|
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN
|
Facility
|
OP
|
$262.17
|
|
|
Service Code
|
NDC 70594011202
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$243.82 |
| Rate for Payer: Aetna Commercial |
$221.27
|
| Rate for Payer: Aetna Medicare |
$83.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$150.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$163.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$96.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$92.28
|
| Rate for Payer: Cash Price |
$157.30
|
| Rate for Payer: Cash Price |
$157.30
|
| Rate for Payer: Centivo All Commercial |
$142.62
|
| Rate for Payer: Cigna All Commercial |
$226.25
|
| Rate for Payer: CORVEL All Commercial |
$243.82
|
| Rate for Payer: Coventry All Commercial |
$230.71
|
| Rate for Payer: Encore All Commercial |
$241.33
|
| Rate for Payer: Frontpath All Commercial |
$241.20
|
| Rate for Payer: Humana ChoiceCare |
$226.44
|
| Rate for Payer: Humana Medicare |
$83.89
|
| Rate for Payer: Lucent All Commercial |
$142.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$235.95
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$196.63
|
| Rate for Payer: PHP All Commercial |
$198.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$102.25
|
| Rate for Payer: Sagamore Health Network All Products |
$202.40
|
| Rate for Payer: Signature Care EPO |
$217.60
|
| Rate for Payer: Signature Care PPO |
$230.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$222.85
|
| Rate for Payer: United Healthcare Commercial |
$206.59
|
| Rate for Payer: United Healthcare Medicare |
$83.89
|
|
|
CARVEDILOL 12.5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904730761
|
| Hospital Charge Code |
15749
|
|
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 |
$0.60
|
| 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
|
|
|
CARVEDILOL 12.5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904730761
|
| Hospital Charge Code |
15749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
CARVEDILOL 3.125 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904730561
|
| Hospital Charge Code |
18551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
CARVEDILOL 3.125 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904730561
|
| Hospital Charge Code |
18551
|
|
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 |
$0.60
|
| 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
|
|
|
CARVEDILOL 6.25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904730661
|
| Hospital Charge Code |
15747
|
|
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 |
$0.60
|
| 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
|
|
|
CARVEDILOL 6.25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904730661
|
| Hospital Charge Code |
15747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| 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 |
$0.32
|
|
|
CATARACT EYE OINTMENT - DR HOLICKI
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
NDC 099999997
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$192.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$186.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$344.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$375.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$220.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$211.20
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Centivo All Commercial |
$326.40
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Humana Medicare |
$192.00
|
| Rate for Payer: Lucent All Commercial |
$326.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.00
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$510.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
| Rate for Payer: United Healthcare Medicare |
$192.00
|
|
|
CATARACT EYE OINTMENT - DR HOLICKI
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
NDC 099999997
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$518.40
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
|
|
CEFAZOLIN 1 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
1445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
CEFAZOLIN 1 G INJ SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
1445
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
CEFAZOLIN 2 G INJ SOLR
|
Facility
|
OP
|
$30.51
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
197497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$28.38 |
| Rate for Payer: Aetna Commercial |
$25.75
|
| Rate for Payer: Aetna Medicare |
$9.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.74
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Centivo All Commercial |
$16.60
|
| Rate for Payer: Cigna All Commercial |
$26.33
|
| Rate for Payer: CORVEL All Commercial |
$28.38
|
| Rate for Payer: Coventry All Commercial |
$26.85
|
| Rate for Payer: Encore All Commercial |
$28.09
|
| Rate for Payer: Frontpath All Commercial |
$28.07
|
| Rate for Payer: Humana ChoiceCare |
$26.35
|
| Rate for Payer: Humana Medicare |
$9.76
|
| Rate for Payer: Lucent All Commercial |
$16.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.46
|
| Rate for Payer: PHCS All Commercial |
$22.88
|
| Rate for Payer: PHP All Commercial |
$23.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.90
|
| Rate for Payer: Sagamore Health Network All Products |
$23.56
|
| Rate for Payer: Signature Care EPO |
$25.33
|
| Rate for Payer: Signature Care PPO |
$26.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.94
|
| Rate for Payer: United Healthcare Commercial |
$24.04
|
| Rate for Payer: United Healthcare Medicare |
$9.76
|
|
|
CEFAZOLIN 2 G INJ SOLR
|
Facility
|
IP
|
$30.51
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
197497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$28.38 |
| Rate for Payer: Aetna Commercial |
$26.36
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cigna All Commercial |
$26.33
|
| Rate for Payer: CORVEL All Commercial |
$28.38
|
| Rate for Payer: Coventry All Commercial |
$26.85
|
| Rate for Payer: Encore All Commercial |
$28.09
|
| Rate for Payer: Frontpath All Commercial |
$28.07
|
| Rate for Payer: Humana ChoiceCare |
$26.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.46
|
| Rate for Payer: PHCS All Commercial |
$22.88
|
| Rate for Payer: PHP All Commercial |
$23.14
|
| Rate for Payer: Sagamore Health Network All Products |
$23.56
|
| Rate for Payer: Signature Care EPO |
$25.33
|
| Rate for Payer: Signature Care PPO |
$26.85
|
| Rate for Payer: United Healthcare Commercial |
$24.04
|
|
|
CEFAZOLIN 3 G IV SOLR
|
Facility
|
OP
|
$35.43
|
|
|
Service Code
|
HCPCS J0688
|
| Hospital Charge Code |
200765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$32.95 |
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Aetna Medicare |
$11.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.47
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Centivo All Commercial |
$19.28
|
| Rate for Payer: Cigna All Commercial |
$30.58
|
| Rate for Payer: CORVEL All Commercial |
$32.95
|
| Rate for Payer: Coventry All Commercial |
$31.18
|
| Rate for Payer: Encore All Commercial |
$32.62
|
| Rate for Payer: Frontpath All Commercial |
$32.60
|
| Rate for Payer: Humana ChoiceCare |
$30.60
|
| Rate for Payer: Humana Medicare |
$11.34
|
| Rate for Payer: Lucent All Commercial |
$19.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.89
|
| Rate for Payer: PHCS All Commercial |
$26.58
|
| Rate for Payer: PHP All Commercial |
$26.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.82
|
| Rate for Payer: Sagamore Health Network All Products |
$27.36
|
| Rate for Payer: Signature Care EPO |
$29.41
|
| Rate for Payer: Signature Care PPO |
$31.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.12
|
| Rate for Payer: United Healthcare Commercial |
$27.92
|
| Rate for Payer: United Healthcare Medicare |
$11.34
|
|
|
CEFAZOLIN 3 G IV SOLR
|
Facility
|
IP
|
$35.43
|
|
|
Service Code
|
HCPCS J0688
|
| Hospital Charge Code |
200765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.58 |
| Max. Negotiated Rate |
$32.95 |
| Rate for Payer: Aetna Commercial |
$30.61
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cigna All Commercial |
$30.58
|
| Rate for Payer: CORVEL All Commercial |
$32.95
|
| Rate for Payer: Coventry All Commercial |
$31.18
|
| Rate for Payer: Encore All Commercial |
$32.62
|
| Rate for Payer: Frontpath All Commercial |
$32.60
|
| Rate for Payer: Humana ChoiceCare |
$30.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.89
|
| Rate for Payer: PHCS All Commercial |
$26.58
|
| Rate for Payer: PHP All Commercial |
$26.87
|
| Rate for Payer: Sagamore Health Network All Products |
$27.36
|
| Rate for Payer: Signature Care EPO |
$29.41
|
| Rate for Payer: Signature Care PPO |
$31.18
|
| Rate for Payer: United Healthcare Commercial |
$27.92
|
|
|
CEFAZOLIN IN DEXTROSE 5 % 2 G/100 ML IV SOLN
|
Facility
|
OP
|
$121.10
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
117341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.54 |
| Max. Negotiated Rate |
$112.62 |
| Rate for Payer: Aetna Commercial |
$102.21
|
| Rate for Payer: Aetna Medicare |
$38.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$69.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.63
|
| Rate for Payer: Cash Price |
$72.66
|
| Rate for Payer: Centivo All Commercial |
$65.88
|
| Rate for Payer: Cigna All Commercial |
$104.51
|
| Rate for Payer: CORVEL All Commercial |
$112.62
|
| Rate for Payer: Coventry All Commercial |
$106.57
|
| Rate for Payer: Encore All Commercial |
$111.47
|
| Rate for Payer: Frontpath All Commercial |
$111.41
|
| Rate for Payer: Humana ChoiceCare |
$104.59
|
| Rate for Payer: Humana Medicare |
$38.75
|
| Rate for Payer: Lucent All Commercial |
$65.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.99
|
| Rate for Payer: PHCS All Commercial |
$90.83
|
| Rate for Payer: PHP All Commercial |
$91.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.23
|
| Rate for Payer: Sagamore Health Network All Products |
$93.49
|
| Rate for Payer: Signature Care EPO |
$100.51
|
| Rate for Payer: Signature Care PPO |
$106.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$102.94
|
| Rate for Payer: United Healthcare Commercial |
$95.43
|
| Rate for Payer: United Healthcare Medicare |
$38.75
|
|
|
CEFAZOLIN IN DEXTROSE 5 % 2 G/100 ML IV SOLN
|
Facility
|
IP
|
$121.10
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
117341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.83 |
| Max. Negotiated Rate |
$112.62 |
| Rate for Payer: Aetna Commercial |
$104.63
|
| Rate for Payer: Cash Price |
$72.66
|
| Rate for Payer: Cigna All Commercial |
$104.51
|
| Rate for Payer: CORVEL All Commercial |
$112.62
|
| Rate for Payer: Coventry All Commercial |
$106.57
|
| Rate for Payer: Encore All Commercial |
$111.47
|
| Rate for Payer: Frontpath All Commercial |
$111.41
|
| Rate for Payer: Humana ChoiceCare |
$104.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.99
|
| Rate for Payer: PHCS All Commercial |
$90.83
|
| Rate for Payer: PHP All Commercial |
$91.84
|
| Rate for Payer: Sagamore Health Network All Products |
$93.49
|
| Rate for Payer: Signature Care EPO |
$100.51
|
| Rate for Payer: Signature Care PPO |
$106.57
|
| Rate for Payer: United Healthcare Commercial |
$95.43
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 1 GRAM/50 ML IV PGBK
|
Facility
|
OP
|
$81.40
|
|
|
Service Code
|
HCPCS J0689
|
| Hospital Charge Code |
25365
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.23 |
| Max. Negotiated Rate |
$75.70 |
| Rate for Payer: Aetna Commercial |
$68.70
|
| Rate for Payer: Aetna Medicare |
$26.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$46.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.65
|
| Rate for Payer: Cash Price |
$48.84
|
| Rate for Payer: Centivo All Commercial |
$44.28
|
| Rate for Payer: Cigna All Commercial |
$70.24
|
| Rate for Payer: CORVEL All Commercial |
$75.70
|
| Rate for Payer: Coventry All Commercial |
$71.63
|
| Rate for Payer: Encore All Commercial |
$74.93
|
| Rate for Payer: Frontpath All Commercial |
$74.88
|
| Rate for Payer: Humana ChoiceCare |
$70.30
|
| Rate for Payer: Humana Medicare |
$26.05
|
| Rate for Payer: Lucent All Commercial |
$44.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.26
|
| Rate for Payer: PHCS All Commercial |
$61.05
|
| Rate for Payer: PHP All Commercial |
$61.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.74
|
| Rate for Payer: Sagamore Health Network All Products |
$62.84
|
| Rate for Payer: Signature Care EPO |
$67.56
|
| Rate for Payer: Signature Care PPO |
$71.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$69.19
|
| Rate for Payer: United Healthcare Commercial |
$64.14
|
| Rate for Payer: United Healthcare Medicare |
$26.05
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 1 GRAM/50 ML IV PGBK
|
Facility
|
IP
|
$81.40
|
|
|
Service Code
|
HCPCS J0689
|
| Hospital Charge Code |
25365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.05 |
| Max. Negotiated Rate |
$75.70 |
| Rate for Payer: Aetna Commercial |
$70.33
|
| Rate for Payer: Cash Price |
$48.84
|
| Rate for Payer: Cigna All Commercial |
$70.24
|
| Rate for Payer: CORVEL All Commercial |
$75.70
|
| Rate for Payer: Coventry All Commercial |
$71.63
|
| Rate for Payer: Encore All Commercial |
$74.93
|
| Rate for Payer: Frontpath All Commercial |
$74.88
|
| Rate for Payer: Humana ChoiceCare |
$70.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.26
|
| Rate for Payer: PHCS All Commercial |
$61.05
|
| Rate for Payer: PHP All Commercial |
$61.73
|
| Rate for Payer: Sagamore Health Network All Products |
$62.84
|
| Rate for Payer: Signature Care EPO |
$67.56
|
| Rate for Payer: Signature Care PPO |
$71.63
|
| Rate for Payer: United Healthcare Commercial |
$64.14
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 G/100 ML IV PGBK
|
Facility
|
OP
|
$65.10
|
|
|
Service Code
|
HCPCS J0689
|
| Hospital Charge Code |
174932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.18 |
| Max. Negotiated Rate |
$60.54 |
| Rate for Payer: Aetna Commercial |
$54.94
|
| Rate for Payer: Aetna Medicare |
$20.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$37.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.92
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Centivo All Commercial |
$35.41
|
| Rate for Payer: Cigna All Commercial |
$56.18
|
| Rate for Payer: CORVEL All Commercial |
$60.54
|
| Rate for Payer: Coventry All Commercial |
$57.29
|
| Rate for Payer: Encore All Commercial |
$59.92
|
| Rate for Payer: Frontpath All Commercial |
$59.89
|
| Rate for Payer: Humana ChoiceCare |
$56.23
|
| Rate for Payer: Humana Medicare |
$20.83
|
| Rate for Payer: Lucent All Commercial |
$35.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$58.59
|
| Rate for Payer: PHCS All Commercial |
$48.83
|
| Rate for Payer: PHP All Commercial |
$49.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.39
|
| Rate for Payer: Sagamore Health Network All Products |
$50.26
|
| Rate for Payer: Signature Care EPO |
$54.03
|
| Rate for Payer: Signature Care PPO |
$57.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$55.34
|
| Rate for Payer: United Healthcare Commercial |
$51.30
|
| Rate for Payer: United Healthcare Medicare |
$20.83
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 G/100 ML IV PGBK
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
HCPCS J0689
|
| Hospital Charge Code |
174932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.83 |
| Max. Negotiated Rate |
$60.54 |
| Rate for Payer: Aetna Commercial |
$56.25
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cigna All Commercial |
$56.18
|
| Rate for Payer: CORVEL All Commercial |
$60.54
|
| Rate for Payer: Coventry All Commercial |
$57.29
|
| Rate for Payer: Encore All Commercial |
$59.92
|
| Rate for Payer: Frontpath All Commercial |
$59.89
|
| Rate for Payer: Humana ChoiceCare |
$56.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$58.59
|
| Rate for Payer: PHCS All Commercial |
$48.83
|
| Rate for Payer: PHP All Commercial |
$49.37
|
| Rate for Payer: Sagamore Health Network All Products |
$50.26
|
| Rate for Payer: Signature Care EPO |
$54.03
|
| Rate for Payer: Signature Care PPO |
$57.29
|
| Rate for Payer: United Healthcare Commercial |
$51.30
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/50 ML IV PGBK
|
Facility
|
OP
|
$91.57
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
154207
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$77.29
|
| Rate for Payer: Aetna Medicare |
$29.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$52.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$57.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$33.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$32.23
|
| Rate for Payer: Cash Price |
$54.94
|
| Rate for Payer: Centivo All Commercial |
$49.82
|
| Rate for Payer: Cigna All Commercial |
$79.03
|
| Rate for Payer: CORVEL All Commercial |
$85.16
|
| Rate for Payer: Coventry All Commercial |
$80.59
|
| Rate for Payer: Encore All Commercial |
$84.29
|
| Rate for Payer: Frontpath All Commercial |
$84.25
|
| Rate for Payer: Humana ChoiceCare |
$79.09
|
| Rate for Payer: Humana Medicare |
$29.30
|
| Rate for Payer: Lucent All Commercial |
$49.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$82.42
|
| Rate for Payer: PHCS All Commercial |
$68.68
|
| Rate for Payer: PHP All Commercial |
$69.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.71
|
| Rate for Payer: Sagamore Health Network All Products |
$70.70
|
| Rate for Payer: Signature Care EPO |
$76.01
|
| Rate for Payer: Signature Care PPO |
$80.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$77.84
|
| Rate for Payer: United Healthcare Commercial |
$72.16
|
| Rate for Payer: United Healthcare Medicare |
$29.30
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/50 ML IV PGBK
|
Facility
|
IP
|
$91.57
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
154207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.68 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$79.12
|
| Rate for Payer: Cash Price |
$54.94
|
| Rate for Payer: Cigna All Commercial |
$79.03
|
| Rate for Payer: CORVEL All Commercial |
$85.16
|
| Rate for Payer: Coventry All Commercial |
$80.59
|
| Rate for Payer: Encore All Commercial |
$84.29
|
| Rate for Payer: Frontpath All Commercial |
$84.25
|
| Rate for Payer: Humana ChoiceCare |
$79.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$82.42
|
| Rate for Payer: PHCS All Commercial |
$68.68
|
| Rate for Payer: PHP All Commercial |
$69.45
|
| Rate for Payer: Sagamore Health Network All Products |
$70.70
|
| Rate for Payer: Signature Care EPO |
$76.01
|
| Rate for Payer: Signature Care PPO |
$80.59
|
| Rate for Payer: United Healthcare Commercial |
$72.16
|
|
|
CEFAZOLIN SKIN TEST (CAMERON)
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 605050749
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
CEFAZOLIN SKIN TEST (CAMERON)
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 605050749
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
