|
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB
|
Facility
|
IP
|
$359.24
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.43 |
| Max. Negotiated Rate |
$334.10 |
| Rate for Payer: Aetna Commercial |
$310.39
|
| Rate for Payer: Cash Price |
$222.73
|
| Rate for Payer: Cigna All Commercial |
$310.03
|
| Rate for Payer: CORVEL All Commercial |
$334.10
|
| Rate for Payer: Coventry All Commercial |
$316.13
|
| Rate for Payer: Encore All Commercial |
$330.68
|
| Rate for Payer: Frontpath All Commercial |
$330.50
|
| Rate for Payer: Humana ChoiceCare |
$310.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.32
|
| Rate for Payer: PHCS All Commercial |
$269.43
|
| Rate for Payer: PHP All Commercial |
$272.45
|
| Rate for Payer: Sagamore Health Network All Products |
$277.34
|
| Rate for Payer: Signature Care EPO |
$298.17
|
| Rate for Payer: Signature Care PPO |
$316.13
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
|
|
ENALAPRILAT 1.25 MG/ML IV SOLN
|
Facility
|
OP
|
$59.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.74 |
| Max. Negotiated Rate |
$55.62 |
| Rate for Payer: Aetna Commercial |
$50.48
|
| Rate for Payer: Aetna Commercial |
$28.26
|
| Rate for Payer: Aetna Medicare |
$19.74
|
| Rate for Payer: Aetna Medicare |
$11.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$34.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.71
|
| Rate for Payer: Cash Price |
$20.76
|
| Rate for Payer: Cash Price |
$37.08
|
| Rate for Payer: Centivo All Commercial |
$17.08
|
| Rate for Payer: Centivo All Commercial |
$30.50
|
| Rate for Payer: Cigna All Commercial |
$51.61
|
| Rate for Payer: Cigna All Commercial |
$28.90
|
| Rate for Payer: CORVEL All Commercial |
$31.14
|
| Rate for Payer: CORVEL All Commercial |
$55.62
|
| Rate for Payer: Coventry All Commercial |
$52.63
|
| Rate for Payer: Coventry All Commercial |
$29.47
|
| Rate for Payer: Encore All Commercial |
$30.83
|
| Rate for Payer: Encore All Commercial |
$55.05
|
| Rate for Payer: Frontpath All Commercial |
$30.81
|
| Rate for Payer: Frontpath All Commercial |
$55.02
|
| Rate for Payer: Humana ChoiceCare |
$51.66
|
| Rate for Payer: Humana ChoiceCare |
$28.92
|
| Rate for Payer: Humana Medicare |
$17.08
|
| Rate for Payer: Humana Medicare |
$30.50
|
| Rate for Payer: Lucent All Commercial |
$30.50
|
| Rate for Payer: Lucent All Commercial |
$17.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.83
|
| Rate for Payer: PHCS All Commercial |
$25.12
|
| Rate for Payer: PHCS All Commercial |
$44.86
|
| Rate for Payer: PHP All Commercial |
$45.36
|
| Rate for Payer: PHP All Commercial |
$25.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.33
|
| Rate for Payer: Sagamore Health Network All Products |
$25.85
|
| Rate for Payer: Sagamore Health Network All Products |
$46.17
|
| Rate for Payer: Signature Care EPO |
$49.64
|
| Rate for Payer: Signature Care EPO |
$27.80
|
| Rate for Payer: Signature Care PPO |
$52.63
|
| Rate for Payer: Signature Care PPO |
$29.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.84
|
| Rate for Payer: United Healthcare Commercial |
$26.39
|
| Rate for Payer: United Healthcare Commercial |
$47.13
|
| Rate for Payer: United Healthcare Medicare |
$11.05
|
| Rate for Payer: United Healthcare Medicare |
$19.74
|
|
|
ENALAPRILAT 1.25 MG/ML IV SOLN
|
Facility
|
IP
|
$59.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.86 |
| Max. Negotiated Rate |
$55.62 |
| Rate for Payer: Aetna Commercial |
$51.67
|
| Rate for Payer: Aetna Commercial |
$28.93
|
| Rate for Payer: Cash Price |
$37.08
|
| Rate for Payer: Cash Price |
$20.76
|
| Rate for Payer: Cigna All Commercial |
$51.61
|
| Rate for Payer: Cigna All Commercial |
$28.90
|
| Rate for Payer: CORVEL All Commercial |
$31.14
|
| Rate for Payer: CORVEL All Commercial |
$55.62
|
| Rate for Payer: Coventry All Commercial |
$29.47
|
| Rate for Payer: Coventry All Commercial |
$52.63
|
| Rate for Payer: Encore All Commercial |
$30.83
|
| Rate for Payer: Encore All Commercial |
$55.05
|
| Rate for Payer: Frontpath All Commercial |
$55.02
|
| Rate for Payer: Frontpath All Commercial |
$30.81
|
| Rate for Payer: Humana ChoiceCare |
$28.92
|
| Rate for Payer: Humana ChoiceCare |
$51.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.14
|
| Rate for Payer: PHCS All Commercial |
$25.12
|
| Rate for Payer: PHCS All Commercial |
$44.86
|
| Rate for Payer: PHP All Commercial |
$25.40
|
| Rate for Payer: PHP All Commercial |
$45.36
|
| Rate for Payer: Sagamore Health Network All Products |
$25.85
|
| Rate for Payer: Sagamore Health Network All Products |
$46.17
|
| Rate for Payer: Signature Care EPO |
$27.80
|
| Rate for Payer: Signature Care EPO |
$49.64
|
| Rate for Payer: Signature Care PPO |
$29.47
|
| Rate for Payer: Signature Care PPO |
$52.63
|
| Rate for Payer: United Healthcare Commercial |
$47.13
|
| Rate for Payer: United Healthcare Commercial |
$26.39
|
|
|
ENALAPRIL MALEATE 5 MG ORAL TAB
|
Facility
|
IP
|
$5.38
|
|
|
Service Code
|
NDC 00904550261
|
| Hospital Charge Code |
9927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
|
|
ENALAPRIL MALEATE 5 MG ORAL TAB
|
Facility
|
OP
|
$5.38
|
|
|
Service Code
|
NDC 00904550261
|
| Hospital Charge Code |
9927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.54
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Centivo All Commercial |
$2.74
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Humana Medicare |
$2.74
|
| Rate for Payer: Lucent All Commercial |
$2.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.10
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.57
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
| Rate for Payer: United Healthcare Medicare |
$1.77
|
|
|
Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 44385
|
| Hospital Charge Code |
CPT-44385
|
|
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
|
|
|
Endoscopy, wrist, surgical, with release of transverse carpal ligament
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29848
|
| Hospital Charge Code |
CPT-29848
|
|
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
|
|
|
ENOXAPARIN 100 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$60.55
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.41 |
| Max. Negotiated Rate |
$56.31 |
| Rate for Payer: Aetna Commercial |
$52.32
|
| Rate for Payer: Cash Price |
$37.54
|
| Rate for Payer: Cigna All Commercial |
$52.25
|
| Rate for Payer: CORVEL All Commercial |
$56.31
|
| Rate for Payer: Coventry All Commercial |
$53.28
|
| Rate for Payer: Encore All Commercial |
$55.74
|
| Rate for Payer: Frontpath All Commercial |
$55.71
|
| Rate for Payer: Humana ChoiceCare |
$52.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.50
|
| Rate for Payer: PHCS All Commercial |
$45.41
|
| Rate for Payer: PHP All Commercial |
$45.92
|
| Rate for Payer: Sagamore Health Network All Products |
$46.74
|
| Rate for Payer: Signature Care EPO |
$50.26
|
| Rate for Payer: Signature Care PPO |
$53.28
|
| Rate for Payer: United Healthcare Commercial |
$47.71
|
|
|
ENOXAPARIN 100 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$60.55
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.98 |
| Max. Negotiated Rate |
$56.31 |
| Rate for Payer: Aetna Commercial |
$51.10
|
| Rate for Payer: Aetna Medicare |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$34.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.98
|
| Rate for Payer: Cash Price |
$37.54
|
| Rate for Payer: Centivo All Commercial |
$30.88
|
| Rate for Payer: Cigna All Commercial |
$52.25
|
| Rate for Payer: CORVEL All Commercial |
$56.31
|
| Rate for Payer: Coventry All Commercial |
$53.28
|
| Rate for Payer: Encore All Commercial |
$55.74
|
| Rate for Payer: Frontpath All Commercial |
$55.71
|
| Rate for Payer: Humana ChoiceCare |
$52.30
|
| Rate for Payer: Humana Medicare |
$30.88
|
| Rate for Payer: Lucent All Commercial |
$30.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.50
|
| Rate for Payer: PHCS All Commercial |
$45.41
|
| Rate for Payer: PHP All Commercial |
$45.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.61
|
| Rate for Payer: Sagamore Health Network All Products |
$46.74
|
| Rate for Payer: Signature Care EPO |
$50.26
|
| Rate for Payer: Signature Care PPO |
$53.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$51.47
|
| Rate for Payer: United Healthcare Commercial |
$47.71
|
| Rate for Payer: United Healthcare Medicare |
$19.98
|
|
|
ENOXAPARIN 150 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$90.96
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.02 |
| Max. Negotiated Rate |
$84.59 |
| Rate for Payer: Aetna Commercial |
$76.77
|
| Rate for Payer: Aetna Medicare |
$30.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$52.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$34.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.02
|
| Rate for Payer: Cash Price |
$56.39
|
| Rate for Payer: Centivo All Commercial |
$46.39
|
| Rate for Payer: Cigna All Commercial |
$78.50
|
| Rate for Payer: CORVEL All Commercial |
$84.59
|
| Rate for Payer: Coventry All Commercial |
$80.04
|
| Rate for Payer: Encore All Commercial |
$83.73
|
| Rate for Payer: Frontpath All Commercial |
$83.68
|
| Rate for Payer: Humana ChoiceCare |
$78.56
|
| Rate for Payer: Humana Medicare |
$46.39
|
| Rate for Payer: Lucent All Commercial |
$46.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81.86
|
| Rate for Payer: PHCS All Commercial |
$68.22
|
| Rate for Payer: PHP All Commercial |
$68.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.47
|
| Rate for Payer: Sagamore Health Network All Products |
$70.22
|
| Rate for Payer: Signature Care EPO |
$75.50
|
| Rate for Payer: Signature Care PPO |
$80.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$77.31
|
| Rate for Payer: United Healthcare Commercial |
$71.67
|
| Rate for Payer: United Healthcare Medicare |
$30.02
|
|
|
ENOXAPARIN 150 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$90.96
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.22 |
| Max. Negotiated Rate |
$84.59 |
| Rate for Payer: Aetna Commercial |
$78.59
|
| Rate for Payer: Cash Price |
$56.39
|
| Rate for Payer: Cigna All Commercial |
$78.50
|
| Rate for Payer: CORVEL All Commercial |
$84.59
|
| Rate for Payer: Coventry All Commercial |
$80.04
|
| Rate for Payer: Encore All Commercial |
$83.73
|
| Rate for Payer: Frontpath All Commercial |
$83.68
|
| Rate for Payer: Humana ChoiceCare |
$78.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81.86
|
| Rate for Payer: PHCS All Commercial |
$68.22
|
| Rate for Payer: PHP All Commercial |
$68.98
|
| Rate for Payer: Sagamore Health Network All Products |
$70.22
|
| Rate for Payer: Signature Care EPO |
$75.50
|
| Rate for Payer: Signature Care PPO |
$80.04
|
| Rate for Payer: United Healthcare Commercial |
$71.67
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG
|
Facility
|
OP
|
$19.32
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$17.97 |
| Rate for Payer: Aetna Commercial |
$16.31
|
| Rate for Payer: Aetna Medicare |
$6.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.01
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Centivo All Commercial |
$9.85
|
| Rate for Payer: Cigna All Commercial |
$16.67
|
| Rate for Payer: CORVEL All Commercial |
$17.97
|
| Rate for Payer: Coventry All Commercial |
$17.00
|
| Rate for Payer: Encore All Commercial |
$17.78
|
| Rate for Payer: Frontpath All Commercial |
$17.77
|
| Rate for Payer: Humana ChoiceCare |
$16.69
|
| Rate for Payer: Humana Medicare |
$9.85
|
| Rate for Payer: Lucent All Commercial |
$9.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.39
|
| Rate for Payer: PHCS All Commercial |
$14.49
|
| Rate for Payer: PHP All Commercial |
$14.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.53
|
| Rate for Payer: Sagamore Health Network All Products |
$14.92
|
| Rate for Payer: Signature Care EPO |
$16.04
|
| Rate for Payer: Signature Care PPO |
$17.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.42
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$6.38
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG
|
Facility
|
IP
|
$19.32
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.49 |
| Max. Negotiated Rate |
$17.97 |
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cigna All Commercial |
$16.67
|
| Rate for Payer: CORVEL All Commercial |
$17.97
|
| Rate for Payer: Coventry All Commercial |
$17.00
|
| Rate for Payer: Encore All Commercial |
$17.78
|
| Rate for Payer: Frontpath All Commercial |
$17.77
|
| Rate for Payer: Humana ChoiceCare |
$16.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.39
|
| Rate for Payer: PHCS All Commercial |
$14.49
|
| Rate for Payer: PHP All Commercial |
$14.65
|
| Rate for Payer: Sagamore Health Network All Products |
$14.92
|
| Rate for Payer: Signature Care EPO |
$16.04
|
| Rate for Payer: Signature Care PPO |
$17.00
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG
|
Facility
|
OP
|
$25.76
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Medicare |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.35
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Centivo All Commercial |
$13.14
|
| Rate for Payer: Cigna All Commercial |
$22.23
|
| Rate for Payer: CORVEL All Commercial |
$23.96
|
| Rate for Payer: Coventry All Commercial |
$22.67
|
| Rate for Payer: Encore All Commercial |
$23.71
|
| Rate for Payer: Frontpath All Commercial |
$23.70
|
| Rate for Payer: Humana ChoiceCare |
$22.25
|
| Rate for Payer: Humana Medicare |
$13.14
|
| Rate for Payer: Lucent All Commercial |
$13.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.18
|
| Rate for Payer: PHCS All Commercial |
$19.32
|
| Rate for Payer: PHP All Commercial |
$19.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.05
|
| Rate for Payer: Sagamore Health Network All Products |
$19.89
|
| Rate for Payer: Signature Care EPO |
$21.38
|
| Rate for Payer: Signature Care PPO |
$22.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.90
|
| Rate for Payer: United Healthcare Commercial |
$20.30
|
| Rate for Payer: United Healthcare Medicare |
$8.50
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG
|
Facility
|
IP
|
$25.76
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Aetna Commercial |
$22.26
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna All Commercial |
$22.23
|
| Rate for Payer: CORVEL All Commercial |
$23.96
|
| Rate for Payer: Coventry All Commercial |
$22.67
|
| Rate for Payer: Encore All Commercial |
$23.71
|
| Rate for Payer: Frontpath All Commercial |
$23.70
|
| Rate for Payer: Humana ChoiceCare |
$22.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.18
|
| Rate for Payer: PHCS All Commercial |
$19.32
|
| Rate for Payer: PHP All Commercial |
$19.54
|
| Rate for Payer: Sagamore Health Network All Products |
$19.89
|
| Rate for Payer: Signature Care EPO |
$21.38
|
| Rate for Payer: Signature Care PPO |
$22.67
|
| Rate for Payer: United Healthcare Commercial |
$20.30
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG
|
Facility
|
IP
|
$36.32
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.24 |
| Max. Negotiated Rate |
$33.78 |
| Rate for Payer: Aetna Commercial |
$31.38
|
| Rate for Payer: Cash Price |
$22.52
|
| Rate for Payer: Cigna All Commercial |
$31.34
|
| Rate for Payer: CORVEL All Commercial |
$33.78
|
| Rate for Payer: Coventry All Commercial |
$31.96
|
| Rate for Payer: Encore All Commercial |
$33.43
|
| Rate for Payer: Frontpath All Commercial |
$33.41
|
| Rate for Payer: Humana ChoiceCare |
$31.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.69
|
| Rate for Payer: PHCS All Commercial |
$27.24
|
| Rate for Payer: PHP All Commercial |
$27.54
|
| Rate for Payer: Sagamore Health Network All Products |
$28.04
|
| Rate for Payer: Signature Care EPO |
$30.14
|
| Rate for Payer: Signature Care PPO |
$31.96
|
| Rate for Payer: United Healthcare Commercial |
$28.62
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG
|
Facility
|
OP
|
$36.32
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$33.78 |
| Rate for Payer: Aetna Commercial |
$30.65
|
| Rate for Payer: Aetna Medicare |
$11.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.18
|
| Rate for Payer: Cash Price |
$22.52
|
| Rate for Payer: Centivo All Commercial |
$18.52
|
| Rate for Payer: Cigna All Commercial |
$31.34
|
| Rate for Payer: CORVEL All Commercial |
$33.78
|
| Rate for Payer: Coventry All Commercial |
$31.96
|
| Rate for Payer: Encore All Commercial |
$33.43
|
| Rate for Payer: Frontpath All Commercial |
$33.41
|
| Rate for Payer: Humana ChoiceCare |
$31.37
|
| Rate for Payer: Humana Medicare |
$18.52
|
| Rate for Payer: Lucent All Commercial |
$18.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.69
|
| Rate for Payer: PHCS All Commercial |
$27.24
|
| Rate for Payer: PHP All Commercial |
$27.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.16
|
| Rate for Payer: Sagamore Health Network All Products |
$28.04
|
| Rate for Payer: Signature Care EPO |
$30.14
|
| Rate for Payer: Signature Care PPO |
$31.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.87
|
| Rate for Payer: United Healthcare Commercial |
$28.62
|
| Rate for Payer: United Healthcare Medicare |
$11.98
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG
|
Facility
|
IP
|
$48.47
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.35 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$41.88
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cigna All Commercial |
$41.83
|
| Rate for Payer: CORVEL All Commercial |
$45.08
|
| Rate for Payer: Coventry All Commercial |
$42.65
|
| Rate for Payer: Encore All Commercial |
$44.61
|
| Rate for Payer: Frontpath All Commercial |
$44.59
|
| Rate for Payer: Humana ChoiceCare |
$41.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.62
|
| Rate for Payer: PHCS All Commercial |
$36.35
|
| Rate for Payer: PHP All Commercial |
$36.76
|
| Rate for Payer: Sagamore Health Network All Products |
$37.42
|
| Rate for Payer: Signature Care EPO |
$40.23
|
| Rate for Payer: Signature Care PPO |
$42.65
|
| Rate for Payer: United Healthcare Commercial |
$38.19
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG
|
Facility
|
OP
|
$48.47
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$40.91
|
| Rate for Payer: Aetna Medicare |
$15.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.59
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Centivo All Commercial |
$24.72
|
| Rate for Payer: Cigna All Commercial |
$41.83
|
| Rate for Payer: CORVEL All Commercial |
$45.08
|
| Rate for Payer: Coventry All Commercial |
$42.65
|
| Rate for Payer: Encore All Commercial |
$44.61
|
| Rate for Payer: Frontpath All Commercial |
$44.59
|
| Rate for Payer: Humana ChoiceCare |
$41.86
|
| Rate for Payer: Humana Medicare |
$24.72
|
| Rate for Payer: Lucent All Commercial |
$24.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.62
|
| Rate for Payer: PHCS All Commercial |
$36.35
|
| Rate for Payer: PHP All Commercial |
$36.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.90
|
| Rate for Payer: Sagamore Health Network All Products |
$37.42
|
| Rate for Payer: Signature Care EPO |
$40.23
|
| Rate for Payer: Signature Care PPO |
$42.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.20
|
| Rate for Payer: United Healthcare Commercial |
$38.19
|
| Rate for Payer: United Healthcare Medicare |
$15.99
|
|
|
EPHEDRINE SULFATE 50 MG/ML IV SOLN
|
Facility
|
OP
|
$107.80
|
|
|
Service Code
|
NDC 43598072525
|
| Hospital Charge Code |
177736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$100.25 |
| Rate for Payer: Aetna Commercial |
$90.98
|
| Rate for Payer: Aetna Medicare |
$35.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.13
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Centivo All Commercial |
$54.98
|
| Rate for Payer: Cigna All Commercial |
$93.03
|
| Rate for Payer: CORVEL All Commercial |
$100.25
|
| Rate for Payer: Coventry All Commercial |
$94.86
|
| Rate for Payer: Encore All Commercial |
$99.23
|
| Rate for Payer: Frontpath All Commercial |
$99.18
|
| Rate for Payer: Humana ChoiceCare |
$93.11
|
| Rate for Payer: Humana Medicare |
$54.98
|
| Rate for Payer: Lucent All Commercial |
$54.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.02
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$80.85
|
| Rate for Payer: PHP All Commercial |
$81.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.04
|
| Rate for Payer: Sagamore Health Network All Products |
$83.22
|
| Rate for Payer: Signature Care EPO |
$89.47
|
| Rate for Payer: Signature Care PPO |
$94.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.63
|
| Rate for Payer: United Healthcare Commercial |
$84.95
|
| Rate for Payer: United Healthcare Medicare |
$35.57
|
|
|
EPHEDRINE SULFATE 50 MG/ML IV SOLN
|
Facility
|
IP
|
$107.80
|
|
|
Service Code
|
NDC 43598072525
|
| Hospital Charge Code |
177736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.85 |
| Max. Negotiated Rate |
$100.25 |
| Rate for Payer: Aetna Commercial |
$93.14
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Cigna All Commercial |
$93.03
|
| Rate for Payer: CORVEL All Commercial |
$100.25
|
| Rate for Payer: Coventry All Commercial |
$94.86
|
| Rate for Payer: Encore All Commercial |
$99.23
|
| Rate for Payer: Frontpath All Commercial |
$99.18
|
| Rate for Payer: Humana ChoiceCare |
$93.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.02
|
| Rate for Payer: PHCS All Commercial |
$80.85
|
| Rate for Payer: PHP All Commercial |
$81.76
|
| Rate for Payer: Sagamore Health Network All Products |
$83.22
|
| Rate for Payer: Signature Care EPO |
$89.47
|
| Rate for Payer: Signature Care PPO |
$94.86
|
| Rate for Payer: United Healthcare Commercial |
$84.95
|
|
|
EPINEPHRINE 0.1 MG/ML INJ SYRG
|
Facility
|
IP
|
$69.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$64.45 |
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Cash Price |
$42.97
|
| Rate for Payer: Cigna All Commercial |
$59.81
|
| Rate for Payer: CORVEL All Commercial |
$64.45
|
| Rate for Payer: Coventry All Commercial |
$60.98
|
| Rate for Payer: Encore All Commercial |
$63.79
|
| Rate for Payer: Frontpath All Commercial |
$63.76
|
| Rate for Payer: Humana ChoiceCare |
$59.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.37
|
| Rate for Payer: PHCS All Commercial |
$51.98
|
| Rate for Payer: PHP All Commercial |
$52.56
|
| Rate for Payer: Sagamore Health Network All Products |
$53.50
|
| Rate for Payer: Signature Care EPO |
$57.52
|
| Rate for Payer: Signature Care PPO |
$60.98
|
| Rate for Payer: United Healthcare Commercial |
$54.61
|
|
|
EPINEPHRINE 0.1 MG/ML INJ SYRG
|
Facility
|
OP
|
$69.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2848
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$64.45 |
| Rate for Payer: Aetna Commercial |
$58.49
|
| Rate for Payer: Aetna Medicare |
$22.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.16
|
| Rate for Payer: Cash Price |
$42.97
|
| Rate for Payer: Centivo All Commercial |
$35.34
|
| Rate for Payer: Cigna All Commercial |
$59.81
|
| Rate for Payer: CORVEL All Commercial |
$64.45
|
| Rate for Payer: Coventry All Commercial |
$60.98
|
| Rate for Payer: Encore All Commercial |
$63.79
|
| Rate for Payer: Frontpath All Commercial |
$63.76
|
| Rate for Payer: Humana ChoiceCare |
$59.85
|
| Rate for Payer: Humana Medicare |
$35.34
|
| Rate for Payer: Lucent All Commercial |
$35.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.37
|
| Rate for Payer: PHCS All Commercial |
$51.98
|
| Rate for Payer: PHP All Commercial |
$52.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.03
|
| Rate for Payer: Sagamore Health Network All Products |
$53.50
|
| Rate for Payer: Signature Care EPO |
$57.52
|
| Rate for Payer: Signature Care PPO |
$60.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.90
|
| Rate for Payer: United Healthcare Commercial |
$54.61
|
| Rate for Payer: United Healthcare Medicare |
$22.87
|
|
|
EPINEPHRINE HCL 1 MG/ML NASL SOLN
|
Facility
|
OP
|
$1,188.30
|
|
|
Service Code
|
NDC 42023010301
|
| Hospital Charge Code |
19604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,105.12 |
| Rate for Payer: Aetna Commercial |
$1,002.93
|
| Rate for Payer: Aetna Medicare |
$392.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$392.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$682.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$742.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$450.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$431.35
|
| Rate for Payer: Cash Price |
$736.75
|
| Rate for Payer: Cash Price |
$736.75
|
| Rate for Payer: Centivo All Commercial |
$606.03
|
| Rate for Payer: Cigna All Commercial |
$1,025.50
|
| Rate for Payer: CORVEL All Commercial |
$1,105.12
|
| Rate for Payer: Coventry All Commercial |
$1,045.70
|
| Rate for Payer: Encore All Commercial |
$1,093.83
|
| Rate for Payer: Frontpath All Commercial |
$1,093.24
|
| Rate for Payer: Humana ChoiceCare |
$1,026.33
|
| Rate for Payer: Humana Medicare |
$606.03
|
| Rate for Payer: Lucent All Commercial |
$606.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,069.47
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$891.22
|
| Rate for Payer: PHP All Commercial |
$901.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$463.44
|
| Rate for Payer: Sagamore Health Network All Products |
$917.37
|
| Rate for Payer: Signature Care EPO |
$986.29
|
| Rate for Payer: Signature Care PPO |
$1,045.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,010.06
|
| Rate for Payer: United Healthcare Commercial |
$936.38
|
| Rate for Payer: United Healthcare Medicare |
$392.14
|
|
|
EPINEPHRINE HCL 1 MG/ML NASL SOLN
|
Facility
|
IP
|
$335.64
|
|
|
Service Code
|
NDC 54288012301
|
| Hospital Charge Code |
19604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.73 |
| Max. Negotiated Rate |
$312.15 |
| Rate for Payer: Aetna Commercial |
$289.99
|
| Rate for Payer: Cash Price |
$208.10
|
| Rate for Payer: Cigna All Commercial |
$289.66
|
| Rate for Payer: CORVEL All Commercial |
$312.15
|
| Rate for Payer: Coventry All Commercial |
$295.36
|
| Rate for Payer: Encore All Commercial |
$308.96
|
| Rate for Payer: Frontpath All Commercial |
$308.79
|
| Rate for Payer: Humana ChoiceCare |
$289.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$302.08
|
| Rate for Payer: PHCS All Commercial |
$251.73
|
| Rate for Payer: PHP All Commercial |
$254.55
|
| Rate for Payer: Sagamore Health Network All Products |
$259.11
|
| Rate for Payer: Signature Care EPO |
$278.58
|
| Rate for Payer: Signature Care PPO |
$295.36
|
| Rate for Payer: United Healthcare Commercial |
$264.48
|
|
