|
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45384
|
| Hospital Charge Code |
CPT-45384
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 45385
|
| Hospital Charge Code |
CPT-45385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 44388
|
| Hospital Charge Code |
CPT-44388
|
|
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
|
|
|
Colonoscopy through stoma; with biopsy, single or multiple
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 44389
|
| Hospital Charge Code |
CPT-44389
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 57520
|
| Hospital Charge Code |
CPT-57520
|
|
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
|
|
|
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision
|
Facility
|
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 57522
|
| Hospital Charge Code |
CPT-57522
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
CONJUGATED ESTROGENS 0.625 MG ORAL TAB
|
Facility
|
IP
|
$45.85
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$42.64 |
| Rate for Payer: Aetna Commercial |
$39.61
|
| Rate for Payer: Cash Price |
$28.43
|
| Rate for Payer: Cigna All Commercial |
$39.57
|
| Rate for Payer: CORVEL All Commercial |
$42.64
|
| Rate for Payer: Coventry All Commercial |
$40.35
|
| Rate for Payer: Encore All Commercial |
$42.20
|
| Rate for Payer: Frontpath All Commercial |
$42.18
|
| Rate for Payer: Humana ChoiceCare |
$39.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.26
|
| Rate for Payer: PHCS All Commercial |
$34.39
|
| Rate for Payer: PHP All Commercial |
$34.77
|
| Rate for Payer: Sagamore Health Network All Products |
$35.40
|
| Rate for Payer: Signature Care EPO |
$38.06
|
| Rate for Payer: Signature Care PPO |
$40.35
|
| Rate for Payer: United Healthcare Commercial |
$36.13
|
|
|
CONJUGATED ESTROGENS 0.625 MG ORAL TAB
|
Facility
|
OP
|
$45.85
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$42.64 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: Aetna Medicare |
$15.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$26.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.64
|
| Rate for Payer: Cash Price |
$28.43
|
| Rate for Payer: Centivo All Commercial |
$23.38
|
| Rate for Payer: Cigna All Commercial |
$39.57
|
| Rate for Payer: CORVEL All Commercial |
$42.64
|
| Rate for Payer: Coventry All Commercial |
$40.35
|
| Rate for Payer: Encore All Commercial |
$42.20
|
| Rate for Payer: Frontpath All Commercial |
$42.18
|
| Rate for Payer: Humana ChoiceCare |
$39.60
|
| Rate for Payer: Humana Medicare |
$23.38
|
| Rate for Payer: Lucent All Commercial |
$23.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.26
|
| Rate for Payer: PHCS All Commercial |
$34.39
|
| Rate for Payer: PHP All Commercial |
$34.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.88
|
| Rate for Payer: Sagamore Health Network All Products |
$35.40
|
| Rate for Payer: Signature Care EPO |
$38.06
|
| Rate for Payer: Signature Care PPO |
$40.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$38.97
|
| Rate for Payer: United Healthcare Commercial |
$36.13
|
| Rate for Payer: United Healthcare Medicare |
$15.13
|
|
|
CONJUGATED ESTROGENS 25 MG INJ SOLR
|
Facility
|
IP
|
$1,396.40
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,047.30 |
| Max. Negotiated Rate |
$1,298.65 |
| Rate for Payer: Aetna Commercial |
$1,206.49
|
| Rate for Payer: Cash Price |
$865.77
|
| Rate for Payer: Cigna All Commercial |
$1,205.09
|
| Rate for Payer: CORVEL All Commercial |
$1,298.65
|
| Rate for Payer: Coventry All Commercial |
$1,228.83
|
| Rate for Payer: Encore All Commercial |
$1,285.39
|
| Rate for Payer: Frontpath All Commercial |
$1,284.69
|
| Rate for Payer: Humana ChoiceCare |
$1,206.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,256.76
|
| Rate for Payer: PHCS All Commercial |
$1,047.30
|
| Rate for Payer: PHP All Commercial |
$1,059.03
|
| Rate for Payer: Sagamore Health Network All Products |
$1,078.02
|
| Rate for Payer: Signature Care EPO |
$1,159.01
|
| Rate for Payer: Signature Care PPO |
$1,228.83
|
| Rate for Payer: United Healthcare Commercial |
$1,100.36
|
|
|
CONJUGATED ESTROGENS 25 MG INJ SOLR
|
Facility
|
OP
|
$1,396.40
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$375.20 |
| Max. Negotiated Rate |
$1,298.65 |
| Rate for Payer: Aetna Commercial |
$1,178.56
|
| Rate for Payer: Aetna Medicare |
$460.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$460.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$801.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$872.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$375.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$529.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$506.89
|
| Rate for Payer: Cash Price |
$865.77
|
| Rate for Payer: Cash Price |
$865.77
|
| Rate for Payer: Centivo All Commercial |
$712.16
|
| Rate for Payer: Cigna All Commercial |
$1,205.09
|
| Rate for Payer: CORVEL All Commercial |
$1,298.65
|
| Rate for Payer: Coventry All Commercial |
$1,228.83
|
| Rate for Payer: Encore All Commercial |
$1,285.39
|
| Rate for Payer: Frontpath All Commercial |
$1,284.69
|
| Rate for Payer: Humana ChoiceCare |
$1,206.07
|
| Rate for Payer: Humana Medicare |
$712.16
|
| Rate for Payer: Lucent All Commercial |
$712.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,256.76
|
| Rate for Payer: Managed Health Services Medicaid |
$375.20
|
| Rate for Payer: MDWise Medicaid |
$375.20
|
| Rate for Payer: PHCS All Commercial |
$1,047.30
|
| Rate for Payer: PHP All Commercial |
$1,059.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$544.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1,078.02
|
| Rate for Payer: Signature Care EPO |
$1,159.01
|
| Rate for Payer: Signature Care PPO |
$1,228.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,186.94
|
| Rate for Payer: United Healthcare Commercial |
$1,100.36
|
| Rate for Payer: United Healthcare Medicare |
$460.81
|
|
|
Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report
|
Facility
|
OP
|
$381.15
|
|
|
Service Code
|
CPT 49465
|
| Hospital Charge Code |
CPT-49465
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$381.15
|
| Rate for Payer: Managed Health Services Medicaid |
$381.15
|
| Rate for Payer: MDWise Medicaid |
$381.15
|
|
|
COPPER 380 SQUARE MM IU IUD
|
Facility
|
OP
|
$2,119.70
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
165649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$699.50 |
| Max. Negotiated Rate |
$1,971.32 |
| Rate for Payer: Aetna Commercial |
$1,789.03
|
| Rate for Payer: Aetna Medicare |
$699.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$699.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,217.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,325.02
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,076.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$804.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$769.45
|
| Rate for Payer: Cash Price |
$1,314.21
|
| Rate for Payer: Cash Price |
$1,314.21
|
| Rate for Payer: Centivo All Commercial |
$1,081.05
|
| Rate for Payer: Cigna All Commercial |
$1,829.30
|
| Rate for Payer: CORVEL All Commercial |
$1,971.32
|
| Rate for Payer: Coventry All Commercial |
$1,865.34
|
| Rate for Payer: Encore All Commercial |
$1,951.18
|
| Rate for Payer: Frontpath All Commercial |
$1,950.12
|
| Rate for Payer: Humana ChoiceCare |
$1,830.78
|
| Rate for Payer: Humana Medicare |
$1,081.05
|
| Rate for Payer: Lucent All Commercial |
$1,081.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,907.73
|
| Rate for Payer: Managed Health Services Medicaid |
$1,076.25
|
| Rate for Payer: MDWise Medicaid |
$1,076.25
|
| Rate for Payer: PHCS All Commercial |
$1,589.78
|
| Rate for Payer: PHP All Commercial |
$1,607.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$826.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1,636.41
|
| Rate for Payer: Signature Care EPO |
$1,759.35
|
| Rate for Payer: Signature Care PPO |
$1,865.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,801.74
|
| Rate for Payer: United Healthcare Commercial |
$1,670.32
|
| Rate for Payer: United Healthcare Medicare |
$699.50
|
|
|
COPPER 380 SQUARE MM IU IUD
|
Facility
|
IP
|
$2,119.70
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
165649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,589.78 |
| Max. Negotiated Rate |
$1,971.32 |
| Rate for Payer: Aetna Commercial |
$1,831.42
|
| Rate for Payer: Cash Price |
$1,314.21
|
| Rate for Payer: Cigna All Commercial |
$1,829.30
|
| Rate for Payer: CORVEL All Commercial |
$1,971.32
|
| Rate for Payer: Coventry All Commercial |
$1,865.34
|
| Rate for Payer: Encore All Commercial |
$1,951.18
|
| Rate for Payer: Frontpath All Commercial |
$1,950.12
|
| Rate for Payer: Humana ChoiceCare |
$1,830.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,907.73
|
| Rate for Payer: PHCS All Commercial |
$1,589.78
|
| Rate for Payer: PHP All Commercial |
$1,607.58
|
| Rate for Payer: Sagamore Health Network All Products |
$1,636.41
|
| Rate for Payer: Signature Care EPO |
$1,759.35
|
| Rate for Payer: Signature Care PPO |
$1,865.34
|
| Rate for Payer: United Healthcare Commercial |
$1,670.32
|
|
|
COPPER CU-64 DOTATATE 148 MBQ/4 ML (4 MCI/4 ML) IV SOLN
|
Facility
|
IP
|
$14,196.00
|
|
|
Service Code
|
HCPCS A9592
|
| Hospital Charge Code |
192491
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$10,647.00 |
| Max. Negotiated Rate |
$13,202.28 |
| Rate for Payer: Aetna Commercial |
$12,265.34
|
| Rate for Payer: Cash Price |
$8,801.52
|
| Rate for Payer: Cigna All Commercial |
$12,251.15
|
| Rate for Payer: CORVEL All Commercial |
$13,202.28
|
| Rate for Payer: Coventry All Commercial |
$12,492.48
|
| Rate for Payer: Encore All Commercial |
$13,067.42
|
| Rate for Payer: Frontpath All Commercial |
$13,060.32
|
| Rate for Payer: Humana ChoiceCare |
$12,261.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12,776.40
|
| Rate for Payer: PHCS All Commercial |
$10,647.00
|
| Rate for Payer: PHP All Commercial |
$10,766.25
|
| Rate for Payer: Sagamore Health Network All Products |
$10,959.31
|
| Rate for Payer: Signature Care EPO |
$11,782.68
|
| Rate for Payer: Signature Care PPO |
$12,492.48
|
| Rate for Payer: United Healthcare Commercial |
$11,186.45
|
|
|
COPPER CU-64 DOTATATE 148 MBQ/4 ML (4 MCI/4 ML) IV SOLN
|
Facility
|
OP
|
$14,196.00
|
|
|
Service Code
|
HCPCS A9592
|
| Hospital Charge Code |
192491
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$4,684.68 |
| Max. Negotiated Rate |
$13,202.28 |
| Rate for Payer: Aetna Commercial |
$11,981.42
|
| Rate for Payer: Aetna Medicare |
$4,684.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,684.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8,152.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8,873.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,387.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,153.15
|
| Rate for Payer: Cash Price |
$8,801.52
|
| Rate for Payer: Centivo All Commercial |
$7,239.96
|
| Rate for Payer: Cigna All Commercial |
$12,251.15
|
| Rate for Payer: CORVEL All Commercial |
$13,202.28
|
| Rate for Payer: Coventry All Commercial |
$12,492.48
|
| Rate for Payer: Encore All Commercial |
$13,067.42
|
| Rate for Payer: Frontpath All Commercial |
$13,060.32
|
| Rate for Payer: Humana ChoiceCare |
$12,261.09
|
| Rate for Payer: Humana Medicare |
$7,239.96
|
| Rate for Payer: Lucent All Commercial |
$7,239.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12,776.40
|
| Rate for Payer: PHCS All Commercial |
$10,647.00
|
| Rate for Payer: PHP All Commercial |
$10,766.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,536.44
|
| Rate for Payer: Sagamore Health Network All Products |
$10,959.31
|
| Rate for Payer: Signature Care EPO |
$11,782.68
|
| Rate for Payer: Signature Care PPO |
$12,492.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,066.60
|
| Rate for Payer: United Healthcare Commercial |
$11,186.45
|
| Rate for Payer: United Healthcare Medicare |
$4,684.68
|
|
|
Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 28296
|
| Hospital Charge Code |
CPT-28296
|
|
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
|
|
|
COSYNTROPIN 0.25 MG INJ SOLR
|
Facility
|
IP
|
$146.87
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
9686
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.15 |
| Max. Negotiated Rate |
$136.59 |
| Rate for Payer: Aetna Commercial |
$126.89
|
| Rate for Payer: Cash Price |
$91.06
|
| Rate for Payer: Cigna All Commercial |
$126.75
|
| Rate for Payer: CORVEL All Commercial |
$136.59
|
| Rate for Payer: Coventry All Commercial |
$129.24
|
| Rate for Payer: Encore All Commercial |
$135.19
|
| Rate for Payer: Frontpath All Commercial |
$135.12
|
| Rate for Payer: Humana ChoiceCare |
$126.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.18
|
| Rate for Payer: PHCS All Commercial |
$110.15
|
| Rate for Payer: PHP All Commercial |
$111.38
|
| Rate for Payer: Sagamore Health Network All Products |
$113.38
|
| Rate for Payer: Signature Care EPO |
$121.90
|
| Rate for Payer: Signature Care PPO |
$129.24
|
| Rate for Payer: United Healthcare Commercial |
$115.73
|
|
|
COSYNTROPIN 0.25 MG INJ SOLR
|
Facility
|
OP
|
$146.87
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
9686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$136.59 |
| Rate for Payer: Aetna Commercial |
$123.96
|
| Rate for Payer: Aetna Medicare |
$48.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$84.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$84.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$55.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.31
|
| Rate for Payer: Cash Price |
$91.06
|
| Rate for Payer: Cash Price |
$91.06
|
| Rate for Payer: Centivo All Commercial |
$74.90
|
| Rate for Payer: Cigna All Commercial |
$126.75
|
| Rate for Payer: CORVEL All Commercial |
$136.59
|
| Rate for Payer: Coventry All Commercial |
$129.24
|
| Rate for Payer: Encore All Commercial |
$135.19
|
| Rate for Payer: Frontpath All Commercial |
$135.12
|
| Rate for Payer: Humana ChoiceCare |
$126.85
|
| Rate for Payer: Humana Medicare |
$74.90
|
| Rate for Payer: Lucent All Commercial |
$74.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.18
|
| Rate for Payer: Managed Health Services Medicaid |
$84.21
|
| Rate for Payer: MDWise Medicaid |
$84.21
|
| Rate for Payer: PHCS All Commercial |
$110.15
|
| Rate for Payer: PHP All Commercial |
$111.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.28
|
| Rate for Payer: Sagamore Health Network All Products |
$113.38
|
| Rate for Payer: Signature Care EPO |
$121.90
|
| Rate for Payer: Signature Care PPO |
$129.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.84
|
| Rate for Payer: United Healthcare Commercial |
$115.73
|
| Rate for Payer: United Healthcare Medicare |
$48.47
|
|
|
COVID VAC 24-25(12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG
|
Facility
|
OP
|
$656.40
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
206044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.75 |
| Max. Negotiated Rate |
$610.45 |
| Rate for Payer: Aetna Commercial |
$554.00
|
| Rate for Payer: Aetna Medicare |
$216.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$216.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$376.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$410.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$120.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$249.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$238.27
|
| Rate for Payer: Cash Price |
$406.97
|
| Rate for Payer: Cash Price |
$406.97
|
| Rate for Payer: Centivo All Commercial |
$334.76
|
| Rate for Payer: Cigna All Commercial |
$566.47
|
| Rate for Payer: CORVEL All Commercial |
$610.45
|
| Rate for Payer: Coventry All Commercial |
$577.63
|
| Rate for Payer: Encore All Commercial |
$604.22
|
| Rate for Payer: Frontpath All Commercial |
$603.89
|
| Rate for Payer: Humana ChoiceCare |
$566.93
|
| Rate for Payer: Humana Medicare |
$334.76
|
| Rate for Payer: Lucent All Commercial |
$334.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$590.76
|
| Rate for Payer: Managed Health Services Medicaid |
$120.75
|
| Rate for Payer: MDWise Medicaid |
$120.75
|
| Rate for Payer: PHCS All Commercial |
$492.30
|
| Rate for Payer: PHP All Commercial |
$497.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$256.00
|
| Rate for Payer: Sagamore Health Network All Products |
$506.74
|
| Rate for Payer: Signature Care EPO |
$544.81
|
| Rate for Payer: Signature Care PPO |
$577.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$557.94
|
| Rate for Payer: United Healthcare Commercial |
$517.24
|
| Rate for Payer: United Healthcare Medicare |
$216.61
|
|
|
COVID VAC 24-25(12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG
|
Facility
|
IP
|
$656.40
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
206044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$492.30 |
| Max. Negotiated Rate |
$610.45 |
| Rate for Payer: Aetna Commercial |
$567.13
|
| Rate for Payer: Cash Price |
$406.97
|
| Rate for Payer: Cigna All Commercial |
$566.47
|
| Rate for Payer: CORVEL All Commercial |
$610.45
|
| Rate for Payer: Coventry All Commercial |
$577.63
|
| Rate for Payer: Encore All Commercial |
$604.22
|
| Rate for Payer: Frontpath All Commercial |
$603.89
|
| Rate for Payer: Humana ChoiceCare |
$566.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$590.76
|
| Rate for Payer: PHCS All Commercial |
$492.30
|
| Rate for Payer: PHP All Commercial |
$497.81
|
| Rate for Payer: Sagamore Health Network All Products |
$506.74
|
| Rate for Payer: Signature Care EPO |
$544.81
|
| Rate for Payer: Signature Care PPO |
$577.63
|
| Rate for Payer: United Healthcare Commercial |
$517.24
|
|
|
CULT SKIN SUBST, HUMAN-BOVINE TOP DISK
|
Facility
|
IP
|
$4,389.01
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,291.76 |
| Max. Negotiated Rate |
$4,081.78 |
| Rate for Payer: Aetna Commercial |
$3,792.10
|
| Rate for Payer: Cash Price |
$2,721.19
|
| Rate for Payer: Cigna All Commercial |
$3,787.71
|
| Rate for Payer: CORVEL All Commercial |
$4,081.78
|
| Rate for Payer: Coventry All Commercial |
$3,862.33
|
| Rate for Payer: Encore All Commercial |
$4,040.08
|
| Rate for Payer: Frontpath All Commercial |
$4,037.89
|
| Rate for Payer: Humana ChoiceCare |
$3,790.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,950.11
|
| Rate for Payer: PHCS All Commercial |
$3,291.76
|
| Rate for Payer: PHP All Commercial |
$3,328.62
|
| Rate for Payer: Sagamore Health Network All Products |
$3,388.31
|
| Rate for Payer: Signature Care EPO |
$3,642.88
|
| Rate for Payer: Signature Care PPO |
$3,862.33
|
| Rate for Payer: United Healthcare Commercial |
$3,458.54
|
|
|
CULT SKIN SUBST, HUMAN-BOVINE TOP DISK
|
Facility
|
OP
|
$4,389.01
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$4,081.78 |
| Rate for Payer: Aetna Commercial |
$3,704.32
|
| Rate for Payer: Aetna Medicare |
$1,448.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,448.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,520.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,743.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,665.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,593.21
|
| Rate for Payer: Cash Price |
$2,721.19
|
| Rate for Payer: Cash Price |
$2,721.19
|
| Rate for Payer: Centivo All Commercial |
$2,238.39
|
| Rate for Payer: Cigna All Commercial |
$3,787.71
|
| Rate for Payer: CORVEL All Commercial |
$4,081.78
|
| Rate for Payer: Coventry All Commercial |
$3,862.33
|
| Rate for Payer: Encore All Commercial |
$4,040.08
|
| Rate for Payer: Frontpath All Commercial |
$4,037.89
|
| Rate for Payer: Humana ChoiceCare |
$3,790.79
|
| Rate for Payer: Humana Medicare |
$2,238.39
|
| Rate for Payer: Lucent All Commercial |
$2,238.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,950.11
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$3,291.76
|
| Rate for Payer: PHP All Commercial |
$3,328.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,711.71
|
| Rate for Payer: Sagamore Health Network All Products |
$3,388.31
|
| Rate for Payer: Signature Care EPO |
$3,642.88
|
| Rate for Payer: Signature Care PPO |
$3,862.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,730.66
|
| Rate for Payer: United Healthcare Commercial |
$3,458.54
|
| Rate for Payer: United Healthcare Medicare |
$1,448.37
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN
|
Facility
|
IP
|
$190.05
|
|
|
Service Code
|
NDC 00409409201
|
| Hospital Charge Code |
110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.54 |
| Max. Negotiated Rate |
$176.75 |
| Rate for Payer: Aetna Commercial |
$164.20
|
| Rate for Payer: Cash Price |
$117.83
|
| Rate for Payer: Cigna All Commercial |
$164.01
|
| Rate for Payer: CORVEL All Commercial |
$176.75
|
| Rate for Payer: Coventry All Commercial |
$167.24
|
| Rate for Payer: Encore All Commercial |
$174.94
|
| Rate for Payer: Frontpath All Commercial |
$174.85
|
| Rate for Payer: Humana ChoiceCare |
$164.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$171.04
|
| Rate for Payer: PHCS All Commercial |
$142.54
|
| Rate for Payer: PHP All Commercial |
$144.13
|
| Rate for Payer: Sagamore Health Network All Products |
$146.72
|
| Rate for Payer: Signature Care EPO |
$157.74
|
| Rate for Payer: Signature Care PPO |
$167.24
|
| Rate for Payer: United Healthcare Commercial |
$149.76
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN
|
Facility
|
OP
|
$190.05
|
|
|
Service Code
|
NDC 00409409201
|
| Hospital Charge Code |
110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$176.75 |
| Rate for Payer: Aetna Commercial |
$160.40
|
| Rate for Payer: Aetna Medicare |
$62.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$62.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$109.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$118.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$72.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.99
|
| Rate for Payer: Cash Price |
$117.83
|
| Rate for Payer: Cash Price |
$117.83
|
| Rate for Payer: Centivo All Commercial |
$96.93
|
| Rate for Payer: Cigna All Commercial |
$164.01
|
| Rate for Payer: CORVEL All Commercial |
$176.75
|
| Rate for Payer: Coventry All Commercial |
$167.24
|
| Rate for Payer: Encore All Commercial |
$174.94
|
| Rate for Payer: Frontpath All Commercial |
$174.85
|
| Rate for Payer: Humana ChoiceCare |
$164.15
|
| Rate for Payer: Humana Medicare |
$96.93
|
| Rate for Payer: Lucent All Commercial |
$96.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$171.04
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$142.54
|
| Rate for Payer: PHP All Commercial |
$144.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$74.12
|
| Rate for Payer: Sagamore Health Network All Products |
$146.72
|
| Rate for Payer: Signature Care EPO |
$157.74
|
| Rate for Payer: Signature Care PPO |
$167.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$161.54
|
| Rate for Payer: United Healthcare Commercial |
$149.76
|
| Rate for Payer: United Healthcare Medicare |
$62.72
|
|
|
CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
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
|
|
