|
GOLIMUMAB 12.5 MG/ML IV SOLN
|
Facility
|
OP
|
$6,822.24
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
165235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.98 |
| Max. Negotiated Rate |
$6,344.69 |
| Rate for Payer: Aetna Commercial |
$5,757.97
|
| Rate for Payer: Aetna Medicare |
$2,183.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$41.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,114.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,918.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,264.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$41.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,510.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,401.43
|
| Rate for Payer: Cash Price |
$4,093.35
|
| Rate for Payer: Cash Price |
$4,093.35
|
| Rate for Payer: Centivo All Commercial |
$3,711.30
|
| Rate for Payer: Cigna All Commercial |
$5,887.59
|
| Rate for Payer: CORVEL All Commercial |
$6,344.69
|
| Rate for Payer: Coventry All Commercial |
$6,003.57
|
| Rate for Payer: Encore All Commercial |
$6,279.87
|
| Rate for Payer: Frontpath All Commercial |
$6,276.46
|
| Rate for Payer: Humana ChoiceCare |
$5,892.37
|
| Rate for Payer: Humana Medicare |
$2,183.12
|
| Rate for Payer: Lucent All Commercial |
$3,711.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,140.02
|
| Rate for Payer: Managed Health Services Medicaid |
$41.98
|
| Rate for Payer: MDWise Medicaid |
$41.98
|
| Rate for Payer: PHCS All Commercial |
$5,116.68
|
| Rate for Payer: PHP All Commercial |
$5,173.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,660.67
|
| Rate for Payer: Sagamore Health Network All Products |
$5,266.77
|
| Rate for Payer: Signature Care EPO |
$5,662.46
|
| Rate for Payer: Signature Care PPO |
$6,003.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,798.91
|
| Rate for Payer: United Healthcare Commercial |
$5,375.93
|
| Rate for Payer: United Healthcare Medicare |
$2,183.12
|
|
|
GOLIMUMAB 12.5 MG/ML IV SOLN
|
Facility
|
IP
|
$6,822.24
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
165235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,116.68 |
| Max. Negotiated Rate |
$6,344.69 |
| Rate for Payer: Aetna Commercial |
$5,894.42
|
| Rate for Payer: Cash Price |
$4,093.35
|
| Rate for Payer: Cigna All Commercial |
$5,887.59
|
| Rate for Payer: CORVEL All Commercial |
$6,344.69
|
| Rate for Payer: Coventry All Commercial |
$6,003.57
|
| Rate for Payer: Encore All Commercial |
$6,279.87
|
| Rate for Payer: Frontpath All Commercial |
$6,276.46
|
| Rate for Payer: Humana ChoiceCare |
$5,892.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,140.02
|
| Rate for Payer: PHCS All Commercial |
$5,116.68
|
| Rate for Payer: PHP All Commercial |
$5,173.99
|
| Rate for Payer: Sagamore Health Network All Products |
$5,266.77
|
| Rate for Payer: Signature Care EPO |
$5,662.46
|
| Rate for Payer: Signature Care PPO |
$6,003.57
|
| Rate for Payer: United Healthcare Commercial |
$5,375.93
|
|
|
GOLIMUMAB 50 MG/0.5 ML SUBQ PNIJ
|
Facility
|
IP
|
$21,645.68
|
|
|
Service Code
|
NDC 57894007002
|
| Hospital Charge Code |
120455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16,234.26 |
| Max. Negotiated Rate |
$20,130.48 |
| Rate for Payer: Aetna Commercial |
$18,701.87
|
| Rate for Payer: Cash Price |
$12,987.41
|
| Rate for Payer: Cigna All Commercial |
$18,680.22
|
| Rate for Payer: CORVEL All Commercial |
$20,130.48
|
| Rate for Payer: Coventry All Commercial |
$19,048.20
|
| Rate for Payer: Encore All Commercial |
$19,924.85
|
| Rate for Payer: Frontpath All Commercial |
$19,914.03
|
| Rate for Payer: Humana ChoiceCare |
$18,695.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19,481.11
|
| Rate for Payer: PHCS All Commercial |
$16,234.26
|
| Rate for Payer: PHP All Commercial |
$16,416.08
|
| Rate for Payer: Sagamore Health Network All Products |
$16,710.46
|
| Rate for Payer: Signature Care EPO |
$17,965.91
|
| Rate for Payer: Signature Care PPO |
$19,048.20
|
| Rate for Payer: United Healthcare Commercial |
$17,056.80
|
|
|
GOLIMUMAB 50 MG/0.5 ML SUBQ PNIJ
|
Facility
|
OP
|
$21,645.68
|
|
|
Service Code
|
NDC 57894007002
|
| Hospital Charge Code |
120455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$20,130.48 |
| Rate for Payer: Aetna Commercial |
$18,268.95
|
| Rate for Payer: Aetna Medicare |
$6,926.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,710.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12,431.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13,530.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,965.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,619.28
|
| Rate for Payer: Cash Price |
$12,987.41
|
| Rate for Payer: Cash Price |
$12,987.41
|
| Rate for Payer: Centivo All Commercial |
$11,775.25
|
| Rate for Payer: Cigna All Commercial |
$18,680.22
|
| Rate for Payer: CORVEL All Commercial |
$20,130.48
|
| Rate for Payer: Coventry All Commercial |
$19,048.20
|
| Rate for Payer: Encore All Commercial |
$19,924.85
|
| Rate for Payer: Frontpath All Commercial |
$19,914.03
|
| Rate for Payer: Humana ChoiceCare |
$18,695.37
|
| Rate for Payer: Humana Medicare |
$6,926.62
|
| Rate for Payer: Lucent All Commercial |
$11,775.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19,481.11
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$16,234.26
|
| Rate for Payer: PHP All Commercial |
$16,416.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,441.82
|
| Rate for Payer: Sagamore Health Network All Products |
$16,710.46
|
| Rate for Payer: Signature Care EPO |
$17,965.91
|
| Rate for Payer: Signature Care PPO |
$19,048.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18,398.83
|
| Rate for Payer: United Healthcare Commercial |
$17,056.80
|
| Rate for Payer: United Healthcare Medicare |
$6,926.62
|
|
|
GOSERELIN 10.8 MG SUBQ IMPL
|
Facility
|
IP
|
$10,220.07
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
16254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,665.05 |
| Max. Negotiated Rate |
$9,504.67 |
| Rate for Payer: Aetna Commercial |
$8,830.14
|
| Rate for Payer: Cash Price |
$6,132.04
|
| Rate for Payer: Cigna All Commercial |
$8,819.92
|
| Rate for Payer: CORVEL All Commercial |
$9,504.67
|
| Rate for Payer: Coventry All Commercial |
$8,993.66
|
| Rate for Payer: Encore All Commercial |
$9,407.57
|
| Rate for Payer: Frontpath All Commercial |
$9,402.46
|
| Rate for Payer: Humana ChoiceCare |
$8,827.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,198.06
|
| Rate for Payer: PHCS All Commercial |
$7,665.05
|
| Rate for Payer: PHP All Commercial |
$7,750.90
|
| Rate for Payer: Sagamore Health Network All Products |
$7,889.89
|
| Rate for Payer: Signature Care EPO |
$8,482.66
|
| Rate for Payer: Signature Care PPO |
$8,993.66
|
| Rate for Payer: United Healthcare Commercial |
$8,053.42
|
|
|
GOSERELIN 10.8 MG SUBQ IMPL
|
Facility
|
OP
|
$10,220.07
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
16254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,168.22 |
| Max. Negotiated Rate |
$9,504.67 |
| Rate for Payer: Aetna Commercial |
$8,625.74
|
| Rate for Payer: Aetna Medicare |
$3,270.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,168.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,869.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,388.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,760.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,597.46
|
| Rate for Payer: Cash Price |
$6,132.04
|
| Rate for Payer: Centivo All Commercial |
$5,559.72
|
| Rate for Payer: Cigna All Commercial |
$8,819.92
|
| Rate for Payer: CORVEL All Commercial |
$9,504.67
|
| Rate for Payer: Coventry All Commercial |
$8,993.66
|
| Rate for Payer: Encore All Commercial |
$9,407.57
|
| Rate for Payer: Frontpath All Commercial |
$9,402.46
|
| Rate for Payer: Humana ChoiceCare |
$8,827.07
|
| Rate for Payer: Humana Medicare |
$3,270.42
|
| Rate for Payer: Lucent All Commercial |
$5,559.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,198.06
|
| Rate for Payer: PHCS All Commercial |
$7,665.05
|
| Rate for Payer: PHP All Commercial |
$7,750.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,985.83
|
| Rate for Payer: Sagamore Health Network All Products |
$7,889.89
|
| Rate for Payer: Signature Care EPO |
$8,482.66
|
| Rate for Payer: Signature Care PPO |
$8,993.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,687.06
|
| Rate for Payer: United Healthcare Commercial |
$8,053.42
|
| Rate for Payer: United Healthcare Medicare |
$3,270.42
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQD
|
Facility
|
IP
|
$13.41
|
|
|
Service Code
|
NDC 00121174400
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Aetna Commercial |
$11.58
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Cigna All Commercial |
$11.57
|
| Rate for Payer: CORVEL All Commercial |
$12.47
|
| Rate for Payer: Coventry All Commercial |
$11.80
|
| Rate for Payer: Encore All Commercial |
$12.34
|
| Rate for Payer: Frontpath All Commercial |
$12.33
|
| Rate for Payer: Humana ChoiceCare |
$11.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.06
|
| Rate for Payer: PHCS All Commercial |
$10.05
|
| Rate for Payer: PHP All Commercial |
$10.17
|
| Rate for Payer: Sagamore Health Network All Products |
$10.35
|
| Rate for Payer: Signature Care EPO |
$11.13
|
| Rate for Payer: Signature Care PPO |
$11.80
|
| Rate for Payer: United Healthcare Commercial |
$10.56
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQD
|
Facility
|
OP
|
$13.41
|
|
|
Service Code
|
NDC 00121174400
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Aetna Commercial |
$11.31
|
| Rate for Payer: Aetna Medicare |
$4.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.72
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Centivo All Commercial |
$7.29
|
| Rate for Payer: Cigna All Commercial |
$11.57
|
| Rate for Payer: CORVEL All Commercial |
$12.47
|
| Rate for Payer: Coventry All Commercial |
$11.80
|
| Rate for Payer: Encore All Commercial |
$12.34
|
| Rate for Payer: Frontpath All Commercial |
$12.33
|
| Rate for Payer: Humana ChoiceCare |
$11.58
|
| Rate for Payer: Humana Medicare |
$4.29
|
| Rate for Payer: Lucent All Commercial |
$7.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.06
|
| Rate for Payer: PHCS All Commercial |
$10.05
|
| Rate for Payer: PHP All Commercial |
$10.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.23
|
| Rate for Payer: Sagamore Health Network All Products |
$10.35
|
| Rate for Payer: Signature Care EPO |
$11.13
|
| Rate for Payer: Signature Care PPO |
$11.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.39
|
| Rate for Payer: United Healthcare Commercial |
$10.56
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 68084057211
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.22
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 68084057211
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Aetna Medicare |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.13
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Centivo All Commercial |
$3.29
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Humana Medicare |
$1.93
|
| Rate for Payer: Lucent All Commercial |
$3.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.36
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.13
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
| Rate for Payer: United Healthcare Medicare |
$1.93
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 68084057201
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Aetna Medicare |
$1.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.13
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Centivo All Commercial |
$3.29
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Humana Medicare |
$1.93
|
| Rate for Payer: Lucent All Commercial |
$3.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.36
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.13
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
| Rate for Payer: United Healthcare Medicare |
$1.93
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 68084057201
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.22
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna All Commercial |
$5.21
|
| Rate for Payer: CORVEL All Commercial |
$5.62
|
| Rate for Payer: Coventry All Commercial |
$5.32
|
| Rate for Payer: Encore All Commercial |
$5.56
|
| Rate for Payer: Frontpath All Commercial |
$5.56
|
| Rate for Payer: Humana ChoiceCare |
$5.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.44
|
| Rate for Payer: PHCS All Commercial |
$4.53
|
| Rate for Payer: PHP All Commercial |
$4.58
|
| Rate for Payer: Sagamore Health Network All Products |
$4.66
|
| Rate for Payer: Signature Care EPO |
$5.01
|
| Rate for Payer: Signature Care PPO |
$5.32
|
| Rate for Payer: United Healthcare Commercial |
$4.76
|
|
|
HAEMPH B POLYSAC CONJ-MENIN PF 7.5 MCG/0.5 ML IM SOLN
|
Facility
|
IP
|
$191.21
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
10153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.41 |
| Max. Negotiated Rate |
$177.83 |
| Rate for Payer: Aetna Commercial |
$165.21
|
| Rate for Payer: Cash Price |
$114.73
|
| Rate for Payer: Cigna All Commercial |
$165.02
|
| Rate for Payer: CORVEL All Commercial |
$177.83
|
| Rate for Payer: Coventry All Commercial |
$168.27
|
| Rate for Payer: Encore All Commercial |
$176.01
|
| Rate for Payer: Frontpath All Commercial |
$175.92
|
| Rate for Payer: Humana ChoiceCare |
$165.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.09
|
| Rate for Payer: PHCS All Commercial |
$143.41
|
| Rate for Payer: PHP All Commercial |
$145.02
|
| Rate for Payer: Sagamore Health Network All Products |
$147.62
|
| Rate for Payer: Signature Care EPO |
$158.71
|
| Rate for Payer: Signature Care PPO |
$168.27
|
| Rate for Payer: United Healthcare Commercial |
$150.68
|
|
|
HAEMPH B POLYSAC CONJ-MENIN PF 7.5 MCG/0.5 ML IM SOLN
|
Facility
|
OP
|
$191.21
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
10153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.28 |
| Max. Negotiated Rate |
$177.83 |
| Rate for Payer: Aetna Commercial |
$161.38
|
| Rate for Payer: Aetna Medicare |
$61.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$109.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$119.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.31
|
| Rate for Payer: Cash Price |
$114.73
|
| Rate for Payer: Centivo All Commercial |
$104.02
|
| Rate for Payer: Cigna All Commercial |
$165.02
|
| Rate for Payer: CORVEL All Commercial |
$177.83
|
| Rate for Payer: Coventry All Commercial |
$168.27
|
| Rate for Payer: Encore All Commercial |
$176.01
|
| Rate for Payer: Frontpath All Commercial |
$175.92
|
| Rate for Payer: Humana ChoiceCare |
$165.15
|
| Rate for Payer: Humana Medicare |
$61.19
|
| Rate for Payer: Lucent All Commercial |
$104.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.09
|
| Rate for Payer: PHCS All Commercial |
$143.41
|
| Rate for Payer: PHP All Commercial |
$145.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$74.57
|
| Rate for Payer: Sagamore Health Network All Products |
$147.62
|
| Rate for Payer: Signature Care EPO |
$158.71
|
| Rate for Payer: Signature Care PPO |
$168.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$162.53
|
| Rate for Payer: United Healthcare Commercial |
$150.68
|
| Rate for Payer: United Healthcare Medicare |
$61.19
|
|
|
HALOPERIDOL 1 MG ORAL TAB
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.15
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Centivo All Commercial |
$1.78
|
| Rate for Payer: Cigna All Commercial |
$2.82
|
| Rate for Payer: CORVEL All Commercial |
$3.04
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.01
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.82
|
| Rate for Payer: Humana Medicare |
$1.05
|
| Rate for Payer: Lucent All Commercial |
$1.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.94
|
| Rate for Payer: PHCS All Commercial |
$2.45
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.52
|
| Rate for Payer: Signature Care EPO |
$2.71
|
| Rate for Payer: Signature Care PPO |
$2.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.78
|
| Rate for Payer: United Healthcare Commercial |
$2.58
|
| Rate for Payer: United Healthcare Medicare |
$1.05
|
|
|
HALOPERIDOL 1 MG ORAL TAB
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3579
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna All Commercial |
$2.82
|
| Rate for Payer: CORVEL All Commercial |
$3.04
|
| Rate for Payer: Coventry All Commercial |
$2.88
|
| Rate for Payer: Encore All Commercial |
$3.01
|
| Rate for Payer: Frontpath All Commercial |
$3.01
|
| Rate for Payer: Humana ChoiceCare |
$2.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.94
|
| Rate for Payer: PHCS All Commercial |
$2.45
|
| Rate for Payer: PHP All Commercial |
$2.48
|
| Rate for Payer: Sagamore Health Network All Products |
$2.52
|
| Rate for Payer: Signature Care EPO |
$2.71
|
| Rate for Payer: Signature Care PPO |
$2.88
|
| Rate for Payer: United Healthcare Commercial |
$2.58
|
|
|
HALOPERIDOL 5 MG ORAL TAB
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
NDC 00904678261
|
| Hospital Charge Code |
3583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.48
|
| Rate for Payer: Coventry All Commercial |
$2.35
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.40
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Sagamore Health Network All Products |
$2.06
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.35
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
|
|
HALOPERIDOL 5 MG ORAL TAB
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 00904678261
|
| Hospital Charge Code |
3583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Aetna Medicare |
$0.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Centivo All Commercial |
$1.45
|
| Rate for Payer: Cigna All Commercial |
$2.30
|
| Rate for Payer: CORVEL All Commercial |
$2.48
|
| Rate for Payer: Coventry All Commercial |
$2.35
|
| Rate for Payer: Encore All Commercial |
$2.45
|
| Rate for Payer: Frontpath All Commercial |
$2.45
|
| Rate for Payer: Humana ChoiceCare |
$2.30
|
| Rate for Payer: Humana Medicare |
$0.85
|
| Rate for Payer: Lucent All Commercial |
$1.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.40
|
| Rate for Payer: PHCS All Commercial |
$2.00
|
| Rate for Payer: PHP All Commercial |
$2.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.04
|
| Rate for Payer: Sagamore Health Network All Products |
$2.06
|
| Rate for Payer: Signature Care EPO |
$2.21
|
| Rate for Payer: Signature Care PPO |
$2.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.27
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$0.85
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN
|
Facility
|
OP
|
$495.54
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
10163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$153.62 |
| Max. Negotiated Rate |
$460.85 |
| Rate for Payer: Aetna Commercial |
$418.24
|
| Rate for Payer: Aetna Medicare |
$158.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$153.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$284.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$309.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$182.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$174.43
|
| Rate for Payer: Cash Price |
$297.32
|
| Rate for Payer: Centivo All Commercial |
$269.57
|
| Rate for Payer: Cigna All Commercial |
$427.65
|
| Rate for Payer: CORVEL All Commercial |
$460.85
|
| Rate for Payer: Coventry All Commercial |
$436.08
|
| Rate for Payer: Encore All Commercial |
$456.14
|
| Rate for Payer: Frontpath All Commercial |
$455.90
|
| Rate for Payer: Humana ChoiceCare |
$428.00
|
| Rate for Payer: Humana Medicare |
$158.57
|
| Rate for Payer: Lucent All Commercial |
$269.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.99
|
| Rate for Payer: PHCS All Commercial |
$371.65
|
| Rate for Payer: PHP All Commercial |
$375.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$193.26
|
| Rate for Payer: Sagamore Health Network All Products |
$382.56
|
| Rate for Payer: Signature Care EPO |
$411.30
|
| Rate for Payer: Signature Care PPO |
$436.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$421.21
|
| Rate for Payer: United Healthcare Commercial |
$390.49
|
| Rate for Payer: United Healthcare Medicare |
$158.57
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN
|
Facility
|
IP
|
$495.54
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
10163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$371.65 |
| Max. Negotiated Rate |
$460.85 |
| Rate for Payer: Aetna Commercial |
$428.15
|
| Rate for Payer: Cash Price |
$297.32
|
| Rate for Payer: Cigna All Commercial |
$427.65
|
| Rate for Payer: CORVEL All Commercial |
$460.85
|
| Rate for Payer: Coventry All Commercial |
$436.08
|
| Rate for Payer: Encore All Commercial |
$456.14
|
| Rate for Payer: Frontpath All Commercial |
$455.90
|
| Rate for Payer: Humana ChoiceCare |
$428.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.99
|
| Rate for Payer: PHCS All Commercial |
$371.65
|
| Rate for Payer: PHP All Commercial |
$375.82
|
| Rate for Payer: Sagamore Health Network All Products |
$382.56
|
| Rate for Payer: Signature Care EPO |
$411.30
|
| Rate for Payer: Signature Care PPO |
$436.08
|
| Rate for Payer: United Healthcare Commercial |
$390.49
|
|
|
HALOPERIDOL LACTATE 5 MG/ML INJ SOLN
|
Facility
|
IP
|
$21.64
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3584
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.23 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Cash Price |
$12.98
|
| Rate for Payer: Cigna All Commercial |
$18.67
|
| Rate for Payer: CORVEL All Commercial |
$20.12
|
| Rate for Payer: Coventry All Commercial |
$19.04
|
| Rate for Payer: Encore All Commercial |
$19.92
|
| Rate for Payer: Frontpath All Commercial |
$19.91
|
| Rate for Payer: Humana ChoiceCare |
$18.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.47
|
| Rate for Payer: PHCS All Commercial |
$16.23
|
| Rate for Payer: PHP All Commercial |
$16.41
|
| Rate for Payer: Sagamore Health Network All Products |
$16.70
|
| Rate for Payer: Signature Care EPO |
$17.96
|
| Rate for Payer: Signature Care PPO |
$19.04
|
| Rate for Payer: United Healthcare Commercial |
$17.05
|
|
|
HALOPERIDOL LACTATE 5 MG/ML INJ SOLN
|
Facility
|
OP
|
$21.64
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna Commercial |
$18.26
|
| Rate for Payer: Aetna Medicare |
$6.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.62
|
| Rate for Payer: Cash Price |
$12.98
|
| Rate for Payer: Centivo All Commercial |
$11.77
|
| Rate for Payer: Cigna All Commercial |
$18.67
|
| Rate for Payer: CORVEL All Commercial |
$20.12
|
| Rate for Payer: Coventry All Commercial |
$19.04
|
| Rate for Payer: Encore All Commercial |
$19.92
|
| Rate for Payer: Frontpath All Commercial |
$19.91
|
| Rate for Payer: Humana ChoiceCare |
$18.69
|
| Rate for Payer: Humana Medicare |
$6.92
|
| Rate for Payer: Lucent All Commercial |
$11.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.47
|
| Rate for Payer: PHCS All Commercial |
$16.23
|
| Rate for Payer: PHP All Commercial |
$16.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.44
|
| Rate for Payer: Sagamore Health Network All Products |
$16.70
|
| Rate for Payer: Signature Care EPO |
$17.96
|
| Rate for Payer: Signature Care PPO |
$19.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.39
|
| Rate for Payer: United Healthcare Commercial |
$17.05
|
| Rate for Payer: United Healthcare Medicare |
$6.92
|
|
|
HC 14FR FIRM INTUB STYLET
|
Facility
|
OP
|
$12.80
|
|
| Hospital Charge Code |
41608050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$31.20 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Medicare |
$4.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.51
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Centivo All Commercial |
$6.96
|
| Rate for Payer: Cigna All Commercial |
$11.05
|
| Rate for Payer: CORVEL All Commercial |
$11.90
|
| Rate for Payer: Coventry All Commercial |
$11.26
|
| Rate for Payer: Encore All Commercial |
$11.78
|
| Rate for Payer: Frontpath All Commercial |
$11.78
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Humana Medicare |
$4.10
|
| Rate for Payer: Lucent All Commercial |
$6.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.52
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$9.60
|
| Rate for Payer: PHP All Commercial |
$9.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.99
|
| Rate for Payer: Sagamore Health Network All Products |
$9.88
|
| Rate for Payer: Signature Care EPO |
$10.62
|
| Rate for Payer: Signature Care PPO |
$11.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.88
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
| Rate for Payer: United Healthcare Medicare |
$4.10
|
|
|
HC 14FR FIRM INTUB STYLET
|
Facility
|
IP
|
$12.80
|
|
| Hospital Charge Code |
41608050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Aetna Commercial |
$11.06
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cigna All Commercial |
$11.05
|
| Rate for Payer: CORVEL All Commercial |
$11.90
|
| Rate for Payer: Coventry All Commercial |
$11.26
|
| Rate for Payer: Encore All Commercial |
$11.78
|
| Rate for Payer: Frontpath All Commercial |
$11.78
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.52
|
| Rate for Payer: PHCS All Commercial |
$9.60
|
| Rate for Payer: PHP All Commercial |
$9.71
|
| Rate for Payer: Sagamore Health Network All Products |
$9.88
|
| Rate for Payer: Signature Care EPO |
$10.62
|
| Rate for Payer: Signature Care PPO |
$11.26
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
|
|
HC 17 HYDROXYPROGESTRERONE-16 & YOUNGER
|
Facility
|
IP
|
$175.99
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
63001574
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.99 |
| Max. Negotiated Rate |
$163.67 |
| Rate for Payer: Aetna Commercial |
$152.06
|
| Rate for Payer: Cash Price |
$105.59
|
| Rate for Payer: Cigna All Commercial |
$151.88
|
| Rate for Payer: CORVEL All Commercial |
$163.67
|
| Rate for Payer: Coventry All Commercial |
$154.87
|
| Rate for Payer: Encore All Commercial |
$162.00
|
| Rate for Payer: Frontpath All Commercial |
$161.91
|
| Rate for Payer: Humana ChoiceCare |
$152.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.39
|
| Rate for Payer: PHCS All Commercial |
$131.99
|
| Rate for Payer: PHP All Commercial |
$133.47
|
| Rate for Payer: Sagamore Health Network All Products |
$135.86
|
| Rate for Payer: Signature Care EPO |
$146.07
|
| Rate for Payer: Signature Care PPO |
$154.87
|
| Rate for Payer: United Healthcare Commercial |
$138.68
|
|
