|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SUSP
|
Facility
|
IP
|
$325.76
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
167647
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.32 |
| Max. Negotiated Rate |
$302.95 |
| Rate for Payer: Aetna Commercial |
$281.45
|
| Rate for Payer: Cash Price |
$195.45
|
| Rate for Payer: Cigna All Commercial |
$281.13
|
| Rate for Payer: CORVEL All Commercial |
$302.95
|
| Rate for Payer: Coventry All Commercial |
$286.67
|
| Rate for Payer: Encore All Commercial |
$299.86
|
| Rate for Payer: Frontpath All Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$281.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$293.18
|
| Rate for Payer: PHCS All Commercial |
$244.32
|
| Rate for Payer: PHP All Commercial |
$247.05
|
| Rate for Payer: Sagamore Health Network All Products |
$251.49
|
| Rate for Payer: Signature Care EPO |
$270.38
|
| Rate for Payer: Signature Care PPO |
$286.67
|
| Rate for Payer: United Healthcare Commercial |
$256.70
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SYRG
|
Facility
|
OP
|
$350.17
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
197146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.55 |
| Max. Negotiated Rate |
$325.66 |
| Rate for Payer: Aetna Commercial |
$295.55
|
| Rate for Payer: Aetna Medicare |
$112.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$128.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$123.26
|
| Rate for Payer: Cash Price |
$210.10
|
| Rate for Payer: Centivo All Commercial |
$190.49
|
| Rate for Payer: Cigna All Commercial |
$302.20
|
| Rate for Payer: CORVEL All Commercial |
$325.66
|
| Rate for Payer: Coventry All Commercial |
$308.15
|
| Rate for Payer: Encore All Commercial |
$322.33
|
| Rate for Payer: Frontpath All Commercial |
$322.16
|
| Rate for Payer: Humana ChoiceCare |
$302.44
|
| Rate for Payer: Humana Medicare |
$112.06
|
| Rate for Payer: Lucent All Commercial |
$190.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.15
|
| Rate for Payer: PHCS All Commercial |
$262.63
|
| Rate for Payer: PHP All Commercial |
$265.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.57
|
| Rate for Payer: Sagamore Health Network All Products |
$270.33
|
| Rate for Payer: Signature Care EPO |
$290.64
|
| Rate for Payer: Signature Care PPO |
$308.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$297.65
|
| Rate for Payer: United Healthcare Commercial |
$275.94
|
| Rate for Payer: United Healthcare Medicare |
$112.06
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SYRG
|
Facility
|
IP
|
$350.17
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
197146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$262.63 |
| Max. Negotiated Rate |
$325.66 |
| Rate for Payer: Aetna Commercial |
$302.55
|
| Rate for Payer: Cash Price |
$210.10
|
| Rate for Payer: Cigna All Commercial |
$302.20
|
| Rate for Payer: CORVEL All Commercial |
$325.66
|
| Rate for Payer: Coventry All Commercial |
$308.15
|
| Rate for Payer: Encore All Commercial |
$322.33
|
| Rate for Payer: Frontpath All Commercial |
$322.16
|
| Rate for Payer: Humana ChoiceCare |
$302.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.15
|
| Rate for Payer: PHCS All Commercial |
$262.63
|
| Rate for Payer: PHP All Commercial |
$265.57
|
| Rate for Payer: Sagamore Health Network All Products |
$270.33
|
| Rate for Payer: Signature Care EPO |
$290.64
|
| Rate for Payer: Signature Care PPO |
$308.15
|
| Rate for Payer: United Healthcare Commercial |
$275.94
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$297.18
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
119850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.13 |
| Max. Negotiated Rate |
$276.38 |
| Rate for Payer: Aetna Commercial |
$250.82
|
| Rate for Payer: Aetna Medicare |
$95.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$92.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$170.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$185.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$109.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$104.61
|
| Rate for Payer: Cash Price |
$178.31
|
| Rate for Payer: Centivo All Commercial |
$161.66
|
| Rate for Payer: Cigna All Commercial |
$256.46
|
| Rate for Payer: CORVEL All Commercial |
$276.38
|
| Rate for Payer: Coventry All Commercial |
$261.52
|
| Rate for Payer: Encore All Commercial |
$273.55
|
| Rate for Payer: Frontpath All Commercial |
$273.40
|
| Rate for Payer: Humana ChoiceCare |
$256.67
|
| Rate for Payer: Humana Medicare |
$95.10
|
| Rate for Payer: Lucent All Commercial |
$161.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$267.46
|
| Rate for Payer: PHCS All Commercial |
$222.88
|
| Rate for Payer: PHP All Commercial |
$225.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$115.90
|
| Rate for Payer: Sagamore Health Network All Products |
$229.42
|
| Rate for Payer: Signature Care EPO |
$246.66
|
| Rate for Payer: Signature Care PPO |
$261.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$252.60
|
| Rate for Payer: United Healthcare Commercial |
$234.18
|
| Rate for Payer: United Healthcare Medicare |
$95.10
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$297.18
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
119850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$222.88 |
| Max. Negotiated Rate |
$276.38 |
| Rate for Payer: Aetna Commercial |
$256.76
|
| Rate for Payer: Cash Price |
$178.31
|
| Rate for Payer: Cigna All Commercial |
$256.46
|
| Rate for Payer: CORVEL All Commercial |
$276.38
|
| Rate for Payer: Coventry All Commercial |
$261.52
|
| Rate for Payer: Encore All Commercial |
$273.55
|
| Rate for Payer: Frontpath All Commercial |
$273.40
|
| Rate for Payer: Humana ChoiceCare |
$256.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$267.46
|
| Rate for Payer: PHCS All Commercial |
$222.88
|
| Rate for Payer: PHP All Commercial |
$225.38
|
| Rate for Payer: Sagamore Health Network All Products |
$229.42
|
| Rate for Payer: Signature Care EPO |
$246.66
|
| Rate for Payer: Signature Care PPO |
$261.52
|
| Rate for Payer: United Healthcare Commercial |
$234.18
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRG
|
Facility
|
OP
|
$354.49
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
92788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.89 |
| Max. Negotiated Rate |
$329.68 |
| Rate for Payer: Aetna Commercial |
$299.19
|
| Rate for Payer: Aetna Medicare |
$113.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$109.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$203.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$221.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$130.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$124.78
|
| Rate for Payer: Cash Price |
$212.70
|
| Rate for Payer: Centivo All Commercial |
$192.84
|
| Rate for Payer: Cigna All Commercial |
$305.93
|
| Rate for Payer: CORVEL All Commercial |
$329.68
|
| Rate for Payer: Coventry All Commercial |
$311.95
|
| Rate for Payer: Encore All Commercial |
$326.31
|
| Rate for Payer: Frontpath All Commercial |
$326.13
|
| Rate for Payer: Humana ChoiceCare |
$306.17
|
| Rate for Payer: Humana Medicare |
$113.44
|
| Rate for Payer: Lucent All Commercial |
$192.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$319.04
|
| Rate for Payer: PHCS All Commercial |
$265.87
|
| Rate for Payer: PHP All Commercial |
$268.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$138.25
|
| Rate for Payer: Sagamore Health Network All Products |
$273.67
|
| Rate for Payer: Signature Care EPO |
$294.23
|
| Rate for Payer: Signature Care PPO |
$311.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$301.32
|
| Rate for Payer: United Healthcare Commercial |
$279.34
|
| Rate for Payer: United Healthcare Medicare |
$113.44
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRG
|
Facility
|
IP
|
$354.49
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
92788
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$265.87 |
| Max. Negotiated Rate |
$329.68 |
| Rate for Payer: Aetna Commercial |
$306.28
|
| Rate for Payer: Cash Price |
$212.70
|
| Rate for Payer: Cigna All Commercial |
$305.93
|
| Rate for Payer: CORVEL All Commercial |
$329.68
|
| Rate for Payer: Coventry All Commercial |
$311.95
|
| Rate for Payer: Encore All Commercial |
$326.31
|
| Rate for Payer: Frontpath All Commercial |
$326.13
|
| Rate for Payer: Humana ChoiceCare |
$306.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$319.04
|
| Rate for Payer: PHCS All Commercial |
$265.87
|
| Rate for Payer: PHP All Commercial |
$268.85
|
| Rate for Payer: Sagamore Health Network All Products |
$273.67
|
| Rate for Payer: Signature Care EPO |
$294.23
|
| Rate for Payer: Signature Care PPO |
$311.95
|
| Rate for Payer: United Healthcare Commercial |
$279.34
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$242.58 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$279.45
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$272.99
|
| Rate for Payer: Aetna Medicare |
$103.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.85
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Centivo All Commercial |
$175.95
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Humana Medicare |
$103.50
|
| Rate for Payer: Lucent All Commercial |
$175.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.14
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$274.93
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
| Rate for Payer: United Healthcare Medicare |
$103.50
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG
|
Facility
|
OP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
119727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.27 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$272.99
|
| Rate for Payer: Aetna Medicare |
$103.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.85
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Centivo All Commercial |
$175.95
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Humana Medicare |
$103.50
|
| Rate for Payer: Lucent All Commercial |
$175.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.14
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$274.93
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
| Rate for Payer: United Healthcare Medicare |
$103.50
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG
|
Facility
|
IP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
119727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.58 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$279.45
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG S.O.
|
Facility
|
OP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4080119727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.27 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$272.99
|
| Rate for Payer: Aetna Medicare |
$103.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.85
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Centivo All Commercial |
$175.95
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Humana Medicare |
$103.50
|
| Rate for Payer: Lucent All Commercial |
$175.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.14
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$274.93
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
| Rate for Payer: United Healthcare Medicare |
$103.50
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG S.O.
|
Facility
|
IP
|
$323.44
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4080119727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.58 |
| Max. Negotiated Rate |
$300.80 |
| Rate for Payer: Aetna Commercial |
$279.45
|
| Rate for Payer: Cash Price |
$194.07
|
| Rate for Payer: Cigna All Commercial |
$279.13
|
| Rate for Payer: CORVEL All Commercial |
$300.80
|
| Rate for Payer: Coventry All Commercial |
$284.63
|
| Rate for Payer: Encore All Commercial |
$297.73
|
| Rate for Payer: Frontpath All Commercial |
$297.57
|
| Rate for Payer: Humana ChoiceCare |
$279.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.10
|
| Rate for Payer: PHCS All Commercial |
$242.58
|
| Rate for Payer: PHP All Commercial |
$245.30
|
| Rate for Payer: Sagamore Health Network All Products |
$249.70
|
| Rate for Payer: Signature Care EPO |
$268.46
|
| Rate for Payer: Signature Care PPO |
$284.63
|
| Rate for Payer: United Healthcare Commercial |
$254.87
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164786
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.80 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$266.26
|
| Rate for Payer: Aetna Medicare |
$100.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$181.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$197.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$116.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$111.05
|
| Rate for Payer: Cash Price |
$189.28
|
| Rate for Payer: Centivo All Commercial |
$171.62
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Humana Medicare |
$100.95
|
| Rate for Payer: Lucent All Commercial |
$171.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.03
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$268.15
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
| Rate for Payer: United Healthcare Medicare |
$100.95
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164786
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.60 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$272.57
|
| Rate for Payer: Cash Price |
$189.28
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
OP
|
$320.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.47 |
| Max. Negotiated Rate |
$298.42 |
| Rate for Payer: Aetna Commercial |
$270.82
|
| Rate for Payer: Aetna Medicare |
$102.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$99.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$184.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$200.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$118.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$112.95
|
| Rate for Payer: Cash Price |
$192.53
|
| Rate for Payer: Centivo All Commercial |
$174.56
|
| Rate for Payer: Cigna All Commercial |
$276.92
|
| Rate for Payer: CORVEL All Commercial |
$298.42
|
| Rate for Payer: Coventry All Commercial |
$282.37
|
| Rate for Payer: Encore All Commercial |
$295.37
|
| Rate for Payer: Frontpath All Commercial |
$295.21
|
| Rate for Payer: Humana ChoiceCare |
$277.14
|
| Rate for Payer: Humana Medicare |
$102.68
|
| Rate for Payer: Lucent All Commercial |
$174.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.79
|
| Rate for Payer: PHCS All Commercial |
$240.66
|
| Rate for Payer: PHP All Commercial |
$243.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$125.14
|
| Rate for Payer: Sagamore Health Network All Products |
$247.72
|
| Rate for Payer: Signature Care EPO |
$266.33
|
| Rate for Payer: Signature Care PPO |
$282.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$272.75
|
| Rate for Payer: United Healthcare Commercial |
$252.85
|
| Rate for Payer: United Healthcare Medicare |
$102.68
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
IP
|
$320.88
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$240.66 |
| Max. Negotiated Rate |
$298.42 |
| Rate for Payer: Aetna Commercial |
$277.24
|
| Rate for Payer: Cash Price |
$192.53
|
| Rate for Payer: Cigna All Commercial |
$276.92
|
| Rate for Payer: CORVEL All Commercial |
$298.42
|
| Rate for Payer: Coventry All Commercial |
$282.37
|
| Rate for Payer: Encore All Commercial |
$295.37
|
| Rate for Payer: Frontpath All Commercial |
$295.21
|
| Rate for Payer: Humana ChoiceCare |
$277.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.79
|
| Rate for Payer: PHCS All Commercial |
$240.66
|
| Rate for Payer: PHP All Commercial |
$243.36
|
| Rate for Payer: Sagamore Health Network All Products |
$247.72
|
| Rate for Payer: Signature Care EPO |
$266.33
|
| Rate for Payer: Signature Care PPO |
$282.37
|
| Rate for Payer: United Healthcare Commercial |
$252.85
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT
|
Facility
|
OP
|
$539.22
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
190933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.55 |
| Max. Negotiated Rate |
$501.47 |
| Rate for Payer: Aetna Commercial |
$455.10
|
| Rate for Payer: Aetna Medicare |
$172.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$107.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$167.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$309.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$337.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$107.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$198.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$189.81
|
| Rate for Payer: Cash Price |
$323.53
|
| Rate for Payer: Cash Price |
$323.53
|
| Rate for Payer: Centivo All Commercial |
$293.34
|
| Rate for Payer: Cigna All Commercial |
$465.35
|
| Rate for Payer: CORVEL All Commercial |
$501.47
|
| Rate for Payer: Coventry All Commercial |
$474.51
|
| Rate for Payer: Encore All Commercial |
$496.35
|
| Rate for Payer: Frontpath All Commercial |
$496.08
|
| Rate for Payer: Humana ChoiceCare |
$465.72
|
| Rate for Payer: Humana Medicare |
$172.55
|
| Rate for Payer: Lucent All Commercial |
$293.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$485.30
|
| Rate for Payer: Managed Health Services Medicaid |
$107.55
|
| Rate for Payer: MDWise Medicaid |
$107.55
|
| Rate for Payer: PHCS All Commercial |
$404.42
|
| Rate for Payer: PHP All Commercial |
$408.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$210.30
|
| Rate for Payer: Sagamore Health Network All Products |
$416.28
|
| Rate for Payer: Signature Care EPO |
$447.55
|
| Rate for Payer: Signature Care PPO |
$474.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$458.34
|
| Rate for Payer: United Healthcare Commercial |
$424.91
|
| Rate for Payer: United Healthcare Medicare |
$172.55
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT
|
Facility
|
IP
|
$539.22
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
190933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$404.42 |
| Max. Negotiated Rate |
$501.47 |
| Rate for Payer: Aetna Commercial |
$465.89
|
| Rate for Payer: Cash Price |
$323.53
|
| Rate for Payer: Cigna All Commercial |
$465.35
|
| Rate for Payer: CORVEL All Commercial |
$501.47
|
| Rate for Payer: Coventry All Commercial |
$474.51
|
| Rate for Payer: Encore All Commercial |
$496.35
|
| Rate for Payer: Frontpath All Commercial |
$496.08
|
| Rate for Payer: Humana ChoiceCare |
$465.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$485.30
|
| Rate for Payer: PHCS All Commercial |
$404.42
|
| Rate for Payer: PHP All Commercial |
$408.94
|
| Rate for Payer: Sagamore Health Network All Products |
$416.28
|
| Rate for Payer: Signature Care EPO |
$447.55
|
| Rate for Payer: Signature Care PPO |
$474.51
|
| Rate for Payer: United Healthcare Commercial |
$424.91
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15 LF UNIT-20 MCG-5 LF/0.5 ML IM KIT
|
Facility
|
IP
|
$562.75
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
92074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$422.06 |
| Max. Negotiated Rate |
$523.36 |
| Rate for Payer: Aetna Commercial |
$486.22
|
| Rate for Payer: Cash Price |
$337.65
|
| Rate for Payer: Cigna All Commercial |
$485.65
|
| Rate for Payer: CORVEL All Commercial |
$523.36
|
| Rate for Payer: Coventry All Commercial |
$495.22
|
| Rate for Payer: Encore All Commercial |
$518.01
|
| Rate for Payer: Frontpath All Commercial |
$517.73
|
| Rate for Payer: Humana ChoiceCare |
$486.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$506.48
|
| Rate for Payer: PHCS All Commercial |
$422.06
|
| Rate for Payer: PHP All Commercial |
$426.79
|
| Rate for Payer: Sagamore Health Network All Products |
$434.44
|
| Rate for Payer: Signature Care EPO |
$467.08
|
| Rate for Payer: Signature Care PPO |
$495.22
|
| Rate for Payer: United Healthcare Commercial |
$443.45
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15 LF UNIT-20 MCG-5 LF/0.5 ML IM KIT
|
Facility
|
OP
|
$562.75
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
92074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.55 |
| Max. Negotiated Rate |
$523.36 |
| Rate for Payer: Aetna Commercial |
$474.96
|
| Rate for Payer: Aetna Medicare |
$180.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$107.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$174.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$323.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$351.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$107.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$207.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$198.09
|
| Rate for Payer: Cash Price |
$337.65
|
| Rate for Payer: Cash Price |
$337.65
|
| Rate for Payer: Centivo All Commercial |
$306.14
|
| Rate for Payer: Cigna All Commercial |
$485.65
|
| Rate for Payer: CORVEL All Commercial |
$523.36
|
| Rate for Payer: Coventry All Commercial |
$495.22
|
| Rate for Payer: Encore All Commercial |
$518.01
|
| Rate for Payer: Frontpath All Commercial |
$517.73
|
| Rate for Payer: Humana ChoiceCare |
$486.05
|
| Rate for Payer: Humana Medicare |
$180.08
|
| Rate for Payer: Lucent All Commercial |
$306.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$506.48
|
| Rate for Payer: Managed Health Services Medicaid |
$107.55
|
| Rate for Payer: MDWise Medicaid |
$107.55
|
| Rate for Payer: PHCS All Commercial |
$422.06
|
| Rate for Payer: PHP All Commercial |
$426.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$219.47
|
| Rate for Payer: Sagamore Health Network All Products |
$434.44
|
| Rate for Payer: Signature Care EPO |
$467.08
|
| Rate for Payer: Signature Care PPO |
$495.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$478.34
|
| Rate for Payer: United Healthcare Commercial |
$443.45
|
| Rate for Payer: United Healthcare Medicare |
$180.08
|
|
|
DIPYRIDAMOLE 25 MG ORAL TAB
|
Facility
|
OP
|
$9.95
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$9.25 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Aetna Medicare |
$3.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.50
|
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Centivo All Commercial |
$5.41
|
| Rate for Payer: Cigna All Commercial |
$8.58
|
| Rate for Payer: CORVEL All Commercial |
$9.25
|
| Rate for Payer: Coventry All Commercial |
$8.75
|
| Rate for Payer: Encore All Commercial |
$9.16
|
| Rate for Payer: Frontpath All Commercial |
$9.15
|
| Rate for Payer: Humana ChoiceCare |
$8.59
|
| Rate for Payer: Humana Medicare |
$3.18
|
| Rate for Payer: Lucent All Commercial |
$5.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.95
|
| Rate for Payer: PHCS All Commercial |
$7.46
|
| Rate for Payer: PHP All Commercial |
$7.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.88
|
| Rate for Payer: Sagamore Health Network All Products |
$7.68
|
| Rate for Payer: Signature Care EPO |
$8.26
|
| Rate for Payer: Signature Care PPO |
$8.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.45
|
| Rate for Payer: United Healthcare Commercial |
$7.84
|
| Rate for Payer: United Healthcare Medicare |
$3.18
|
|
|
DIPYRIDAMOLE 25 MG ORAL TAB
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$9.25 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Cigna All Commercial |
$8.58
|
| Rate for Payer: CORVEL All Commercial |
$9.25
|
| Rate for Payer: Coventry All Commercial |
$8.75
|
| Rate for Payer: Encore All Commercial |
$9.16
|
| Rate for Payer: Frontpath All Commercial |
$9.15
|
| Rate for Payer: Humana ChoiceCare |
$8.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.95
|
| Rate for Payer: PHCS All Commercial |
$7.46
|
| Rate for Payer: PHP All Commercial |
$7.54
|
| Rate for Payer: Sagamore Health Network All Products |
$7.68
|
| Rate for Payer: Signature Care EPO |
$8.26
|
| Rate for Payer: Signature Care PPO |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$7.84
|
|
|
DISORDERS OF PERSONALITY & IMPULSE CONTROL
|
Facility
|
IP
|
$2,204.62
|
|
|
Service Code
|
APR-DRG 7522
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,204.62 |
| 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
|
|
|
DISORDERS OF PERSONALITY & IMPULSE CONTROL
|
Facility
|
IP
|
$1,685.88
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$1,685.88 |
| 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
|
|
