|
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 |
$5.94 |
| 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
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ PNKT
|
Facility
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| 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 PNKT
|
Facility
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
184523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,897.87 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$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 |
$4,482.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,287.65
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,023.97
|
| 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 |
$6,023.97
|
| Rate for Payer: Lucent All Commercial |
$6,023.97
|
| 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 |
$3,897.87
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ SYKT
|
Facility
OP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
184535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,817.19 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,783.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,383.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,817.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,482.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,287.65
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,023.97
|
| 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 |
$6,023.97
|
| Rate for Payer: Lucent All Commercial |
$6,023.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,630.54
|
| Rate for Payer: Managed Health Services Medicaid |
$1,817.19
|
| Rate for Payer: MDWise Medicaid |
$1,817.19
|
| 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 |
$3,897.87
|
|
|
ADALIMUMAB 40 MG/0.4 ML SUBQ SYKT
|
Facility
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| 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/0.8 ML SUBQ PEN KIT
|
Facility
IP
|
$11,811.71
|
|
|
Service Code
|
HCPCS J0135
|
| 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 J0135
|
| Hospital Charge Code |
118234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,897.87 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$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 |
$4,482.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,287.65
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,023.97
|
| 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 |
$6,023.97
|
| Rate for Payer: Lucent All Commercial |
$6,023.97
|
| 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 |
$3,897.87
|
|
|
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 |
$3,897.87 |
| Max. Negotiated Rate |
$10,984.89 |
| Rate for Payer: Aetna Commercial |
$9,969.09
|
| Rate for Payer: Aetna Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,897.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$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 |
$4,482.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,287.65
|
| Rate for Payer: Cash Price |
$7,323.26
|
| Rate for Payer: Centivo All Commercial |
$6,023.97
|
| 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 |
$6,023.97
|
| Rate for Payer: Lucent All Commercial |
$6,023.97
|
| 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 |
$3,897.87
|
|
|
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
|
|
|
ADALIMUMAB 80 MG/0.8 ML SUBQ SYKT
|
Facility
OP
|
$23,623.53
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
184526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,795.76 |
| Max. Negotiated Rate |
$21,969.88 |
| Rate for Payer: Aetna Commercial |
$19,938.26
|
| Rate for Payer: Aetna Medicare |
$7,795.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7,795.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13,566.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14,767.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8,965.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8,575.34
|
| Rate for Payer: Cash Price |
$14,646.59
|
| Rate for Payer: Centivo All Commercial |
$12,048.00
|
| Rate for Payer: Cigna All Commercial |
$20,387.11
|
| Rate for Payer: CORVEL All Commercial |
$21,969.88
|
| Rate for Payer: Coventry All Commercial |
$20,788.71
|
| Rate for Payer: Encore All Commercial |
$21,745.46
|
| Rate for Payer: Frontpath All Commercial |
$21,733.65
|
| Rate for Payer: Humana ChoiceCare |
$20,403.64
|
| Rate for Payer: Humana Medicare |
$12,048.00
|
| Rate for Payer: Lucent All Commercial |
$12,048.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21,261.18
|
| Rate for Payer: PHCS All Commercial |
$17,717.65
|
| Rate for Payer: PHP All Commercial |
$17,916.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9,213.18
|
| Rate for Payer: Sagamore Health Network All Products |
$18,237.37
|
| Rate for Payer: Signature Care EPO |
$19,607.53
|
| Rate for Payer: Signature Care PPO |
$20,788.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20,080.00
|
| Rate for Payer: United Healthcare Commercial |
$18,615.34
|
| Rate for Payer: United Healthcare Medicare |
$7,795.76
|
|
|
ADALIMUMAB 80 MG/0.8 ML SUBQ SYKT
|
Facility
IP
|
$23,623.53
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
184526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17,717.65 |
| Max. Negotiated Rate |
$21,969.88 |
| Rate for Payer: Aetna Commercial |
$20,410.73
|
| Rate for Payer: Cash Price |
$14,646.59
|
| Rate for Payer: Cigna All Commercial |
$20,387.11
|
| Rate for Payer: CORVEL All Commercial |
$21,969.88
|
| Rate for Payer: Coventry All Commercial |
$20,788.71
|
| Rate for Payer: Encore All Commercial |
$21,745.46
|
| Rate for Payer: Frontpath All Commercial |
$21,733.65
|
| Rate for Payer: Humana ChoiceCare |
$20,403.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21,261.18
|
| Rate for Payer: PHCS All Commercial |
$17,717.65
|
| Rate for Payer: PHP All Commercial |
$17,916.09
|
| Rate for Payer: Sagamore Health Network All Products |
$18,237.37
|
| Rate for Payer: Signature Care EPO |
$19,607.53
|
| Rate for Payer: Signature Care PPO |
$20,788.71
|
| Rate for Payer: United Healthcare Commercial |
$18,615.34
|
|
|
ADENOSINE 3 MG/ML IV SOLN
|
Facility
IP
|
$39.83
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
39477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.87 |
| Max. Negotiated Rate |
$37.04 |
| Rate for Payer: Aetna Commercial |
$34.41
|
| Rate for Payer: Cash Price |
$24.69
|
| Rate for Payer: Cigna All Commercial |
$34.37
|
| Rate for Payer: CORVEL All Commercial |
$37.04
|
| Rate for Payer: Coventry All Commercial |
$35.05
|
| Rate for Payer: Encore All Commercial |
$36.66
|
| Rate for Payer: Frontpath All Commercial |
$36.64
|
| Rate for Payer: Humana ChoiceCare |
$34.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: PHCS All Commercial |
$29.87
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| Rate for Payer: Sagamore Health Network All Products |
$30.75
|
| Rate for Payer: Signature Care EPO |
$33.06
|
| Rate for Payer: Signature Care PPO |
$35.05
|
| Rate for Payer: United Healthcare Commercial |
$31.39
|
|
|
ADENOSINE 3 MG/ML IV SOLN
|
Facility
OP
|
$39.83
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
39477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.14 |
| Max. Negotiated Rate |
$37.04 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna Medicare |
$13.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.46
|
| Rate for Payer: Cash Price |
$24.69
|
| Rate for Payer: Centivo All Commercial |
$20.31
|
| Rate for Payer: Cigna All Commercial |
$34.37
|
| Rate for Payer: CORVEL All Commercial |
$37.04
|
| Rate for Payer: Coventry All Commercial |
$35.05
|
| Rate for Payer: Encore All Commercial |
$36.66
|
| Rate for Payer: Frontpath All Commercial |
$36.64
|
| Rate for Payer: Humana ChoiceCare |
$34.40
|
| Rate for Payer: Humana Medicare |
$20.31
|
| Rate for Payer: Lucent All Commercial |
$20.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.85
|
| Rate for Payer: PHCS All Commercial |
$29.87
|
| Rate for Payer: PHP All Commercial |
$30.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.53
|
| Rate for Payer: Sagamore Health Network All Products |
$30.75
|
| Rate for Payer: Signature Care EPO |
$33.06
|
| Rate for Payer: Signature Care PPO |
$35.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.86
|
| Rate for Payer: United Healthcare Commercial |
$31.39
|
| Rate for Payer: United Healthcare Medicare |
$13.14
|
|
|
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 14301
|
| Hospital Charge Code |
CPT-14301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 14302
|
| Hospital Charge Code |
CPT-14302
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 14021
|
| Hospital Charge Code |
CPT-14021
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
ADUCANUMAB-AVWA 100 MG/ML IV SOLN
|
Facility
OP
|
$1,917.60
|
|
|
Service Code
|
HCPCS J0172
|
| Hospital Charge Code |
195299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$1,783.37 |
| Rate for Payer: Aetna Commercial |
$1,618.45
|
| Rate for Payer: Aetna Medicare |
$632.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$632.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,101.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,198.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$5.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$727.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$696.09
|
| Rate for Payer: Cash Price |
$1,188.91
|
| Rate for Payer: Cash Price |
$1,188.91
|
| Rate for Payer: Centivo All Commercial |
$977.98
|
| Rate for Payer: Cigna All Commercial |
$1,654.89
|
| Rate for Payer: CORVEL All Commercial |
$1,783.37
|
| Rate for Payer: Coventry All Commercial |
$1,687.49
|
| Rate for Payer: Encore All Commercial |
$1,765.15
|
| Rate for Payer: Frontpath All Commercial |
$1,764.19
|
| Rate for Payer: Humana ChoiceCare |
$1,656.23
|
| Rate for Payer: Humana Medicare |
$977.98
|
| Rate for Payer: Lucent All Commercial |
$977.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,725.84
|
| Rate for Payer: Managed Health Services Medicaid |
$5.92
|
| Rate for Payer: MDWise Medicaid |
$5.92
|
| Rate for Payer: PHCS All Commercial |
$1,438.20
|
| Rate for Payer: PHP All Commercial |
$1,454.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$747.86
|
| Rate for Payer: Sagamore Health Network All Products |
$1,480.39
|
| Rate for Payer: Signature Care EPO |
$1,591.61
|
| Rate for Payer: Signature Care PPO |
$1,687.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,629.96
|
| Rate for Payer: United Healthcare Commercial |
$1,511.07
|
| Rate for Payer: United Healthcare Medicare |
$632.81
|
|
|
ADUCANUMAB-AVWA 100 MG/ML IV SOLN
|
Facility
IP
|
$1,917.60
|
|
|
Service Code
|
HCPCS J0172
|
| Hospital Charge Code |
195299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,438.20 |
| Max. Negotiated Rate |
$1,783.37 |
| Rate for Payer: Aetna Commercial |
$1,656.81
|
| Rate for Payer: Cash Price |
$1,188.91
|
| Rate for Payer: Cigna All Commercial |
$1,654.89
|
| Rate for Payer: CORVEL All Commercial |
$1,783.37
|
| Rate for Payer: Coventry All Commercial |
$1,687.49
|
| Rate for Payer: Encore All Commercial |
$1,765.15
|
| Rate for Payer: Frontpath All Commercial |
$1,764.19
|
| Rate for Payer: Humana ChoiceCare |
$1,656.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,725.84
|
| Rate for Payer: PHCS All Commercial |
$1,438.20
|
| Rate for Payer: PHP All Commercial |
$1,454.31
|
| Rate for Payer: Sagamore Health Network All Products |
$1,480.39
|
| Rate for Payer: Signature Care EPO |
$1,591.61
|
| Rate for Payer: Signature Care PPO |
$1,687.49
|
| Rate for Payer: United Healthcare Commercial |
$1,511.07
|
|
|
AGALSIDASE BETA 35 MG IV SOLR
|
Facility
IP
|
$26,091.56
|
|
|
Service Code
|
HCPCS J0180
|
| Hospital Charge Code |
35775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19,568.67 |
| Max. Negotiated Rate |
$24,265.15 |
| Rate for Payer: Aetna Commercial |
$22,543.10
|
| Rate for Payer: Cash Price |
$16,176.76
|
| Rate for Payer: Cigna All Commercial |
$22,517.01
|
| Rate for Payer: CORVEL All Commercial |
$24,265.15
|
| Rate for Payer: Coventry All Commercial |
$22,960.57
|
| Rate for Payer: Encore All Commercial |
$24,017.28
|
| Rate for Payer: Frontpath All Commercial |
$24,004.23
|
| Rate for Payer: Humana ChoiceCare |
$22,535.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,482.40
|
| Rate for Payer: PHCS All Commercial |
$19,568.67
|
| Rate for Payer: PHP All Commercial |
$19,787.84
|
| Rate for Payer: Sagamore Health Network All Products |
$20,142.68
|
| Rate for Payer: Signature Care EPO |
$21,655.99
|
| Rate for Payer: Signature Care PPO |
$22,960.57
|
| Rate for Payer: United Healthcare Commercial |
$20,560.15
|
|
|
AGALSIDASE BETA 35 MG IV SOLR
|
Facility
OP
|
$26,091.56
|
|
|
Service Code
|
HCPCS J0180
|
| Hospital Charge Code |
35775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.09 |
| Max. Negotiated Rate |
$24,265.15 |
| Rate for Payer: Aetna Commercial |
$22,021.27
|
| Rate for Payer: Aetna Medicare |
$8,610.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,610.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14,984.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,309.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$217.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9,901.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,471.23
|
| Rate for Payer: Cash Price |
$16,176.76
|
| Rate for Payer: Cash Price |
$16,176.76
|
| Rate for Payer: Centivo All Commercial |
$13,306.69
|
| Rate for Payer: Cigna All Commercial |
$22,517.01
|
| Rate for Payer: CORVEL All Commercial |
$24,265.15
|
| Rate for Payer: Coventry All Commercial |
$22,960.57
|
| Rate for Payer: Encore All Commercial |
$24,017.28
|
| Rate for Payer: Frontpath All Commercial |
$24,004.23
|
| Rate for Payer: Humana ChoiceCare |
$22,535.28
|
| Rate for Payer: Humana Medicare |
$13,306.69
|
| Rate for Payer: Lucent All Commercial |
$13,306.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,482.40
|
| Rate for Payer: Managed Health Services Medicaid |
$217.09
|
| Rate for Payer: MDWise Medicaid |
$217.09
|
| Rate for Payer: PHCS All Commercial |
$19,568.67
|
| Rate for Payer: PHP All Commercial |
$19,787.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,175.71
|
| Rate for Payer: Sagamore Health Network All Products |
$20,142.68
|
| Rate for Payer: Signature Care EPO |
$21,655.99
|
| Rate for Payer: Signature Care PPO |
$22,960.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22,177.82
|
| Rate for Payer: United Healthcare Commercial |
$20,560.15
|
| Rate for Payer: United Healthcare Medicare |
$8,610.21
|
|
|
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 |
$48.31 |
| Max. Negotiated Rate |
$301.09 |
| Rate for Payer: Aetna Commercial |
$273.24
|
| Rate for Payer: Aetna Medicare |
$106.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$185.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$48.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$122.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$117.52
|
| Rate for Payer: Cash Price |
$200.73
|
| Rate for Payer: Cash Price |
$200.73
|
| Rate for Payer: Centivo All Commercial |
$165.11
|
| 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 |
$165.11
|
| Rate for Payer: Lucent All Commercial |
$165.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$291.38
|
| Rate for Payer: Managed Health Services Medicaid |
$48.31
|
| Rate for Payer: MDWise Medicaid |
$48.31
|
| 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 |
$106.84
|
|
|
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 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
|
|
|
ALBUMIN, HUMAN 5 % 5 % IV SOLP
|
Facility
OP
|
$492.00
|
|
|
Service Code
|
HCPCS P9045
|
| Hospital Charge Code |
8982
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.89 |
| Max. Negotiated Rate |
$457.56 |
| Rate for Payer: Aetna Commercial |
$415.25
|
| Rate for Payer: Aetna Medicare |
$162.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$282.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$307.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$48.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$186.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$178.60
|
| Rate for Payer: Cash Price |
$305.04
|
| Rate for Payer: Cash Price |
$305.04
|
| Rate for Payer: Centivo All Commercial |
$250.92
|
| 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: Humana Medicare |
$250.92
|
| Rate for Payer: Lucent All Commercial |
$250.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$442.80
|
| Rate for Payer: Managed Health Services Medicaid |
$48.89
|
| Rate for Payer: MDWise Medicaid |
$48.89
|
| Rate for Payer: PHCS All Commercial |
$369.00
|
| Rate for Payer: PHP All Commercial |
$373.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$191.88
|
| 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: Three Rivers Preferred All Commercial |
$418.20
|
| Rate for Payer: United Healthcare Commercial |
$387.70
|
| Rate for Payer: United Healthcare Medicare |
$162.36
|
|
|
ALBUTEROL INHALER ED PACK (CAMERON)
|
Facility
IP
|
$75.43
|
|
|
Service Code
|
NDC 001730682
|
| Hospital Charge Code |
1401000800173
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$56.57 |
| Max. Negotiated Rate |
$70.15 |
| Rate for Payer: Aetna Commercial |
$65.17
|
| Rate for Payer: Cash Price |
$46.77
|
| Rate for Payer: Cigna All Commercial |
$65.10
|
| Rate for Payer: CORVEL All Commercial |
$70.15
|
| Rate for Payer: Coventry All Commercial |
$66.38
|
| Rate for Payer: Encore All Commercial |
$69.44
|
| Rate for Payer: Frontpath All Commercial |
$69.40
|
| Rate for Payer: Humana ChoiceCare |
$65.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.89
|
| Rate for Payer: PHCS All Commercial |
$56.57
|
| Rate for Payer: PHP All Commercial |
$57.21
|
| Rate for Payer: Sagamore Health Network All Products |
$58.23
|
| Rate for Payer: Signature Care EPO |
$62.61
|
| Rate for Payer: Signature Care PPO |
$66.38
|
| Rate for Payer: United Healthcare Commercial |
$59.44
|
|
