Payer: Aetna Commercial |
$230.61
|
| Rate for Payer: Cash Price |
$165.48
|
| Rate for Payer: Cigna All Commercial |
$230.34
|
| Rate for Payer: CORVEL All Commercial |
$248.23
|
| Rate for Payer: Coventry All Commercial |
$234.88
|
| Rate for Payer: Encore All Commercial |
$245.69
|
| Rate for Payer: Frontpath All Commercial |
$245.56
|
| Rate for Payer: Humana ChoiceCare |
$230.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$240.22
|
| Rate for Payer: PHCS All Commercial |
$200.18
|
| Rate for Payer: PHP All Commercial |
$202.42
|
| Rate for Payer: Sagamore Health Network All Products |
$206.05
|
| Rate for Payer: Signature Care EPO |
$221.54
|
| Rate for Payer: Signature Care PPO |
$234.88
|
| Rate for Payer: United Healthcare Commercial |
$210.33
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
OP
|
$51.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.98 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.42
|
| Rate for Payer: Aetna Medicare |
$16.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.68
|
| Rate for Payer: Cash Price |
$31.90
|
| Rate for Payer: Centivo All Commercial |
$26.24
|
| Rate for Payer: Cigna All Commercial |
$44.40
|
| Rate for Payer: CORVEL All Commercial |
$47.85
|
| Rate for Payer: Coventry All Commercial |
$45.28
|
| Rate for Payer: Encore All Commercial |
$47.36
|
| Rate for Payer: Frontpath All Commercial |
$47.33
|
| Rate for Payer: Humana ChoiceCare |
$44.44
|
| Rate for Payer: Humana Medicare |
$26.24
|
| Rate for Payer: Lucent All Commercial |
$26.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.30
|
| Rate for Payer: PHCS All Commercial |
$38.59
|
| Rate for Payer: PHP All Commercial |
$39.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.07
|
| Rate for Payer: Sagamore Health Network All Products |
$39.72
|
| Rate for Payer: Signature Care EPO |
$42.70
|
| Rate for Payer: Signature Care PPO |
$45.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.73
|
| Rate for Payer: United Healthcare Commercial |
$40.54
|
| Rate for Payer: United Healthcare Medicare |
$16.98
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
IP
|
$51.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103221
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$38.59 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$44.45
|
| Rate for Payer: Cash Price |
$31.90
|
| Rate for Payer: Cigna All Commercial |
$44.40
|
| Rate for Payer: CORVEL All Commercial |
$47.85
|
| Rate for Payer: Coventry All Commercial |
$45.28
|
| Rate for Payer: Encore All Commercial |
$47.36
|
| Rate for Payer: Frontpath All Commercial |
$47.33
|
| Rate for Payer: Humana ChoiceCare |
$44.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.30
|
| Rate for Payer: PHCS All Commercial |
$38.59
|
| Rate for Payer: PHP All Commercial |
$39.02
|
| Rate for Payer: Sagamore Health Network All Products |
$39.72
|
| Rate for Payer: Signature Care EPO |
$42.70
|
| Rate for Payer: Signature Care PPO |
$45.28
|
| Rate for Payer: United Healthcare Commercial |
$40.54
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
OP
|
$109.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.04 |
| Max. Negotiated Rate |
$101.56 |
| Rate for Payer: Aetna Commercial |
$92.16
|
| Rate for Payer: Aetna Medicare |
$36.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$62.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$68.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.64
|
| Rate for Payer: Cash Price |
$67.70
|
| Rate for Payer: Centivo All Commercial |
$55.69
|
| Rate for Payer: Cigna All Commercial |
$94.24
|
| Rate for Payer: CORVEL All Commercial |
$101.56
|
| Rate for Payer: Coventry All Commercial |
$96.10
|
| Rate for Payer: Encore All Commercial |
$100.52
|
| Rate for Payer: Frontpath All Commercial |
$100.46
|
| Rate for Payer: Humana ChoiceCare |
$94.32
|
| Rate for Payer: Humana Medicare |
$55.69
|
| Rate for Payer: Lucent All Commercial |
$55.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$98.28
|
| Rate for Payer: PHCS All Commercial |
$81.90
|
| Rate for Payer: PHP All Commercial |
$82.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.59
|
| Rate for Payer: Sagamore Health Network All Products |
$84.30
|
| Rate for Payer: Signature Care EPO |
$90.64
|
| Rate for Payer: Signature Care PPO |
$96.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$92.82
|
| Rate for Payer: United Healthcare Commercial |
$86.05
|
| Rate for Payer: United Healthcare Medicare |
$36.04
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
IP
|
$109.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103231
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$101.56 |
| Rate for Payer: Aetna Commercial |
$94.35
|
| Rate for Payer: Cash Price |
$67.70
|
| Rate for Payer: Cigna All Commercial |
$94.24
|
| Rate for Payer: CORVEL All Commercial |
$101.56
|
| Rate for Payer: Coventry All Commercial |
$96.10
|
| Rate for Payer: Encore All Commercial |
$100.52
|
| Rate for Payer: Frontpath All Commercial |
$100.46
|
| Rate for Payer: Humana ChoiceCare |
$94.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$98.28
|
| Rate for Payer: PHCS All Commercial |
$81.90
|
| Rate for Payer: PHP All Commercial |
$82.82
|
| Rate for Payer: Sagamore Health Network All Products |
$84.30
|
| Rate for Payer: Signature Care EPO |
$90.64
|
| Rate for Payer: Signature Care PPO |
$96.10
|
| Rate for Payer: United Healthcare Commercial |
$86.05
|
|
