|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SUSP
|
Facility
|
IP
|
$325.76
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
167647
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.32 |
| Max. Negotiated Rate |
$302.95 |
| Rate for Payer: Aetna Commercial |
$281.45
|
| Rate for Payer: Cash Price |
$201.97
|
| Rate for Payer: Cigna All Commercial |
$281.13
|
| Rate for Payer: CORVEL All Commercial |
$302.95
|
| Rate for Payer: Coventry All Commercial |
$286.67
|
| Rate for Payer: Encore All Commercial |
$299.86
|
| Rate for Payer: Frontpath All Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$281.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$293.18
|
| Rate for Payer: PHCS All Commercial |
$244.32
|
| Rate for Payer: PHP All Commercial |
$247.05
|
| Rate for Payer: Sagamore Health Network All Products |
$251.49
|
| Rate for Payer: Signature Care EPO |
$270.38
|
| Rate for Payer: Signature Care PPO |
$286.67
|
| Rate for Payer: United Healthcare Commercial |
$256.70
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SYRG
|
Facility
|
OP
|
$341.15
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
197146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.58 |
| Max. Negotiated Rate |
$317.27 |
| Rate for Payer: Aetna Commercial |
$287.93
|
| Rate for Payer: Aetna Medicare |
$112.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$112.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$195.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$129.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$123.84
|
| Rate for Payer: Cash Price |
$211.51
|
| Rate for Payer: Centivo All Commercial |
$173.99
|
| Rate for Payer: Cigna All Commercial |
$294.41
|
| Rate for Payer: CORVEL All Commercial |
$317.27
|
| Rate for Payer: Coventry All Commercial |
$300.21
|
| Rate for Payer: Encore All Commercial |
$314.03
|
| Rate for Payer: Frontpath All Commercial |
$313.86
|
| Rate for Payer: Humana ChoiceCare |
$294.65
|
| Rate for Payer: Humana Medicare |
$173.99
|
| Rate for Payer: Lucent All Commercial |
$173.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.03
|
| Rate for Payer: PHCS All Commercial |
$255.86
|
| Rate for Payer: PHP All Commercial |
$258.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.05
|
| Rate for Payer: Sagamore Health Network All Products |
$263.37
|
| Rate for Payer: Signature Care EPO |
$283.15
|
| Rate for Payer: Signature Care PPO |
$300.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$289.98
|
| Rate for Payer: United Healthcare Commercial |
$268.82
|
| Rate for Payer: United Healthcare Medicare |
$112.58
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML IM SYRG
|
Facility
|
IP
|
$341.15
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
197146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$255.86 |
| Max. Negotiated Rate |
$317.27 |
| Rate for Payer: Aetna Commercial |
$294.75
|
| Rate for Payer: Cash Price |
$211.51
|
| Rate for Payer: Cigna All Commercial |
$294.41
|
| Rate for Payer: CORVEL All Commercial |
$317.27
|
| Rate for Payer: Coventry All Commercial |
$300.21
|
| Rate for Payer: Encore All Commercial |
$314.03
|
| Rate for Payer: Frontpath All Commercial |
$313.86
|
| Rate for Payer: Humana ChoiceCare |
$294.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.03
|
| Rate for Payer: PHCS All Commercial |
$255.86
|
| Rate for Payer: PHP All Commercial |
$258.73
|
| Rate for Payer: Sagamore Health Network All Products |
$263.37
|
| Rate for Payer: Signature Care EPO |
$283.15
|
| Rate for Payer: Signature Care PPO |
$300.21
|
| Rate for Payer: United Healthcare Commercial |
$268.82
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$297.18
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
119850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.07 |
| Max. Negotiated Rate |
$276.38 |
| Rate for Payer: Aetna Commercial |
$250.82
|
| Rate for Payer: Aetna Medicare |
$98.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$98.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$170.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$185.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$112.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$107.88
|
| Rate for Payer: Cash Price |
$184.25
|
| Rate for Payer: Centivo All Commercial |
$151.56
|
| Rate for Payer: Cigna All Commercial |
$256.46
|
| Rate for Payer: CORVEL All Commercial |
$276.38
|
| Rate for Payer: Coventry All Commercial |
$261.52
|
| Rate for Payer: Encore All Commercial |
$273.55
|
| Rate for Payer: Frontpath All Commercial |
$273.40
|
| Rate for Payer: Humana ChoiceCare |
$256.67
|
| Rate for Payer: Humana Medicare |
$151.56
|
| Rate for Payer: Lucent All Commercial |
$151.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$267.46
|
| Rate for Payer: PHCS All Commercial |
$222.88
|
| Rate for Payer: PHP All Commercial |
$225.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$115.90
|
| Rate for Payer: Sagamore Health Network All Products |
$229.42
|
| Rate for Payer: Signature Care EPO |
$246.66
|
| Rate for Payer: Signature Care PPO |
$261.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$252.60
|
| Rate for Payer: United Healthcare Commercial |
$234.18
|
| Rate for Payer: United Healthcare Medicare |
$98.07
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$297.18
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
119850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$222.88 |
| Max. Negotiated Rate |
$276.38 |
| Rate for Payer: Aetna Commercial |
$256.76
|
| Rate for Payer: Cash Price |
$184.25
|
| Rate for Payer: Cigna All Commercial |
$256.46
|
| Rate for Payer: CORVEL All Commercial |
$276.38
|
| Rate for Payer: Coventry All Commercial |
$261.52
|
| Rate for Payer: Encore All Commercial |
$273.55
|
| Rate for Payer: Frontpath All Commercial |
$273.40
|
| Rate for Payer: Humana ChoiceCare |
$256.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$267.46
|
| Rate for Payer: PHCS All Commercial |
$222.88
|
| Rate for Payer: PHP All Commercial |
$225.38
|
| Rate for Payer: Sagamore Health Network All Products |
$229.42
|
| Rate for Payer: Signature Care EPO |
$246.66
|
| Rate for Payer: Signature Care PPO |
$261.52
|
| Rate for Payer: United Healthcare Commercial |
$234.18
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRG
|
Facility
|
OP
|
$348.53
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
92788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.01 |
| Max. Negotiated Rate |
$324.13 |
| Rate for Payer: Aetna Commercial |
$294.16
|
| Rate for Payer: Aetna Medicare |
$115.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$115.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$200.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$217.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.52
|
| Rate for Payer: Cash Price |
$216.09
|
| Rate for Payer: Centivo All Commercial |
$177.75
|
| Rate for Payer: Cigna All Commercial |
$300.78
|
| Rate for Payer: CORVEL All Commercial |
$324.13
|
| Rate for Payer: Coventry All Commercial |
$306.70
|
| Rate for Payer: Encore All Commercial |
$320.82
|
| Rate for Payer: Frontpath All Commercial |
$320.65
|
| Rate for Payer: Humana ChoiceCare |
$301.02
|
| Rate for Payer: Humana Medicare |
$177.75
|
| Rate for Payer: Lucent All Commercial |
$177.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$313.68
|
| Rate for Payer: PHCS All Commercial |
$261.40
|
| Rate for Payer: PHP All Commercial |
$264.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$135.93
|
| Rate for Payer: Sagamore Health Network All Products |
$269.06
|
| Rate for Payer: Signature Care EPO |
$289.28
|
| Rate for Payer: Signature Care PPO |
$306.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$296.25
|
| Rate for Payer: United Healthcare Commercial |
$274.64
|
| Rate for Payer: United Healthcare Medicare |
$115.01
|
|
|
DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRG
|
Facility
|
IP
|
$348.53
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
92788
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$261.40 |
| Max. Negotiated Rate |
$324.13 |
| Rate for Payer: Aetna Commercial |
$301.13
|
| Rate for Payer: Cash Price |
$216.09
|
| Rate for Payer: Cigna All Commercial |
$300.78
|
| Rate for Payer: CORVEL All Commercial |
$324.13
|
| Rate for Payer: Coventry All Commercial |
$306.70
|
| Rate for Payer: Encore All Commercial |
$320.82
|
| Rate for Payer: Frontpath All Commercial |
$320.65
|
| Rate for Payer: Humana ChoiceCare |
$301.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$313.68
|
| Rate for Payer: PHCS All Commercial |
$261.40
|
| Rate for Payer: PHP All Commercial |
$264.32
|
| Rate for Payer: Sagamore Health Network All Products |
$269.06
|
| Rate for Payer: Signature Care EPO |
$289.28
|
| Rate for Payer: Signature Care PPO |
$306.70
|
| Rate for Payer: United Healthcare Commercial |
$274.64
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$238.48 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$274.73
|
| Rate for Payer: Cash Price |
$197.14
|
| Rate for Payer: Cigna All Commercial |
$274.41
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: PHCS All Commercial |
$238.48
|
| Rate for Payer: PHP All Commercial |
$241.15
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.92
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: United Healthcare Commercial |
$250.56
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$268.37
|
| Rate for Payer: Aetna Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$182.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$198.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$120.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.42
|
| Rate for Payer: Cash Price |
$197.14
|
| Rate for Payer: Cash Price |
$197.14
|
| Rate for Payer: Centivo All Commercial |
$162.17
|
| Rate for Payer: Cigna All Commercial |
$274.41
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Humana Medicare |
$162.17
|
| Rate for Payer: Lucent All Commercial |
$162.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$238.48
|
| Rate for Payer: PHP All Commercial |
$241.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.01
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.92
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$270.28
|
| Rate for Payer: United Healthcare Commercial |
$250.56
|
| Rate for Payer: United Healthcare Medicare |
$104.93
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG
|
Facility
|
OP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
119727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.93 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$268.38
|
| Rate for Payer: Aetna Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$182.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$198.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$120.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.43
|
| Rate for Payer: Cash Price |
$197.15
|
| Rate for Payer: Centivo All Commercial |
$162.17
|
| Rate for Payer: Cigna All Commercial |
$274.42
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Humana Medicare |
$162.17
|
| Rate for Payer: Lucent All Commercial |
$162.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: PHCS All Commercial |
$238.49
|
| Rate for Payer: PHP All Commercial |
$241.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.01
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.93
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$270.28
|
| Rate for Payer: United Healthcare Commercial |
$250.57
|
| Rate for Payer: United Healthcare Medicare |
$104.93
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG
|
Facility
|
IP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
119727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$238.49 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$274.74
|
| Rate for Payer: Cash Price |
$197.15
|
| Rate for Payer: Cigna All Commercial |
$274.42
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: PHCS All Commercial |
$238.49
|
| Rate for Payer: PHP All Commercial |
$241.16
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.93
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: United Healthcare Commercial |
$250.57
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG S.O.
|
Facility
|
OP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4080119727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.93 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$268.37
|
| Rate for Payer: Aetna Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$182.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$198.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$120.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.42
|
| Rate for Payer: Cash Price |
$197.14
|
| Rate for Payer: Centivo All Commercial |
$162.17
|
| Rate for Payer: Cigna All Commercial |
$274.41
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Humana Medicare |
$162.17
|
| Rate for Payer: Lucent All Commercial |
$162.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: PHCS All Commercial |
$238.48
|
| Rate for Payer: PHP All Commercial |
$241.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.01
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.92
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$270.28
|
| Rate for Payer: United Healthcare Commercial |
$250.56
|
| Rate for Payer: United Healthcare Medicare |
$104.93
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG S.O.
|
Facility
|
IP
|
$317.98
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
4080119727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$238.48 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$274.73
|
| Rate for Payer: Cash Price |
$197.14
|
| Rate for Payer: Cigna All Commercial |
$274.41
|
| Rate for Payer: CORVEL All Commercial |
$295.72
|
| Rate for Payer: Coventry All Commercial |
$279.82
|
| Rate for Payer: Encore All Commercial |
$292.70
|
| Rate for Payer: Frontpath All Commercial |
$292.54
|
| Rate for Payer: Humana ChoiceCare |
$274.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.18
|
| Rate for Payer: PHCS All Commercial |
$238.48
|
| Rate for Payer: PHP All Commercial |
$241.15
|
| Rate for Payer: Sagamore Health Network All Products |
$245.48
|
| Rate for Payer: Signature Care EPO |
$263.92
|
| Rate for Payer: Signature Care PPO |
$279.82
|
| Rate for Payer: United Healthcare Commercial |
$250.56
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164786
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.60 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$272.57
|
| Rate for Payer: Cash Price |
$195.59
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164786
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.10 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$266.26
|
| Rate for Payer: Aetna Medicare |
$104.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$181.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$197.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$114.52
|
| Rate for Payer: Cash Price |
$195.59
|
| Rate for Payer: Centivo All Commercial |
$160.89
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Humana Medicare |
$160.89
|
| Rate for Payer: Lucent All Commercial |
$160.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.03
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$268.15
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
| Rate for Payer: United Healthcare Medicare |
$104.10
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
IP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.60 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$272.57
|
| Rate for Payer: Cash Price |
$195.59
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
|
|
DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG
|
Facility
|
OP
|
$315.47
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
164761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.10 |
| Max. Negotiated Rate |
$293.39 |
| Rate for Payer: Aetna Commercial |
$266.26
|
| Rate for Payer: Aetna Medicare |
$104.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$181.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$197.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$114.52
|
| Rate for Payer: Cash Price |
$195.59
|
| Rate for Payer: Centivo All Commercial |
$160.89
|
| Rate for Payer: Cigna All Commercial |
$272.25
|
| Rate for Payer: CORVEL All Commercial |
$293.39
|
| Rate for Payer: Coventry All Commercial |
$277.61
|
| Rate for Payer: Encore All Commercial |
$290.39
|
| Rate for Payer: Frontpath All Commercial |
$290.23
|
| Rate for Payer: Humana ChoiceCare |
$272.47
|
| Rate for Payer: Humana Medicare |
$160.89
|
| Rate for Payer: Lucent All Commercial |
$160.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.92
|
| Rate for Payer: PHCS All Commercial |
$236.60
|
| Rate for Payer: PHP All Commercial |
$239.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.03
|
| Rate for Payer: Sagamore Health Network All Products |
$243.54
|
| Rate for Payer: Signature Care EPO |
$261.84
|
| Rate for Payer: Signature Care PPO |
$277.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$268.15
|
| Rate for Payer: United Healthcare Commercial |
$248.59
|
| Rate for Payer: United Healthcare Medicare |
$104.10
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-48MCG-62DU -10 MCG/0.5ML IM KIT
|
Facility
|
IP
|
$520.25
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
190933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$390.19 |
| Max. Negotiated Rate |
$483.83 |
| Rate for Payer: Aetna Commercial |
$449.50
|
| Rate for Payer: Cash Price |
$322.56
|
| Rate for Payer: Cigna All Commercial |
$448.98
|
| Rate for Payer: CORVEL All Commercial |
$483.83
|
| Rate for Payer: Coventry All Commercial |
$457.82
|
| Rate for Payer: Encore All Commercial |
$478.89
|
| Rate for Payer: Frontpath All Commercial |
$478.63
|
| Rate for Payer: Humana ChoiceCare |
$449.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$468.22
|
| Rate for Payer: PHCS All Commercial |
$390.19
|
| Rate for Payer: PHP All Commercial |
$394.56
|
| Rate for Payer: Sagamore Health Network All Products |
$401.63
|
| Rate for Payer: Signature Care EPO |
$431.81
|
| Rate for Payer: Signature Care PPO |
$457.82
|
| Rate for Payer: United Healthcare Commercial |
$409.96
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-48MCG-62DU -10 MCG/0.5ML IM KIT
|
Facility
|
OP
|
$520.25
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
190933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.55 |
| Max. Negotiated Rate |
$483.83 |
| Rate for Payer: Aetna Commercial |
$439.09
|
| Rate for Payer: Aetna Medicare |
$171.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$171.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$298.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$325.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$107.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$197.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$188.85
|
| Rate for Payer: Cash Price |
$322.56
|
| Rate for Payer: Cash Price |
$322.56
|
| Rate for Payer: Centivo All Commercial |
$265.33
|
| Rate for Payer: Cigna All Commercial |
$448.98
|
| Rate for Payer: CORVEL All Commercial |
$483.83
|
| Rate for Payer: Coventry All Commercial |
$457.82
|
| Rate for Payer: Encore All Commercial |
$478.89
|
| Rate for Payer: Frontpath All Commercial |
$478.63
|
| Rate for Payer: Humana ChoiceCare |
$449.34
|
| Rate for Payer: Humana Medicare |
$265.33
|
| Rate for Payer: Lucent All Commercial |
$265.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$468.22
|
| Rate for Payer: Managed Health Services Medicaid |
$107.55
|
| Rate for Payer: MDWise Medicaid |
$107.55
|
| Rate for Payer: PHCS All Commercial |
$390.19
|
| Rate for Payer: PHP All Commercial |
$394.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$202.90
|
| Rate for Payer: Sagamore Health Network All Products |
$401.63
|
| Rate for Payer: Signature Care EPO |
$431.81
|
| Rate for Payer: Signature Care PPO |
$457.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$442.21
|
| Rate for Payer: United Healthcare Commercial |
$409.96
|
| Rate for Payer: United Healthcare Medicare |
$171.68
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15 LF UNIT-20 MCG-5 LF/0.5 ML IM KIT
|
Facility
|
OP
|
$562.75
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
92074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.55 |
| Max. Negotiated Rate |
$523.36 |
| Rate for Payer: Aetna Commercial |
$474.96
|
| Rate for Payer: Aetna Medicare |
$185.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$185.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$323.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$351.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$107.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$213.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$204.28
|
| Rate for Payer: Cash Price |
$348.91
|
| Rate for Payer: Cash Price |
$348.91
|
| Rate for Payer: Centivo All Commercial |
$287.00
|
| Rate for Payer: Cigna All Commercial |
$485.65
|
| Rate for Payer: CORVEL All Commercial |
$523.36
|
| Rate for Payer: Coventry All Commercial |
$495.22
|
| Rate for Payer: Encore All Commercial |
$518.01
|
| Rate for Payer: Frontpath All Commercial |
$517.73
|
| Rate for Payer: Humana ChoiceCare |
$486.05
|
| Rate for Payer: Humana Medicare |
$287.00
|
| Rate for Payer: Lucent All Commercial |
$287.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$506.48
|
| Rate for Payer: Managed Health Services Medicaid |
$107.55
|
| Rate for Payer: MDWise Medicaid |
$107.55
|
| Rate for Payer: PHCS All Commercial |
$422.06
|
| Rate for Payer: PHP All Commercial |
$426.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$219.47
|
| Rate for Payer: Sagamore Health Network All Products |
$434.44
|
| Rate for Payer: Signature Care EPO |
$467.08
|
| Rate for Payer: Signature Care PPO |
$495.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$478.34
|
| Rate for Payer: United Healthcare Commercial |
$443.45
|
| Rate for Payer: United Healthcare Medicare |
$185.71
|
|
|
DIP-PERT(A)-TET-POLIO-HIB (PF) 15 LF UNIT-20 MCG-5 LF/0.5 ML IM KIT
|
Facility
|
IP
|
$562.75
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
92074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$422.06 |
| Max. Negotiated Rate |
$523.36 |
| Rate for Payer: Aetna Commercial |
$486.22
|
| Rate for Payer: Cash Price |
$348.91
|
| Rate for Payer: Cigna All Commercial |
$485.65
|
| Rate for Payer: CORVEL All Commercial |
$523.36
|
| Rate for Payer: Coventry All Commercial |
$495.22
|
| Rate for Payer: Encore All Commercial |
$518.01
|
| Rate for Payer: Frontpath All Commercial |
$517.73
|
| Rate for Payer: Humana ChoiceCare |
$486.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$506.48
|
| Rate for Payer: PHCS All Commercial |
$422.06
|
| Rate for Payer: PHP All Commercial |
$426.79
|
| Rate for Payer: Sagamore Health Network All Products |
$434.44
|
| Rate for Payer: Signature Care EPO |
$467.08
|
| Rate for Payer: Signature Care PPO |
$495.22
|
| Rate for Payer: United Healthcare Commercial |
$443.45
|
|
|
DIPYRIDAMOLE 25 MG ORAL TAB
|
Facility
|
OP
|
$9.95
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$9.25 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Aetna Medicare |
$3.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.61
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Centivo All Commercial |
$5.07
|
| Rate for Payer: Cigna All Commercial |
$8.58
|
| Rate for Payer: CORVEL All Commercial |
$9.25
|
| Rate for Payer: Coventry All Commercial |
$8.75
|
| Rate for Payer: Encore All Commercial |
$9.16
|
| Rate for Payer: Frontpath All Commercial |
$9.15
|
| Rate for Payer: Humana ChoiceCare |
$8.59
|
| Rate for Payer: Humana Medicare |
$5.07
|
| Rate for Payer: Lucent All Commercial |
$5.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.95
|
| Rate for Payer: PHCS All Commercial |
$7.46
|
| Rate for Payer: PHP All Commercial |
$7.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.88
|
| Rate for Payer: Sagamore Health Network All Products |
$7.68
|
| Rate for Payer: Signature Care EPO |
$8.26
|
| Rate for Payer: Signature Care PPO |
$8.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.45
|
| Rate for Payer: United Healthcare Commercial |
$7.84
|
| Rate for Payer: United Healthcare Medicare |
$3.28
|
|
|
DIPYRIDAMOLE 25 MG ORAL TAB
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$9.25 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Cigna All Commercial |
$8.58
|
| Rate for Payer: CORVEL All Commercial |
$9.25
|
| Rate for Payer: Coventry All Commercial |
$8.75
|
| Rate for Payer: Encore All Commercial |
$9.16
|
| Rate for Payer: Frontpath All Commercial |
$9.15
|
| Rate for Payer: Humana ChoiceCare |
$8.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.95
|
| Rate for Payer: PHCS All Commercial |
$7.46
|
| Rate for Payer: PHP All Commercial |
$7.54
|
| Rate for Payer: Sagamore Health Network All Products |
$7.68
|
| Rate for Payer: Signature Care EPO |
$8.26
|
| Rate for Payer: Signature Care PPO |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$7.84
|
|
|
DIVALPROEX 125 MG ORAL CDRS
|
Facility
|
IP
|
$5.34
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$4.61
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna All Commercial |
$4.61
|
| Rate for Payer: CORVEL All Commercial |
$4.97
|
| Rate for Payer: Coventry All Commercial |
$4.70
|
| Rate for Payer: Encore All Commercial |
$4.92
|
| Rate for Payer: Frontpath All Commercial |
$4.91
|
| Rate for Payer: Humana ChoiceCare |
$4.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.81
|
| Rate for Payer: PHCS All Commercial |
$4.01
|
| Rate for Payer: PHP All Commercial |
$4.05
|
| Rate for Payer: Sagamore Health Network All Products |
$4.12
|
| Rate for Payer: Signature Care EPO |
$4.43
|
| Rate for Payer: Signature Care PPO |
$4.70
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
|
|
DIVALPROEX 125 MG ORAL CDRS
|
Facility
|
OP
|
$5.34
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$4.51
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.94
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Centivo All Commercial |
$2.72
|
| Rate for Payer: Cigna All Commercial |
$4.61
|
| Rate for Payer: CORVEL All Commercial |
$4.97
|
| Rate for Payer: Coventry All Commercial |
$4.70
|
| Rate for Payer: Encore All Commercial |
$4.92
|
| Rate for Payer: Frontpath All Commercial |
$4.91
|
| Rate for Payer: Humana ChoiceCare |
$4.61
|
| Rate for Payer: Humana Medicare |
$2.72
|
| Rate for Payer: Lucent All Commercial |
$2.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.81
|
| Rate for Payer: PHCS All Commercial |
$4.01
|
| Rate for Payer: PHP All Commercial |
$4.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.08
|
| Rate for Payer: Sagamore Health Network All Products |
$4.12
|
| Rate for Payer: Signature Care EPO |
$4.43
|
| Rate for Payer: Signature Care PPO |
$4.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.54
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
| Rate for Payer: United Healthcare Medicare |
$1.76
|
|
