|
RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLN
|
Facility
IP
|
$11,310.43
|
|
|
Service Code
|
HCPCS 90375
|
| Hospital Charge Code |
184464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,482.82 |
| Max. Negotiated Rate |
$10,518.70 |
| Rate for Payer: Aetna Commercial |
$9,772.21
|
| Rate for Payer: Aetna Commercial |
$2,233.65
|
| Rate for Payer: Cash Price |
$7,012.46
|
| Rate for Payer: Cash Price |
$1,602.85
|
| Rate for Payer: Cigna All Commercial |
$9,760.90
|
| Rate for Payer: Cigna All Commercial |
$2,231.06
|
| Rate for Payer: CORVEL All Commercial |
$2,404.27
|
| Rate for Payer: CORVEL All Commercial |
$10,518.70
|
| Rate for Payer: Coventry All Commercial |
$9,953.17
|
| Rate for Payer: Coventry All Commercial |
$2,275.01
|
| Rate for Payer: Encore All Commercial |
$10,411.25
|
| Rate for Payer: Encore All Commercial |
$2,379.71
|
| 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: Lutheran Preferred All Commercial |
$10,179.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,326.72
|
| 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: Sagamore Health Network All Products |
$1,995.81
|
| Rate for Payer: Sagamore Health Network All Products |
$8,731.65
|
| 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: United Healthcare Commercial |
$2,037.17
|
| Rate for Payer: United Healthcare Commercial |
$8,912.61
|
|
|
RABIES VACCINE, PCEC (PF) 2.5 UNITS IM SUSR
|
Facility
OP
|
$1,570.36
|
|
|
Service Code
|
HCPCS 90675
|
| Hospital Charge Code |
22120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.99 |
| Max. Negotiated Rate |
$1,460.43 |
| Rate for Payer: Aetna Commercial |
$1,325.38
|
| Rate for Payer: Aetna Medicare |
$518.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$518.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$901.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$981.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$397.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$595.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$570.04
|
| Rate for Payer: Cash Price |
$973.62
|
| Rate for Payer: Cash Price |
$973.62
|
| Rate for Payer: Centivo All Commercial |
$800.88
|
| Rate for Payer: Cigna All Commercial |
$1,355.22
|
| Rate for Payer: CORVEL All Commercial |
$1,460.43
|
| Rate for Payer: Coventry All Commercial |
$1,381.92
|
| Rate for Payer: Encore All Commercial |
$1,445.52
|
| Rate for Payer: Frontpath All Commercial |
$1,444.73
|
| Rate for Payer: Humana ChoiceCare |
$1,356.32
|
| Rate for Payer: Humana Medicare |
$800.88
|
| Rate for Payer: Lucent All Commercial |
$800.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,413.32
|
| Rate for Payer: Managed Health Services Medicaid |
$397.99
|
| Rate for Payer: MDWise Medicaid |
$397.99
|
| Rate for Payer: PHCS All Commercial |
$1,177.77
|
| Rate for Payer: PHP All Commercial |
$1,190.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$612.44
|
| Rate for Payer: Sagamore Health Network All Products |
$1,212.32
|
| Rate for Payer: Signature Care EPO |
$1,303.40
|
| Rate for Payer: Signature Care PPO |
$1,381.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,334.81
|
| Rate for Payer: United Healthcare Commercial |
$1,237.44
|
| Rate for Payer: United Healthcare Medicare |
$518.22
|
|
|
RABIES VACCINE, PCEC (PF) 2.5 UNITS IM SUSR
|
Facility
IP
|
$1,570.36
|
|
|
Service Code
|
HCPCS 90675
|
| Hospital Charge Code |
22120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,177.77 |
| Max. Negotiated Rate |
$1,460.43 |
| Rate for Payer: Aetna Commercial |
$1,356.79
|
| Rate for Payer: Cash Price |
$973.62
|
| Rate for Payer: Cigna All Commercial |
$1,355.22
|
| Rate for Payer: CORVEL All Commercial |
$1,460.43
|
| Rate for Payer: Coventry All Commercial |
$1,381.92
|
| Rate for Payer: Encore All Commercial |
$1,445.52
|
| Rate for Payer: Frontpath All Commercial |
$1,444.73
|
| Rate for Payer: Humana ChoiceCare |
$1,356.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,413.32
|
| Rate for Payer: PHCS All Commercial |
$1,177.77
|
| Rate for Payer: PHP All Commercial |
$1,190.96
|
| Rate for Payer: Sagamore Health Network All Products |
$1,212.32
|
| Rate for Payer: Signature Care EPO |
$1,303.40
|
| Rate for Payer: Signature Care PPO |
$1,381.92
|
| Rate for Payer: United Healthcare Commercial |
$1,237.44
|
|
|
RACEPINEPHRINE 2.25 % INHL NEBU
|
Facility
IP
|
$9.80
|
|
|
Service Code
|
NDC 00487590199
|
| Hospital Charge Code |
2851
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cigna All Commercial |
$8.46
|
| Rate for Payer: CORVEL All Commercial |
$9.11
|
| Rate for Payer: Coventry All Commercial |
$8.62
|
| Rate for Payer: Encore All Commercial |
$9.02
|
| Rate for Payer: Frontpath All Commercial |
$9.02
|
| Rate for Payer: Humana ChoiceCare |
$8.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.82
|
| Rate for Payer: PHCS All Commercial |
$7.35
|
| Rate for Payer: PHP All Commercial |
$7.43
|
| Rate for Payer: Sagamore Health Network All Products |
$7.57
|
| Rate for Payer: Signature Care EPO |
$8.13
|
| Rate for Payer: Signature Care PPO |
$8.62
|
| Rate for Payer: United Healthcare Commercial |
$7.72
|
|
|
RACEPINEPHRINE 2.25 % INHL NEBU
|
Facility
OP
|
$9.80
|
|
|
Service Code
|
NDC 00487590199
|
| Hospital Charge Code |
2851
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$8.27
|
| Rate for Payer: Aetna Medicare |
$3.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.13
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.56
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Centivo All Commercial |
$5.00
|
| Rate for Payer: Cigna All Commercial |
$8.46
|
| Rate for Payer: CORVEL All Commercial |
$9.11
|
| Rate for Payer: Coventry All Commercial |
$8.62
|
| Rate for Payer: Encore All Commercial |
$9.02
|
| Rate for Payer: Frontpath All Commercial |
$9.02
|
| Rate for Payer: Humana ChoiceCare |
$8.46
|
| Rate for Payer: Humana Medicare |
$5.00
|
| Rate for Payer: Lucent All Commercial |
$5.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.82
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$7.35
|
| Rate for Payer: PHP All Commercial |
$7.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.82
|
| Rate for Payer: Sagamore Health Network All Products |
$7.57
|
| Rate for Payer: Signature Care EPO |
$8.13
|
| Rate for Payer: Signature Care PPO |
$8.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.33
|
| Rate for Payer: United Healthcare Commercial |
$7.72
|
| Rate for Payer: United Healthcare Medicare |
$3.23
|
|
|
RADIOPAQUE PVC MARKERS-BARIUM 24 MARKERS ORAL CAP
|
Facility
IP
|
$568.53
|
|
|
Service Code
|
HCPCS A9698
|
| Hospital Charge Code |
21381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$426.40 |
| Max. Negotiated Rate |
$528.73 |
| Rate for Payer: Aetna Commercial |
$491.21
|
| Rate for Payer: Cash Price |
$352.49
|
| Rate for Payer: Cigna All Commercial |
$490.64
|
| Rate for Payer: CORVEL All Commercial |
$528.73
|
| Rate for Payer: Coventry All Commercial |
$500.31
|
| Rate for Payer: Encore All Commercial |
$523.33
|
| Rate for Payer: Frontpath All Commercial |
$523.05
|
| Rate for Payer: Humana ChoiceCare |
$491.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.68
|
| Rate for Payer: PHCS All Commercial |
$426.40
|
| Rate for Payer: PHP All Commercial |
$431.17
|
| Rate for Payer: Sagamore Health Network All Products |
$438.91
|
| Rate for Payer: Signature Care EPO |
$471.88
|
| Rate for Payer: Signature Care PPO |
$500.31
|
| Rate for Payer: United Healthcare Commercial |
$448.00
|
|
|
RADIOPAQUE PVC MARKERS-BARIUM 24 MARKERS ORAL CAP
|
Facility
OP
|
$568.53
|
|
|
Service Code
|
HCPCS A9698
|
| Hospital Charge Code |
21381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$528.73 |
| Rate for Payer: Aetna Commercial |
$479.84
|
| Rate for Payer: Aetna Medicare |
$187.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$187.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$326.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$355.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$215.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$206.38
|
| Rate for Payer: Cash Price |
$352.49
|
| Rate for Payer: Cash Price |
$352.49
|
| Rate for Payer: Centivo All Commercial |
$289.95
|
| Rate for Payer: Cigna All Commercial |
$490.64
|
| Rate for Payer: CORVEL All Commercial |
$528.73
|
| Rate for Payer: Coventry All Commercial |
$500.31
|
| Rate for Payer: Encore All Commercial |
$523.33
|
| Rate for Payer: Frontpath All Commercial |
$523.05
|
| Rate for Payer: Humana ChoiceCare |
$491.04
|
| Rate for Payer: Humana Medicare |
$289.95
|
| Rate for Payer: Lucent All Commercial |
$289.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.68
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$426.40
|
| Rate for Payer: PHP All Commercial |
$431.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$221.73
|
| Rate for Payer: Sagamore Health Network All Products |
$438.91
|
| Rate for Payer: Signature Care EPO |
$471.88
|
| Rate for Payer: Signature Care PPO |
$500.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$483.25
|
| Rate for Payer: United Healthcare Commercial |
$448.00
|
| Rate for Payer: United Healthcare Medicare |
$187.61
|
|
|
RALTEGRAVIR 400 MG ORAL TAB
|
Facility
OP
|
$227.14
|
|
|
Service Code
|
NDC 00006022761
|
| Hospital Charge Code |
88608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.95 |
| Max. Negotiated Rate |
$211.24 |
| Rate for Payer: Humana ChoiceCare |
$196.18
|
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Medicare |
$74.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$130.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$86.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$82.45
|
| Rate for Payer: Cash Price |
$140.82
|
| Rate for Payer: Centivo All Commercial |
$115.84
|
| Rate for Payer: Cigna All Commercial |
$196.02
|
| Rate for Payer: CORVEL All Commercial |
$211.24
|
| Rate for Payer: Coventry All Commercial |
$199.88
|
| Rate for Payer: Encore All Commercial |
$209.08
|
| Rate for Payer: Frontpath All Commercial |
$208.97
|
| Rate for Payer: Humana Medicare |
$115.84
|
| Rate for Payer: Lucent All Commercial |
$115.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.42
|
| Rate for Payer: PHCS All Commercial |
$170.35
|
| Rate for Payer: PHP All Commercial |
$172.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$88.58
|
| Rate for Payer: Sagamore Health Network All Products |
$175.35
|
| Rate for Payer: Signature Care EPO |
$188.52
|
| Rate for Payer: Signature Care PPO |
$199.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$193.07
|
| Rate for Payer: United Healthcare Commercial |
$178.98
|
| Rate for Payer: United Healthcare Medicare |
$74.95
|
|
|
RALTEGRAVIR 400 MG ORAL TAB
|
Facility
IP
|
$227.14
|
|
|
Service Code
|
NDC 00006022761
|
| Hospital Charge Code |
88608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.35 |
| Max. Negotiated Rate |
$211.24 |
| Rate for Payer: Aetna Commercial |
$196.25
|
| Rate for Payer: Cash Price |
$140.82
|
| Rate for Payer: Cigna All Commercial |
$196.02
|
| Rate for Payer: CORVEL All Commercial |
$211.24
|
| Rate for Payer: Coventry All Commercial |
$199.88
|
| Rate for Payer: Encore All Commercial |
$209.08
|
| Rate for Payer: Frontpath All Commercial |
$208.97
|
| Rate for Payer: Humana ChoiceCare |
$196.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$204.42
|
| Rate for Payer: PHCS All Commercial |
$170.35
|
| Rate for Payer: PHP All Commercial |
$172.26
|
| Rate for Payer: Sagamore Health Network All Products |
$175.35
|
| Rate for Payer: Signature Care EPO |
$188.52
|
| Rate for Payer: Signature Care PPO |
$199.88
|
| Rate for Payer: United Healthcare Commercial |
$178.98
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
IP
|
$8.60
|
|
|
Service Code
|
NDC 60687054921
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.45 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna All Commercial |
$7.42
|
| Rate for Payer: CORVEL All Commercial |
$7.99
|
| Rate for Payer: Coventry All Commercial |
$7.56
|
| Rate for Payer: Encore All Commercial |
$7.91
|
| Rate for Payer: Frontpath All Commercial |
$7.91
|
| Rate for Payer: Humana ChoiceCare |
$7.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.74
|
| Rate for Payer: PHCS All Commercial |
$6.45
|
| Rate for Payer: PHP All Commercial |
$6.52
|
| Rate for Payer: Sagamore Health Network All Products |
$6.64
|
| Rate for Payer: Signature Care EPO |
$7.13
|
| Rate for Payer: Signature Care PPO |
$7.56
|
| Rate for Payer: United Healthcare Commercial |
$6.77
|
|
|
RANOLAZINE 500 MG ORAL TB12
|
Facility
OP
|
$8.60
|
|
|
Service Code
|
NDC 60687054921
|
| Hospital Charge Code |
70434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Aetna Medicare |
$2.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.12
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Centivo All Commercial |
$4.38
|
| Rate for Payer: Cigna All Commercial |
$7.42
|
| Rate for Payer: CORVEL All Commercial |
$7.99
|
| Rate for Payer: Coventry All Commercial |
$7.56
|
| Rate for Payer: Encore All Commercial |
$7.91
|
| Rate for Payer: Frontpath All Commercial |
$7.91
|
| Rate for Payer: Humana ChoiceCare |
$7.42
|
| Rate for Payer: Humana Medicare |
$4.38
|
| Rate for Payer: Lucent All Commercial |
$4.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.74
|
| Rate for Payer: PHCS All Commercial |
$6.45
|
| Rate for Payer: PHP All Commercial |
$6.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.35
|
| Rate for Payer: Sagamore Health Network All Products |
$6.64
|
| Rate for Payer: Signature Care EPO |
$7.13
|
| Rate for Payer: Signature Care PPO |
$7.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.31
|
| Rate for Payer: United Healthcare Commercial |
$6.77
|
| Rate for Payer: United Healthcare Medicare |
$2.84
|
|
|
REGADENOSON 0.4 MG/5 ML IV SYRG
|
Facility
IP
|
$1,136.85
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
91408
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$852.64 |
| Max. Negotiated Rate |
$1,057.27 |
| Rate for Payer: Aetna Commercial |
$982.24
|
| Rate for Payer: Cash Price |
$704.85
|
| Rate for Payer: Cigna All Commercial |
$981.10
|
| Rate for Payer: CORVEL All Commercial |
$1,057.27
|
| Rate for Payer: Coventry All Commercial |
$1,000.43
|
| Rate for Payer: Encore All Commercial |
$1,046.47
|
| Rate for Payer: Frontpath All Commercial |
$1,045.90
|
| Rate for Payer: Humana ChoiceCare |
$981.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,023.16
|
| Rate for Payer: PHCS All Commercial |
$852.64
|
| Rate for Payer: PHP All Commercial |
$862.19
|
| Rate for Payer: Sagamore Health Network All Products |
$877.65
|
| Rate for Payer: Signature Care EPO |
$943.59
|
| Rate for Payer: Signature Care PPO |
$1,000.43
|
| Rate for Payer: United Healthcare Commercial |
$895.84
|
|
|
REGADENOSON 0.4 MG/5 ML IV SYRG
|
Facility
OP
|
$1,136.85
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
91408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$1,057.27 |
| Rate for Payer: Aetna Commercial |
$959.50
|
| Rate for Payer: Aetna Medicare |
$375.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$375.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$652.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$710.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$7.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$431.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$412.68
|
| Rate for Payer: Cash Price |
$704.85
|
| Rate for Payer: Cash Price |
$704.85
|
| Rate for Payer: Centivo All Commercial |
$579.79
|
| Rate for Payer: Cigna All Commercial |
$981.10
|
| Rate for Payer: CORVEL All Commercial |
$1,057.27
|
| Rate for Payer: Coventry All Commercial |
$1,000.43
|
| Rate for Payer: Encore All Commercial |
$1,046.47
|
| Rate for Payer: Frontpath All Commercial |
$1,045.90
|
| Rate for Payer: Humana ChoiceCare |
$981.90
|
| Rate for Payer: Humana Medicare |
$579.79
|
| Rate for Payer: Lucent All Commercial |
$579.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,023.16
|
| Rate for Payer: Managed Health Services Medicaid |
$7.88
|
| Rate for Payer: MDWise Medicaid |
$7.88
|
| Rate for Payer: PHCS All Commercial |
$852.64
|
| Rate for Payer: PHP All Commercial |
$862.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$443.37
|
| Rate for Payer: Sagamore Health Network All Products |
$877.65
|
| Rate for Payer: Signature Care EPO |
$943.59
|
| Rate for Payer: Signature Care PPO |
$1,000.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$966.32
|
| Rate for Payer: United Healthcare Commercial |
$895.84
|
| Rate for Payer: United Healthcare Medicare |
$375.16
|
|
|
Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 24342
|
| Hospital Charge Code |
CPT-24342
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
REMDESIVIR 100 MG IV SOLR
|
Facility
IP
|
$2,397.92
|
|
|
Service Code
|
HCPCS J0248
|
| Hospital Charge Code |
191228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,798.44 |
| Max. Negotiated Rate |
$2,230.07 |
| Rate for Payer: Aetna Commercial |
$2,071.80
|
| Rate for Payer: Cash Price |
$1,486.71
|
| Rate for Payer: Cigna All Commercial |
$2,069.40
|
| Rate for Payer: CORVEL All Commercial |
$2,230.07
|
| Rate for Payer: Coventry All Commercial |
$2,110.17
|
| Rate for Payer: Encore All Commercial |
$2,207.29
|
| Rate for Payer: Frontpath All Commercial |
$2,206.09
|
| Rate for Payer: Humana ChoiceCare |
$2,071.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,158.13
|
| Rate for Payer: PHCS All Commercial |
$1,798.44
|
| Rate for Payer: PHP All Commercial |
$1,818.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1,851.19
|
| Rate for Payer: Signature Care EPO |
$1,990.27
|
| Rate for Payer: Signature Care PPO |
$2,110.17
|
| Rate for Payer: United Healthcare Commercial |
$1,889.56
|
|
|
REMDESIVIR 100 MG IV SOLR
|
Facility
OP
|
$2,397.92
|
|
|
Service Code
|
HCPCS J0248
|
| Hospital Charge Code |
191228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$2,230.07 |
| Rate for Payer: Aetna Commercial |
$2,023.84
|
| Rate for Payer: Aetna Medicare |
$791.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$791.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,377.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,498.94
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$5.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$910.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$870.44
|
| Rate for Payer: Cash Price |
$1,486.71
|
| Rate for Payer: Cash Price |
$1,486.71
|
| Rate for Payer: Centivo All Commercial |
$1,222.94
|
| Rate for Payer: Cigna All Commercial |
$2,069.40
|
| Rate for Payer: CORVEL All Commercial |
$2,230.07
|
| Rate for Payer: Coventry All Commercial |
$2,110.17
|
| Rate for Payer: Encore All Commercial |
$2,207.29
|
| Rate for Payer: Frontpath All Commercial |
$2,206.09
|
| Rate for Payer: Humana ChoiceCare |
$2,071.08
|
| Rate for Payer: Humana Medicare |
$1,222.94
|
| Rate for Payer: Lucent All Commercial |
$1,222.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,158.13
|
| Rate for Payer: Managed Health Services Medicaid |
$5.46
|
| Rate for Payer: MDWise Medicaid |
$5.46
|
| Rate for Payer: PHCS All Commercial |
$1,798.44
|
| Rate for Payer: PHP All Commercial |
$1,818.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$935.19
|
| Rate for Payer: Sagamore Health Network All Products |
$1,851.19
|
| Rate for Payer: Signature Care EPO |
$1,990.27
|
| Rate for Payer: Signature Care PPO |
$2,110.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,038.23
|
| Rate for Payer: United Healthcare Commercial |
$1,889.56
|
| Rate for Payer: United Healthcare Medicare |
$791.31
|
|
|
Removal, non-biodegradable drug delivery implant
|
Facility
OP
|
$85.25
|
|
|
Service Code
|
CPT 11982
|
| Hospital Charge Code |
CPT-11982
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$85.25 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$85.25
|
| Rate for Payer: Managed Health Services Medicaid |
$85.25
|
| Rate for Payer: MDWise Medicaid |
$85.25
|
|
|
Removal of foreign body, foot; deep
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 28192
|
| Hospital Charge Code |
CPT-28192
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
Removal of foreign body, foot; subcutaneous
|
Facility
OP
|
$381.15
|
|
|
Service Code
|
CPT 28190
|
| Hospital Charge Code |
CPT-28190
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$381.15
|
| Rate for Payer: Managed Health Services Medicaid |
$381.15
|
| Rate for Payer: MDWise Medicaid |
$381.15
|
|
|
Removal of implantable defibrillator pulse generator only
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 33241
|
| Hospital Charge Code |
CPT-33241
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 20680
|
| Hospital Charge Code |
CPT-20680
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Removal of intrauterine device (IUD)
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 58301
|
| Hospital Charge Code |
CPT-58301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.87 |
| Max. Negotiated Rate |
$285.87 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$285.87
|
| Rate for Payer: Managed Health Services Medicaid |
$285.87
|
| Rate for Payer: MDWise Medicaid |
$285.87
|
|
|
Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
|
Facility
OP
|
$8,683.74
|
|
|
Service Code
|
CPT 33228
|
| Hospital Charge Code |
CPT-33228
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,683.74 |
| Max. Negotiated Rate |
$8,683.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8,683.74
|
| Rate for Payer: Managed Health Services Medicaid |
$8,683.74
|
| Rate for Payer: MDWise Medicaid |
$8,683.74
|
|
|
Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
|
Facility
OP
|
$381.15
|
|
|
Service Code
|
CPT 11200
|
| Hospital Charge Code |
CPT-11200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$381.15
|
| Rate for Payer: Managed Health Services Medicaid |
$381.15
|
| Rate for Payer: MDWise Medicaid |
$381.15
|
|
|
Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 36590
|
| Hospital Charge Code |
CPT-36590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
