|
ACYCLOVIR 5 % TOP CREA
|
Facility
|
OP
|
$937.50
|
|
|
Service Code
|
NDC 00187099445
|
| Hospital Charge Code |
8967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$290.62 |
| Max. Negotiated Rate |
$871.88 |
| Rate for Payer: Aetna Commercial |
$791.25
|
| Rate for Payer: Aetna Medicare |
$300.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$290.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$538.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$586.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$345.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$330.00
|
| Rate for Payer: Cash Price |
$581.25
|
| Rate for Payer: Centivo All Commercial |
$510.00
|
| Rate for Payer: Cigna All Commercial |
$809.06
|
| Rate for Payer: CORVEL All Commercial |
$871.88
|
| Rate for Payer: Coventry All Commercial |
$825.00
|
| Rate for Payer: Encore All Commercial |
$862.97
|
| Rate for Payer: Frontpath All Commercial |
$862.50
|
| Rate for Payer: Humana ChoiceCare |
$809.72
|
| Rate for Payer: Humana Medicare |
$300.00
|
| Rate for Payer: Lucent All Commercial |
$510.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$843.75
|
| Rate for Payer: PHCS All Commercial |
$703.12
|
| Rate for Payer: PHP All Commercial |
$711.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$365.62
|
| Rate for Payer: Sagamore Health Network All Products |
$723.75
|
| Rate for Payer: Signature Care EPO |
$778.12
|
| Rate for Payer: Signature Care PPO |
$825.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$796.88
|
| Rate for Payer: United Healthcare Commercial |
$738.75
|
| Rate for Payer: United Healthcare Medicare |
$300.00
|
|
|
ACYCLOVIR 5 % TOP CREA
|
Facility
|
IP
|
$937.50
|
|
|
Service Code
|
NDC 00187099445
|
| Hospital Charge Code |
8967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$703.12 |
| Max. Negotiated Rate |
$871.88 |
| Rate for Payer: Aetna Commercial |
$810.00
|
| Rate for Payer: Cash Price |
$581.25
|
| Rate for Payer: Cigna All Commercial |
$809.06
|
| Rate for Payer: CORVEL All Commercial |
$871.88
|
| Rate for Payer: Coventry All Commercial |
$825.00
|
| Rate for Payer: Encore All Commercial |
$862.97
|
| Rate for Payer: Frontpath All Commercial |
$862.50
|
| Rate for Payer: Humana ChoiceCare |
$809.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$843.75
|
| Rate for Payer: PHCS All Commercial |
$703.12
|
| Rate for Payer: PHP All Commercial |
$711.00
|
| Rate for Payer: Sagamore Health Network All Products |
$723.75
|
| Rate for Payer: Signature Care EPO |
$778.12
|
| Rate for Payer: Signature Care PPO |
$825.00
|
| Rate for Payer: United Healthcare Commercial |
$738.75
|
|
|
ACYCLOVIR SODIUM 50 MG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
23128
|
|
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
|
|
|
ACYCLOVIR SODIUM 50 MG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
23128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ PNKT
|
Facility
|
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
184523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,661.63 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,779.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,661.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,783.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,383.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,346.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,157.72
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,425.57
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Humana Medicare |
$3,779.75
|
| Rate for Payer: Lucent All Commercial |
$6,425.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,606.57
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,039.96
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
| Rate for Payer: United Healthcare Medicare |
$3,779.75
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ PNKT
|
Facility
|
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
184523
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,858.78 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$10,205.32
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ SYKT
|
Facility
|
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
184535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,858.78 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$10,205.32
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ SYKT
|
Facility
|
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
184535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.86 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,779.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$90.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,661.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,783.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,383.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$90.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,346.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,157.72
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,425.57
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Humana Medicare |
$3,779.75
|
| Rate for Payer: Lucent All Commercial |
$6,425.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: Managed Health Services Medicaid |
$90.86
|
| Rate for Payer: MDWise Medicaid |
$90.86
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,606.57
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,039.96
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
| Rate for Payer: United Healthcare Medicare |
$3,779.75
|
|
|
ADALIMUMAB 40 MG/0.8 ML SUBQ PEN KIT
|
Facility
|
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
118234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,858.78 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$10,205.32
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
|
|
ADALIMUMAB 40 MG/0.8 ML SUBQ PEN KIT
|
Facility
|
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0139
|
| Hospital Charge Code |
118234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,661.63 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,779.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,661.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,783.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,383.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,346.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,157.72
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,425.57
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Humana Medicare |
$3,779.75
|
| Rate for Payer: Lucent All Commercial |
$6,425.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,606.57
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,039.96
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
| Rate for Payer: United Healthcare Medicare |
$3,779.75
|
|
|
ADALIMUMAB 40 MG/0.8 ML SUBQ SYRINGE KIT
|
Facility
|
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
34652
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,661.63 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,779.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,661.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,783.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,383.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,346.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,157.72
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,425.57
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Humana Medicare |
$3,779.75
|
| Rate for Payer: Lucent All Commercial |
$6,425.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,606.57
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,039.96
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
| Rate for Payer: United Healthcare Medicare |
$3,779.75
|
|
|
ADALIMUMAB 40 MG/0.8 ML SUBQ SYRINGE KIT
|
Facility
|
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
34652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,858.78 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$10,205.32
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cigna All Commercial |
$10,193.51
|
| Rate for Payer: CORVEL All Commercial |
$10,984.89
|
| Rate for Payer: Coventry All Commercial |
$10,394.31
|
| Rate for Payer: Encore All Commercial |
$10,872.68
|
| Rate for Payer: Frontpath All Commercial |
$10,866.78
|
| Rate for Payer: Humana ChoiceCare |
$10,201.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: PHCS All Commercial |
$8,858.78
|
| Rate for Payer: PHP All Commercial |
$8,958.00
|
| Rate for Payer: Sagamore Health Network All Products |
$9,118.64
|
| Rate for Payer: Signature Care EPO |
$9,803.72
|
| Rate for Payer: Signature Care PPO |
$10,394.31
|
| Rate for Payer: United Healthcare Commercial |
$9,307.63
|
|
|
ADENOSINE 3 MG/ML IV SOLN
|
Facility
|
IP
|
$39.37
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
39477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.53 |
| Max. Negotiated Rate |
$36.61 |
| Rate for Payer: Aetna Commercial |
$34.01
|
| Rate for Payer: Cash Price |
$24.41
|
| Rate for Payer: Cigna All Commercial |
$33.97
|
| Rate for Payer: CORVEL All Commercial |
$36.61
|
| Rate for Payer: Coventry All Commercial |
$34.64
|
| Rate for Payer: Encore All Commercial |
$36.24
|
| Rate for Payer: Frontpath All Commercial |
$36.22
|
| Rate for Payer: Humana ChoiceCare |
$34.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.43
|
| Rate for Payer: PHCS All Commercial |
$29.53
|
| Rate for Payer: PHP All Commercial |
$29.86
|
| Rate for Payer: Sagamore Health Network All Products |
$30.39
|
| Rate for Payer: Signature Care EPO |
$32.68
|
| Rate for Payer: Signature Care PPO |
$34.64
|
| Rate for Payer: United Healthcare Commercial |
$31.02
|
|
|
ADENOSINE 3 MG/ML IV SOLN
|
Facility
|
OP
|
$39.37
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
39477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.20 |
| Max. Negotiated Rate |
$36.61 |
| Rate for Payer: Aetna Commercial |
$33.23
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.86
|
| Rate for Payer: Cash Price |
$24.41
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$33.97
|
| Rate for Payer: CORVEL All Commercial |
$36.61
|
| Rate for Payer: Coventry All Commercial |
$34.64
|
| Rate for Payer: Encore All Commercial |
$36.24
|
| Rate for Payer: Frontpath All Commercial |
$36.22
|
| Rate for Payer: Humana ChoiceCare |
$34.00
|
| Rate for Payer: Humana Medicare |
$12.60
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.43
|
| Rate for Payer: PHCS All Commercial |
$29.53
|
| Rate for Payer: PHP All Commercial |
$29.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.35
|
| Rate for Payer: Sagamore Health Network All Products |
$30.39
|
| Rate for Payer: Signature Care EPO |
$32.68
|
| Rate for Payer: Signature Care PPO |
$34.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.46
|
| Rate for Payer: United Healthcare Commercial |
$31.02
|
| Rate for Payer: United Healthcare Medicare |
$12.60
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
|
OP
|
$488.57
|
|
|
Service Code
|
CPT 14041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.57 |
| Max. Negotiated Rate |
$488.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$488.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$488.57
|
| Rate for Payer: Managed Health Services Medicaid |
$488.57
|
| Rate for Payer: MDWise Medicaid |
$488.57
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$443.28
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$443.28 |
| Max. Negotiated Rate |
$443.28 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$443.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$443.28
|
| Rate for Payer: Managed Health Services Medicaid |
$443.28
|
| Rate for Payer: MDWise Medicaid |
$443.28
|
|
|
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$2,723.35
|
|
|
Service Code
|
APR-DRG 7552
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,723.35 |
| 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
|
|
|
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$4,711.83
|
|
|
Service Code
|
APR-DRG 7553
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,711.83 |
| 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
|
|
|
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$4,841.51
|
|
|
Service Code
|
APR-DRG 7554
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,841.51 |
| 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
|
|
|
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$2,247.85
|
|
|
Service Code
|
APR-DRG 7551
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,247.85 |
| 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
|
|
|
AGALSIDASE BETA 35 MG IV SOLR
|
Facility
|
IP
|
$27,396.15
|
|
|
Service Code
|
HCPCS J0180
|
| Hospital Charge Code |
35775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20,547.11 |
| Max. Negotiated Rate |
$25,478.41 |
| Rate for Payer: Aetna Commercial |
$23,670.27
|
| Rate for Payer: Cash Price |
$16,985.61
|
| Rate for Payer: Cigna All Commercial |
$23,642.87
|
| Rate for Payer: CORVEL All Commercial |
$25,478.41
|
| Rate for Payer: Coventry All Commercial |
$24,108.61
|
| Rate for Payer: Encore All Commercial |
$25,218.15
|
| Rate for Payer: Frontpath All Commercial |
$25,204.45
|
| Rate for Payer: Humana ChoiceCare |
$23,662.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,656.53
|
| Rate for Payer: PHCS All Commercial |
$20,547.11
|
| Rate for Payer: PHP All Commercial |
$20,777.24
|
| Rate for Payer: Sagamore Health Network All Products |
$21,149.82
|
| Rate for Payer: Signature Care EPO |
$22,738.80
|
| Rate for Payer: Signature Care PPO |
$24,108.61
|
| Rate for Payer: United Healthcare Commercial |
$21,588.16
|
|
|
AGALSIDASE BETA 35 MG IV SOLR
|
Facility
|
OP
|
$27,396.15
|
|
|
Service Code
|
HCPCS J0180
|
| Hospital Charge Code |
35775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.78 |
| Max. Negotiated Rate |
$25,478.41 |
| Rate for Payer: Aetna Commercial |
$23,122.35
|
| Rate for Payer: Aetna Medicare |
$8,766.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$234.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,492.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15,733.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17,125.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$234.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,081.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,643.44
|
| Rate for Payer: Cash Price |
$16,985.61
|
| Rate for Payer: Cash Price |
$16,985.61
|
| Rate for Payer: Centivo All Commercial |
$14,903.50
|
| Rate for Payer: Cigna All Commercial |
$23,642.87
|
| Rate for Payer: CORVEL All Commercial |
$25,478.41
|
| Rate for Payer: Coventry All Commercial |
$24,108.61
|
| Rate for Payer: Encore All Commercial |
$25,218.15
|
| Rate for Payer: Frontpath All Commercial |
$25,204.45
|
| Rate for Payer: Humana ChoiceCare |
$23,662.05
|
| Rate for Payer: Humana Medicare |
$8,766.77
|
| Rate for Payer: Lucent All Commercial |
$14,903.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,656.53
|
| Rate for Payer: Managed Health Services Medicaid |
$234.78
|
| Rate for Payer: MDWise Medicaid |
$234.78
|
| Rate for Payer: PHCS All Commercial |
$20,547.11
|
| Rate for Payer: PHP All Commercial |
$20,777.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,684.50
|
| Rate for Payer: Sagamore Health Network All Products |
$21,149.82
|
| Rate for Payer: Signature Care EPO |
$22,738.80
|
| Rate for Payer: Signature Care PPO |
$24,108.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23,286.72
|
| Rate for Payer: United Healthcare Commercial |
$21,588.16
|
| Rate for Payer: United Healthcare Medicare |
$8,766.77
|
|
|
ALBUMIN, HUMAN 25 % 25 % IV SOLP
|
Facility
|
IP
|
$323.75
|
|
|
Service Code
|
HCPCS P9047
|
| Hospital Charge Code |
8981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.81 |
| Max. Negotiated Rate |
$301.09 |
| Rate for Payer: Aetna Commercial |
$279.72
|
| Rate for Payer: Cash Price |
$200.73
|
| Rate for Payer: Cigna All Commercial |
$279.40
|
| Rate for Payer: CORVEL All Commercial |
$301.09
|
| Rate for Payer: Coventry All Commercial |
$284.90
|
| Rate for Payer: Encore All Commercial |
$298.01
|
| Rate for Payer: Frontpath All Commercial |
$297.85
|
| Rate for Payer: Humana ChoiceCare |
$279.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.38
|
| Rate for Payer: PHCS All Commercial |
$242.81
|
| Rate for Payer: PHP All Commercial |
$245.53
|
| Rate for Payer: Sagamore Health Network All Products |
$249.94
|
| Rate for Payer: Signature Care EPO |
$268.71
|
| Rate for Payer: Signature Care PPO |
$284.90
|
| Rate for Payer: United Healthcare Commercial |
$255.12
|
|
|
ALBUMIN, HUMAN 25 % 25 % IV SOLP
|
Facility
|
OP
|
$323.75
|
|
|
Service Code
|
HCPCS P9047
|
| Hospital Charge Code |
8981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.80 |
| Max. Negotiated Rate |
$301.09 |
| Rate for Payer: Aetna Commercial |
$273.25
|
| Rate for Payer: Aetna Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.96
|
| Rate for Payer: Cash Price |
$200.73
|
| Rate for Payer: Cash Price |
$200.73
|
| Rate for Payer: Centivo All Commercial |
$176.12
|
| Rate for Payer: Cigna All Commercial |
$279.40
|
| Rate for Payer: CORVEL All Commercial |
$301.09
|
| Rate for Payer: Coventry All Commercial |
$284.90
|
| Rate for Payer: Encore All Commercial |
$298.01
|
| Rate for Payer: Frontpath All Commercial |
$297.85
|
| Rate for Payer: Humana ChoiceCare |
$279.62
|
| Rate for Payer: Humana Medicare |
$103.60
|
| Rate for Payer: Lucent All Commercial |
$176.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.38
|
| Rate for Payer: Managed Health Services Medicaid |
$62.80
|
| Rate for Payer: MDWise Medicaid |
$62.80
|
| Rate for Payer: PHCS All Commercial |
$242.81
|
| Rate for Payer: PHP All Commercial |
$245.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.26
|
| Rate for Payer: Sagamore Health Network All Products |
$249.94
|
| Rate for Payer: Signature Care EPO |
$268.71
|
| Rate for Payer: Signature Care PPO |
$284.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$275.19
|
| Rate for Payer: United Healthcare Commercial |
$255.12
|
| Rate for Payer: United Healthcare Medicare |
$103.60
|
|
|
ALBUMIN, HUMAN 5 % 5 % IV SOLP
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
HCPCS P9045
|
| Hospital Charge Code |
8982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$369.00 |
| Max. Negotiated Rate |
$457.56 |
| Rate for Payer: Aetna Commercial |
$425.09
|
| Rate for Payer: Cash Price |
$305.04
|
| Rate for Payer: Cigna All Commercial |
$424.60
|
| Rate for Payer: CORVEL All Commercial |
$457.56
|
| Rate for Payer: Coventry All Commercial |
$432.96
|
| Rate for Payer: Encore All Commercial |
$452.89
|
| Rate for Payer: Frontpath All Commercial |
$452.64
|
| Rate for Payer: Humana ChoiceCare |
$424.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$442.80
|
| Rate for Payer: PHCS All Commercial |
$369.00
|
| Rate for Payer: PHP All Commercial |
$373.13
|
| Rate for Payer: Sagamore Health Network All Products |
$379.82
|
| Rate for Payer: Signature Care EPO |
$408.36
|
| Rate for Payer: Signature Care PPO |
$432.96
|
| Rate for Payer: United Healthcare Commercial |
$387.70
|
|
