|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL HFAA
|
Facility
IP
|
$985.04
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
41142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$738.78 |
| Max. Negotiated Rate |
$916.09 |
| Rate for Payer: Aetna Commercial |
$851.08
|
| Rate for Payer: Cash Price |
$610.73
|
| 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: 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: 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: United Healthcare Commercial |
$776.21
|
|
|
IRON DEXTRAN 50 MG/ML INJ SOLN
|
Facility
OP
|
$235.63
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
184397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.76 |
| Max. Negotiated Rate |
$219.14 |
| Rate for Payer: Aetna Commercial |
$198.88
|
| Rate for Payer: Aetna Medicare |
$77.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$77.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$135.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$147.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$85.54
|
| Rate for Payer: Cash Price |
$146.09
|
| Rate for Payer: Centivo All Commercial |
$120.17
|
| Rate for Payer: Cigna All Commercial |
$203.35
|
| Rate for Payer: CORVEL All Commercial |
$219.14
|
| Rate for Payer: Coventry All Commercial |
$207.36
|
| Rate for Payer: Encore All Commercial |
$216.90
|
| Rate for Payer: Frontpath All Commercial |
$216.78
|
| Rate for Payer: Humana ChoiceCare |
$203.52
|
| Rate for Payer: Humana Medicare |
$120.17
|
| Rate for Payer: Lucent All Commercial |
$120.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.07
|
| Rate for Payer: PHCS All Commercial |
$176.73
|
| Rate for Payer: PHP All Commercial |
$178.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$91.90
|
| Rate for Payer: Sagamore Health Network All Products |
$181.91
|
| Rate for Payer: Signature Care EPO |
$195.58
|
| Rate for Payer: Signature Care PPO |
$207.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$200.29
|
| Rate for Payer: United Healthcare Commercial |
$185.68
|
| Rate for Payer: United Healthcare Medicare |
$77.76
|
|
|
IRON DEXTRAN 50 MG/ML INJ SOLN
|
Facility
IP
|
$235.63
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
184397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$176.73 |
| Max. Negotiated Rate |
$219.14 |
| Rate for Payer: Aetna Commercial |
$203.59
|
| Rate for Payer: Cash Price |
$146.09
|
| Rate for Payer: Cigna All Commercial |
$203.35
|
| Rate for Payer: CORVEL All Commercial |
$219.14
|
| Rate for Payer: Coventry All Commercial |
$207.36
|
| Rate for Payer: Encore All Commercial |
$216.90
|
| Rate for Payer: Frontpath All Commercial |
$216.78
|
| Rate for Payer: Humana ChoiceCare |
$203.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.07
|
| Rate for Payer: PHCS All Commercial |
$176.73
|
| Rate for Payer: PHP All Commercial |
$178.70
|
| Rate for Payer: Sagamore Health Network All Products |
$181.91
|
| Rate for Payer: Signature Care EPO |
$195.58
|
| Rate for Payer: Signature Care PPO |
$207.36
|
| Rate for Payer: United Healthcare Commercial |
$185.68
|
|
|
IRON SUCROSE 100 MG IRON/5 ML IV SOLN
|
Facility
IP
|
$274.47
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.85 |
| Max. Negotiated Rate |
$255.26 |
| Rate for Payer: Aetna Commercial |
$237.14
|
| Rate for Payer: Cash Price |
$170.17
|
| Rate for Payer: Cigna All Commercial |
$236.87
|
| Rate for Payer: CORVEL All Commercial |
$255.26
|
| Rate for Payer: Coventry All Commercial |
$241.53
|
| Rate for Payer: Encore All Commercial |
$252.65
|
| Rate for Payer: Frontpath All Commercial |
$252.51
|
| Rate for Payer: Humana ChoiceCare |
$237.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$247.02
|
| Rate for Payer: PHCS All Commercial |
$205.85
|
| Rate for Payer: PHP All Commercial |
$208.16
|
| Rate for Payer: Sagamore Health Network All Products |
$211.89
|
| Rate for Payer: Signature Care EPO |
$227.81
|
| Rate for Payer: Signature Care PPO |
$241.53
|
| Rate for Payer: United Healthcare Commercial |
$216.28
|
|
|
IRON SUCROSE 100 MG IRON/5 ML IV SOLN
|
Facility
OP
|
$274.47
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$255.26 |
| Rate for Payer: Aetna Commercial |
$231.65
|
| Rate for Payer: Aetna Medicare |
$90.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$90.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$157.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$171.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.63
|
| Rate for Payer: Cash Price |
$170.17
|
| Rate for Payer: Cash Price |
$170.17
|
| Rate for Payer: Centivo All Commercial |
$139.98
|
| Rate for Payer: Cigna All Commercial |
$236.87
|
| Rate for Payer: CORVEL All Commercial |
$255.26
|
| Rate for Payer: Coventry All Commercial |
$241.53
|
| Rate for Payer: Encore All Commercial |
$252.65
|
| Rate for Payer: Frontpath All Commercial |
$252.51
|
| Rate for Payer: Humana ChoiceCare |
$237.06
|
| Rate for Payer: Humana Medicare |
$139.98
|
| Rate for Payer: Lucent All Commercial |
$139.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$247.02
|
| Rate for Payer: Managed Health Services Medicaid |
$0.38
|
| Rate for Payer: MDWise Medicaid |
$0.38
|
| Rate for Payer: PHCS All Commercial |
$205.85
|
| Rate for Payer: PHP All Commercial |
$208.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$107.04
|
| Rate for Payer: Sagamore Health Network All Products |
$211.89
|
| Rate for Payer: Signature Care EPO |
$227.81
|
| Rate for Payer: Signature Care PPO |
$241.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$233.30
|
| Rate for Payer: United Healthcare Commercial |
$216.28
|
| Rate for Payer: United Healthcare Medicare |
$90.58
|
|
|
ISONIAZID 300 MG ORAL TAB
|
Facility
IP
|
$6.98
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.23 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Aetna Commercial |
$6.03
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna All Commercial |
$6.02
|
| Rate for Payer: CORVEL All Commercial |
$6.49
|
| Rate for Payer: Coventry All Commercial |
$6.14
|
| Rate for Payer: Encore All Commercial |
$6.42
|
| Rate for Payer: Frontpath All Commercial |
$6.42
|
| Rate for Payer: Humana ChoiceCare |
$6.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.28
|
| Rate for Payer: PHCS All Commercial |
$5.23
|
| Rate for Payer: PHP All Commercial |
$5.29
|
| Rate for Payer: Sagamore Health Network All Products |
$5.39
|
| Rate for Payer: Signature Care EPO |
$5.79
|
| Rate for Payer: Signature Care PPO |
$6.14
|
| Rate for Payer: United Healthcare Commercial |
$5.50
|
|
|
ISONIAZID 300 MG ORAL TAB
|
Facility
OP
|
$6.98
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Aetna Commercial |
$5.89
|
| Rate for Payer: Aetna Medicare |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.53
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Centivo All Commercial |
$3.56
|
| Rate for Payer: Cigna All Commercial |
$6.02
|
| Rate for Payer: CORVEL All Commercial |
$6.49
|
| Rate for Payer: Coventry All Commercial |
$6.14
|
| Rate for Payer: Encore All Commercial |
$6.42
|
| Rate for Payer: Frontpath All Commercial |
$6.42
|
| Rate for Payer: Humana ChoiceCare |
$6.03
|
| Rate for Payer: Humana Medicare |
$3.56
|
| Rate for Payer: Lucent All Commercial |
$3.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.28
|
| Rate for Payer: PHCS All Commercial |
$5.23
|
| Rate for Payer: PHP All Commercial |
$5.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.72
|
| Rate for Payer: Sagamore Health Network All Products |
$5.39
|
| Rate for Payer: Signature Care EPO |
$5.79
|
| Rate for Payer: Signature Care PPO |
$6.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.93
|
| Rate for Payer: United Healthcare Commercial |
$5.50
|
| Rate for Payer: United Healthcare Medicare |
$2.30
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
OP
|
$3.80
|
|
|
Service Code
|
NDC 68084008211
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.38
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Centivo All Commercial |
$1.94
|
| Rate for Payer: Cigna All Commercial |
$3.28
|
| Rate for Payer: CORVEL All Commercial |
$3.53
|
| Rate for Payer: Coventry All Commercial |
$3.34
|
| Rate for Payer: Encore All Commercial |
$3.50
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.28
|
| Rate for Payer: Humana Medicare |
$1.94
|
| Rate for Payer: Lucent All Commercial |
$1.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.42
|
| Rate for Payer: PHCS All Commercial |
$2.85
|
| Rate for Payer: PHP All Commercial |
$2.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.48
|
| Rate for Payer: Sagamore Health Network All Products |
$2.93
|
| Rate for Payer: Signature Care EPO |
$3.15
|
| Rate for Payer: Signature Care PPO |
$3.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.23
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
IP
|
$3.80
|
|
|
Service Code
|
NDC 68084008211
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna All Commercial |
$3.28
|
| Rate for Payer: CORVEL All Commercial |
$3.53
|
| Rate for Payer: Coventry All Commercial |
$3.34
|
| Rate for Payer: Encore All Commercial |
$3.50
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.42
|
| Rate for Payer: PHCS All Commercial |
$2.85
|
| Rate for Payer: PHP All Commercial |
$2.88
|
| Rate for Payer: Sagamore Health Network All Products |
$2.93
|
| Rate for Payer: Signature Care EPO |
$3.15
|
| Rate for Payer: Signature Care PPO |
$3.34
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
OP
|
$3.80
|
|
|
Service Code
|
NDC 68084008201
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.38
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Centivo All Commercial |
$1.94
|
| Rate for Payer: Cigna All Commercial |
$3.28
|
| Rate for Payer: CORVEL All Commercial |
$3.53
|
| Rate for Payer: Coventry All Commercial |
$3.34
|
| Rate for Payer: Encore All Commercial |
$3.50
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.28
|
| Rate for Payer: Humana Medicare |
$1.94
|
| Rate for Payer: Lucent All Commercial |
$1.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.42
|
| Rate for Payer: PHCS All Commercial |
$2.85
|
| Rate for Payer: PHP All Commercial |
$2.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.48
|
| Rate for Payer: Sagamore Health Network All Products |
$2.93
|
| Rate for Payer: Signature Care EPO |
$3.15
|
| Rate for Payer: Signature Care PPO |
$3.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.23
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
|
|
ISOSORBIDE DINITRATE 10 MG ORAL TAB
|
Facility
IP
|
$3.80
|
|
|
Service Code
|
NDC 68084008201
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna All Commercial |
$3.28
|
| Rate for Payer: CORVEL All Commercial |
$3.53
|
| Rate for Payer: Coventry All Commercial |
$3.34
|
| Rate for Payer: Encore All Commercial |
$3.50
|
| Rate for Payer: Frontpath All Commercial |
$3.50
|
| Rate for Payer: Humana ChoiceCare |
$3.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.42
|
| Rate for Payer: PHCS All Commercial |
$2.85
|
| Rate for Payer: PHP All Commercial |
$2.88
|
| Rate for Payer: Sagamore Health Network All Products |
$2.93
|
| Rate for Payer: Signature Care EPO |
$3.15
|
| Rate for Payer: Signature Care PPO |
$3.34
|
| Rate for Payer: United Healthcare Commercial |
$3.00
|
|
|
ISOSORBIDE MONONITRATE 30 MG ORAL TB24
|
Facility
OP
|
$1.48
|
|
|
Service Code
|
NDC 00904644961
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.25
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.75
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.30
|
| Rate for Payer: Encore All Commercial |
$1.36
|
| Rate for Payer: Frontpath All Commercial |
$1.36
|
| Rate for Payer: Humana ChoiceCare |
$1.28
|
| Rate for Payer: Humana Medicare |
$0.75
|
| Rate for Payer: Lucent All Commercial |
$0.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.33
|
| Rate for Payer: PHCS All Commercial |
$1.11
|
| Rate for Payer: PHP All Commercial |
$1.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1.14
|
| Rate for Payer: Signature Care EPO |
$1.23
|
| Rate for Payer: Signature Care PPO |
$1.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
ISOSORBIDE MONONITRATE 30 MG ORAL TB24
|
Facility
IP
|
$1.48
|
|
|
Service Code
|
NDC 00904644961
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.27
|
| Rate for Payer: CORVEL All Commercial |
$1.37
|
| Rate for Payer: Coventry All Commercial |
$1.30
|
| Rate for Payer: Encore All Commercial |
$1.36
|
| Rate for Payer: Frontpath All Commercial |
$1.36
|
| Rate for Payer: Humana ChoiceCare |
$1.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.33
|
| Rate for Payer: PHCS All Commercial |
$1.11
|
| Rate for Payer: PHP All Commercial |
$1.12
|
| Rate for Payer: Sagamore Health Network All Products |
$1.14
|
| Rate for Payer: Signature Care EPO |
$1.23
|
| Rate for Payer: Signature Care PPO |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
ISOSULFAN BLUE 1 % SUBQ SOLN
|
Facility
OP
|
$3,714.60
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
10358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,225.82 |
| Max. Negotiated Rate |
$3,454.58 |
| Rate for Payer: Aetna Commercial |
$3,135.12
|
| Rate for Payer: Aetna Medicare |
$1,225.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,225.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,133.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,322.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,409.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,348.40
|
| Rate for Payer: Cash Price |
$2,303.05
|
| Rate for Payer: Centivo All Commercial |
$1,894.45
|
| Rate for Payer: Cigna All Commercial |
$3,205.70
|
| Rate for Payer: CORVEL All Commercial |
$3,454.58
|
| Rate for Payer: Coventry All Commercial |
$3,268.85
|
| Rate for Payer: Encore All Commercial |
$3,419.29
|
| Rate for Payer: Frontpath All Commercial |
$3,417.43
|
| Rate for Payer: Humana ChoiceCare |
$3,208.30
|
| Rate for Payer: Humana Medicare |
$1,894.45
|
| Rate for Payer: Lucent All Commercial |
$1,894.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,343.14
|
| Rate for Payer: PHCS All Commercial |
$2,785.95
|
| Rate for Payer: PHP All Commercial |
$2,817.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,448.70
|
| Rate for Payer: Sagamore Health Network All Products |
$2,867.67
|
| Rate for Payer: Signature Care EPO |
$3,083.12
|
| Rate for Payer: Signature Care PPO |
$3,268.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,157.41
|
| Rate for Payer: United Healthcare Commercial |
$2,927.11
|
| Rate for Payer: United Healthcare Medicare |
$1,225.82
|
|
|
ISOSULFAN BLUE 1 % SUBQ SOLN
|
Facility
IP
|
$3,714.60
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
10358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,785.95 |
| Max. Negotiated Rate |
$3,454.58 |
| Rate for Payer: Aetna Commercial |
$3,209.42
|
| Rate for Payer: Cash Price |
$2,303.05
|
| Rate for Payer: Cigna All Commercial |
$3,205.70
|
| Rate for Payer: CORVEL All Commercial |
$3,454.58
|
| Rate for Payer: Coventry All Commercial |
$3,268.85
|
| Rate for Payer: Encore All Commercial |
$3,419.29
|
| Rate for Payer: Frontpath All Commercial |
$3,417.43
|
| Rate for Payer: Humana ChoiceCare |
$3,208.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,343.14
|
| Rate for Payer: PHCS All Commercial |
$2,785.95
|
| Rate for Payer: PHP All Commercial |
$2,817.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2,867.67
|
| Rate for Payer: Signature Care EPO |
$3,083.12
|
| Rate for Payer: Signature Care PPO |
$3,268.85
|
| Rate for Payer: United Healthcare Commercial |
$2,927.11
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYRG
|
Facility
OP
|
$35.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
152711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$29.60
|
| Rate for Payer: Aetna Medicare |
$11.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.73
|
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Centivo All Commercial |
$17.89
|
| Rate for Payer: Cigna All Commercial |
$30.27
|
| Rate for Payer: CORVEL All Commercial |
$32.62
|
| Rate for Payer: Coventry All Commercial |
$30.86
|
| Rate for Payer: Encore All Commercial |
$32.28
|
| Rate for Payer: Frontpath All Commercial |
$32.26
|
| Rate for Payer: Humana ChoiceCare |
$30.29
|
| Rate for Payer: Humana Medicare |
$17.89
|
| Rate for Payer: Lucent All Commercial |
$17.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.56
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$26.30
|
| Rate for Payer: PHP All Commercial |
$26.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.68
|
| Rate for Payer: Sagamore Health Network All Products |
$27.07
|
| Rate for Payer: Signature Care EPO |
$29.11
|
| Rate for Payer: Signature Care PPO |
$30.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.81
|
| Rate for Payer: United Healthcare Commercial |
$27.64
|
| Rate for Payer: United Healthcare Medicare |
$11.57
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYRG
|
Facility
IP
|
$35.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
152711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.30 |
| Max. Negotiated Rate |
$32.62 |
| Rate for Payer: Aetna Commercial |
$30.30
|
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Cigna All Commercial |
$30.27
|
| Rate for Payer: CORVEL All Commercial |
$32.62
|
| Rate for Payer: Coventry All Commercial |
$30.86
|
| Rate for Payer: Encore All Commercial |
$32.28
|
| Rate for Payer: Frontpath All Commercial |
$32.26
|
| Rate for Payer: Humana ChoiceCare |
$30.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.56
|
| Rate for Payer: PHCS All Commercial |
$26.30
|
| Rate for Payer: PHP All Commercial |
$26.60
|
| Rate for Payer: Sagamore Health Network All Products |
$27.07
|
| Rate for Payer: Signature Care EPO |
$29.11
|
| Rate for Payer: Signature Care PPO |
$30.86
|
| Rate for Payer: United Healthcare Commercial |
$27.64
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
IP
|
$19.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.75 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
OP
|
$19.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$16.60
|
| Rate for Payer: Aetna Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.14
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Centivo All Commercial |
$10.03
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Humana Medicare |
$10.03
|
| Rate for Payer: Lucent All Commercial |
$10.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.67
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.72
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$6.49
|
|
|
KETAMINE 50 MG/ML INJ SOLN FOR ANE ORDER SET (CAMERON)
|
Facility
OP
|
$19.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1401000423801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$16.60
|
| Rate for Payer: Aetna Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.14
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Centivo All Commercial |
$10.03
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Humana Medicare |
$10.03
|
| Rate for Payer: Lucent All Commercial |
$10.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.67
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.72
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$6.49
|
|
|
KETAMINE 50 MG/ML INJ SOLN FOR ANE ORDER SET (CAMERON)
|
Facility
IP
|
$19.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1401000423801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.75 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
|
|
KETAMINE IN STERILE WATER 50 MG/ML INJ SYRG
|
Facility
IP
|
$31.50
|
|
|
Service Code
|
NDC 69374051101
|
| Hospital Charge Code |
188192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$27.22
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
KETAMINE IN STERILE WATER 50 MG/ML INJ SYRG
|
Facility
OP
|
$31.50
|
|
|
Service Code
|
NDC 69374051101
|
| Hospital Charge Code |
188192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$26.59
|
| Rate for Payer: Aetna Medicare |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Centivo All Commercial |
$16.06
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana Medicare |
$16.06
|
| Rate for Payer: Lucent All Commercial |
$16.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.28
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.78
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
|
|
KETOCONAZOLE 2 % TOP CREA
|
Facility
OP
|
$76.44
|
|
|
Service Code
|
NDC 00168009930
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.23 |
| Max. Negotiated Rate |
$71.09 |
| Rate for Payer: Aetna Commercial |
$64.52
|
| Rate for Payer: Aetna Medicare |
$25.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.75
|
| Rate for Payer: Cash Price |
$47.39
|
| Rate for Payer: Centivo All Commercial |
$38.98
|
| Rate for Payer: Cigna All Commercial |
$65.97
|
| Rate for Payer: CORVEL All Commercial |
$71.09
|
| Rate for Payer: Coventry All Commercial |
$67.27
|
| Rate for Payer: Encore All Commercial |
$70.36
|
| Rate for Payer: Frontpath All Commercial |
$70.32
|
| Rate for Payer: Humana ChoiceCare |
$66.02
|
| Rate for Payer: Humana Medicare |
$38.98
|
| Rate for Payer: Lucent All Commercial |
$38.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$68.80
|
| Rate for Payer: PHCS All Commercial |
$57.33
|
| Rate for Payer: PHP All Commercial |
$57.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.81
|
| Rate for Payer: Sagamore Health Network All Products |
$59.01
|
| Rate for Payer: Signature Care EPO |
$63.45
|
| Rate for Payer: Signature Care PPO |
$67.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$64.97
|
| Rate for Payer: United Healthcare Commercial |
$60.23
|
| Rate for Payer: United Healthcare Medicare |
$25.23
|
|
|
KETOCONAZOLE 2 % TOP CREA
|
Facility
IP
|
$76.44
|
|
|
Service Code
|
NDC 00168009930
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.33 |
| Max. Negotiated Rate |
$71.09 |
| Rate for Payer: Aetna Commercial |
$66.04
|
| Rate for Payer: Cash Price |
$47.39
|
| Rate for Payer: Cigna All Commercial |
$65.97
|
| Rate for Payer: CORVEL All Commercial |
$71.09
|
| Rate for Payer: Coventry All Commercial |
$67.27
|
| Rate for Payer: Encore All Commercial |
$70.36
|
| Rate for Payer: Frontpath All Commercial |
$70.32
|
| Rate for Payer: Humana ChoiceCare |
$66.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$68.80
|
| Rate for Payer: PHCS All Commercial |
$57.33
|
| Rate for Payer: PHP All Commercial |
$57.97
|
| Rate for Payer: Sagamore Health Network All Products |
$59.01
|
| Rate for Payer: Signature Care EPO |
$63.45
|
| Rate for Payer: Signature Care PPO |
$67.27
|
| Rate for Payer: United Healthcare Commercial |
$60.23
|
|
