|
BARIUM SULFATE 0.1 % ORAL SUSP 450 ML BTL
|
Facility
|
OP
|
$47.25
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
93052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$39.88
|
| Rate for Payer: Aetna Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.63
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Centivo All Commercial |
$25.70
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Humana Medicare |
$15.12
|
| Rate for Payer: Lucent All Commercial |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.43
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
| Rate for Payer: United Healthcare Medicare |
$15.12
|
|
|
BARIUM SULFATE 0.1 % ORAL SUSP 450 ML BTL
|
Facility
|
IP
|
$47.25
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
93052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.44 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$28.35
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
|
|
BARIUM SULFATE 105 % (W/V) ORAL SUSP BTL
|
Facility
|
OP
|
$115.50
|
|
|
Service Code
|
NDC 32909016755
|
| Hospital Charge Code |
97296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$107.42 |
| Rate for Payer: Aetna Commercial |
$97.48
|
| Rate for Payer: Aetna Medicare |
$36.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$66.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.66
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Centivo All Commercial |
$62.83
|
| Rate for Payer: Cigna All Commercial |
$99.68
|
| Rate for Payer: CORVEL All Commercial |
$107.42
|
| Rate for Payer: Coventry All Commercial |
$101.64
|
| Rate for Payer: Encore All Commercial |
$106.32
|
| Rate for Payer: Frontpath All Commercial |
$106.26
|
| Rate for Payer: Humana ChoiceCare |
$99.76
|
| Rate for Payer: Humana Medicare |
$36.96
|
| Rate for Payer: Lucent All Commercial |
$62.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.95
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$86.62
|
| Rate for Payer: PHP All Commercial |
$87.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.05
|
| Rate for Payer: Sagamore Health Network All Products |
$89.17
|
| Rate for Payer: Signature Care EPO |
$95.86
|
| Rate for Payer: Signature Care PPO |
$101.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.17
|
| Rate for Payer: United Healthcare Commercial |
$91.01
|
| Rate for Payer: United Healthcare Medicare |
$36.96
|
|
|
BARIUM SULFATE 105 % (W/V) ORAL SUSP BTL
|
Facility
|
IP
|
$115.50
|
|
|
Service Code
|
NDC 32909016755
|
| Hospital Charge Code |
97296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.62 |
| Max. Negotiated Rate |
$107.42 |
| Rate for Payer: Aetna Commercial |
$99.79
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna All Commercial |
$99.68
|
| Rate for Payer: CORVEL All Commercial |
$107.42
|
| Rate for Payer: Coventry All Commercial |
$101.64
|
| Rate for Payer: Encore All Commercial |
$106.32
|
| Rate for Payer: Frontpath All Commercial |
$106.26
|
| Rate for Payer: Humana ChoiceCare |
$99.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.95
|
| Rate for Payer: PHCS All Commercial |
$86.62
|
| Rate for Payer: PHP All Commercial |
$87.60
|
| Rate for Payer: Sagamore Health Network All Products |
$89.17
|
| Rate for Payer: Signature Care EPO |
$95.86
|
| Rate for Payer: Signature Care PPO |
$101.64
|
| Rate for Payer: United Healthcare Commercial |
$91.01
|
|
|
BARIUM SULFATE 60 % ORAL CREA 454 G TUBE
|
Facility
|
IP
|
$101.70
|
|
|
Service Code
|
NDC 32909077001
|
| Hospital Charge Code |
96947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$94.58 |
| Rate for Payer: Aetna Commercial |
$87.87
|
| Rate for Payer: Cash Price |
$61.02
|
| Rate for Payer: Cigna All Commercial |
$87.76
|
| Rate for Payer: CORVEL All Commercial |
$94.58
|
| Rate for Payer: Coventry All Commercial |
$89.49
|
| Rate for Payer: Encore All Commercial |
$93.61
|
| Rate for Payer: Frontpath All Commercial |
$93.56
|
| Rate for Payer: Humana ChoiceCare |
$87.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.53
|
| Rate for Payer: PHCS All Commercial |
$76.27
|
| Rate for Payer: PHP All Commercial |
$77.13
|
| Rate for Payer: Sagamore Health Network All Products |
$78.51
|
| Rate for Payer: Signature Care EPO |
$84.41
|
| Rate for Payer: Signature Care PPO |
$89.49
|
| Rate for Payer: United Healthcare Commercial |
$80.14
|
|
|
BARIUM SULFATE 60 % ORAL CREA 454 G TUBE
|
Facility
|
OP
|
$101.70
|
|
|
Service Code
|
NDC 32909077001
|
| Hospital Charge Code |
96947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$94.58 |
| Rate for Payer: Aetna Commercial |
$85.83
|
| Rate for Payer: Aetna Medicare |
$32.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$58.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.80
|
| Rate for Payer: Cash Price |
$61.02
|
| Rate for Payer: Cash Price |
$61.02
|
| Rate for Payer: Centivo All Commercial |
$55.32
|
| Rate for Payer: Cigna All Commercial |
$87.76
|
| Rate for Payer: CORVEL All Commercial |
$94.58
|
| Rate for Payer: Coventry All Commercial |
$89.49
|
| Rate for Payer: Encore All Commercial |
$93.61
|
| Rate for Payer: Frontpath All Commercial |
$93.56
|
| Rate for Payer: Humana ChoiceCare |
$87.83
|
| Rate for Payer: Humana Medicare |
$32.54
|
| Rate for Payer: Lucent All Commercial |
$55.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.53
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$76.27
|
| Rate for Payer: PHP All Commercial |
$77.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.66
|
| Rate for Payer: Sagamore Health Network All Products |
$78.51
|
| Rate for Payer: Signature Care EPO |
$84.41
|
| Rate for Payer: Signature Care PPO |
$89.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.44
|
| Rate for Payer: United Healthcare Commercial |
$80.14
|
| Rate for Payer: United Healthcare Medicare |
$32.54
|
|
|
BARIUM SULFATE 700 MG ORAL TAB
|
Facility
|
OP
|
$19.08
|
|
|
Service Code
|
NDC 10361077831
|
| Hospital Charge Code |
100992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$17.75 |
| Rate for Payer: Aetna Commercial |
$16.11
|
| Rate for Payer: Aetna Medicare |
$6.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.72
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: Centivo All Commercial |
$10.38
|
| Rate for Payer: Cigna All Commercial |
$16.47
|
| Rate for Payer: CORVEL All Commercial |
$17.75
|
| Rate for Payer: Coventry All Commercial |
$16.79
|
| Rate for Payer: Encore All Commercial |
$17.56
|
| Rate for Payer: Frontpath All Commercial |
$17.56
|
| Rate for Payer: Humana ChoiceCare |
$16.48
|
| Rate for Payer: Humana Medicare |
$6.11
|
| Rate for Payer: Lucent All Commercial |
$10.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.17
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$14.31
|
| Rate for Payer: PHP All Commercial |
$14.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.44
|
| Rate for Payer: Sagamore Health Network All Products |
$14.73
|
| Rate for Payer: Signature Care EPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$16.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$15.04
|
| Rate for Payer: United Healthcare Medicare |
$6.11
|
|
|
BARIUM SULFATE 700 MG ORAL TAB
|
Facility
|
IP
|
$19.08
|
|
|
Service Code
|
NDC 10361077831
|
| Hospital Charge Code |
100992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$17.75 |
| Rate for Payer: Aetna Commercial |
$16.49
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: Cigna All Commercial |
$16.47
|
| Rate for Payer: CORVEL All Commercial |
$17.75
|
| Rate for Payer: Coventry All Commercial |
$16.79
|
| Rate for Payer: Encore All Commercial |
$17.56
|
| Rate for Payer: Frontpath All Commercial |
$17.56
|
| Rate for Payer: Humana ChoiceCare |
$16.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.17
|
| Rate for Payer: PHCS All Commercial |
$14.31
|
| Rate for Payer: PHP All Commercial |
$14.47
|
| Rate for Payer: Sagamore Health Network All Products |
$14.73
|
| Rate for Payer: Signature Care EPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$16.79
|
| Rate for Payer: United Healthcare Commercial |
$15.04
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL SUSR 176 G BTL
|
Facility
|
OP
|
$34.50
|
|
|
Service Code
|
NDC 32909075003
|
| Hospital Charge Code |
13031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$32.08 |
| Rate for Payer: Aetna Commercial |
$29.11
|
| Rate for Payer: Aetna Medicare |
$11.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.14
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Centivo All Commercial |
$18.77
|
| Rate for Payer: Cigna All Commercial |
$29.77
|
| Rate for Payer: CORVEL All Commercial |
$32.08
|
| Rate for Payer: Coventry All Commercial |
$30.36
|
| Rate for Payer: Encore All Commercial |
$31.75
|
| Rate for Payer: Frontpath All Commercial |
$31.74
|
| Rate for Payer: Humana ChoiceCare |
$29.79
|
| Rate for Payer: Humana Medicare |
$11.04
|
| Rate for Payer: Lucent All Commercial |
$18.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.05
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$25.87
|
| Rate for Payer: PHP All Commercial |
$26.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.45
|
| Rate for Payer: Sagamore Health Network All Products |
$26.63
|
| Rate for Payer: Signature Care EPO |
$28.63
|
| Rate for Payer: Signature Care PPO |
$30.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.32
|
| Rate for Payer: United Healthcare Commercial |
$27.18
|
| Rate for Payer: United Healthcare Medicare |
$11.04
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL SUSR 176 G BTL
|
Facility
|
IP
|
$34.50
|
|
|
Service Code
|
NDC 32909075003
|
| Hospital Charge Code |
13031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$32.08 |
| Rate for Payer: Aetna Commercial |
$29.80
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna All Commercial |
$29.77
|
| Rate for Payer: CORVEL All Commercial |
$32.08
|
| Rate for Payer: Coventry All Commercial |
$30.36
|
| Rate for Payer: Encore All Commercial |
$31.75
|
| Rate for Payer: Frontpath All Commercial |
$31.74
|
| Rate for Payer: Humana ChoiceCare |
$29.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.05
|
| Rate for Payer: PHCS All Commercial |
$25.87
|
| Rate for Payer: PHP All Commercial |
$26.16
|
| Rate for Payer: Sagamore Health Network All Products |
$26.63
|
| Rate for Payer: Signature Care EPO |
$28.63
|
| Rate for Payer: Signature Care PPO |
$30.36
|
| Rate for Payer: United Healthcare Commercial |
$27.18
|
|
|
BARIUM SULFATE 98 % ORAL SUSR 340 ML BTL
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$42.05 |
| Rate for Payer: Aetna Commercial |
$38.17
|
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$25.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.92
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Centivo All Commercial |
$24.60
|
| Rate for Payer: Cigna All Commercial |
$39.02
|
| Rate for Payer: CORVEL All Commercial |
$42.05
|
| Rate for Payer: Coventry All Commercial |
$39.79
|
| Rate for Payer: Encore All Commercial |
$41.63
|
| Rate for Payer: Frontpath All Commercial |
$41.60
|
| Rate for Payer: Humana ChoiceCare |
$39.06
|
| Rate for Payer: Humana Medicare |
$14.47
|
| Rate for Payer: Lucent All Commercial |
$24.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$40.70
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$33.91
|
| Rate for Payer: PHP All Commercial |
$34.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.64
|
| Rate for Payer: Sagamore Health Network All Products |
$34.91
|
| Rate for Payer: Signature Care EPO |
$37.53
|
| Rate for Payer: Signature Care PPO |
$39.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$38.44
|
| Rate for Payer: United Healthcare Commercial |
$35.63
|
| Rate for Payer: United Healthcare Medicare |
$14.47
|
|
|
BARIUM SULFATE 98 % ORAL SUSR 340 ML BTL
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.91 |
| Max. Negotiated Rate |
$42.05 |
| Rate for Payer: Aetna Commercial |
$39.07
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cigna All Commercial |
$39.02
|
| Rate for Payer: CORVEL All Commercial |
$42.05
|
| Rate for Payer: Coventry All Commercial |
$39.79
|
| Rate for Payer: Encore All Commercial |
$41.63
|
| Rate for Payer: Frontpath All Commercial |
$41.60
|
| Rate for Payer: Humana ChoiceCare |
$39.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$40.70
|
| Rate for Payer: PHCS All Commercial |
$33.91
|
| Rate for Payer: PHP All Commercial |
$34.29
|
| Rate for Payer: Sagamore Health Network All Products |
$34.91
|
| Rate for Payer: Signature Care EPO |
$37.53
|
| Rate for Payer: Signature Care PPO |
$39.79
|
| Rate for Payer: United Healthcare Commercial |
$35.63
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7584
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7582
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7583
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7581
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
BELIMUMAB 120 MG IV SOLR
|
Facility
|
IP
|
$2,539.00
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
108842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,904.25 |
| Max. Negotiated Rate |
$2,361.27 |
| Rate for Payer: Aetna Commercial |
$2,193.70
|
| Rate for Payer: Cash Price |
$1,523.40
|
| Rate for Payer: Cigna All Commercial |
$2,191.16
|
| Rate for Payer: CORVEL All Commercial |
$2,361.27
|
| Rate for Payer: Coventry All Commercial |
$2,234.32
|
| Rate for Payer: Encore All Commercial |
$2,337.15
|
| Rate for Payer: Frontpath All Commercial |
$2,335.88
|
| Rate for Payer: Humana ChoiceCare |
$2,192.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,285.10
|
| Rate for Payer: PHCS All Commercial |
$1,904.25
|
| Rate for Payer: PHP All Commercial |
$1,925.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1,960.11
|
| Rate for Payer: Signature Care EPO |
$2,107.37
|
| Rate for Payer: Signature Care PPO |
$2,234.32
|
| Rate for Payer: United Healthcare Commercial |
$2,000.73
|
|
|
BELIMUMAB 120 MG IV SOLR
|
Facility
|
OP
|
$2,539.00
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
108842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.54 |
| Max. Negotiated Rate |
$2,361.27 |
| Rate for Payer: Aetna Commercial |
$2,142.92
|
| Rate for Payer: Aetna Medicare |
$812.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$55.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$787.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,458.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,587.13
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$55.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$934.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$893.73
|
| Rate for Payer: Cash Price |
$1,523.40
|
| Rate for Payer: Cash Price |
$1,523.40
|
| Rate for Payer: Centivo All Commercial |
$1,381.22
|
| Rate for Payer: Cigna All Commercial |
$2,191.16
|
| Rate for Payer: CORVEL All Commercial |
$2,361.27
|
| Rate for Payer: Coventry All Commercial |
$2,234.32
|
| Rate for Payer: Encore All Commercial |
$2,337.15
|
| Rate for Payer: Frontpath All Commercial |
$2,335.88
|
| Rate for Payer: Humana ChoiceCare |
$2,192.93
|
| Rate for Payer: Humana Medicare |
$812.48
|
| Rate for Payer: Lucent All Commercial |
$1,381.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,285.10
|
| Rate for Payer: Managed Health Services Medicaid |
$55.54
|
| Rate for Payer: MDWise Medicaid |
$55.54
|
| Rate for Payer: PHCS All Commercial |
$1,904.25
|
| Rate for Payer: PHP All Commercial |
$1,925.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$990.21
|
| Rate for Payer: Sagamore Health Network All Products |
$1,960.11
|
| Rate for Payer: Signature Care EPO |
$2,107.37
|
| Rate for Payer: Signature Care PPO |
$2,234.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,158.15
|
| Rate for Payer: United Healthcare Commercial |
$2,000.73
|
| Rate for Payer: United Healthcare Medicare |
$812.48
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RECT SUPP
|
Facility
|
OP
|
$175.62
|
|
|
Service Code
|
NDC 00574704012
|
| Hospital Charge Code |
24731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.44 |
| Max. Negotiated Rate |
$163.33 |
| Rate for Payer: Aetna Commercial |
$148.23
|
| Rate for Payer: Aetna Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$54.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$64.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$61.82
|
| Rate for Payer: Cash Price |
$105.37
|
| Rate for Payer: Centivo All Commercial |
$95.54
|
| Rate for Payer: Cigna All Commercial |
$151.56
|
| Rate for Payer: CORVEL All Commercial |
$163.33
|
| Rate for Payer: Coventry All Commercial |
$154.55
|
| Rate for Payer: Encore All Commercial |
$161.66
|
| Rate for Payer: Frontpath All Commercial |
$161.57
|
| Rate for Payer: Humana ChoiceCare |
$151.69
|
| Rate for Payer: Humana Medicare |
$56.20
|
| Rate for Payer: Lucent All Commercial |
$95.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.06
|
| Rate for Payer: PHCS All Commercial |
$131.72
|
| Rate for Payer: PHP All Commercial |
$133.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$68.49
|
| Rate for Payer: Sagamore Health Network All Products |
$135.58
|
| Rate for Payer: Signature Care EPO |
$145.77
|
| Rate for Payer: Signature Care PPO |
$154.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$149.28
|
| Rate for Payer: United Healthcare Commercial |
$138.39
|
| Rate for Payer: United Healthcare Medicare |
$56.20
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RECT SUPP
|
Facility
|
OP
|
$175.62
|
|
|
Service Code
|
NDC 00574704001
|
| Hospital Charge Code |
24731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.44 |
| Max. Negotiated Rate |
$163.33 |
| Rate for Payer: Aetna Commercial |
$148.23
|
| Rate for Payer: Aetna Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$54.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$64.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$61.82
|
| Rate for Payer: Cash Price |
$105.37
|
| Rate for Payer: Centivo All Commercial |
$95.54
|
| Rate for Payer: Cigna All Commercial |
$151.56
|
| Rate for Payer: CORVEL All Commercial |
$163.33
|
| Rate for Payer: Coventry All Commercial |
$154.55
|
| Rate for Payer: Encore All Commercial |
$161.66
|
| Rate for Payer: Frontpath All Commercial |
$161.57
|
| Rate for Payer: Humana ChoiceCare |
$151.69
|
| Rate for Payer: Humana Medicare |
$56.20
|
| Rate for Payer: Lucent All Commercial |
$95.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.06
|
| Rate for Payer: PHCS All Commercial |
$131.72
|
| Rate for Payer: PHP All Commercial |
$133.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$68.49
|
| Rate for Payer: Sagamore Health Network All Products |
$135.58
|
| Rate for Payer: Signature Care EPO |
$145.77
|
| Rate for Payer: Signature Care PPO |
$154.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$149.28
|
| Rate for Payer: United Healthcare Commercial |
$138.39
|
| Rate for Payer: United Healthcare Medicare |
$56.20
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RECT SUPP
|
Facility
|
IP
|
$175.62
|
|
|
Service Code
|
NDC 00574704012
|
| Hospital Charge Code |
24731
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.72 |
| Max. Negotiated Rate |
$163.33 |
| Rate for Payer: Aetna Commercial |
$151.74
|
| Rate for Payer: Cash Price |
$105.37
|
| Rate for Payer: Cigna All Commercial |
$151.56
|
| Rate for Payer: CORVEL All Commercial |
$163.33
|
| Rate for Payer: Coventry All Commercial |
$154.55
|
| Rate for Payer: Encore All Commercial |
$161.66
|
| Rate for Payer: Frontpath All Commercial |
$161.57
|
| Rate for Payer: Humana ChoiceCare |
$151.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.06
|
| Rate for Payer: PHCS All Commercial |
$131.72
|
| Rate for Payer: PHP All Commercial |
$133.19
|
| Rate for Payer: Sagamore Health Network All Products |
$135.58
|
| Rate for Payer: Signature Care EPO |
$145.77
|
| Rate for Payer: Signature Care PPO |
$154.55
|
| Rate for Payer: United Healthcare Commercial |
$138.39
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RECT SUPP
|
Facility
|
IP
|
$175.62
|
|
|
Service Code
|
NDC 00574704001
|
| Hospital Charge Code |
24731
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.72 |
| Max. Negotiated Rate |
$163.33 |
| Rate for Payer: Aetna Commercial |
$151.74
|
| Rate for Payer: Cash Price |
$105.37
|
| Rate for Payer: Cigna All Commercial |
$151.56
|
| Rate for Payer: CORVEL All Commercial |
$163.33
|
| Rate for Payer: Coventry All Commercial |
$154.55
|
| Rate for Payer: Encore All Commercial |
$161.66
|
| Rate for Payer: Frontpath All Commercial |
$161.57
|
| Rate for Payer: Humana ChoiceCare |
$151.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.06
|
| Rate for Payer: PHCS All Commercial |
$131.72
|
| Rate for Payer: PHP All Commercial |
$133.19
|
| Rate for Payer: Sagamore Health Network All Products |
$135.58
|
| Rate for Payer: Signature Care EPO |
$145.77
|
| Rate for Payer: Signature Care PPO |
$154.55
|
| Rate for Payer: United Healthcare Commercial |
$138.39
|
|
|
BENRALIZUMAB 30 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$18,111.24
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
183039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$204.65 |
| Max. Negotiated Rate |
$16,843.45 |
| Rate for Payer: Aetna Commercial |
$15,285.89
|
| Rate for Payer: Aetna Medicare |
$5,795.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$204.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,614.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10,401.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11,321.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$204.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,664.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,375.16
|
| Rate for Payer: Cash Price |
$10,866.74
|
| Rate for Payer: Cash Price |
$10,866.74
|
| Rate for Payer: Centivo All Commercial |
$9,852.51
|
| Rate for Payer: Cigna All Commercial |
$15,630.00
|
| Rate for Payer: CORVEL All Commercial |
$16,843.45
|
| Rate for Payer: Coventry All Commercial |
$15,937.89
|
| Rate for Payer: Encore All Commercial |
$16,671.40
|
| Rate for Payer: Frontpath All Commercial |
$16,662.34
|
| Rate for Payer: Humana ChoiceCare |
$15,642.68
|
| Rate for Payer: Humana Medicare |
$5,795.60
|
| Rate for Payer: Lucent All Commercial |
$9,852.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16,300.12
|
| Rate for Payer: Managed Health Services Medicaid |
$204.65
|
| Rate for Payer: MDWise Medicaid |
$204.65
|
| Rate for Payer: PHCS All Commercial |
$13,583.43
|
| Rate for Payer: PHP All Commercial |
$13,735.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,063.38
|
| Rate for Payer: Sagamore Health Network All Products |
$13,981.88
|
| Rate for Payer: Signature Care EPO |
$15,032.33
|
| Rate for Payer: Signature Care PPO |
$15,937.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15,394.55
|
| Rate for Payer: United Healthcare Commercial |
$14,271.66
|
| Rate for Payer: United Healthcare Medicare |
$5,795.60
|
|
|
BENRALIZUMAB 30 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$18,111.24
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
183039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,583.43 |
| Max. Negotiated Rate |
$16,843.45 |
| Rate for Payer: Aetna Commercial |
$15,648.11
|
| Rate for Payer: Cash Price |
$10,866.74
|
| Rate for Payer: Cigna All Commercial |
$15,630.00
|
| Rate for Payer: CORVEL All Commercial |
$16,843.45
|
| Rate for Payer: Coventry All Commercial |
$15,937.89
|
| Rate for Payer: Encore All Commercial |
$16,671.40
|
| Rate for Payer: Frontpath All Commercial |
$16,662.34
|
| Rate for Payer: Humana ChoiceCare |
$15,642.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16,300.12
|
| Rate for Payer: PHCS All Commercial |
$13,583.43
|
| Rate for Payer: PHP All Commercial |
$13,735.56
|
| Rate for Payer: Sagamore Health Network All Products |
$13,981.88
|
| Rate for Payer: Signature Care EPO |
$15,032.33
|
| Rate for Payer: Signature Care PPO |
$15,937.89
|
| Rate for Payer: United Healthcare Commercial |
$14,271.66
|
|
|
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
152887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.15
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Centivo All Commercial |
$0.74
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.20
|
| Rate for Payer: Encore All Commercial |
$1.25
|
| Rate for Payer: Frontpath All Commercial |
$1.25
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Humana Medicare |
$0.43
|
| Rate for Payer: Lucent All Commercial |
$0.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| Rate for Payer: PHCS All Commercial |
$1.02
|
| Rate for Payer: PHP All Commercial |
$1.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1.05
|
| Rate for Payer: Signature Care EPO |
$1.13
|
| Rate for Payer: Signature Care PPO |
$1.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
