|
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG
|
Facility
|
IP
|
$5,277.27
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,957.95 |
| Max. Negotiated Rate |
$4,907.86 |
| Rate for Payer: Aetna Commercial |
$4,559.56
|
| Rate for Payer: Cash Price |
$3,166.36
|
| Rate for Payer: Cigna All Commercial |
$4,554.28
|
| Rate for Payer: CORVEL All Commercial |
$4,907.86
|
| Rate for Payer: Coventry All Commercial |
$4,643.99
|
| Rate for Payer: Encore All Commercial |
$4,857.72
|
| Rate for Payer: Frontpath All Commercial |
$4,855.08
|
| Rate for Payer: Humana ChoiceCare |
$4,557.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,749.54
|
| Rate for Payer: PHCS All Commercial |
$3,957.95
|
| Rate for Payer: PHP All Commercial |
$4,002.28
|
| Rate for Payer: Sagamore Health Network All Products |
$4,074.05
|
| Rate for Payer: Signature Care EPO |
$4,380.13
|
| Rate for Payer: Signature Care PPO |
$4,643.99
|
| Rate for Payer: United Healthcare Commercial |
$4,158.48
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML INJ SOLN
|
Facility
|
OP
|
$942.38
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$876.41 |
| Rate for Payer: Aetna Commercial |
$795.36
|
| Rate for Payer: Aetna Medicare |
$301.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$292.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$541.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$589.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$346.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$331.72
|
| Rate for Payer: Cash Price |
$565.43
|
| Rate for Payer: Cash Price |
$565.43
|
| Rate for Payer: Centivo All Commercial |
$512.65
|
| Rate for Payer: Cigna All Commercial |
$813.27
|
| Rate for Payer: CORVEL All Commercial |
$876.41
|
| Rate for Payer: Coventry All Commercial |
$829.29
|
| Rate for Payer: Encore All Commercial |
$867.46
|
| Rate for Payer: Frontpath All Commercial |
$866.99
|
| Rate for Payer: Humana ChoiceCare |
$813.93
|
| Rate for Payer: Humana Medicare |
$301.56
|
| Rate for Payer: Lucent All Commercial |
$512.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$848.14
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$706.78
|
| Rate for Payer: PHP All Commercial |
$714.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$367.53
|
| Rate for Payer: Sagamore Health Network All Products |
$727.51
|
| Rate for Payer: Signature Care EPO |
$782.17
|
| Rate for Payer: Signature Care PPO |
$829.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$801.02
|
| Rate for Payer: United Healthcare Commercial |
$742.59
|
| Rate for Payer: United Healthcare Medicare |
$301.56
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML INJ SOLN
|
Facility
|
IP
|
$942.38
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76962
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$706.78 |
| Max. Negotiated Rate |
$876.41 |
| Rate for Payer: Aetna Commercial |
$814.21
|
| Rate for Payer: Cash Price |
$565.43
|
| Rate for Payer: Cigna All Commercial |
$813.27
|
| Rate for Payer: CORVEL All Commercial |
$876.41
|
| Rate for Payer: Coventry All Commercial |
$829.29
|
| Rate for Payer: Encore All Commercial |
$867.46
|
| Rate for Payer: Frontpath All Commercial |
$866.99
|
| Rate for Payer: Humana ChoiceCare |
$813.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$848.14
|
| Rate for Payer: PHCS All Commercial |
$706.78
|
| Rate for Payer: PHP All Commercial |
$714.70
|
| Rate for Payer: Sagamore Health Network All Products |
$727.51
|
| Rate for Payer: Signature Care EPO |
$782.17
|
| Rate for Payer: Signature Care PPO |
$829.29
|
| Rate for Payer: United Healthcare Commercial |
$742.59
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG
|
Facility
|
OP
|
$7,915.92
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$7,361.80 |
| Rate for Payer: Aetna Commercial |
$6,681.03
|
| Rate for Payer: Aetna Medicare |
$2,533.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,453.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,546.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,948.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,913.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,786.40
|
| Rate for Payer: Cash Price |
$4,749.55
|
| Rate for Payer: Cash Price |
$4,749.55
|
| Rate for Payer: Centivo All Commercial |
$4,306.26
|
| Rate for Payer: Cigna All Commercial |
$6,831.43
|
| Rate for Payer: CORVEL All Commercial |
$7,361.80
|
| Rate for Payer: Coventry All Commercial |
$6,966.01
|
| Rate for Payer: Encore All Commercial |
$7,286.60
|
| Rate for Payer: Frontpath All Commercial |
$7,282.64
|
| Rate for Payer: Humana ChoiceCare |
$6,836.98
|
| Rate for Payer: Humana Medicare |
$2,533.09
|
| Rate for Payer: Lucent All Commercial |
$4,306.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,124.32
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$5,936.94
|
| Rate for Payer: PHP All Commercial |
$6,003.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,087.21
|
| Rate for Payer: Sagamore Health Network All Products |
$6,111.09
|
| Rate for Payer: Signature Care EPO |
$6,570.21
|
| Rate for Payer: Signature Care PPO |
$6,966.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,728.53
|
| Rate for Payer: United Healthcare Commercial |
$6,237.74
|
| Rate for Payer: United Healthcare Medicare |
$2,533.09
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG
|
Facility
|
IP
|
$7,915.92
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,936.94 |
| Max. Negotiated Rate |
$7,361.80 |
| Rate for Payer: Aetna Commercial |
$6,839.35
|
| Rate for Payer: Cash Price |
$4,749.55
|
| Rate for Payer: Cigna All Commercial |
$6,831.43
|
| Rate for Payer: CORVEL All Commercial |
$7,361.80
|
| Rate for Payer: Coventry All Commercial |
$6,966.01
|
| Rate for Payer: Encore All Commercial |
$7,286.60
|
| Rate for Payer: Frontpath All Commercial |
$7,282.64
|
| Rate for Payer: Humana ChoiceCare |
$6,836.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,124.32
|
| Rate for Payer: PHCS All Commercial |
$5,936.94
|
| Rate for Payer: PHP All Commercial |
$6,003.43
|
| Rate for Payer: Sagamore Health Network All Products |
$6,111.09
|
| Rate for Payer: Signature Care EPO |
$6,570.21
|
| Rate for Payer: Signature Care PPO |
$6,966.01
|
| Rate for Payer: United Healthcare Commercial |
$6,237.74
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYRG
|
Facility
|
OP
|
$1,206.23
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$1,121.79 |
| Rate for Payer: Aetna Commercial |
$1,018.06
|
| Rate for Payer: Aetna Medicare |
$385.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$373.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$692.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$754.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$443.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$424.59
|
| Rate for Payer: Cash Price |
$723.74
|
| Rate for Payer: Cash Price |
$723.74
|
| Rate for Payer: Centivo All Commercial |
$656.19
|
| Rate for Payer: Cigna All Commercial |
$1,040.98
|
| Rate for Payer: CORVEL All Commercial |
$1,121.79
|
| Rate for Payer: Coventry All Commercial |
$1,061.48
|
| Rate for Payer: Encore All Commercial |
$1,110.34
|
| Rate for Payer: Frontpath All Commercial |
$1,109.73
|
| Rate for Payer: Humana ChoiceCare |
$1,041.82
|
| Rate for Payer: Humana Medicare |
$385.99
|
| Rate for Payer: Lucent All Commercial |
$656.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,085.61
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$904.67
|
| Rate for Payer: PHP All Commercial |
$914.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$470.43
|
| Rate for Payer: Sagamore Health Network All Products |
$931.21
|
| Rate for Payer: Signature Care EPO |
$1,001.17
|
| Rate for Payer: Signature Care PPO |
$1,061.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,025.30
|
| Rate for Payer: United Healthcare Commercial |
$950.51
|
| Rate for Payer: United Healthcare Medicare |
$385.99
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYRG
|
Facility
|
IP
|
$1,206.23
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$904.67 |
| Max. Negotiated Rate |
$1,121.79 |
| Rate for Payer: Aetna Commercial |
$1,042.18
|
| Rate for Payer: Cash Price |
$723.74
|
| Rate for Payer: Cigna All Commercial |
$1,040.98
|
| Rate for Payer: CORVEL All Commercial |
$1,121.79
|
| Rate for Payer: Coventry All Commercial |
$1,061.48
|
| Rate for Payer: Encore All Commercial |
$1,110.34
|
| Rate for Payer: Frontpath All Commercial |
$1,109.73
|
| Rate for Payer: Humana ChoiceCare |
$1,041.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,085.61
|
| Rate for Payer: PHCS All Commercial |
$904.67
|
| Rate for Payer: PHP All Commercial |
$914.81
|
| Rate for Payer: Sagamore Health Network All Products |
$931.21
|
| Rate for Payer: Signature Care EPO |
$1,001.17
|
| Rate for Payer: Signature Care PPO |
$1,061.48
|
| Rate for Payer: United Healthcare Commercial |
$950.51
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYRG
|
Facility
|
OP
|
$1,809.35
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$1,682.70 |
| Rate for Payer: Aetna Commercial |
$1,527.09
|
| Rate for Payer: Aetna Medicare |
$578.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$560.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,039.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,131.03
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$665.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$636.89
|
| Rate for Payer: Cash Price |
$1,085.61
|
| Rate for Payer: Cash Price |
$1,085.61
|
| Rate for Payer: Centivo All Commercial |
$984.29
|
| Rate for Payer: Cigna All Commercial |
$1,561.47
|
| Rate for Payer: CORVEL All Commercial |
$1,682.70
|
| Rate for Payer: Coventry All Commercial |
$1,592.23
|
| Rate for Payer: Encore All Commercial |
$1,665.51
|
| Rate for Payer: Frontpath All Commercial |
$1,664.60
|
| Rate for Payer: Humana ChoiceCare |
$1,562.74
|
| Rate for Payer: Humana Medicare |
$578.99
|
| Rate for Payer: Lucent All Commercial |
$984.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,628.42
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$1,357.01
|
| Rate for Payer: PHP All Commercial |
$1,372.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$705.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1,396.82
|
| Rate for Payer: Signature Care EPO |
$1,501.76
|
| Rate for Payer: Signature Care PPO |
$1,592.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,537.95
|
| Rate for Payer: United Healthcare Commercial |
$1,425.77
|
| Rate for Payer: United Healthcare Medicare |
$578.99
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYRG
|
Facility
|
IP
|
$1,809.35
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,357.01 |
| Max. Negotiated Rate |
$1,682.70 |
| Rate for Payer: Aetna Commercial |
$1,563.28
|
| Rate for Payer: Cash Price |
$1,085.61
|
| Rate for Payer: Cigna All Commercial |
$1,561.47
|
| Rate for Payer: CORVEL All Commercial |
$1,682.70
|
| Rate for Payer: Coventry All Commercial |
$1,592.23
|
| Rate for Payer: Encore All Commercial |
$1,665.51
|
| Rate for Payer: Frontpath All Commercial |
$1,664.60
|
| Rate for Payer: Humana ChoiceCare |
$1,562.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,628.42
|
| Rate for Payer: PHCS All Commercial |
$1,357.01
|
| Rate for Payer: PHP All Commercial |
$1,372.21
|
| Rate for Payer: Sagamore Health Network All Products |
$1,396.82
|
| Rate for Payer: Signature Care EPO |
$1,501.76
|
| Rate for Payer: Signature Care PPO |
$1,592.23
|
| Rate for Payer: United Healthcare Commercial |
$1,425.77
|
|
|
DEFEROXAMINE 500 MG INJ SOLR
|
Facility
|
OP
|
$236.97
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
9723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.46 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$200.00
|
| Rate for Payer: Aetna Medicare |
$75.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$136.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$87.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.41
|
| Rate for Payer: Cash Price |
$142.18
|
| Rate for Payer: Centivo All Commercial |
$128.91
|
| Rate for Payer: Cigna All Commercial |
$204.51
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Humana Medicare |
$75.83
|
| Rate for Payer: Lucent All Commercial |
$128.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.73
|
| Rate for Payer: PHP All Commercial |
$179.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.42
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.69
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.43
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
| Rate for Payer: United Healthcare Medicare |
$75.83
|
|
|
DEFEROXAMINE 500 MG INJ SOLR
|
Facility
|
IP
|
$236.97
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
9723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.73 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$204.74
|
| Rate for Payer: Cash Price |
$142.18
|
| Rate for Payer: Cigna All Commercial |
$204.51
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.73
|
| Rate for Payer: PHP All Commercial |
$179.72
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.69
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
|
|
DEGARELIX 120 MG SUBQ SOLR
|
Facility
|
IP
|
$2,857.84
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
96987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,143.38 |
| Max. Negotiated Rate |
$2,657.79 |
| Rate for Payer: Aetna Commercial |
$2,469.17
|
| Rate for Payer: Cash Price |
$1,714.70
|
| Rate for Payer: Cigna All Commercial |
$2,466.32
|
| Rate for Payer: CORVEL All Commercial |
$2,657.79
|
| Rate for Payer: Coventry All Commercial |
$2,514.90
|
| Rate for Payer: Encore All Commercial |
$2,630.64
|
| Rate for Payer: Frontpath All Commercial |
$2,629.21
|
| Rate for Payer: Humana ChoiceCare |
$2,468.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,572.06
|
| Rate for Payer: PHCS All Commercial |
$2,143.38
|
| Rate for Payer: PHP All Commercial |
$2,167.39
|
| Rate for Payer: Sagamore Health Network All Products |
$2,206.25
|
| Rate for Payer: Signature Care EPO |
$2,372.01
|
| Rate for Payer: Signature Care PPO |
$2,514.90
|
| Rate for Payer: United Healthcare Commercial |
$2,251.98
|
|
|
DEGARELIX 120 MG SUBQ SOLR
|
Facility
|
OP
|
$2,857.84
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
96987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$2,657.79 |
| Rate for Payer: Aetna Commercial |
$2,412.02
|
| Rate for Payer: Aetna Medicare |
$914.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$6.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$885.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,641.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,786.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$6.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,051.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,005.96
|
| Rate for Payer: Cash Price |
$1,714.70
|
| Rate for Payer: Cash Price |
$1,714.70
|
| Rate for Payer: Centivo All Commercial |
$1,554.66
|
| Rate for Payer: Cigna All Commercial |
$2,466.32
|
| Rate for Payer: CORVEL All Commercial |
$2,657.79
|
| Rate for Payer: Coventry All Commercial |
$2,514.90
|
| Rate for Payer: Encore All Commercial |
$2,630.64
|
| Rate for Payer: Frontpath All Commercial |
$2,629.21
|
| Rate for Payer: Humana ChoiceCare |
$2,468.32
|
| Rate for Payer: Humana Medicare |
$914.51
|
| Rate for Payer: Lucent All Commercial |
$1,554.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,572.06
|
| Rate for Payer: Managed Health Services Medicaid |
$6.41
|
| Rate for Payer: MDWise Medicaid |
$6.41
|
| Rate for Payer: PHCS All Commercial |
$2,143.38
|
| Rate for Payer: PHP All Commercial |
$2,167.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,114.56
|
| Rate for Payer: Sagamore Health Network All Products |
$2,206.25
|
| Rate for Payer: Signature Care EPO |
$2,372.01
|
| Rate for Payer: Signature Care PPO |
$2,514.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,429.16
|
| Rate for Payer: United Healthcare Commercial |
$2,251.98
|
| Rate for Payer: United Healthcare Medicare |
$914.51
|
|
|
DENOSUMAB 60 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$6,153.14
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.19 |
| Max. Negotiated Rate |
$5,722.42 |
| Rate for Payer: Aetna Commercial |
$5,193.25
|
| Rate for Payer: Aetna Medicare |
$1,969.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$30.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,907.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,533.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,846.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$30.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,264.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,165.91
|
| Rate for Payer: Cash Price |
$3,691.88
|
| Rate for Payer: Cash Price |
$3,691.88
|
| Rate for Payer: Centivo All Commercial |
$3,347.31
|
| Rate for Payer: Cigna All Commercial |
$5,310.16
|
| Rate for Payer: CORVEL All Commercial |
$5,722.42
|
| Rate for Payer: Coventry All Commercial |
$5,414.76
|
| Rate for Payer: Encore All Commercial |
$5,663.97
|
| Rate for Payer: Frontpath All Commercial |
$5,660.89
|
| Rate for Payer: Humana ChoiceCare |
$5,314.47
|
| Rate for Payer: Humana Medicare |
$1,969.00
|
| Rate for Payer: Lucent All Commercial |
$3,347.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,537.83
|
| Rate for Payer: Managed Health Services Medicaid |
$30.19
|
| Rate for Payer: MDWise Medicaid |
$30.19
|
| Rate for Payer: PHCS All Commercial |
$4,614.85
|
| Rate for Payer: PHP All Commercial |
$4,666.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,399.72
|
| Rate for Payer: Sagamore Health Network All Products |
$4,750.22
|
| Rate for Payer: Signature Care EPO |
$5,107.11
|
| Rate for Payer: Signature Care PPO |
$5,414.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,230.17
|
| Rate for Payer: United Healthcare Commercial |
$4,848.67
|
| Rate for Payer: United Healthcare Medicare |
$1,969.00
|
|
|
DENOSUMAB 60 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$6,153.14
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,614.85 |
| Max. Negotiated Rate |
$5,722.42 |
| Rate for Payer: Aetna Commercial |
$5,316.31
|
| Rate for Payer: Cash Price |
$3,691.88
|
| Rate for Payer: Cigna All Commercial |
$5,310.16
|
| Rate for Payer: CORVEL All Commercial |
$5,722.42
|
| Rate for Payer: Coventry All Commercial |
$5,414.76
|
| Rate for Payer: Encore All Commercial |
$5,663.97
|
| Rate for Payer: Frontpath All Commercial |
$5,660.89
|
| Rate for Payer: Humana ChoiceCare |
$5,314.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,537.83
|
| Rate for Payer: PHCS All Commercial |
$4,614.85
|
| Rate for Payer: PHP All Commercial |
$4,666.54
|
| Rate for Payer: Sagamore Health Network All Products |
$4,750.22
|
| Rate for Payer: Signature Care EPO |
$5,107.11
|
| Rate for Payer: Signature Care PPO |
$5,414.76
|
| Rate for Payer: United Healthcare Commercial |
$4,848.67
|
|
|
DENOSUMAB 70 MG/ML SUBQ SOLN
|
Facility
|
OP
|
$10,753.47
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.19 |
| Max. Negotiated Rate |
$10,000.73 |
| Rate for Payer: Aetna Commercial |
$9,075.93
|
| Rate for Payer: Aetna Medicare |
$3,441.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$30.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,333.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,175.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,721.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$30.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,957.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,785.22
|
| Rate for Payer: Cash Price |
$6,452.08
|
| Rate for Payer: Cash Price |
$6,452.08
|
| Rate for Payer: Centivo All Commercial |
$5,849.89
|
| Rate for Payer: Cigna All Commercial |
$9,280.25
|
| Rate for Payer: CORVEL All Commercial |
$10,000.73
|
| Rate for Payer: Coventry All Commercial |
$9,463.05
|
| Rate for Payer: Encore All Commercial |
$9,898.57
|
| Rate for Payer: Frontpath All Commercial |
$9,893.19
|
| Rate for Payer: Humana ChoiceCare |
$9,287.77
|
| Rate for Payer: Humana Medicare |
$3,441.11
|
| Rate for Payer: Lucent All Commercial |
$5,849.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,678.12
|
| Rate for Payer: Managed Health Services Medicaid |
$30.19
|
| Rate for Payer: MDWise Medicaid |
$30.19
|
| Rate for Payer: PHCS All Commercial |
$8,065.10
|
| Rate for Payer: PHP All Commercial |
$8,155.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,193.85
|
| Rate for Payer: Sagamore Health Network All Products |
$8,301.68
|
| Rate for Payer: Signature Care EPO |
$8,925.38
|
| Rate for Payer: Signature Care PPO |
$9,463.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,140.45
|
| Rate for Payer: United Healthcare Commercial |
$8,473.74
|
| Rate for Payer: United Healthcare Medicare |
$3,441.11
|
|
|
DENOSUMAB 70 MG/ML SUBQ SOLN
|
Facility
|
IP
|
$10,753.47
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,065.10 |
| Max. Negotiated Rate |
$10,000.73 |
| Rate for Payer: Aetna Commercial |
$9,291.00
|
| Rate for Payer: Cash Price |
$6,452.08
|
| Rate for Payer: Cigna All Commercial |
$9,280.25
|
| Rate for Payer: CORVEL All Commercial |
$10,000.73
|
| Rate for Payer: Coventry All Commercial |
$9,463.05
|
| Rate for Payer: Encore All Commercial |
$9,898.57
|
| Rate for Payer: Frontpath All Commercial |
$9,893.19
|
| Rate for Payer: Humana ChoiceCare |
$9,287.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,678.12
|
| Rate for Payer: PHCS All Commercial |
$8,065.10
|
| Rate for Payer: PHP All Commercial |
$8,155.43
|
| Rate for Payer: Sagamore Health Network All Products |
$8,301.68
|
| Rate for Payer: Signature Care EPO |
$8,925.38
|
| Rate for Payer: Signature Care PPO |
$9,463.05
|
| Rate for Payer: United Healthcare Commercial |
$8,473.74
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7543
|
| 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
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7544
|
| 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
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7541
|
| 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
|
|
|
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
|
Facility
|
IP
|
$408.50
|
|
|
Service Code
|
APR-DRG 7542
|
| 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
|
|
|
DESMOPRESSIN 4 MCG/ML INJ SOLN
|
Facility
|
OP
|
$96.73
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
9748
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$89.96 |
| Rate for Payer: Aetna Commercial |
$81.64
|
| Rate for Payer: Aetna Commercial |
$784.92
|
| Rate for Payer: Aetna Medicare |
$297.60
|
| Rate for Payer: Aetna Medicare |
$30.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$288.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$55.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$534.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$581.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$60.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$342.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$327.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.05
|
| Rate for Payer: Cash Price |
$58.04
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Centivo All Commercial |
$52.62
|
| Rate for Payer: Centivo All Commercial |
$505.92
|
| Rate for Payer: Cigna All Commercial |
$802.59
|
| Rate for Payer: Cigna All Commercial |
$83.48
|
| Rate for Payer: CORVEL All Commercial |
$864.90
|
| Rate for Payer: CORVEL All Commercial |
$89.96
|
| Rate for Payer: Coventry All Commercial |
$818.40
|
| Rate for Payer: Coventry All Commercial |
$85.13
|
| Rate for Payer: Encore All Commercial |
$856.07
|
| Rate for Payer: Encore All Commercial |
$89.04
|
| Rate for Payer: Frontpath All Commercial |
$88.99
|
| Rate for Payer: Frontpath All Commercial |
$855.60
|
| Rate for Payer: Humana ChoiceCare |
$83.55
|
| Rate for Payer: Humana ChoiceCare |
$803.24
|
| Rate for Payer: Humana Medicare |
$30.95
|
| Rate for Payer: Humana Medicare |
$297.60
|
| Rate for Payer: Lucent All Commercial |
$505.92
|
| Rate for Payer: Lucent All Commercial |
$52.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$87.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$837.00
|
| Rate for Payer: PHCS All Commercial |
$72.55
|
| Rate for Payer: PHCS All Commercial |
$697.50
|
| Rate for Payer: PHP All Commercial |
$705.31
|
| Rate for Payer: PHP All Commercial |
$73.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$362.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.73
|
| Rate for Payer: Sagamore Health Network All Products |
$717.96
|
| Rate for Payer: Sagamore Health Network All Products |
$74.68
|
| Rate for Payer: Signature Care EPO |
$80.29
|
| Rate for Payer: Signature Care EPO |
$771.90
|
| Rate for Payer: Signature Care PPO |
$818.40
|
| Rate for Payer: Signature Care PPO |
$85.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$82.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$790.50
|
| Rate for Payer: United Healthcare Commercial |
$732.84
|
| Rate for Payer: United Healthcare Commercial |
$76.23
|
| Rate for Payer: United Healthcare Medicare |
$297.60
|
| Rate for Payer: United Healthcare Medicare |
$30.95
|
|
|
DESMOPRESSIN 4 MCG/ML INJ SOLN
|
Facility
|
IP
|
$96.73
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
9748
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.55 |
| Max. Negotiated Rate |
$89.96 |
| Rate for Payer: Aetna Commercial |
$83.58
|
| Rate for Payer: Aetna Commercial |
$803.52
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cash Price |
$58.04
|
| Rate for Payer: Cigna All Commercial |
$802.59
|
| Rate for Payer: Cigna All Commercial |
$83.48
|
| Rate for Payer: CORVEL All Commercial |
$864.90
|
| Rate for Payer: CORVEL All Commercial |
$89.96
|
| Rate for Payer: Coventry All Commercial |
$85.13
|
| Rate for Payer: Coventry All Commercial |
$818.40
|
| Rate for Payer: Encore All Commercial |
$89.04
|
| Rate for Payer: Encore All Commercial |
$856.07
|
| Rate for Payer: Frontpath All Commercial |
$855.60
|
| Rate for Payer: Frontpath All Commercial |
$88.99
|
| Rate for Payer: Humana ChoiceCare |
$803.24
|
| Rate for Payer: Humana ChoiceCare |
$83.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$837.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$87.06
|
| Rate for Payer: PHCS All Commercial |
$72.55
|
| Rate for Payer: PHCS All Commercial |
$697.50
|
| Rate for Payer: PHP All Commercial |
$705.31
|
| Rate for Payer: PHP All Commercial |
$73.36
|
| Rate for Payer: Sagamore Health Network All Products |
$74.68
|
| Rate for Payer: Sagamore Health Network All Products |
$717.96
|
| Rate for Payer: Signature Care EPO |
$80.29
|
| Rate for Payer: Signature Care EPO |
$771.90
|
| Rate for Payer: Signature Care PPO |
$818.40
|
| Rate for Payer: Signature Care PPO |
$85.13
|
| Rate for Payer: United Healthcare Commercial |
$732.84
|
| Rate for Payer: United Healthcare Commercial |
$76.23
|
|
|
DESVENLAFAXINE SUCCINATE 100 MG ORAL TB24
|
Facility
|
OP
|
$6.63
|
|
|
Service Code
|
NDC 70436001304
|
| Hospital Charge Code |
91074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$6.16 |
| Rate for Payer: Aetna Commercial |
$5.59
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.33
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Centivo All Commercial |
$3.61
|
| Rate for Payer: Cigna All Commercial |
$5.72
|
| Rate for Payer: CORVEL All Commercial |
$6.16
|
| Rate for Payer: Coventry All Commercial |
$5.83
|
| Rate for Payer: Encore All Commercial |
$6.10
|
| Rate for Payer: Frontpath All Commercial |
$6.10
|
| Rate for Payer: Humana ChoiceCare |
$5.73
|
| Rate for Payer: Humana Medicare |
$2.12
|
| Rate for Payer: Lucent All Commercial |
$3.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.97
|
| Rate for Payer: PHCS All Commercial |
$4.97
|
| Rate for Payer: PHP All Commercial |
$5.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$5.12
|
| Rate for Payer: Signature Care EPO |
$5.50
|
| Rate for Payer: Signature Care PPO |
$5.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.63
|
| Rate for Payer: United Healthcare Commercial |
$5.22
|
| Rate for Payer: United Healthcare Medicare |
$2.12
|
|
|
DESVENLAFAXINE SUCCINATE 100 MG ORAL TB24
|
Facility
|
IP
|
$6.63
|
|
|
Service Code
|
NDC 70436001304
|
| Hospital Charge Code |
91074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$6.16 |
| Rate for Payer: Aetna Commercial |
$5.73
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Cigna All Commercial |
$5.72
|
| Rate for Payer: CORVEL All Commercial |
$6.16
|
| Rate for Payer: Coventry All Commercial |
$5.83
|
| Rate for Payer: Encore All Commercial |
$6.10
|
| Rate for Payer: Frontpath All Commercial |
$6.10
|
| Rate for Payer: Humana ChoiceCare |
$5.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.97
|
| Rate for Payer: PHCS All Commercial |
$4.97
|
| Rate for Payer: PHP All Commercial |
$5.03
|
| Rate for Payer: Sagamore Health Network All Products |
$5.12
|
| Rate for Payer: Signature Care EPO |
$5.50
|
| Rate for Payer: Signature Care PPO |
$5.83
|
| Rate for Payer: United Healthcare Commercial |
$5.22
|
|
