|
DAPTOMYCIN 500 MG IV SOLR
|
Facility
|
OP
|
$225.61
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$209.82 |
| Rate for Payer: Aetna Commercial |
$190.41
|
| Rate for Payer: Aetna Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$129.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.03
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$85.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$81.90
|
| Rate for Payer: Cash Price |
$139.88
|
| Rate for Payer: Cash Price |
$139.88
|
| Rate for Payer: Centivo All Commercial |
$115.06
|
| Rate for Payer: Cigna All Commercial |
$194.70
|
| Rate for Payer: CORVEL All Commercial |
$209.82
|
| Rate for Payer: Coventry All Commercial |
$198.54
|
| Rate for Payer: Encore All Commercial |
$207.67
|
| Rate for Payer: Frontpath All Commercial |
$207.56
|
| Rate for Payer: Humana ChoiceCare |
$194.86
|
| Rate for Payer: Humana Medicare |
$115.06
|
| Rate for Payer: Lucent All Commercial |
$115.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.05
|
| Rate for Payer: Managed Health Services Medicaid |
$0.04
|
| Rate for Payer: MDWise Medicaid |
$0.04
|
| Rate for Payer: PHCS All Commercial |
$169.21
|
| Rate for Payer: PHP All Commercial |
$171.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$87.99
|
| Rate for Payer: Sagamore Health Network All Products |
$174.17
|
| Rate for Payer: Signature Care EPO |
$187.26
|
| Rate for Payer: Signature Care PPO |
$198.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$191.77
|
| Rate for Payer: United Healthcare Commercial |
$177.78
|
| Rate for Payer: United Healthcare Medicare |
$74.45
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$2,984.65
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,238.49 |
| Max. Negotiated Rate |
$2,775.72 |
| Rate for Payer: Aetna Commercial |
$2,578.74
|
| Rate for Payer: Cash Price |
$1,850.48
|
| Rate for Payer: Cigna All Commercial |
$2,575.75
|
| Rate for Payer: CORVEL All Commercial |
$2,775.72
|
| Rate for Payer: Coventry All Commercial |
$2,626.49
|
| Rate for Payer: Encore All Commercial |
$2,747.37
|
| Rate for Payer: Frontpath All Commercial |
$2,745.88
|
| Rate for Payer: Humana ChoiceCare |
$2,577.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,686.18
|
| Rate for Payer: PHCS All Commercial |
$2,238.49
|
| Rate for Payer: PHP All Commercial |
$2,263.56
|
| Rate for Payer: Sagamore Health Network All Products |
$2,304.15
|
| Rate for Payer: Signature Care EPO |
$2,477.26
|
| Rate for Payer: Signature Care PPO |
$2,626.49
|
| Rate for Payer: United Healthcare Commercial |
$2,351.90
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$2,984.65
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$2,775.72 |
| Rate for Payer: Aetna Commercial |
$2,519.04
|
| Rate for Payer: Aetna Medicare |
$984.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$984.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,714.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,865.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,132.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,083.43
|
| Rate for Payer: Cash Price |
$1,850.48
|
| Rate for Payer: Cash Price |
$1,850.48
|
| Rate for Payer: Centivo All Commercial |
$1,522.17
|
| Rate for Payer: Cigna All Commercial |
$2,575.75
|
| Rate for Payer: CORVEL All Commercial |
$2,775.72
|
| Rate for Payer: Coventry All Commercial |
$2,626.49
|
| Rate for Payer: Encore All Commercial |
$2,747.37
|
| Rate for Payer: Frontpath All Commercial |
$2,745.88
|
| Rate for Payer: Humana ChoiceCare |
$2,577.84
|
| Rate for Payer: Humana Medicare |
$1,522.17
|
| Rate for Payer: Lucent All Commercial |
$1,522.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,686.18
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$2,238.49
|
| Rate for Payer: PHP All Commercial |
$2,263.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,164.01
|
| Rate for Payer: Sagamore Health Network All Products |
$2,304.15
|
| Rate for Payer: Signature Care EPO |
$2,477.26
|
| Rate for Payer: Signature Care PPO |
$2,626.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,536.95
|
| Rate for Payer: United Healthcare Commercial |
$2,351.90
|
| Rate for Payer: United Healthcare Medicare |
$984.93
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYRG
|
Facility
|
OP
|
$3,917.37
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$3,643.15 |
| Rate for Payer: Aetna Commercial |
$3,306.26
|
| Rate for Payer: Aetna Medicare |
$1,292.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,292.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,249.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,448.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,486.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,422.00
|
| Rate for Payer: Cash Price |
$2,428.77
|
| Rate for Payer: Cash Price |
$2,428.77
|
| Rate for Payer: Centivo All Commercial |
$1,997.86
|
| Rate for Payer: Cigna All Commercial |
$3,380.69
|
| Rate for Payer: CORVEL All Commercial |
$3,643.15
|
| Rate for Payer: Coventry All Commercial |
$3,447.28
|
| Rate for Payer: Encore All Commercial |
$3,605.94
|
| Rate for Payer: Frontpath All Commercial |
$3,603.98
|
| Rate for Payer: Humana ChoiceCare |
$3,383.43
|
| Rate for Payer: Humana Medicare |
$1,997.86
|
| Rate for Payer: Lucent All Commercial |
$1,997.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,525.63
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$2,938.03
|
| Rate for Payer: PHP All Commercial |
$2,970.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,527.77
|
| Rate for Payer: Sagamore Health Network All Products |
$3,024.21
|
| Rate for Payer: Signature Care EPO |
$3,251.41
|
| Rate for Payer: Signature Care PPO |
$3,447.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,329.76
|
| Rate for Payer: United Healthcare Commercial |
$3,086.89
|
| Rate for Payer: United Healthcare Medicare |
$1,292.73
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYRG
|
Facility
|
IP
|
$3,917.37
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,938.03 |
| Max. Negotiated Rate |
$3,643.15 |
| Rate for Payer: Aetna Commercial |
$3,384.61
|
| Rate for Payer: Cash Price |
$2,428.77
|
| Rate for Payer: Cigna All Commercial |
$3,380.69
|
| Rate for Payer: CORVEL All Commercial |
$3,643.15
|
| Rate for Payer: Coventry All Commercial |
$3,447.28
|
| Rate for Payer: Encore All Commercial |
$3,605.94
|
| Rate for Payer: Frontpath All Commercial |
$3,603.98
|
| Rate for Payer: Humana ChoiceCare |
$3,383.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,525.63
|
| Rate for Payer: PHCS All Commercial |
$2,938.03
|
| Rate for Payer: PHP All Commercial |
$2,970.93
|
| Rate for Payer: Sagamore Health Network All Products |
$3,024.21
|
| Rate for Payer: Signature Care EPO |
$3,251.41
|
| Rate for Payer: Signature Care PPO |
$3,447.28
|
| Rate for Payer: United Healthcare Commercial |
$3,086.89
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG
|
Facility
|
OP
|
$5,223.16
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$4,857.53 |
| Rate for Payer: Aetna Commercial |
$4,408.34
|
| Rate for Payer: Aetna Medicare |
$1,723.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,723.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,999.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,264.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,982.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,896.01
|
| Rate for Payer: Cash Price |
$3,238.36
|
| Rate for Payer: Cash Price |
$3,238.36
|
| Rate for Payer: Centivo All Commercial |
$2,663.81
|
| Rate for Payer: Cigna All Commercial |
$4,507.58
|
| Rate for Payer: CORVEL All Commercial |
$4,857.53
|
| Rate for Payer: Coventry All Commercial |
$4,596.38
|
| Rate for Payer: Encore All Commercial |
$4,807.91
|
| Rate for Payer: Frontpath All Commercial |
$4,805.30
|
| Rate for Payer: Humana ChoiceCare |
$4,511.24
|
| Rate for Payer: Humana Medicare |
$2,663.81
|
| Rate for Payer: Lucent All Commercial |
$2,663.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,700.84
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$3,917.37
|
| Rate for Payer: PHP All Commercial |
$3,961.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,037.03
|
| Rate for Payer: Sagamore Health Network All Products |
$4,032.28
|
| Rate for Payer: Signature Care EPO |
$4,335.22
|
| Rate for Payer: Signature Care PPO |
$4,596.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,439.68
|
| Rate for Payer: United Healthcare Commercial |
$4,115.85
|
| Rate for Payer: United Healthcare Medicare |
$1,723.64
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG
|
Facility
|
IP
|
$5,223.16
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,917.37 |
| Max. Negotiated Rate |
$4,857.53 |
| Rate for Payer: Aetna Commercial |
$4,512.81
|
| Rate for Payer: Cash Price |
$3,238.36
|
| Rate for Payer: Cigna All Commercial |
$4,507.58
|
| Rate for Payer: CORVEL All Commercial |
$4,857.53
|
| Rate for Payer: Coventry All Commercial |
$4,596.38
|
| Rate for Payer: Encore All Commercial |
$4,807.91
|
| Rate for Payer: Frontpath All Commercial |
$4,805.30
|
| Rate for Payer: Humana ChoiceCare |
$4,511.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,700.84
|
| Rate for Payer: PHCS All Commercial |
$3,917.37
|
| Rate for Payer: PHP All Commercial |
$3,961.24
|
| Rate for Payer: Sagamore Health Network All Products |
$4,032.28
|
| Rate for Payer: Signature Care EPO |
$4,335.22
|
| Rate for Payer: Signature Care PPO |
$4,596.38
|
| Rate for Payer: United Healthcare Commercial |
$4,115.85
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML INJ SOLN
|
Facility
|
OP
|
$932.72
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$867.42 |
| Rate for Payer: Aetna Commercial |
$787.21
|
| Rate for Payer: Aetna Medicare |
$307.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$307.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$535.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$583.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$353.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$338.58
|
| Rate for Payer: Cash Price |
$578.28
|
| Rate for Payer: Cash Price |
$578.28
|
| Rate for Payer: Centivo All Commercial |
$475.68
|
| Rate for Payer: Cigna All Commercial |
$804.93
|
| Rate for Payer: CORVEL All Commercial |
$867.42
|
| Rate for Payer: Coventry All Commercial |
$820.79
|
| Rate for Payer: Encore All Commercial |
$858.56
|
| Rate for Payer: Frontpath All Commercial |
$858.10
|
| Rate for Payer: Humana ChoiceCare |
$805.59
|
| Rate for Payer: Humana Medicare |
$475.68
|
| Rate for Payer: Lucent All Commercial |
$475.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$839.44
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$699.54
|
| Rate for Payer: PHP All Commercial |
$707.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$363.76
|
| Rate for Payer: Sagamore Health Network All Products |
$720.06
|
| Rate for Payer: Signature Care EPO |
$774.15
|
| Rate for Payer: Signature Care PPO |
$820.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$792.81
|
| Rate for Payer: United Healthcare Commercial |
$734.98
|
| Rate for Payer: United Healthcare Medicare |
$307.80
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/ML INJ SOLN
|
Facility
|
IP
|
$932.72
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76962
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$699.54 |
| Max. Negotiated Rate |
$867.42 |
| Rate for Payer: Aetna Commercial |
$805.87
|
| Rate for Payer: Cash Price |
$578.28
|
| Rate for Payer: Cigna All Commercial |
$804.93
|
| Rate for Payer: CORVEL All Commercial |
$867.42
|
| Rate for Payer: Coventry All Commercial |
$820.79
|
| Rate for Payer: Encore All Commercial |
$858.56
|
| Rate for Payer: Frontpath All Commercial |
$858.10
|
| Rate for Payer: Humana ChoiceCare |
$805.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$839.44
|
| Rate for Payer: PHCS All Commercial |
$699.54
|
| Rate for Payer: PHP All Commercial |
$707.37
|
| Rate for Payer: Sagamore Health Network All Products |
$720.06
|
| Rate for Payer: Signature Care EPO |
$774.15
|
| Rate for Payer: Signature Care PPO |
$820.79
|
| Rate for Payer: United Healthcare Commercial |
$734.98
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG
|
Facility
|
IP
|
$7,834.75
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,876.06 |
| Max. Negotiated Rate |
$7,286.32 |
| Rate for Payer: Aetna Commercial |
$6,769.22
|
| Rate for Payer: Cash Price |
$4,857.55
|
| Rate for Payer: Cigna All Commercial |
$6,761.39
|
| Rate for Payer: CORVEL All Commercial |
$7,286.32
|
| Rate for Payer: Coventry All Commercial |
$6,894.58
|
| Rate for Payer: Encore All Commercial |
$7,211.89
|
| Rate for Payer: Frontpath All Commercial |
$7,207.97
|
| Rate for Payer: Humana ChoiceCare |
$6,766.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,051.28
|
| Rate for Payer: PHCS All Commercial |
$5,876.06
|
| Rate for Payer: PHP All Commercial |
$5,941.87
|
| Rate for Payer: Sagamore Health Network All Products |
$6,048.43
|
| Rate for Payer: Signature Care EPO |
$6,502.84
|
| Rate for Payer: Signature Care PPO |
$6,894.58
|
| Rate for Payer: United Healthcare Commercial |
$6,173.78
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG
|
Facility
|
OP
|
$7,834.75
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$7,286.32 |
| Rate for Payer: Aetna Commercial |
$6,612.53
|
| Rate for Payer: Aetna Medicare |
$2,585.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,585.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,499.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,897.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,973.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,844.01
|
| Rate for Payer: Cash Price |
$4,857.55
|
| Rate for Payer: Cash Price |
$4,857.55
|
| Rate for Payer: Centivo All Commercial |
$3,995.72
|
| Rate for Payer: Cigna All Commercial |
$6,761.39
|
| Rate for Payer: CORVEL All Commercial |
$7,286.32
|
| Rate for Payer: Coventry All Commercial |
$6,894.58
|
| Rate for Payer: Encore All Commercial |
$7,211.89
|
| Rate for Payer: Frontpath All Commercial |
$7,207.97
|
| Rate for Payer: Humana ChoiceCare |
$6,766.87
|
| Rate for Payer: Humana Medicare |
$3,995.72
|
| Rate for Payer: Lucent All Commercial |
$3,995.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,051.28
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$5,876.06
|
| Rate for Payer: PHP All Commercial |
$5,941.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,055.55
|
| Rate for Payer: Sagamore Health Network All Products |
$6,048.43
|
| Rate for Payer: Signature Care EPO |
$6,502.84
|
| Rate for Payer: Signature Care PPO |
$6,894.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,659.54
|
| Rate for Payer: United Healthcare Commercial |
$6,173.78
|
| Rate for Payer: United Healthcare Medicare |
$2,585.47
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYRG
|
Facility
|
IP
|
$1,193.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$895.40 |
| Max. Negotiated Rate |
$1,110.29 |
| Rate for Payer: Aetna Commercial |
$1,031.50
|
| Rate for Payer: Cash Price |
$740.19
|
| Rate for Payer: Cigna All Commercial |
$1,030.30
|
| Rate for Payer: CORVEL All Commercial |
$1,110.29
|
| Rate for Payer: Coventry All Commercial |
$1,050.60
|
| Rate for Payer: Encore All Commercial |
$1,098.95
|
| Rate for Payer: Frontpath All Commercial |
$1,098.35
|
| Rate for Payer: Humana ChoiceCare |
$1,031.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,074.47
|
| Rate for Payer: PHCS All Commercial |
$895.40
|
| Rate for Payer: PHP All Commercial |
$905.42
|
| Rate for Payer: Sagamore Health Network All Products |
$921.66
|
| Rate for Payer: Signature Care EPO |
$990.90
|
| Rate for Payer: Signature Care PPO |
$1,050.60
|
| Rate for Payer: United Healthcare Commercial |
$940.76
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYRG
|
Facility
|
OP
|
$1,193.86
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$1,110.29 |
| Rate for Payer: Aetna Commercial |
$1,007.62
|
| Rate for Payer: Aetna Medicare |
$393.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$393.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$685.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$746.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$453.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$433.37
|
| Rate for Payer: Cash Price |
$740.19
|
| Rate for Payer: Cash Price |
$740.19
|
| Rate for Payer: Centivo All Commercial |
$608.87
|
| Rate for Payer: Cigna All Commercial |
$1,030.30
|
| Rate for Payer: CORVEL All Commercial |
$1,110.29
|
| Rate for Payer: Coventry All Commercial |
$1,050.60
|
| Rate for Payer: Encore All Commercial |
$1,098.95
|
| Rate for Payer: Frontpath All Commercial |
$1,098.35
|
| Rate for Payer: Humana ChoiceCare |
$1,031.14
|
| Rate for Payer: Humana Medicare |
$608.87
|
| Rate for Payer: Lucent All Commercial |
$608.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,074.47
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$895.40
|
| Rate for Payer: PHP All Commercial |
$905.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$465.61
|
| Rate for Payer: Sagamore Health Network All Products |
$921.66
|
| Rate for Payer: Signature Care EPO |
$990.90
|
| Rate for Payer: Signature Care PPO |
$1,050.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,014.78
|
| Rate for Payer: United Healthcare Commercial |
$940.76
|
| Rate for Payer: United Healthcare Medicare |
$393.97
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYRG
|
Facility
|
OP
|
$1,790.79
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$1,665.43 |
| Rate for Payer: Aetna Commercial |
$1,511.43
|
| Rate for Payer: Aetna Medicare |
$590.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$590.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,028.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,119.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$8.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$679.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$650.06
|
| Rate for Payer: Cash Price |
$1,110.29
|
| Rate for Payer: Cash Price |
$1,110.29
|
| Rate for Payer: Centivo All Commercial |
$913.30
|
| Rate for Payer: Cigna All Commercial |
$1,545.45
|
| Rate for Payer: CORVEL All Commercial |
$1,665.43
|
| Rate for Payer: Coventry All Commercial |
$1,575.90
|
| Rate for Payer: Encore All Commercial |
$1,648.42
|
| Rate for Payer: Frontpath All Commercial |
$1,647.53
|
| Rate for Payer: Humana ChoiceCare |
$1,546.71
|
| Rate for Payer: Humana Medicare |
$913.30
|
| Rate for Payer: Lucent All Commercial |
$913.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,611.71
|
| Rate for Payer: Managed Health Services Medicaid |
$8.13
|
| Rate for Payer: MDWise Medicaid |
$8.13
|
| Rate for Payer: PHCS All Commercial |
$1,343.09
|
| Rate for Payer: PHP All Commercial |
$1,358.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$698.41
|
| Rate for Payer: Sagamore Health Network All Products |
$1,382.49
|
| Rate for Payer: Signature Care EPO |
$1,486.36
|
| Rate for Payer: Signature Care PPO |
$1,575.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,522.17
|
| Rate for Payer: United Healthcare Commercial |
$1,411.14
|
| Rate for Payer: United Healthcare Medicare |
$590.96
|
|
|
DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYRG
|
Facility
|
IP
|
$1,790.79
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
108043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,343.09 |
| Max. Negotiated Rate |
$1,665.43 |
| Rate for Payer: Aetna Commercial |
$1,547.24
|
| Rate for Payer: Cash Price |
$1,110.29
|
| Rate for Payer: Cigna All Commercial |
$1,545.45
|
| Rate for Payer: CORVEL All Commercial |
$1,665.43
|
| Rate for Payer: Coventry All Commercial |
$1,575.90
|
| Rate for Payer: Encore All Commercial |
$1,648.42
|
| Rate for Payer: Frontpath All Commercial |
$1,647.53
|
| Rate for Payer: Humana ChoiceCare |
$1,546.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,611.71
|
| Rate for Payer: PHCS All Commercial |
$1,343.09
|
| Rate for Payer: PHP All Commercial |
$1,358.14
|
| Rate for Payer: Sagamore Health Network All Products |
$1,382.49
|
| Rate for Payer: Signature Care EPO |
$1,486.36
|
| Rate for Payer: Signature Care PPO |
$1,575.90
|
| Rate for Payer: United Healthcare Commercial |
$1,411.14
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 11012
|
| Hospital Charge Code |
CPT-11012
|
|
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
|
|
|
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$648.18
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
CPT-11045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$648.18 |
| Max. Negotiated Rate |
$648.18 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$648.18
|
| Rate for Payer: Managed Health Services Medicaid |
$648.18
|
| Rate for Payer: MDWise Medicaid |
$648.18
|
|
|
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
|
Facility
|
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
CPT-11042
|
|
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
|
|
|
DEFEROXAMINE 500 MG INJ SOLR
|
Facility
|
IP
|
$236.97
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
9723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.73 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$204.74
|
| Rate for Payer: Cash Price |
$146.92
|
| Rate for Payer: Cigna All Commercial |
$204.51
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.73
|
| Rate for Payer: PHP All Commercial |
$179.72
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.69
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
|
|
DEFEROXAMINE 500 MG INJ SOLR
|
Facility
|
OP
|
$236.97
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
9723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.20 |
| Max. Negotiated Rate |
$220.38 |
| Rate for Payer: Aetna Commercial |
$200.00
|
| Rate for Payer: Aetna Medicare |
$78.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$78.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$136.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.02
|
| Rate for Payer: Cash Price |
$146.92
|
| Rate for Payer: Centivo All Commercial |
$120.86
|
| Rate for Payer: Cigna All Commercial |
$204.51
|
| Rate for Payer: CORVEL All Commercial |
$220.38
|
| Rate for Payer: Coventry All Commercial |
$208.53
|
| Rate for Payer: Encore All Commercial |
$218.13
|
| Rate for Payer: Frontpath All Commercial |
$218.01
|
| Rate for Payer: Humana ChoiceCare |
$204.67
|
| Rate for Payer: Humana Medicare |
$120.86
|
| Rate for Payer: Lucent All Commercial |
$120.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.27
|
| Rate for Payer: PHCS All Commercial |
$177.73
|
| Rate for Payer: PHP All Commercial |
$179.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.42
|
| Rate for Payer: Sagamore Health Network All Products |
$182.94
|
| Rate for Payer: Signature Care EPO |
$196.69
|
| Rate for Payer: Signature Care PPO |
$208.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.43
|
| Rate for Payer: United Healthcare Commercial |
$186.73
|
| Rate for Payer: United Healthcare Medicare |
$78.20
|
|
|
DEGARELIX 120 MG SUBQ SOLR
|
Facility
|
IP
|
$2,891.36
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
96987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,168.52 |
| Max. Negotiated Rate |
$2,688.96 |
| Rate for Payer: Aetna Commercial |
$2,498.14
|
| Rate for Payer: Cash Price |
$1,792.64
|
| Rate for Payer: Cigna All Commercial |
$2,495.24
|
| Rate for Payer: CORVEL All Commercial |
$2,688.96
|
| Rate for Payer: Coventry All Commercial |
$2,544.40
|
| Rate for Payer: Encore All Commercial |
$2,661.50
|
| Rate for Payer: Frontpath All Commercial |
$2,660.05
|
| Rate for Payer: Humana ChoiceCare |
$2,497.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,602.22
|
| Rate for Payer: PHCS All Commercial |
$2,168.52
|
| Rate for Payer: PHP All Commercial |
$2,192.81
|
| Rate for Payer: Sagamore Health Network All Products |
$2,232.13
|
| Rate for Payer: Signature Care EPO |
$2,399.83
|
| Rate for Payer: Signature Care PPO |
$2,544.40
|
| Rate for Payer: United Healthcare Commercial |
$2,278.39
|
|
|
DEGARELIX 120 MG SUBQ SOLR
|
Facility
|
OP
|
$2,891.36
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
96987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$2,688.96 |
| Rate for Payer: Aetna Commercial |
$2,440.31
|
| Rate for Payer: Aetna Medicare |
$954.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$954.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,660.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,807.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,097.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,049.56
|
| Rate for Payer: Cash Price |
$1,792.64
|
| Rate for Payer: Cash Price |
$1,792.64
|
| Rate for Payer: Centivo All Commercial |
$1,474.59
|
| Rate for Payer: Cigna All Commercial |
$2,495.24
|
| Rate for Payer: CORVEL All Commercial |
$2,688.96
|
| Rate for Payer: Coventry All Commercial |
$2,544.40
|
| Rate for Payer: Encore All Commercial |
$2,661.50
|
| Rate for Payer: Frontpath All Commercial |
$2,660.05
|
| Rate for Payer: Humana ChoiceCare |
$2,497.27
|
| Rate for Payer: Humana Medicare |
$1,474.59
|
| Rate for Payer: Lucent All Commercial |
$1,474.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,602.22
|
| Rate for Payer: Managed Health Services Medicaid |
$6.41
|
| Rate for Payer: MDWise Medicaid |
$6.41
|
| Rate for Payer: PHCS All Commercial |
$2,168.52
|
| Rate for Payer: PHP All Commercial |
$2,192.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,127.63
|
| Rate for Payer: Sagamore Health Network All Products |
$2,232.13
|
| Rate for Payer: Signature Care EPO |
$2,399.83
|
| Rate for Payer: Signature Care PPO |
$2,544.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,457.66
|
| Rate for Payer: United Healthcare Commercial |
$2,278.39
|
| Rate for Payer: United Healthcare Medicare |
$954.15
|
|
|
DENOSUMAB 60 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$5,929.46
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$5,514.39 |
| Rate for Payer: Aetna Commercial |
$5,004.46
|
| Rate for Payer: Aetna Medicare |
$1,956.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,956.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,405.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,706.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$26.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,250.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,152.39
|
| Rate for Payer: Cash Price |
$3,676.26
|
| Rate for Payer: Cash Price |
$3,676.26
|
| Rate for Payer: Centivo All Commercial |
$3,024.02
|
| Rate for Payer: Cigna All Commercial |
$5,117.12
|
| Rate for Payer: CORVEL All Commercial |
$5,514.39
|
| Rate for Payer: Coventry All Commercial |
$5,217.92
|
| Rate for Payer: Encore All Commercial |
$5,458.06
|
| Rate for Payer: Frontpath All Commercial |
$5,455.10
|
| Rate for Payer: Humana ChoiceCare |
$5,121.27
|
| Rate for Payer: Humana Medicare |
$3,024.02
|
| Rate for Payer: Lucent All Commercial |
$3,024.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,336.51
|
| Rate for Payer: Managed Health Services Medicaid |
$26.15
|
| Rate for Payer: MDWise Medicaid |
$26.15
|
| Rate for Payer: PHCS All Commercial |
$4,447.09
|
| Rate for Payer: PHP All Commercial |
$4,496.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,312.49
|
| Rate for Payer: Sagamore Health Network All Products |
$4,577.54
|
| Rate for Payer: Signature Care EPO |
$4,921.45
|
| Rate for Payer: Signature Care PPO |
$5,217.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,040.04
|
| Rate for Payer: United Healthcare Commercial |
$4,672.41
|
| Rate for Payer: United Healthcare Medicare |
$1,956.72
|
|
|
DENOSUMAB 60 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$5,929.46
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,447.09 |
| Max. Negotiated Rate |
$5,514.39 |
| Rate for Payer: Aetna Commercial |
$5,123.05
|
| Rate for Payer: Cash Price |
$3,676.26
|
| Rate for Payer: Cigna All Commercial |
$5,117.12
|
| Rate for Payer: CORVEL All Commercial |
$5,514.39
|
| Rate for Payer: Coventry All Commercial |
$5,217.92
|
| Rate for Payer: Encore All Commercial |
$5,458.06
|
| Rate for Payer: Frontpath All Commercial |
$5,455.10
|
| Rate for Payer: Humana ChoiceCare |
$5,121.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,336.51
|
| Rate for Payer: PHCS All Commercial |
$4,447.09
|
| Rate for Payer: PHP All Commercial |
$4,496.90
|
| Rate for Payer: Sagamore Health Network All Products |
$4,577.54
|
| Rate for Payer: Signature Care EPO |
$4,921.45
|
| Rate for Payer: Signature Care PPO |
$5,217.92
|
| Rate for Payer: United Healthcare Commercial |
$4,672.41
|
|
|
DENOSUMAB 70 MG/ML SUBQ SOLN
|
Facility
|
IP
|
$10,905.86
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,179.40 |
| Max. Negotiated Rate |
$10,142.45 |
| Rate for Payer: Aetna Commercial |
$9,422.67
|
| Rate for Payer: Cash Price |
$6,761.64
|
| Rate for Payer: Cigna All Commercial |
$9,411.76
|
| Rate for Payer: CORVEL All Commercial |
$10,142.45
|
| Rate for Payer: Coventry All Commercial |
$9,597.16
|
| Rate for Payer: Encore All Commercial |
$10,038.85
|
| Rate for Payer: Frontpath All Commercial |
$10,033.39
|
| Rate for Payer: Humana ChoiceCare |
$9,419.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,815.28
|
| Rate for Payer: PHCS All Commercial |
$8,179.40
|
| Rate for Payer: PHP All Commercial |
$8,271.01
|
| Rate for Payer: Sagamore Health Network All Products |
$8,419.33
|
| Rate for Payer: Signature Care EPO |
$9,051.87
|
| Rate for Payer: Signature Care PPO |
$9,597.16
|
| Rate for Payer: United Healthcare Commercial |
$8,593.82
|
|
