|
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN
|
Facility
|
OP
|
$754.00
|
|
|
Service Code
|
NDC 43598069858
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$701.22 |
| Rate for Payer: Aetna Commercial |
$636.38
|
| Rate for Payer: Aetna Medicare |
$248.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$248.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$433.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$471.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$286.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$273.70
|
| Rate for Payer: Cash Price |
$467.48
|
| Rate for Payer: Cash Price |
$467.48
|
| Rate for Payer: Centivo All Commercial |
$384.54
|
| Rate for Payer: Cigna All Commercial |
$650.70
|
| Rate for Payer: CORVEL All Commercial |
$701.22
|
| Rate for Payer: Coventry All Commercial |
$663.52
|
| Rate for Payer: Encore All Commercial |
$694.06
|
| Rate for Payer: Frontpath All Commercial |
$693.68
|
| Rate for Payer: Humana ChoiceCare |
$651.23
|
| Rate for Payer: Humana Medicare |
$384.54
|
| Rate for Payer: Lucent All Commercial |
$384.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$678.60
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$565.50
|
| Rate for Payer: PHP All Commercial |
$571.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$294.06
|
| Rate for Payer: Sagamore Health Network All Products |
$582.09
|
| Rate for Payer: Signature Care EPO |
$625.82
|
| Rate for Payer: Signature Care PPO |
$663.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$640.90
|
| Rate for Payer: United Healthcare Commercial |
$594.15
|
| Rate for Payer: United Healthcare Medicare |
$248.82
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN
|
Facility
|
IP
|
$754.00
|
|
|
Service Code
|
NDC 43598069858
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$565.50 |
| Max. Negotiated Rate |
$701.22 |
| Rate for Payer: Aetna Commercial |
$651.46
|
| Rate for Payer: Cash Price |
$467.48
|
| Rate for Payer: Cigna All Commercial |
$650.70
|
| Rate for Payer: CORVEL All Commercial |
$701.22
|
| Rate for Payer: Coventry All Commercial |
$663.52
|
| Rate for Payer: Encore All Commercial |
$694.06
|
| Rate for Payer: Frontpath All Commercial |
$693.68
|
| Rate for Payer: Humana ChoiceCare |
$651.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$678.60
|
| Rate for Payer: PHCS All Commercial |
$565.50
|
| Rate for Payer: PHP All Commercial |
$571.83
|
| Rate for Payer: Sagamore Health Network All Products |
$582.09
|
| Rate for Payer: Signature Care EPO |
$625.82
|
| Rate for Payer: Signature Care PPO |
$663.52
|
| Rate for Payer: United Healthcare Commercial |
$594.15
|
|
|
Cardioversion, elective, electrical conversion of arrhythmia; external
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 92960
|
| Hospital Charge Code |
CPT-92960
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
CARVEDILOL 12.5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904630261
|
| Hospital Charge Code |
15749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
CARVEDILOL 12.5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904630261
|
| Hospital Charge Code |
15749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
CARVEDILOL 3.125 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904630061
|
| Hospital Charge Code |
18551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
CARVEDILOL 3.125 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904630061
|
| Hospital Charge Code |
18551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
CARVEDILOL 6.25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904630161
|
| Hospital Charge Code |
15747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
CARVEDILOL 6.25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904630161
|
| Hospital Charge Code |
15747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
CASIRIVIMAB-IMDEVIMAB 60 MG-60 MG/ ML IV SOLN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 61755003901
|
| Hospital Charge Code |
195306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
CASIRIVIMAB-IMDEVIMAB 60 MG-60 MG/ ML IV SOLN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 61755003901
|
| Hospital Charge Code |
195306
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
CASIRIVIMAB (REGN10933) 120 MG/ML IV SOLN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0244
|
| Hospital Charge Code |
193081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
CASIRIVIMAB (REGN10933) 120 MG/ML IV SOLN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0244
|
| Hospital Charge Code |
193081
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
CATARACT EYE OINTMENT - DR HOLICKI
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
NDC 099999997
|
| Hospital Charge Code |
1401000700016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$198.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$198.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$344.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$375.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.80
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Centivo All Commercial |
$306.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Humana Medicare |
$306.00
|
| Rate for Payer: Lucent All Commercial |
$306.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.00
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$510.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
| Rate for Payer: United Healthcare Medicare |
$198.00
|
|
|
CATARACT EYE OINTMENT - DR HOLICKI
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
NDC 099999997
|
| Hospital Charge Code |
1401000700016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$518.40
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
|
|
Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
|
Facility
|
OP
|
$285.87
|
|
|
Service Code
|
CPT 58340
|
| Hospital Charge Code |
CPT-58340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.87 |
| Max. Negotiated Rate |
$285.87 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$285.87
|
| Rate for Payer: Managed Health Services Medicaid |
$285.87
|
| Rate for Payer: MDWise Medicaid |
$285.87
|
|
|
CEFAZOLIN 1 G INJ SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
1445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
CEFAZOLIN 1 G INJ SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
1445
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
CEFAZOLIN 2 G INJ SOLR
|
Facility
|
OP
|
$30.87
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
197497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$28.71 |
| Rate for Payer: Aetna Commercial |
$26.05
|
| Rate for Payer: Aetna Medicare |
$10.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.21
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Centivo All Commercial |
$15.74
|
| Rate for Payer: Cigna All Commercial |
$26.64
|
| Rate for Payer: CORVEL All Commercial |
$28.71
|
| Rate for Payer: Coventry All Commercial |
$27.17
|
| Rate for Payer: Encore All Commercial |
$28.42
|
| Rate for Payer: Frontpath All Commercial |
$28.40
|
| Rate for Payer: Humana ChoiceCare |
$26.66
|
| Rate for Payer: Humana Medicare |
$15.74
|
| Rate for Payer: Lucent All Commercial |
$15.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.78
|
| Rate for Payer: PHCS All Commercial |
$23.15
|
| Rate for Payer: PHP All Commercial |
$23.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.04
|
| Rate for Payer: Sagamore Health Network All Products |
$23.83
|
| Rate for Payer: Signature Care EPO |
$25.62
|
| Rate for Payer: Signature Care PPO |
$27.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.24
|
| Rate for Payer: United Healthcare Commercial |
$24.33
|
| Rate for Payer: United Healthcare Medicare |
$10.19
|
|
|
CEFAZOLIN 2 G INJ SOLR
|
Facility
|
IP
|
$30.87
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
197497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$28.71 |
| Rate for Payer: Aetna Commercial |
$26.67
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Cigna All Commercial |
$26.64
|
| Rate for Payer: CORVEL All Commercial |
$28.71
|
| Rate for Payer: Coventry All Commercial |
$27.17
|
| Rate for Payer: Encore All Commercial |
$28.42
|
| Rate for Payer: Frontpath All Commercial |
$28.40
|
| Rate for Payer: Humana ChoiceCare |
$26.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.78
|
| Rate for Payer: PHCS All Commercial |
$23.15
|
| Rate for Payer: PHP All Commercial |
$23.41
|
| Rate for Payer: Sagamore Health Network All Products |
$23.83
|
| Rate for Payer: Signature Care EPO |
$25.62
|
| Rate for Payer: Signature Care PPO |
$27.17
|
| Rate for Payer: United Healthcare Commercial |
$24.33
|
|
|
CEFAZOLIN 3 G IV SOLR
|
Facility
|
OP
|
$43.21
|
|
|
Service Code
|
HCPCS J0688
|
| Hospital Charge Code |
200765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.26 |
| Max. Negotiated Rate |
$40.18 |
| Rate for Payer: Aetna Commercial |
$36.47
|
| Rate for Payer: Aetna Medicare |
$14.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.68
|
| Rate for Payer: Cash Price |
$26.79
|
| Rate for Payer: Centivo All Commercial |
$22.04
|
| Rate for Payer: Cigna All Commercial |
$37.29
|
| Rate for Payer: CORVEL All Commercial |
$40.18
|
| Rate for Payer: Coventry All Commercial |
$38.02
|
| Rate for Payer: Encore All Commercial |
$39.77
|
| Rate for Payer: Frontpath All Commercial |
$39.75
|
| Rate for Payer: Humana ChoiceCare |
$37.32
|
| Rate for Payer: Humana Medicare |
$22.04
|
| Rate for Payer: Lucent All Commercial |
$22.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.89
|
| Rate for Payer: PHCS All Commercial |
$32.41
|
| Rate for Payer: PHP All Commercial |
$32.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.85
|
| Rate for Payer: Sagamore Health Network All Products |
$33.36
|
| Rate for Payer: Signature Care EPO |
$35.86
|
| Rate for Payer: Signature Care PPO |
$38.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$36.73
|
| Rate for Payer: United Healthcare Commercial |
$34.05
|
| Rate for Payer: United Healthcare Medicare |
$14.26
|
|
|
CEFAZOLIN 3 G IV SOLR
|
Facility
|
IP
|
$43.21
|
|
|
Service Code
|
HCPCS J0688
|
| Hospital Charge Code |
200765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.41 |
| Max. Negotiated Rate |
$40.18 |
| Rate for Payer: Aetna Commercial |
$37.33
|
| Rate for Payer: Cash Price |
$26.79
|
| Rate for Payer: Cigna All Commercial |
$37.29
|
| Rate for Payer: CORVEL All Commercial |
$40.18
|
| Rate for Payer: Coventry All Commercial |
$38.02
|
| Rate for Payer: Encore All Commercial |
$39.77
|
| Rate for Payer: Frontpath All Commercial |
$39.75
|
| Rate for Payer: Humana ChoiceCare |
$37.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$38.89
|
| Rate for Payer: PHCS All Commercial |
$32.41
|
| Rate for Payer: PHP All Commercial |
$32.77
|
| Rate for Payer: Sagamore Health Network All Products |
$33.36
|
| Rate for Payer: Signature Care EPO |
$35.86
|
| Rate for Payer: Signature Care PPO |
$38.02
|
| Rate for Payer: United Healthcare Commercial |
$34.05
|
|
|
CEFAZOLIN IN DEXTROSE 5 % 2 G/100 ML IV SOLN
|
Facility
|
OP
|
$121.10
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
117341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.96 |
| Max. Negotiated Rate |
$112.62 |
| Rate for Payer: Aetna Commercial |
$102.21
|
| Rate for Payer: Aetna Medicare |
$39.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$69.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$45.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$43.96
|
| Rate for Payer: Cash Price |
$75.08
|
| Rate for Payer: Centivo All Commercial |
$61.76
|
| Rate for Payer: Cigna All Commercial |
$104.51
|
| Rate for Payer: CORVEL All Commercial |
$112.62
|
| Rate for Payer: Coventry All Commercial |
$106.57
|
| Rate for Payer: Encore All Commercial |
$111.47
|
| Rate for Payer: Frontpath All Commercial |
$111.41
|
| Rate for Payer: Humana ChoiceCare |
$104.59
|
| Rate for Payer: Humana Medicare |
$61.76
|
| Rate for Payer: Lucent All Commercial |
$61.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.99
|
| Rate for Payer: PHCS All Commercial |
$90.82
|
| Rate for Payer: PHP All Commercial |
$91.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.23
|
| Rate for Payer: Sagamore Health Network All Products |
$93.49
|
| Rate for Payer: Signature Care EPO |
$100.51
|
| Rate for Payer: Signature Care PPO |
$106.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$102.94
|
| Rate for Payer: United Healthcare Commercial |
$95.43
|
| Rate for Payer: United Healthcare Medicare |
$39.96
|
|
|
CEFAZOLIN IN DEXTROSE 5 % 2 G/100 ML IV SOLN
|
Facility
|
IP
|
$121.10
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
117341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.82 |
| Max. Negotiated Rate |
$112.62 |
| Rate for Payer: Aetna Commercial |
$104.63
|
| Rate for Payer: Cash Price |
$75.08
|
| Rate for Payer: Cigna All Commercial |
$104.51
|
| Rate for Payer: CORVEL All Commercial |
$112.62
|
| Rate for Payer: Coventry All Commercial |
$106.57
|
| Rate for Payer: Encore All Commercial |
$111.47
|
| Rate for Payer: Frontpath All Commercial |
$111.41
|
| Rate for Payer: Humana ChoiceCare |
$104.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.99
|
| Rate for Payer: PHCS All Commercial |
$90.82
|
| Rate for Payer: PHP All Commercial |
$91.84
|
| Rate for Payer: Sagamore Health Network All Products |
$93.49
|
| Rate for Payer: Signature Care EPO |
$100.51
|
| Rate for Payer: Signature Care PPO |
$106.57
|
| Rate for Payer: United Healthcare Commercial |
$95.43
|
|
|
CEFAZOLIN IN DEXTROSE (ISO-OS) 1 GRAM/50 ML IV PGBK
|
Facility
|
IP
|
$82.36
|
|
|
Service Code
|
HCPCS J0689
|
| Hospital Charge Code |
25365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.77 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Aetna Commercial |
$71.15
|
| Rate for Payer: Cash Price |
$51.06
|
| Rate for Payer: Cigna All Commercial |
$71.07
|
| Rate for Payer: CORVEL All Commercial |
$76.59
|
| Rate for Payer: Coventry All Commercial |
$72.47
|
| Rate for Payer: Encore All Commercial |
$75.81
|
| Rate for Payer: Frontpath All Commercial |
$75.77
|
| Rate for Payer: Humana ChoiceCare |
$71.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.12
|
| Rate for Payer: PHCS All Commercial |
$61.77
|
| Rate for Payer: PHP All Commercial |
$62.46
|
| Rate for Payer: Sagamore Health Network All Products |
$63.58
|
| Rate for Payer: Signature Care EPO |
$68.35
|
| Rate for Payer: Signature Care PPO |
$72.47
|
| Rate for Payer: United Healthcare Commercial |
$64.90
|
|
