|
IOHEXOL 350 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
OP
|
$55.65
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Aetna Commercial |
$46.97
|
| Rate for Payer: Aetna Medicare |
$18.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$31.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$34.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Centivo All Commercial |
$28.38
|
| Rate for Payer: Cigna All Commercial |
$48.03
|
| Rate for Payer: CORVEL All Commercial |
$51.75
|
| Rate for Payer: Coventry All Commercial |
$48.97
|
| Rate for Payer: Encore All Commercial |
$51.23
|
| Rate for Payer: Frontpath All Commercial |
$51.20
|
| Rate for Payer: Humana ChoiceCare |
$48.06
|
| Rate for Payer: Humana Medicare |
$28.38
|
| Rate for Payer: Lucent All Commercial |
$28.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.08
|
| Rate for Payer: PHCS All Commercial |
$41.74
|
| Rate for Payer: PHP All Commercial |
$42.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.70
|
| Rate for Payer: Sagamore Health Network All Products |
$42.96
|
| Rate for Payer: Signature Care EPO |
$46.19
|
| Rate for Payer: Signature Care PPO |
$48.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$47.30
|
| Rate for Payer: United Healthcare Commercial |
$43.85
|
| Rate for Payer: United Healthcare Medicare |
$18.36
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
IP
|
$55.65
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$41.74 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Aetna Commercial |
$48.08
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna All Commercial |
$48.03
|
| Rate for Payer: CORVEL All Commercial |
$51.75
|
| Rate for Payer: Coventry All Commercial |
$48.97
|
| Rate for Payer: Encore All Commercial |
$51.23
|
| Rate for Payer: Frontpath All Commercial |
$51.20
|
| Rate for Payer: Humana ChoiceCare |
$48.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.08
|
| Rate for Payer: PHCS All Commercial |
$41.74
|
| Rate for Payer: PHP All Commercial |
$42.20
|
| Rate for Payer: Sagamore Health Network All Products |
$42.96
|
| Rate for Payer: Signature Care EPO |
$46.19
|
| Rate for Payer: Signature Care PPO |
$48.97
|
| Rate for Payer: United Healthcare Commercial |
$43.85
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 75 ML BTL
|
Facility
OP
|
$62.48
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
40810323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.62 |
| Max. Negotiated Rate |
$58.10 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: Aetna Medicare |
$20.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$35.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.68
|
| Rate for Payer: Cash Price |
$38.73
|
| Rate for Payer: Centivo All Commercial |
$31.86
|
| Rate for Payer: Cigna All Commercial |
$53.92
|
| Rate for Payer: CORVEL All Commercial |
$58.10
|
| Rate for Payer: Coventry All Commercial |
$54.98
|
| Rate for Payer: Encore All Commercial |
$57.51
|
| Rate for Payer: Frontpath All Commercial |
$57.48
|
| Rate for Payer: Humana ChoiceCare |
$53.96
|
| Rate for Payer: Humana Medicare |
$31.86
|
| Rate for Payer: Lucent All Commercial |
$31.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.23
|
| Rate for Payer: PHCS All Commercial |
$46.86
|
| Rate for Payer: PHP All Commercial |
$47.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.37
|
| Rate for Payer: Sagamore Health Network All Products |
$48.23
|
| Rate for Payer: Signature Care EPO |
$51.85
|
| Rate for Payer: Signature Care PPO |
$54.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.10
|
| Rate for Payer: United Healthcare Commercial |
$49.23
|
| Rate for Payer: United Healthcare Medicare |
$20.62
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 75 ML BTL
|
Facility
IP
|
$62.48
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
40810323
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$46.86 |
| Max. Negotiated Rate |
$58.10 |
| Rate for Payer: Aetna Commercial |
$53.98
|
| Rate for Payer: Cash Price |
$38.73
|
| Rate for Payer: Cigna All Commercial |
$53.92
|
| Rate for Payer: CORVEL All Commercial |
$58.10
|
| Rate for Payer: Coventry All Commercial |
$54.98
|
| Rate for Payer: Encore All Commercial |
$57.51
|
| Rate for Payer: Frontpath All Commercial |
$57.48
|
| Rate for Payer: Humana ChoiceCare |
$53.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.23
|
| Rate for Payer: PHCS All Commercial |
$46.86
|
| Rate for Payer: PHP All Commercial |
$47.38
|
| Rate for Payer: Sagamore Health Network All Products |
$48.23
|
| Rate for Payer: Signature Care EPO |
$51.85
|
| Rate for Payer: Signature Care PPO |
$54.98
|
| Rate for Payer: United Healthcare Commercial |
$49.23
|
|
|
IOPAMIDOL 41 % IT SOLN 10 ML VIAL
|
Facility
IP
|
$367.80
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
40810325
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$275.85 |
| Max. Negotiated Rate |
$342.05 |
| Rate for Payer: Aetna Commercial |
$317.78
|
| Rate for Payer: Cash Price |
$228.04
|
| Rate for Payer: Cigna All Commercial |
$317.41
|
| Rate for Payer: CORVEL All Commercial |
$342.05
|
| Rate for Payer: Coventry All Commercial |
$323.66
|
| Rate for Payer: Encore All Commercial |
$338.56
|
| Rate for Payer: Frontpath All Commercial |
$338.38
|
| Rate for Payer: Humana ChoiceCare |
$317.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$331.02
|
| Rate for Payer: PHCS All Commercial |
$275.85
|
| Rate for Payer: PHP All Commercial |
$278.94
|
| Rate for Payer: Sagamore Health Network All Products |
$283.94
|
| Rate for Payer: Signature Care EPO |
$305.27
|
| Rate for Payer: Signature Care PPO |
$323.66
|
| Rate for Payer: United Healthcare Commercial |
$289.83
|
|
|
IOPAMIDOL 41 % IT SOLN 10 ML VIAL
|
Facility
OP
|
$367.80
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
40810325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.37 |
| Max. Negotiated Rate |
$342.05 |
| Rate for Payer: Aetna Commercial |
$310.42
|
| Rate for Payer: Aetna Medicare |
$121.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$121.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$211.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$229.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$139.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$133.51
|
| Rate for Payer: Cash Price |
$228.04
|
| Rate for Payer: Centivo All Commercial |
$187.58
|
| Rate for Payer: Cigna All Commercial |
$317.41
|
| Rate for Payer: CORVEL All Commercial |
$342.05
|
| Rate for Payer: Coventry All Commercial |
$323.66
|
| Rate for Payer: Encore All Commercial |
$338.56
|
| Rate for Payer: Frontpath All Commercial |
$338.38
|
| Rate for Payer: Humana ChoiceCare |
$317.67
|
| Rate for Payer: Humana Medicare |
$187.58
|
| Rate for Payer: Lucent All Commercial |
$187.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$331.02
|
| Rate for Payer: PHCS All Commercial |
$275.85
|
| Rate for Payer: PHP All Commercial |
$278.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$143.44
|
| Rate for Payer: Sagamore Health Network All Products |
$283.94
|
| Rate for Payer: Signature Care EPO |
$305.27
|
| Rate for Payer: Signature Care PPO |
$323.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$312.63
|
| Rate for Payer: United Healthcare Commercial |
$289.83
|
| Rate for Payer: United Healthcare Medicare |
$121.37
|
|
|
IOPAMIDOL 41 % IT SOLN 20 ML VIAL
|
Facility
IP
|
$503.88
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$377.91 |
| Max. Negotiated Rate |
$468.61 |
| Rate for Payer: Aetna Commercial |
$435.35
|
| Rate for Payer: Cash Price |
$312.41
|
| Rate for Payer: Cigna All Commercial |
$434.85
|
| Rate for Payer: CORVEL All Commercial |
$468.61
|
| Rate for Payer: Coventry All Commercial |
$443.41
|
| Rate for Payer: Encore All Commercial |
$463.82
|
| Rate for Payer: Frontpath All Commercial |
$463.57
|
| Rate for Payer: Humana ChoiceCare |
$435.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$453.49
|
| Rate for Payer: PHCS All Commercial |
$377.91
|
| Rate for Payer: PHP All Commercial |
$382.14
|
| Rate for Payer: Sagamore Health Network All Products |
$389.00
|
| Rate for Payer: Signature Care EPO |
$418.22
|
| Rate for Payer: Signature Care PPO |
$443.41
|
| Rate for Payer: United Healthcare Commercial |
$397.06
|
|
|
IOPAMIDOL 41 % IT SOLN 20 ML VIAL
|
Facility
OP
|
$503.88
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.28 |
| Max. Negotiated Rate |
$468.61 |
| Rate for Payer: Aetna Commercial |
$425.27
|
| Rate for Payer: Aetna Medicare |
$166.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$166.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$289.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$314.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$191.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$182.91
|
| Rate for Payer: Cash Price |
$312.41
|
| Rate for Payer: Centivo All Commercial |
$256.98
|
| Rate for Payer: Cigna All Commercial |
$434.85
|
| Rate for Payer: CORVEL All Commercial |
$468.61
|
| Rate for Payer: Coventry All Commercial |
$443.41
|
| Rate for Payer: Encore All Commercial |
$463.82
|
| Rate for Payer: Frontpath All Commercial |
$463.57
|
| Rate for Payer: Humana ChoiceCare |
$435.20
|
| Rate for Payer: Humana Medicare |
$256.98
|
| Rate for Payer: Lucent All Commercial |
$256.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$453.49
|
| Rate for Payer: PHCS All Commercial |
$377.91
|
| Rate for Payer: PHP All Commercial |
$382.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$196.51
|
| Rate for Payer: Sagamore Health Network All Products |
$389.00
|
| Rate for Payer: Signature Care EPO |
$418.22
|
| Rate for Payer: Signature Care PPO |
$443.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$428.30
|
| Rate for Payer: United Healthcare Commercial |
$397.06
|
| Rate for Payer: United Healthcare Medicare |
$166.28
|
|
|
IOPAMIDOL 61 % IT SOLN 15 ML VIAL
|
Facility
IP
|
$978.98
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$734.23 |
| Max. Negotiated Rate |
$910.45 |
| Rate for Payer: Aetna Commercial |
$845.83
|
| Rate for Payer: Cash Price |
$606.96
|
| Rate for Payer: Cigna All Commercial |
$844.86
|
| Rate for Payer: CORVEL All Commercial |
$910.45
|
| Rate for Payer: Coventry All Commercial |
$861.50
|
| Rate for Payer: Encore All Commercial |
$901.15
|
| Rate for Payer: Frontpath All Commercial |
$900.66
|
| Rate for Payer: Humana ChoiceCare |
$845.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$881.08
|
| Rate for Payer: PHCS All Commercial |
$734.23
|
| Rate for Payer: PHP All Commercial |
$742.45
|
| Rate for Payer: Sagamore Health Network All Products |
$755.77
|
| Rate for Payer: Signature Care EPO |
$812.55
|
| Rate for Payer: Signature Care PPO |
$861.50
|
| Rate for Payer: United Healthcare Commercial |
$771.43
|
|
|
IOPAMIDOL 61 % IT SOLN 15 ML VIAL
|
Facility
OP
|
$978.98
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$323.06 |
| Max. Negotiated Rate |
$910.45 |
| Rate for Payer: Aetna Commercial |
$826.25
|
| Rate for Payer: Aetna Medicare |
$323.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$323.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$562.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$611.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$371.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$355.37
|
| Rate for Payer: Cash Price |
$606.96
|
| Rate for Payer: Centivo All Commercial |
$499.28
|
| Rate for Payer: Cigna All Commercial |
$844.86
|
| Rate for Payer: CORVEL All Commercial |
$910.45
|
| Rate for Payer: Coventry All Commercial |
$861.50
|
| Rate for Payer: Encore All Commercial |
$901.15
|
| Rate for Payer: Frontpath All Commercial |
$900.66
|
| Rate for Payer: Humana ChoiceCare |
$845.54
|
| Rate for Payer: Humana Medicare |
$499.28
|
| Rate for Payer: Lucent All Commercial |
$499.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$881.08
|
| Rate for Payer: PHCS All Commercial |
$734.23
|
| Rate for Payer: PHP All Commercial |
$742.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$381.80
|
| Rate for Payer: Sagamore Health Network All Products |
$755.77
|
| Rate for Payer: Signature Care EPO |
$812.55
|
| Rate for Payer: Signature Care PPO |
$861.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$832.13
|
| Rate for Payer: United Healthcare Commercial |
$771.43
|
| Rate for Payer: United Healthcare Medicare |
$323.06
|
|
|
IOPAMIDOL 61 % IV SOLN 50 ML VIAL
|
Facility
IP
|
$65.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$49.09 |
| Max. Negotiated Rate |
$60.87 |
| Rate for Payer: Aetna Commercial |
$56.55
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cigna All Commercial |
$56.48
|
| Rate for Payer: CORVEL All Commercial |
$60.87
|
| Rate for Payer: Coventry All Commercial |
$57.60
|
| Rate for Payer: Encore All Commercial |
$60.25
|
| Rate for Payer: Frontpath All Commercial |
$60.21
|
| Rate for Payer: Humana ChoiceCare |
$56.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$58.90
|
| Rate for Payer: PHCS All Commercial |
$49.09
|
| Rate for Payer: PHP All Commercial |
$49.64
|
| Rate for Payer: Sagamore Health Network All Products |
$50.53
|
| Rate for Payer: Signature Care EPO |
$54.32
|
| Rate for Payer: Signature Care PPO |
$57.60
|
| Rate for Payer: United Healthcare Commercial |
$51.57
|
|
|
IOPAMIDOL 61 % IV SOLN 50 ML VIAL
|
Facility
OP
|
$65.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$60.87 |
| Rate for Payer: Aetna Commercial |
$55.24
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$37.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.76
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Centivo All Commercial |
$33.38
|
| Rate for Payer: Cigna All Commercial |
$56.48
|
| Rate for Payer: CORVEL All Commercial |
$60.87
|
| Rate for Payer: Coventry All Commercial |
$57.60
|
| Rate for Payer: Encore All Commercial |
$60.25
|
| Rate for Payer: Frontpath All Commercial |
$60.21
|
| Rate for Payer: Humana ChoiceCare |
$56.53
|
| Rate for Payer: Humana Medicare |
$33.38
|
| Rate for Payer: Lucent All Commercial |
$33.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$58.90
|
| Rate for Payer: PHCS All Commercial |
$49.09
|
| Rate for Payer: PHP All Commercial |
$49.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.53
|
| Rate for Payer: Sagamore Health Network All Products |
$50.53
|
| Rate for Payer: Signature Care EPO |
$54.32
|
| Rate for Payer: Signature Care PPO |
$57.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$55.63
|
| Rate for Payer: United Healthcare Commercial |
$51.57
|
| Rate for Payer: United Healthcare Medicare |
$21.60
|
|
|
IOPAMIDOL 76 % IV SOLN 100 ML BTL
|
Facility
IP
|
$727.50
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$545.62 |
| Max. Negotiated Rate |
$676.58 |
| Rate for Payer: Aetna Commercial |
$628.56
|
| Rate for Payer: Cash Price |
$451.05
|
| Rate for Payer: Cigna All Commercial |
$627.83
|
| Rate for Payer: CORVEL All Commercial |
$676.58
|
| Rate for Payer: Coventry All Commercial |
$640.20
|
| Rate for Payer: Encore All Commercial |
$669.66
|
| Rate for Payer: Frontpath All Commercial |
$669.30
|
| Rate for Payer: Humana ChoiceCare |
$628.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$654.75
|
| Rate for Payer: PHCS All Commercial |
$545.62
|
| Rate for Payer: PHP All Commercial |
$551.74
|
| Rate for Payer: Sagamore Health Network All Products |
$561.63
|
| Rate for Payer: Signature Care EPO |
$603.82
|
| Rate for Payer: Signature Care PPO |
$640.20
|
| Rate for Payer: United Healthcare Commercial |
$573.27
|
|
|
IOPAMIDOL 76 % IV SOLN 100 ML BTL
|
Facility
OP
|
$727.50
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.08 |
| Max. Negotiated Rate |
$676.58 |
| Rate for Payer: Aetna Commercial |
$614.01
|
| Rate for Payer: Aetna Medicare |
$240.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$240.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$417.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$454.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$276.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$264.08
|
| Rate for Payer: Cash Price |
$451.05
|
| Rate for Payer: Centivo All Commercial |
$371.02
|
| Rate for Payer: Cigna All Commercial |
$627.83
|
| Rate for Payer: CORVEL All Commercial |
$676.58
|
| Rate for Payer: Coventry All Commercial |
$640.20
|
| Rate for Payer: Encore All Commercial |
$669.66
|
| Rate for Payer: Frontpath All Commercial |
$669.30
|
| Rate for Payer: Humana ChoiceCare |
$628.34
|
| Rate for Payer: Humana Medicare |
$371.02
|
| Rate for Payer: Lucent All Commercial |
$371.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$654.75
|
| Rate for Payer: PHCS All Commercial |
$545.62
|
| Rate for Payer: PHP All Commercial |
$551.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$283.72
|
| Rate for Payer: Sagamore Health Network All Products |
$561.63
|
| Rate for Payer: Signature Care EPO |
$603.82
|
| Rate for Payer: Signature Care PPO |
$640.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$618.38
|
| Rate for Payer: United Healthcare Commercial |
$573.27
|
| Rate for Payer: United Healthcare Medicare |
$240.08
|
|
|
IOPAMIDOL 76 % IV SOLN 125 ML BTL
|
Facility
IP
|
$342.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103284
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$256.50 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$295.49
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cigna All Commercial |
$295.15
|
| Rate for Payer: CORVEL All Commercial |
$318.06
|
| Rate for Payer: Coventry All Commercial |
$300.96
|
| Rate for Payer: Encore All Commercial |
$314.81
|
| Rate for Payer: Frontpath All Commercial |
$314.64
|
| Rate for Payer: Humana ChoiceCare |
$295.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.80
|
| Rate for Payer: PHCS All Commercial |
$256.50
|
| Rate for Payer: PHP All Commercial |
$259.37
|
| Rate for Payer: Sagamore Health Network All Products |
$264.02
|
| Rate for Payer: Signature Care EPO |
$283.86
|
| Rate for Payer: Signature Care PPO |
$300.96
|
| Rate for Payer: United Healthcare Commercial |
$269.50
|
|
|
IOPAMIDOL 76 % IV SOLN 125 ML BTL
|
Facility
OP
|
$342.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.86 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$288.65
|
| Rate for Payer: Aetna Medicare |
$112.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$112.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$196.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$129.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$124.15
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Centivo All Commercial |
$174.42
|
| Rate for Payer: Cigna All Commercial |
$295.15
|
| Rate for Payer: CORVEL All Commercial |
$318.06
|
| Rate for Payer: Coventry All Commercial |
$300.96
|
| Rate for Payer: Encore All Commercial |
$314.81
|
| Rate for Payer: Frontpath All Commercial |
$314.64
|
| Rate for Payer: Humana ChoiceCare |
$295.39
|
| Rate for Payer: Humana Medicare |
$174.42
|
| Rate for Payer: Lucent All Commercial |
$174.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.80
|
| Rate for Payer: PHCS All Commercial |
$256.50
|
| Rate for Payer: PHP All Commercial |
$259.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.38
|
| Rate for Payer: Sagamore Health Network All Products |
$264.02
|
| Rate for Payer: Signature Care EPO |
$283.86
|
| Rate for Payer: Signature Care PPO |
$300.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.70
|
| Rate for Payer: United Healthcare Commercial |
$269.50
|
| Rate for Payer: United Healthcare Medicare |
$112.86
|
|
|
IOPAMIDOL 76 % IV SOLN 50 ML BTL
|
Facility
OP
|
$72.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$67.70 |
| Rate for Payer: Aetna Commercial |
$61.44
|
| Rate for Payer: Aetna Medicare |
$24.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$41.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.43
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Centivo All Commercial |
$37.13
|
| Rate for Payer: Cigna All Commercial |
$62.83
|
| Rate for Payer: CORVEL All Commercial |
$67.70
|
| Rate for Payer: Coventry All Commercial |
$64.06
|
| Rate for Payer: Encore All Commercial |
$67.01
|
| Rate for Payer: Frontpath All Commercial |
$66.98
|
| Rate for Payer: Humana ChoiceCare |
$62.88
|
| Rate for Payer: Humana Medicare |
$37.13
|
| Rate for Payer: Lucent All Commercial |
$37.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.52
|
| Rate for Payer: PHCS All Commercial |
$54.60
|
| Rate for Payer: PHP All Commercial |
$55.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.39
|
| Rate for Payer: Sagamore Health Network All Products |
$56.20
|
| Rate for Payer: Signature Care EPO |
$60.42
|
| Rate for Payer: Signature Care PPO |
$64.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$61.88
|
| Rate for Payer: United Healthcare Commercial |
$57.37
|
| Rate for Payer: United Healthcare Medicare |
$24.02
|
|
|
IOPAMIDOL 76 % IV SOLN 50 ML BTL
|
Facility
IP
|
$72.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103282
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$67.70 |
| Rate for Payer: Aetna Commercial |
$62.90
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cigna All Commercial |
$62.83
|
| Rate for Payer: CORVEL All Commercial |
$67.70
|
| Rate for Payer: Coventry All Commercial |
$64.06
|
| Rate for Payer: Encore All Commercial |
$67.01
|
| Rate for Payer: Frontpath All Commercial |
$66.98
|
| Rate for Payer: Humana ChoiceCare |
$62.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.52
|
| Rate for Payer: PHCS All Commercial |
$54.60
|
| Rate for Payer: PHP All Commercial |
$55.21
|
| Rate for Payer: Sagamore Health Network All Products |
$56.20
|
| Rate for Payer: Signature Care EPO |
$60.42
|
| Rate for Payer: Signature Care PPO |
$64.06
|
| Rate for Payer: United Healthcare Commercial |
$57.37
|
|
|
IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHL NEBU
|
Facility
IP
|
$19.53
|
|
|
Service Code
|
NDC 00487020101
|
| Hospital Charge Code |
30510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Aetna Commercial |
$16.87
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cigna All Commercial |
$16.85
|
| Rate for Payer: CORVEL All Commercial |
$18.16
|
| Rate for Payer: Coventry All Commercial |
$17.19
|
| Rate for Payer: Encore All Commercial |
$17.98
|
| Rate for Payer: Frontpath All Commercial |
$17.97
|
| Rate for Payer: Humana ChoiceCare |
$16.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.58
|
| Rate for Payer: PHCS All Commercial |
$14.65
|
| Rate for Payer: PHP All Commercial |
$14.81
|
| Rate for Payer: Sagamore Health Network All Products |
$15.08
|
| Rate for Payer: Signature Care EPO |
$16.21
|
| Rate for Payer: Signature Care PPO |
$17.19
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
|
|
IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML INHL NEBU
|
Facility
OP
|
$19.53
|
|
|
Service Code
|
NDC 00487020101
|
| Hospital Charge Code |
30510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$16.48
|
| Rate for Payer: Aetna Medicare |
$6.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.09
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Centivo All Commercial |
$9.96
|
| Rate for Payer: Cigna All Commercial |
$16.85
|
| Rate for Payer: CORVEL All Commercial |
$18.16
|
| Rate for Payer: Coventry All Commercial |
$17.19
|
| Rate for Payer: Encore All Commercial |
$17.98
|
| Rate for Payer: Frontpath All Commercial |
$17.97
|
| Rate for Payer: Humana ChoiceCare |
$16.87
|
| Rate for Payer: Humana Medicare |
$9.96
|
| Rate for Payer: Lucent All Commercial |
$9.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.58
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$14.65
|
| Rate for Payer: PHP All Commercial |
$14.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.62
|
| Rate for Payer: Sagamore Health Network All Products |
$15.08
|
| Rate for Payer: Signature Care EPO |
$16.21
|
| Rate for Payer: Signature Care PPO |
$17.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.60
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare |
$6.44
|
|
|
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST
|
Facility
IP
|
$867.94
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
170346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$650.96 |
| Max. Negotiated Rate |
$807.19 |
| Rate for Payer: Aetna Commercial |
$749.90
|
| Rate for Payer: Cash Price |
$538.13
|
| Rate for Payer: Cigna All Commercial |
$749.04
|
| Rate for Payer: CORVEL All Commercial |
$807.19
|
| Rate for Payer: Coventry All Commercial |
$763.79
|
| Rate for Payer: Encore All Commercial |
$798.94
|
| Rate for Payer: Frontpath All Commercial |
$798.51
|
| Rate for Payer: Humana ChoiceCare |
$749.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$781.15
|
| Rate for Payer: PHCS All Commercial |
$650.96
|
| Rate for Payer: PHP All Commercial |
$658.25
|
| Rate for Payer: Sagamore Health Network All Products |
$670.05
|
| Rate for Payer: Signature Care EPO |
$720.39
|
| Rate for Payer: Signature Care PPO |
$763.79
|
| Rate for Payer: United Healthcare Commercial |
$683.94
|
|
|
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST
|
Facility
OP
|
$867.94
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
170346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.42 |
| Max. Negotiated Rate |
$807.19 |
| Rate for Payer: Aetna Commercial |
$732.54
|
| Rate for Payer: Aetna Medicare |
$286.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$286.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$498.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$542.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$329.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$315.06
|
| Rate for Payer: Cash Price |
$538.13
|
| Rate for Payer: Centivo All Commercial |
$442.65
|
| Rate for Payer: Cigna All Commercial |
$749.04
|
| Rate for Payer: CORVEL All Commercial |
$807.19
|
| Rate for Payer: Coventry All Commercial |
$763.79
|
| Rate for Payer: Encore All Commercial |
$798.94
|
| Rate for Payer: Frontpath All Commercial |
$798.51
|
| Rate for Payer: Humana ChoiceCare |
$749.64
|
| Rate for Payer: Humana Medicare |
$442.65
|
| Rate for Payer: Lucent All Commercial |
$442.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$781.15
|
| Rate for Payer: PHCS All Commercial |
$650.96
|
| Rate for Payer: PHP All Commercial |
$658.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$338.50
|
| Rate for Payer: Sagamore Health Network All Products |
$670.05
|
| Rate for Payer: Signature Care EPO |
$720.39
|
| Rate for Payer: Signature Care PPO |
$763.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$737.75
|
| Rate for Payer: United Healthcare Commercial |
$683.94
|
| Rate for Payer: United Healthcare Medicare |
$286.42
|
|
|
IPRATROPIUM BROMIDE 0.02 % INHL SOLN
|
Facility
OP
|
$1.82
|
|
|
Service Code
|
NDC 00487980101
|
| Hospital Charge Code |
12580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.54
|
| Rate for Payer: Aetna Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Centivo All Commercial |
$0.93
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$0.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
|
|
IPRATROPIUM BROMIDE 0.02 % INHL SOLN
|
Facility
IP
|
$1.82
|
|
|
Service Code
|
NDC 00487980101
|
| Hospital Charge Code |
12580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL HFAA
|
Facility
OP
|
$985.04
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
41142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$325.06 |
| Max. Negotiated Rate |
$916.09 |
| Rate for Payer: Aetna Commercial |
$831.38
|
| Rate for Payer: Aetna Medicare |
$325.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$325.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$565.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$615.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$373.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$357.57
|
| Rate for Payer: Cash Price |
$610.73
|
| Rate for Payer: Centivo All Commercial |
$502.37
|
| Rate for Payer: Cigna All Commercial |
$850.09
|
| Rate for Payer: CORVEL All Commercial |
$916.09
|
| Rate for Payer: Coventry All Commercial |
$866.84
|
| Rate for Payer: Encore All Commercial |
$906.73
|
| Rate for Payer: Frontpath All Commercial |
$906.24
|
| Rate for Payer: Humana ChoiceCare |
$850.78
|
| Rate for Payer: Humana Medicare |
$502.37
|
| Rate for Payer: Lucent All Commercial |
$502.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$886.54
|
| Rate for Payer: PHCS All Commercial |
$738.78
|
| Rate for Payer: PHP All Commercial |
$747.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$384.17
|
| Rate for Payer: Sagamore Health Network All Products |
$760.45
|
| Rate for Payer: Signature Care EPO |
$817.58
|
| Rate for Payer: Signature Care PPO |
$866.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$837.29
|
| Rate for Payer: United Healthcare Commercial |
$776.21
|
| Rate for Payer: United Healthcare Medicare |
$325.06
|
|
