|
PR WAX TRAPS
|
Professional
|
$400.00
|
|
|
Service Code
|
CPT V5267
|
| Hospital Charge Code |
zV5267A
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Cash Price |
$248.00
|
| Rate for Payer: PHCS All Commercial |
$300.00
|
| Rate for Payer: Signature Care EPO |
$400.00
|
| Rate for Payer: Signature Care PPO |
$400.00
|
|
|
PR WEDGE BIOPSY OF LIVER
|
Professional
|
$1,516.92
|
|
|
Service Code
|
CPT 47100
|
| Hospital Charge Code |
z47100
|
| Min. Negotiated Rate |
$586.30 |
| Max. Negotiated Rate |
$1,327.31 |
| Rate for Payer: Aetna Medicare |
$777.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$586.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$586.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$894.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$855.16
|
| Rate for Payer: Cash Price |
$940.49
|
| Rate for Payer: Cash Price |
$940.49
|
| Rate for Payer: Coventry All Commercial |
$932.90
|
| Rate for Payer: Frontpath All Commercial |
$1,119.13
|
| Rate for Payer: Humana ChoiceCare |
$807.39
|
| Rate for Payer: Humana Medicare |
$777.42
|
| Rate for Payer: Lucent All Commercial |
$1,321.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,166.00
|
| Rate for Payer: PHCS All Commercial |
$1,137.69
|
| Rate for Payer: PHP All Commercial |
$1,327.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$777.42
|
| Rate for Payer: Signature Care EPO |
$1,010.65
|
| Rate for Payer: Signature Care PPO |
$1,010.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,088.00
|
| Rate for Payer: United Healthcare Commercial |
$881.53
|
| Rate for Payer: United Healthcare Medicare |
$777.42
|
|
|
PR WEDGING OF CAST
|
Professional
|
$178.54
|
|
|
Service Code
|
CPT 29740
|
| Hospital Charge Code |
z29740
|
| Min. Negotiated Rate |
$63.41 |
| Max. Negotiated Rate |
$133.90 |
| Rate for Payer: Aetna Medicare |
$63.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$122.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$122.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$72.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$69.75
|
| Rate for Payer: Cash Price |
$110.69
|
| Rate for Payer: Cash Price |
$110.69
|
| Rate for Payer: Coventry All Commercial |
$76.09
|
| Rate for Payer: Frontpath All Commercial |
$90.05
|
| Rate for Payer: Humana ChoiceCare |
$71.70
|
| Rate for Payer: Humana Medicare |
$63.41
|
| Rate for Payer: Lucent All Commercial |
$107.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.00
|
| Rate for Payer: PHCS All Commercial |
$133.90
|
| Rate for Payer: PHP All Commercial |
$107.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$63.41
|
| Rate for Payer: Signature Care EPO |
$130.05
|
| Rate for Payer: Signature Care PPO |
$130.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.00
|
| Rate for Payer: United Healthcare Commercial |
$75.23
|
| Rate for Payer: United Healthcare Medicare |
$63.41
|
|
|
PR WINDOWING OF CAST
|
Professional
|
$116.00
|
|
|
Service Code
|
CPT 29730
|
| Hospital Charge Code |
z29730
|
| Min. Negotiated Rate |
$41.24 |
| Max. Negotiated Rate |
$88.40 |
| Rate for Payer: Aetna Medicare |
$41.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$83.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$83.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.36
|
| Rate for Payer: Cash Price |
$71.92
|
| Rate for Payer: Cash Price |
$71.92
|
| Rate for Payer: Coventry All Commercial |
$49.49
|
| Rate for Payer: Frontpath All Commercial |
$57.30
|
| Rate for Payer: Humana ChoiceCare |
$48.87
|
| Rate for Payer: Humana Medicare |
$41.24
|
| Rate for Payer: Lucent All Commercial |
$70.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.00
|
| Rate for Payer: PHCS All Commercial |
$87.00
|
| Rate for Payer: PHP All Commercial |
$70.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.24
|
| Rate for Payer: Signature Care EPO |
$88.40
|
| Rate for Payer: Signature Care PPO |
$88.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.00
|
| Rate for Payer: United Healthcare Commercial |
$51.54
|
| Rate for Payer: United Healthcare Medicare |
$41.24
|
|
|
PR WND PREP PED, FACE/NCK/HND/FT/GEN 1ST 100 CM
|
Professional
|
$719.30
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
z15004
|
| Min. Negotiated Rate |
$234.01 |
| Max. Negotiated Rate |
$539.48 |
| Rate for Payer: Aetna Medicare |
$242.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$436.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$436.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$278.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$266.61
|
| Rate for Payer: Cash Price |
$445.97
|
| Rate for Payer: Cash Price |
$445.97
|
| Rate for Payer: Coventry All Commercial |
$290.84
|
| Rate for Payer: Frontpath All Commercial |
$338.26
|
| Rate for Payer: Humana ChoiceCare |
$234.01
|
| Rate for Payer: Humana Medicare |
$242.37
|
| Rate for Payer: Lucent All Commercial |
$412.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$539.48
|
| Rate for Payer: PHP All Commercial |
$331.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$242.37
|
| Rate for Payer: Signature Care EPO |
$368.05
|
| Rate for Payer: Signature Care PPO |
$368.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$291.00
|
| Rate for Payer: United Healthcare Commercial |
$311.79
|
| Rate for Payer: United Healthcare Medicare |
$242.37
|
|
|
PR WRIST ARTHROSCOP,RELEASE XVERS LIG
|
Professional
|
$935.76
|
|
|
Service Code
|
CPT 29848
|
| Hospital Charge Code |
z29848
|
| Min. Negotiated Rate |
$475.73 |
| Max. Negotiated Rate |
$815.29 |
| Rate for Payer: Aetna Medicare |
$479.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$551.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$527.54
|
| Rate for Payer: Cash Price |
$580.17
|
| Rate for Payer: Cash Price |
$580.17
|
| Rate for Payer: Coventry All Commercial |
$575.50
|
| Rate for Payer: Frontpath All Commercial |
$659.11
|
| Rate for Payer: Humana ChoiceCare |
$475.73
|
| Rate for Payer: Humana Medicare |
$479.58
|
| Rate for Payer: Lucent All Commercial |
$815.29
|
| Rate for Payer: PHCS All Commercial |
$701.82
|
| Rate for Payer: PHP All Commercial |
$814.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$479.58
|
| Rate for Payer: Signature Care EPO |
$632.40
|
| Rate for Payer: Signature Care PPO |
$632.40
|
| Rate for Payer: United Healthcare Commercial |
$529.69
|
| Rate for Payer: United Healthcare Medicare |
$479.58
|
|
|
PR XFER SINGLE DEEP LOW LEG TENDON
|
Professional
|
$1,356.62
|
|
|
Service Code
|
CPT 27691
|
| Hospital Charge Code |
z27691
|
| Min. Negotiated Rate |
$695.27 |
| Max. Negotiated Rate |
$1,181.96 |
| Rate for Payer: Aetna Medicare |
$695.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$947.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$947.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$799.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$764.80
|
| Rate for Payer: Cash Price |
$841.10
|
| Rate for Payer: Cash Price |
$841.10
|
| Rate for Payer: Coventry All Commercial |
$834.32
|
| Rate for Payer: Frontpath All Commercial |
$962.47
|
| Rate for Payer: Humana ChoiceCare |
$773.35
|
| Rate for Payer: Humana Medicare |
$695.27
|
| Rate for Payer: Lucent All Commercial |
$1,181.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,112.00
|
| Rate for Payer: PHCS All Commercial |
$1,017.46
|
| Rate for Payer: PHP All Commercial |
$1,180.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$695.27
|
| Rate for Payer: Signature Care EPO |
$1,041.25
|
| Rate for Payer: Signature Care PPO |
$1,041.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,043.00
|
| Rate for Payer: United Healthcare Commercial |
$817.31
|
| Rate for Payer: United Healthcare Medicare |
$695.27
|
|
|
PR XTRNL ECG CONTINUOUS RHYTHM W/I&R UP TO 48 HRS
|
Professional
|
$34.54
|
|
|
Service Code
|
CPT 93227
|
| Hospital Charge Code |
z93227
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna Medicare |
$17.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$25.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.47
|
| Rate for Payer: Cash Price |
$21.41
|
| Rate for Payer: Cash Price |
$21.41
|
| Rate for Payer: Coventry All Commercial |
$21.24
|
| Rate for Payer: Frontpath All Commercial |
$20.13
|
| Rate for Payer: Humana ChoiceCare |
$36.10
|
| Rate for Payer: Humana Medicare |
$17.70
|
| Rate for Payer: Lucent All Commercial |
$30.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.00
|
| Rate for Payer: PHCS All Commercial |
$25.90
|
| Rate for Payer: PHP All Commercial |
$25.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.70
|
| Rate for Payer: Signature Care EPO |
$30.63
|
| Rate for Payer: Signature Care PPO |
$30.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.00
|
| Rate for Payer: United Healthcare Commercial |
$34.33
|
| Rate for Payer: United Healthcare Medicare |
$17.70
|
|
|
PR XTRNL MOBILE CV TELEMETRY W/I&REPORT 30 DAYS
|
Professional
|
$46.84
|
|
|
Service Code
|
CPT 93228
|
| Hospital Charge Code |
z93228
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna Medicare |
$24.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$26.41
|
| Rate for Payer: Cash Price |
$29.04
|
| Rate for Payer: Cash Price |
$29.04
|
| Rate for Payer: Coventry All Commercial |
$28.81
|
| Rate for Payer: Frontpath All Commercial |
$27.93
|
| Rate for Payer: Humana ChoiceCare |
$33.73
|
| Rate for Payer: Humana Medicare |
$24.01
|
| Rate for Payer: Lucent All Commercial |
$40.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.00
|
| Rate for Payer: PHCS All Commercial |
$35.13
|
| Rate for Payer: PHP All Commercial |
$34.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.01
|
| Rate for Payer: Signature Care EPO |
$37.97
|
| Rate for Payer: Signature Care PPO |
$37.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$36.00
|
| Rate for Payer: United Healthcare Commercial |
$31.03
|
| Rate for Payer: United Healthcare Medicare |
$24.01
|
|
|
PR XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT
|
Professional
|
$1,507.24
|
|
|
Service Code
|
CPT 93229
|
| Hospital Charge Code |
z93229
|
| Min. Negotiated Rate |
$381.10 |
| Max. Negotiated Rate |
$1,313.18 |
| Rate for Payer: Aetna Medicare |
$772.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$679.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$679.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$888.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$849.71
|
| Rate for Payer: Cash Price |
$934.49
|
| Rate for Payer: Cash Price |
$934.49
|
| Rate for Payer: Coventry All Commercial |
$926.95
|
| Rate for Payer: Frontpath All Commercial |
$916.49
|
| Rate for Payer: Humana ChoiceCare |
$885.81
|
| Rate for Payer: Humana Medicare |
$772.46
|
| Rate for Payer: Lucent All Commercial |
$1,313.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,236.00
|
| Rate for Payer: PHCS All Commercial |
$1,130.43
|
| Rate for Payer: PHP All Commercial |
$1,107.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$772.46
|
| Rate for Payer: Signature Care EPO |
$1,157.58
|
| Rate for Payer: Signature Care PPO |
$1,157.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,159.00
|
| Rate for Payer: United Healthcare Commercial |
$381.10
|
| Rate for Payer: United Healthcare Medicare |
$772.46
|
|
|
PR XTRNL PT ACTIV ECG TRANSMIS W/R&I </30 DAYS
|
Professional
|
$322.96
|
|
|
Service Code
|
CPT 93268
|
| Hospital Charge Code |
z93268
|
| Min. Negotiated Rate |
$165.52 |
| Max. Negotiated Rate |
$381.16 |
| Rate for Payer: Aetna Medicare |
$165.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$205.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$205.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$190.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$182.07
|
| Rate for Payer: Cash Price |
$200.24
|
| Rate for Payer: Cash Price |
$200.24
|
| Rate for Payer: Coventry All Commercial |
$198.62
|
| Rate for Payer: Frontpath All Commercial |
$192.10
|
| Rate for Payer: Humana ChoiceCare |
$381.16
|
| Rate for Payer: Humana Medicare |
$165.52
|
| Rate for Payer: Lucent All Commercial |
$281.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$265.00
|
| Rate for Payer: PHCS All Commercial |
$242.22
|
| Rate for Payer: PHP All Commercial |
$237.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$165.52
|
| Rate for Payer: Signature Care EPO |
$291.65
|
| Rate for Payer: Signature Care PPO |
$291.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$248.00
|
| Rate for Payer: United Healthcare Commercial |
$302.50
|
| Rate for Payer: United Healthcare Medicare |
$165.52
|
|
|
PR XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS
|
Professional
|
$45.26
|
|
|
Service Code
|
CPT 93272
|
| Hospital Charge Code |
z93272
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$40.66 |
| Rate for Payer: Aetna Medicare |
$23.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.51
|
| Rate for Payer: Cash Price |
$28.06
|
| Rate for Payer: Cash Price |
$28.06
|
| Rate for Payer: Coventry All Commercial |
$27.83
|
| Rate for Payer: Frontpath All Commercial |
$26.88
|
| Rate for Payer: Humana ChoiceCare |
$36.10
|
| Rate for Payer: Humana Medicare |
$23.19
|
| Rate for Payer: Lucent All Commercial |
$39.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.00
|
| Rate for Payer: PHCS All Commercial |
$33.94
|
| Rate for Payer: PHP All Commercial |
$33.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.19
|
| Rate for Payer: Signature Care EPO |
$40.66
|
| Rate for Payer: Signature Care PPO |
$40.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.00
|
| Rate for Payer: United Healthcare Commercial |
$33.09
|
| Rate for Payer: United Healthcare Medicare |
$23.19
|
|
|
PSEUDOEPHEDRINE HCL 30 MG ORAL TAB
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 00904505359
|
| Hospital Charge Code |
6714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.13
|
| Rate for Payer: Aetna Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Centivo All Commercial |
$0.08
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.14
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Humana Medicare |
$0.08
|
| Rate for Payer: Lucent All Commercial |
$0.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.14
|
| Rate for Payer: PHCS All Commercial |
$0.12
|
| Rate for Payer: PHP All Commercial |
$0.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.06
|
| Rate for Payer: Sagamore Health Network All Products |
$0.12
|
| Rate for Payer: Signature Care EPO |
$0.13
|
| Rate for Payer: Signature Care PPO |
$0.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
|
|
PSEUDOEPHEDRINE HCL 30 MG ORAL TAB
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 00904505359
|
| Hospital Charge Code |
6714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna All Commercial |
$0.13
|
| Rate for Payer: CORVEL All Commercial |
$0.14
|
| Rate for Payer: Coventry All Commercial |
$0.14
|
| Rate for Payer: Encore All Commercial |
$0.14
|
| Rate for Payer: Frontpath All Commercial |
$0.14
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.14
|
| Rate for Payer: PHCS All Commercial |
$0.12
|
| Rate for Payer: PHP All Commercial |
$0.12
|
| Rate for Payer: Sagamore Health Network All Products |
$0.12
|
| Rate for Payer: Signature Care EPO |
$0.13
|
| Rate for Payer: Signature Care PPO |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 G ORAL PWPK
|
Facility
IP
|
$3.41
|
|
|
Service Code
|
NDC 37000002404
|
| Hospital Charge Code |
11218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 G ORAL PWPK
|
Facility
OP
|
$3.41
|
|
|
Service Code
|
NDC 37000002404
|
| Hospital Charge Code |
11218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Centivo All Commercial |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Humana Medicare |
$1.74
|
| Rate for Payer: Lucent All Commercial |
$1.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.90
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Medicare |
$1.12
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 G ORAL PWPK
|
Facility
IP
|
$3.41
|
|
|
Service Code
|
NDC 37000002310
|
| Hospital Charge Code |
168105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 G ORAL PWPK
|
Facility
IP
|
$3.41
|
|
|
Service Code
|
NDC 37000002304
|
| Hospital Charge Code |
168105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 G ORAL PWPK
|
Facility
OP
|
$3.41
|
|
|
Service Code
|
NDC 37000002310
|
| Hospital Charge Code |
168105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Centivo All Commercial |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Humana Medicare |
$1.74
|
| Rate for Payer: Lucent All Commercial |
$1.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.90
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Medicare |
$1.12
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 G ORAL PWPK
|
Facility
OP
|
$3.41
|
|
|
Service Code
|
NDC 37000002304
|
| Hospital Charge Code |
168105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Centivo All Commercial |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.94
|
| Rate for Payer: CORVEL All Commercial |
$3.17
|
| Rate for Payer: Coventry All Commercial |
$3.00
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.94
|
| Rate for Payer: Humana Medicare |
$1.74
|
| Rate for Payer: Lucent All Commercial |
$1.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$2.63
|
| Rate for Payer: Signature Care EPO |
$2.83
|
| Rate for Payer: Signature Care PPO |
$3.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.90
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Medicare |
$1.12
|
|
|
QUETIAPINE 100 MG ORAL TAB
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 00904664061
|
| Hospital Charge Code |
21824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna Commercial |
$0.98
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Centivo All Commercial |
$0.59
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.08
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.07
|
| Rate for Payer: Frontpath All Commercial |
$1.07
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Humana Medicare |
$0.59
|
| Rate for Payer: Lucent All Commercial |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.05
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.90
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$0.92
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
QUETIAPINE 100 MG ORAL TAB
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 00904664061
|
| Hospital Charge Code |
21824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.08
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.07
|
| Rate for Payer: Frontpath All Commercial |
$1.07
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.05
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Sagamore Health Network All Products |
$0.90
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$0.92
|
|
|
QUETIAPINE 25 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904663861
|
| Hospital Charge Code |
21823
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
QUETIAPINE 25 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904663861
|
| Hospital Charge Code |
21823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLN
|
Facility
OP
|
$2,585.24
|
|
|
Service Code
|
HCPCS 90375
|
| Hospital Charge Code |
184464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$714.52 |
| Max. Negotiated Rate |
$2,404.27 |
| Rate for Payer: Aetna Commercial |
$2,181.94
|
| Rate for Payer: Aetna Commercial |
$9,546.00
|
| Rate for Payer: Aetna Medicare |
$853.13
|
| Rate for Payer: Aetna Medicare |
$3,732.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,732.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$853.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,495.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,484.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,070.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,616.03
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$714.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$714.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,292.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$981.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,105.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$938.44
|
| Rate for Payer: Cash Price |
$1,602.85
|
| Rate for Payer: Cash Price |
$1,602.85
|
| Rate for Payer: Cash Price |
$7,012.46
|
| Rate for Payer: Cash Price |
$7,012.46
|
| Rate for Payer: Centivo All Commercial |
$5,768.32
|
| Rate for Payer: Centivo All Commercial |
$1,318.47
|
| Rate for Payer: Cigna All Commercial |
$2,231.06
|
| Rate for Payer: Cigna All Commercial |
$9,760.90
|
| Rate for Payer: CORVEL All Commercial |
$2,404.27
|
| Rate for Payer: CORVEL All Commercial |
$10,518.70
|
| Rate for Payer: Coventry All Commercial |
$2,275.01
|
| Rate for Payer: Coventry All Commercial |
$9,953.17
|
| Rate for Payer: Encore All Commercial |
$2,379.71
|
| Rate for Payer: Encore All Commercial |
$10,411.25
|
| Rate for Payer: Frontpath All Commercial |
$10,405.59
|
| Rate for Payer: Frontpath All Commercial |
$2,378.42
|
| Rate for Payer: Humana ChoiceCare |
$2,232.87
|
| Rate for Payer: Humana ChoiceCare |
$9,768.81
|
| Rate for Payer: Humana Medicare |
$1,318.47
|
| Rate for Payer: Humana Medicare |
$5,768.32
|
| Rate for Payer: Lucent All Commercial |
$5,768.32
|
| Rate for Payer: Lucent All Commercial |
$1,318.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,326.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,179.38
|
| Rate for Payer: Managed Health Services Medicaid |
$714.52
|
| Rate for Payer: Managed Health Services Medicaid |
$714.52
|
| Rate for Payer: MDWise Medicaid |
$714.52
|
| Rate for Payer: MDWise Medicaid |
$714.52
|
| Rate for Payer: PHCS All Commercial |
$8,482.82
|
| Rate for Payer: PHCS All Commercial |
$1,938.93
|
| Rate for Payer: PHP All Commercial |
$8,577.83
|
| Rate for Payer: PHP All Commercial |
$1,960.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,411.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,008.24
|
| Rate for Payer: Sagamore Health Network All Products |
$8,731.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1,995.81
|
| Rate for Payer: Signature Care EPO |
$2,145.75
|
| Rate for Payer: Signature Care EPO |
$9,387.65
|
| Rate for Payer: Signature Care PPO |
$9,953.17
|
| Rate for Payer: Signature Care PPO |
$2,275.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,613.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,197.45
|
| Rate for Payer: United Healthcare Commercial |
$8,912.61
|
| Rate for Payer: United Healthcare Commercial |
$2,037.17
|
| Rate for Payer: United Healthcare Medicare |
$3,732.44
|
| Rate for Payer: United Healthcare Medicare |
$853.13
|
|
