|
EATING DISORDERS
|
Facility
|
IP
|
$4,625.37
|
|
|
Service Code
|
APR-DRG 7591
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,625.37 |
| 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
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$6,181.58
|
|
|
Service Code
|
APR-DRG 7592
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$6,181.58 |
| 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
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$14,654.22
|
|
|
Service Code
|
APR-DRG 7594
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$14,654.22 |
| 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
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$8,732.02
|
|
|
Service Code
|
APR-DRG 7593
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$8,732.02 |
| 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
|
|
|
EMPAGLIFLOZIN 10 MG ORAL TAB
|
Facility
|
IP
|
$137.69
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
169570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.27 |
| Max. Negotiated Rate |
$128.05 |
| Rate for Payer: Aetna Commercial |
$118.96
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Cigna All Commercial |
$118.83
|
| Rate for Payer: CORVEL All Commercial |
$128.05
|
| Rate for Payer: Coventry All Commercial |
$121.17
|
| Rate for Payer: Encore All Commercial |
$126.74
|
| Rate for Payer: Frontpath All Commercial |
$126.67
|
| Rate for Payer: Humana ChoiceCare |
$118.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.92
|
| Rate for Payer: PHCS All Commercial |
$103.27
|
| Rate for Payer: PHP All Commercial |
$104.42
|
| Rate for Payer: Sagamore Health Network All Products |
$106.30
|
| Rate for Payer: Signature Care EPO |
$114.28
|
| Rate for Payer: Signature Care PPO |
$121.17
|
| Rate for Payer: United Healthcare Commercial |
$108.50
|
|
|
EMPAGLIFLOZIN 10 MG ORAL TAB
|
Facility
|
OP
|
$137.69
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
169570
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$128.05 |
| Rate for Payer: Aetna Commercial |
$116.21
|
| Rate for Payer: Aetna Medicare |
$44.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.47
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Centivo All Commercial |
$74.90
|
| Rate for Payer: Cigna All Commercial |
$118.83
|
| Rate for Payer: CORVEL All Commercial |
$128.05
|
| Rate for Payer: Coventry All Commercial |
$121.17
|
| Rate for Payer: Encore All Commercial |
$126.74
|
| Rate for Payer: Frontpath All Commercial |
$126.67
|
| Rate for Payer: Humana ChoiceCare |
$118.92
|
| Rate for Payer: Humana Medicare |
$44.06
|
| Rate for Payer: Lucent All Commercial |
$74.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.92
|
| Rate for Payer: PHCS All Commercial |
$103.27
|
| Rate for Payer: PHP All Commercial |
$104.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.70
|
| Rate for Payer: Sagamore Health Network All Products |
$106.30
|
| Rate for Payer: Signature Care EPO |
$114.28
|
| Rate for Payer: Signature Care PPO |
$121.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.04
|
| Rate for Payer: United Healthcare Commercial |
$108.50
|
| Rate for Payer: United Healthcare Medicare |
$44.06
|
|
|
EMPAGLIFLOZIN 25 MG ORAL TAB
|
Facility
|
OP
|
$137.69
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
169569
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$128.05 |
| Rate for Payer: Aetna Commercial |
$116.21
|
| Rate for Payer: Aetna Medicare |
$44.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.47
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Centivo All Commercial |
$74.90
|
| Rate for Payer: Cigna All Commercial |
$118.83
|
| Rate for Payer: CORVEL All Commercial |
$128.05
|
| Rate for Payer: Coventry All Commercial |
$121.17
|
| Rate for Payer: Encore All Commercial |
$126.74
|
| Rate for Payer: Frontpath All Commercial |
$126.67
|
| Rate for Payer: Humana ChoiceCare |
$118.92
|
| Rate for Payer: Humana Medicare |
$44.06
|
| Rate for Payer: Lucent All Commercial |
$74.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.92
|
| Rate for Payer: PHCS All Commercial |
$103.27
|
| Rate for Payer: PHP All Commercial |
$104.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.70
|
| Rate for Payer: Sagamore Health Network All Products |
$106.30
|
| Rate for Payer: Signature Care EPO |
$114.28
|
| Rate for Payer: Signature Care PPO |
$121.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.04
|
| Rate for Payer: United Healthcare Commercial |
$108.50
|
| Rate for Payer: United Healthcare Medicare |
$44.06
|
|
|
EMPAGLIFLOZIN 25 MG ORAL TAB
|
Facility
|
IP
|
$137.69
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
169569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.27 |
| Max. Negotiated Rate |
$128.05 |
| Rate for Payer: Aetna Commercial |
$118.96
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Cigna All Commercial |
$118.83
|
| Rate for Payer: CORVEL All Commercial |
$128.05
|
| Rate for Payer: Coventry All Commercial |
$121.17
|
| Rate for Payer: Encore All Commercial |
$126.74
|
| Rate for Payer: Frontpath All Commercial |
$126.67
|
| Rate for Payer: Humana ChoiceCare |
$118.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.92
|
| Rate for Payer: PHCS All Commercial |
$103.27
|
| Rate for Payer: PHP All Commercial |
$104.42
|
| Rate for Payer: Sagamore Health Network All Products |
$106.30
|
| Rate for Payer: Signature Care EPO |
$114.28
|
| Rate for Payer: Signature Care PPO |
$121.17
|
| Rate for Payer: United Healthcare Commercial |
$108.50
|
|
|
EMPTY CONTAINER, PLASTIC BAG 100 ML
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 000747951PH100
|
| Hospital Charge Code |
408115964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB
|
Facility
|
IP
|
$359.24
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.43 |
| Max. Negotiated Rate |
$334.10 |
| Rate for Payer: Aetna Commercial |
$310.39
|
| Rate for Payer: Cash Price |
$215.55
|
| Rate for Payer: Cigna All Commercial |
$310.03
|
| Rate for Payer: CORVEL All Commercial |
$334.10
|
| Rate for Payer: Coventry All Commercial |
$316.13
|
| Rate for Payer: Encore All Commercial |
$330.68
|
| Rate for Payer: Frontpath All Commercial |
$330.50
|
| Rate for Payer: Humana ChoiceCare |
$310.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.32
|
| Rate for Payer: PHCS All Commercial |
$269.43
|
| Rate for Payer: PHP All Commercial |
$272.45
|
| Rate for Payer: Sagamore Health Network All Products |
$277.34
|
| Rate for Payer: Signature Care EPO |
$298.17
|
| Rate for Payer: Signature Care PPO |
$316.13
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
|
|
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB
|
Facility
|
OP
|
$359.24
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.37 |
| Max. Negotiated Rate |
$334.10 |
| Rate for Payer: Aetna Commercial |
$303.20
|
| Rate for Payer: Aetna Medicare |
$114.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$111.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$206.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$224.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.45
|
| Rate for Payer: Cash Price |
$215.55
|
| Rate for Payer: Centivo All Commercial |
$195.43
|
| Rate for Payer: Cigna All Commercial |
$310.03
|
| Rate for Payer: CORVEL All Commercial |
$334.10
|
| Rate for Payer: Coventry All Commercial |
$316.13
|
| Rate for Payer: Encore All Commercial |
$330.68
|
| Rate for Payer: Frontpath All Commercial |
$330.50
|
| Rate for Payer: Humana ChoiceCare |
$310.28
|
| Rate for Payer: Humana Medicare |
$114.96
|
| Rate for Payer: Lucent All Commercial |
$195.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.32
|
| Rate for Payer: PHCS All Commercial |
$269.43
|
| Rate for Payer: PHP All Commercial |
$272.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$140.11
|
| Rate for Payer: Sagamore Health Network All Products |
$277.34
|
| Rate for Payer: Signature Care EPO |
$298.17
|
| Rate for Payer: Signature Care PPO |
$316.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.36
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
| Rate for Payer: United Healthcare Medicare |
$114.96
|
|
|
ENALAPRILAT 1.25 MG/ML IV SOLN
|
Facility
|
OP
|
$59.12
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$54.98 |
| Rate for Payer: Aetna Commercial |
$49.90
|
| Rate for Payer: Aetna Commercial |
$27.94
|
| Rate for Payer: Aetna Medicare |
$10.59
|
| Rate for Payer: Aetna Medicare |
$18.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.81
|
| Rate for Payer: Cash Price |
$35.47
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Centivo All Commercial |
$32.16
|
| Rate for Payer: Centivo All Commercial |
$18.01
|
| Rate for Payer: Cigna All Commercial |
$28.57
|
| Rate for Payer: Cigna All Commercial |
$51.02
|
| Rate for Payer: CORVEL All Commercial |
$30.79
|
| Rate for Payer: CORVEL All Commercial |
$54.98
|
| Rate for Payer: Coventry All Commercial |
$29.13
|
| Rate for Payer: Coventry All Commercial |
$52.03
|
| Rate for Payer: Encore All Commercial |
$30.47
|
| Rate for Payer: Encore All Commercial |
$54.42
|
| Rate for Payer: Frontpath All Commercial |
$54.39
|
| Rate for Payer: Frontpath All Commercial |
$30.45
|
| Rate for Payer: Humana ChoiceCare |
$51.06
|
| Rate for Payer: Humana ChoiceCare |
$28.59
|
| Rate for Payer: Humana Medicare |
$18.92
|
| Rate for Payer: Humana Medicare |
$10.59
|
| Rate for Payer: Lucent All Commercial |
$18.01
|
| Rate for Payer: Lucent All Commercial |
$32.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.79
|
| Rate for Payer: PHCS All Commercial |
$44.34
|
| Rate for Payer: PHCS All Commercial |
$24.83
|
| Rate for Payer: PHP All Commercial |
$25.11
|
| Rate for Payer: PHP All Commercial |
$44.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.06
|
| Rate for Payer: Sagamore Health Network All Products |
$25.56
|
| Rate for Payer: Sagamore Health Network All Products |
$45.64
|
| Rate for Payer: Signature Care EPO |
$49.07
|
| Rate for Payer: Signature Care EPO |
$27.48
|
| Rate for Payer: Signature Care PPO |
$29.13
|
| Rate for Payer: Signature Care PPO |
$52.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.14
|
| Rate for Payer: United Healthcare Commercial |
$26.09
|
| Rate for Payer: United Healthcare Commercial |
$46.59
|
| Rate for Payer: United Healthcare Medicare |
$10.59
|
| Rate for Payer: United Healthcare Medicare |
$18.92
|
|
|
ENALAPRILAT 1.25 MG/ML IV SOLN
|
Facility
|
IP
|
$59.12
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$54.98 |
| Rate for Payer: Aetna Commercial |
$51.08
|
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cash Price |
$35.47
|
| Rate for Payer: Cigna All Commercial |
$28.57
|
| Rate for Payer: Cigna All Commercial |
$51.02
|
| Rate for Payer: CORVEL All Commercial |
$30.79
|
| Rate for Payer: CORVEL All Commercial |
$54.98
|
| Rate for Payer: Coventry All Commercial |
$52.03
|
| Rate for Payer: Coventry All Commercial |
$29.13
|
| Rate for Payer: Encore All Commercial |
$54.42
|
| Rate for Payer: Encore All Commercial |
$30.47
|
| Rate for Payer: Frontpath All Commercial |
$30.45
|
| Rate for Payer: Frontpath All Commercial |
$54.39
|
| Rate for Payer: Humana ChoiceCare |
$28.59
|
| Rate for Payer: Humana ChoiceCare |
$51.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.21
|
| Rate for Payer: PHCS All Commercial |
$44.34
|
| Rate for Payer: PHCS All Commercial |
$24.83
|
| Rate for Payer: PHP All Commercial |
$25.11
|
| Rate for Payer: PHP All Commercial |
$44.84
|
| Rate for Payer: Sagamore Health Network All Products |
$45.64
|
| Rate for Payer: Sagamore Health Network All Products |
$25.56
|
| Rate for Payer: Signature Care EPO |
$49.07
|
| Rate for Payer: Signature Care EPO |
$27.48
|
| Rate for Payer: Signature Care PPO |
$29.13
|
| Rate for Payer: Signature Care PPO |
$52.03
|
| Rate for Payer: United Healthcare Commercial |
$26.09
|
| Rate for Payer: United Healthcare Commercial |
$46.59
|
|
|
ENALAPRIL MALEATE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 23155070501
|
| Hospital Charge Code |
9927
|
|
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
|
|
|
ENALAPRIL MALEATE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 23155070501
|
| Hospital Charge Code |
9927
|
|
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
|
|
|
ENOXAPARIN 100 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$59.85
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Aetna Commercial |
$50.51
|
| Rate for Payer: Aetna Medicare |
$19.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$34.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.07
|
| Rate for Payer: Cash Price |
$35.91
|
| Rate for Payer: Centivo All Commercial |
$32.56
|
| Rate for Payer: Cigna All Commercial |
$51.65
|
| Rate for Payer: CORVEL All Commercial |
$55.66
|
| Rate for Payer: Coventry All Commercial |
$52.67
|
| Rate for Payer: Encore All Commercial |
$55.09
|
| Rate for Payer: Frontpath All Commercial |
$55.06
|
| Rate for Payer: Humana ChoiceCare |
$51.69
|
| Rate for Payer: Humana Medicare |
$19.15
|
| Rate for Payer: Lucent All Commercial |
$32.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.87
|
| Rate for Payer: PHCS All Commercial |
$44.89
|
| Rate for Payer: PHP All Commercial |
$45.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.34
|
| Rate for Payer: Sagamore Health Network All Products |
$46.20
|
| Rate for Payer: Signature Care EPO |
$49.68
|
| Rate for Payer: Signature Care PPO |
$52.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.87
|
| Rate for Payer: United Healthcare Commercial |
$47.16
|
| Rate for Payer: United Healthcare Medicare |
$19.15
|
|
|
ENOXAPARIN 100 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$59.85
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.89 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Aetna Commercial |
$51.71
|
| Rate for Payer: Cash Price |
$35.91
|
| Rate for Payer: Cigna All Commercial |
$51.65
|
| Rate for Payer: CORVEL All Commercial |
$55.66
|
| Rate for Payer: Coventry All Commercial |
$52.67
|
| Rate for Payer: Encore All Commercial |
$55.09
|
| Rate for Payer: Frontpath All Commercial |
$55.06
|
| Rate for Payer: Humana ChoiceCare |
$51.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.87
|
| Rate for Payer: PHCS All Commercial |
$44.89
|
| Rate for Payer: PHP All Commercial |
$45.39
|
| Rate for Payer: Sagamore Health Network All Products |
$46.20
|
| Rate for Payer: Signature Care EPO |
$49.68
|
| Rate for Payer: Signature Care PPO |
$52.67
|
| Rate for Payer: United Healthcare Commercial |
$47.16
|
|
|
ENOXAPARIN 150 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$89.91
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$83.61 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Cash Price |
$53.94
|
| Rate for Payer: Cigna All Commercial |
$77.59
|
| Rate for Payer: CORVEL All Commercial |
$83.61
|
| Rate for Payer: Coventry All Commercial |
$79.12
|
| Rate for Payer: Encore All Commercial |
$82.76
|
| Rate for Payer: Frontpath All Commercial |
$82.72
|
| Rate for Payer: Humana ChoiceCare |
$77.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.92
|
| Rate for Payer: PHCS All Commercial |
$67.43
|
| Rate for Payer: PHP All Commercial |
$68.19
|
| Rate for Payer: Sagamore Health Network All Products |
$69.41
|
| Rate for Payer: Signature Care EPO |
$74.62
|
| Rate for Payer: Signature Care PPO |
$79.12
|
| Rate for Payer: United Healthcare Commercial |
$70.85
|
|
|
ENOXAPARIN 150 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$89.91
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.87 |
| Max. Negotiated Rate |
$83.61 |
| Rate for Payer: Aetna Commercial |
$75.88
|
| Rate for Payer: Aetna Medicare |
$28.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$51.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$33.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31.65
|
| Rate for Payer: Cash Price |
$53.94
|
| Rate for Payer: Centivo All Commercial |
$48.91
|
| Rate for Payer: Cigna All Commercial |
$77.59
|
| Rate for Payer: CORVEL All Commercial |
$83.61
|
| Rate for Payer: Coventry All Commercial |
$79.12
|
| Rate for Payer: Encore All Commercial |
$82.76
|
| Rate for Payer: Frontpath All Commercial |
$82.72
|
| Rate for Payer: Humana ChoiceCare |
$77.65
|
| Rate for Payer: Humana Medicare |
$28.77
|
| Rate for Payer: Lucent All Commercial |
$48.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$80.92
|
| Rate for Payer: PHCS All Commercial |
$67.43
|
| Rate for Payer: PHP All Commercial |
$68.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.06
|
| Rate for Payer: Sagamore Health Network All Products |
$69.41
|
| Rate for Payer: Signature Care EPO |
$74.62
|
| Rate for Payer: Signature Care PPO |
$79.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$76.42
|
| Rate for Payer: United Healthcare Commercial |
$70.85
|
| Rate for Payer: United Healthcare Medicare |
$28.77
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$17.76 |
| Rate for Payer: Aetna Commercial |
$16.50
|
| Rate for Payer: Cash Price |
$11.46
|
| Rate for Payer: Cigna All Commercial |
$16.48
|
| Rate for Payer: CORVEL All Commercial |
$17.76
|
| Rate for Payer: Coventry All Commercial |
$16.80
|
| Rate for Payer: Encore All Commercial |
$17.58
|
| Rate for Payer: Frontpath All Commercial |
$17.57
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.19
|
| Rate for Payer: PHCS All Commercial |
$14.32
|
| Rate for Payer: PHP All Commercial |
$14.48
|
| Rate for Payer: Sagamore Health Network All Products |
$14.74
|
| Rate for Payer: Signature Care EPO |
$15.85
|
| Rate for Payer: Signature Care PPO |
$16.80
|
| Rate for Payer: United Healthcare Commercial |
$15.05
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$17.76 |
| Rate for Payer: Aetna Commercial |
$16.12
|
| Rate for Payer: Aetna Medicare |
$6.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.72
|
| Rate for Payer: Cash Price |
$11.46
|
| Rate for Payer: Centivo All Commercial |
$10.39
|
| Rate for Payer: Cigna All Commercial |
$16.48
|
| Rate for Payer: CORVEL All Commercial |
$17.76
|
| Rate for Payer: Coventry All Commercial |
$16.80
|
| Rate for Payer: Encore All Commercial |
$17.58
|
| Rate for Payer: Frontpath All Commercial |
$17.57
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare |
$6.11
|
| Rate for Payer: Lucent All Commercial |
$10.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.19
|
| Rate for Payer: PHCS All Commercial |
$14.32
|
| Rate for Payer: PHP All Commercial |
$14.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.45
|
| Rate for Payer: Sagamore Health Network All Products |
$14.74
|
| Rate for Payer: Signature Care EPO |
$15.85
|
| Rate for Payer: Signature Care PPO |
$16.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.23
|
| Rate for Payer: United Healthcare Commercial |
$15.05
|
| Rate for Payer: United Healthcare Medicare |
$6.11
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG
|
Facility
|
IP
|
$25.47
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$23.68 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Cash Price |
$15.28
|
| Rate for Payer: Cigna All Commercial |
$21.98
|
| Rate for Payer: CORVEL All Commercial |
$23.68
|
| Rate for Payer: Coventry All Commercial |
$22.41
|
| Rate for Payer: Encore All Commercial |
$23.44
|
| Rate for Payer: Frontpath All Commercial |
$23.43
|
| Rate for Payer: Humana ChoiceCare |
$21.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.92
|
| Rate for Payer: PHCS All Commercial |
$19.10
|
| Rate for Payer: PHP All Commercial |
$19.31
|
| Rate for Payer: Sagamore Health Network All Products |
$19.66
|
| Rate for Payer: Signature Care EPO |
$21.14
|
| Rate for Payer: Signature Care PPO |
$22.41
|
| Rate for Payer: United Healthcare Commercial |
$20.07
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG
|
Facility
|
OP
|
$25.47
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$23.68 |
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.96
|
| Rate for Payer: Cash Price |
$15.28
|
| Rate for Payer: Centivo All Commercial |
$13.85
|
| Rate for Payer: Cigna All Commercial |
$21.98
|
| Rate for Payer: CORVEL All Commercial |
$23.68
|
| Rate for Payer: Coventry All Commercial |
$22.41
|
| Rate for Payer: Encore All Commercial |
$23.44
|
| Rate for Payer: Frontpath All Commercial |
$23.43
|
| Rate for Payer: Humana ChoiceCare |
$21.99
|
| Rate for Payer: Humana Medicare |
$8.15
|
| Rate for Payer: Lucent All Commercial |
$13.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.92
|
| Rate for Payer: PHCS All Commercial |
$19.10
|
| Rate for Payer: PHP All Commercial |
$19.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.93
|
| Rate for Payer: Sagamore Health Network All Products |
$19.66
|
| Rate for Payer: Signature Care EPO |
$21.14
|
| Rate for Payer: Signature Care PPO |
$22.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.65
|
| Rate for Payer: United Healthcare Commercial |
$20.07
|
| Rate for Payer: United Healthcare Medicare |
$8.15
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG
|
Facility
|
IP
|
$35.90
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.92 |
| Max. Negotiated Rate |
$33.39 |
| Rate for Payer: Aetna Commercial |
$31.02
|
| Rate for Payer: Cash Price |
$21.54
|
| Rate for Payer: Cigna All Commercial |
$30.98
|
| Rate for Payer: CORVEL All Commercial |
$33.39
|
| Rate for Payer: Coventry All Commercial |
$31.59
|
| Rate for Payer: Encore All Commercial |
$33.04
|
| Rate for Payer: Frontpath All Commercial |
$33.03
|
| Rate for Payer: Humana ChoiceCare |
$31.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.31
|
| Rate for Payer: PHCS All Commercial |
$26.92
|
| Rate for Payer: PHP All Commercial |
$27.23
|
| Rate for Payer: Sagamore Health Network All Products |
$27.71
|
| Rate for Payer: Signature Care EPO |
$29.80
|
| Rate for Payer: Signature Care PPO |
$31.59
|
| Rate for Payer: United Healthcare Commercial |
$28.29
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG
|
Facility
|
OP
|
$35.90
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$33.39 |
| Rate for Payer: Aetna Commercial |
$30.30
|
| Rate for Payer: Aetna Medicare |
$11.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.64
|
| Rate for Payer: Cash Price |
$21.54
|
| Rate for Payer: Centivo All Commercial |
$19.53
|
| Rate for Payer: Cigna All Commercial |
$30.98
|
| Rate for Payer: CORVEL All Commercial |
$33.39
|
| Rate for Payer: Coventry All Commercial |
$31.59
|
| Rate for Payer: Encore All Commercial |
$33.04
|
| Rate for Payer: Frontpath All Commercial |
$33.03
|
| Rate for Payer: Humana ChoiceCare |
$31.01
|
| Rate for Payer: Humana Medicare |
$11.49
|
| Rate for Payer: Lucent All Commercial |
$19.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.31
|
| Rate for Payer: PHCS All Commercial |
$26.92
|
| Rate for Payer: PHP All Commercial |
$27.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.00
|
| Rate for Payer: Sagamore Health Network All Products |
$27.71
|
| Rate for Payer: Signature Care EPO |
$29.80
|
| Rate for Payer: Signature Care PPO |
$31.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.51
|
| Rate for Payer: United Healthcare Commercial |
$28.29
|
| Rate for Payer: United Healthcare Medicare |
$11.49
|
|
