|
Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 43236
|
| Hospital Charge Code |
CPT-43236
|
|
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
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 43247
|
| Hospital Charge Code |
CPT-43247
|
|
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
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 43251
|
| Hospital Charge Code |
CPT-43251
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
Esophagoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 43202
|
| Hospital Charge Code |
CPT-43202
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
Esophagoscopy, flexible, transoral; with removal of foreign body(s)
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 43215
|
| Hospital Charge Code |
CPT-43215
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
ESTRADIOL 0.01 % (0.1 MG/GRAM) VAGL CREA
|
Facility
OP
|
$777.75
|
|
|
Service Code
|
NDC 47781010444
|
| Hospital Charge Code |
9969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$256.66 |
| Max. Negotiated Rate |
$723.31 |
| Rate for Payer: Aetna Commercial |
$656.42
|
| Rate for Payer: Aetna Medicare |
$256.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$256.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$446.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$486.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$295.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$282.32
|
| Rate for Payer: Cash Price |
$482.21
|
| Rate for Payer: Centivo All Commercial |
$396.65
|
| Rate for Payer: Cigna All Commercial |
$671.20
|
| Rate for Payer: CORVEL All Commercial |
$723.31
|
| Rate for Payer: Coventry All Commercial |
$684.42
|
| Rate for Payer: Encore All Commercial |
$715.92
|
| Rate for Payer: Frontpath All Commercial |
$715.53
|
| Rate for Payer: Humana ChoiceCare |
$671.74
|
| Rate for Payer: Humana Medicare |
$396.65
|
| Rate for Payer: Lucent All Commercial |
$396.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$699.98
|
| Rate for Payer: PHCS All Commercial |
$583.31
|
| Rate for Payer: PHP All Commercial |
$589.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$303.32
|
| Rate for Payer: Sagamore Health Network All Products |
$600.42
|
| Rate for Payer: Signature Care EPO |
$645.53
|
| Rate for Payer: Signature Care PPO |
$684.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$661.09
|
| Rate for Payer: United Healthcare Commercial |
$612.87
|
| Rate for Payer: United Healthcare Medicare |
$256.66
|
|
|
ESTRADIOL 0.01 % (0.1 MG/GRAM) VAGL CREA
|
Facility
IP
|
$777.75
|
|
|
Service Code
|
NDC 47781010444
|
| Hospital Charge Code |
9969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$583.31 |
| Max. Negotiated Rate |
$723.31 |
| Rate for Payer: Aetna Commercial |
$671.98
|
| Rate for Payer: Cash Price |
$482.21
|
| Rate for Payer: Cigna All Commercial |
$671.20
|
| Rate for Payer: CORVEL All Commercial |
$723.31
|
| Rate for Payer: Coventry All Commercial |
$684.42
|
| Rate for Payer: Encore All Commercial |
$715.92
|
| Rate for Payer: Frontpath All Commercial |
$715.53
|
| Rate for Payer: Humana ChoiceCare |
$671.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$699.98
|
| Rate for Payer: PHCS All Commercial |
$583.31
|
| Rate for Payer: PHP All Commercial |
$589.85
|
| Rate for Payer: Sagamore Health Network All Products |
$600.42
|
| Rate for Payer: Signature Care EPO |
$645.53
|
| Rate for Payer: Signature Care PPO |
$684.42
|
| Rate for Payer: United Healthcare Commercial |
$612.87
|
|
|
ESTRADIOL 0.05 MG/24 HR TD PTWK
|
Facility
IP
|
$81.83
|
|
|
Service Code
|
NDC 00781713354
|
| Hospital Charge Code |
110634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.37 |
| Max. Negotiated Rate |
$76.10 |
| Rate for Payer: Aetna Commercial |
$70.70
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cigna All Commercial |
$70.62
|
| Rate for Payer: CORVEL All Commercial |
$76.10
|
| Rate for Payer: Coventry All Commercial |
$72.01
|
| Rate for Payer: Encore All Commercial |
$75.32
|
| Rate for Payer: Frontpath All Commercial |
$75.28
|
| Rate for Payer: Humana ChoiceCare |
$70.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.65
|
| Rate for Payer: PHCS All Commercial |
$61.37
|
| Rate for Payer: PHP All Commercial |
$62.06
|
| Rate for Payer: Sagamore Health Network All Products |
$63.17
|
| Rate for Payer: Signature Care EPO |
$67.92
|
| Rate for Payer: Signature Care PPO |
$72.01
|
| Rate for Payer: United Healthcare Commercial |
$64.48
|
|
|
ESTRADIOL 0.05 MG/24 HR TD PTWK
|
Facility
OP
|
$81.83
|
|
|
Service Code
|
NDC 00781713354
|
| Hospital Charge Code |
110634
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$76.10 |
| Rate for Payer: Aetna Commercial |
$69.06
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$46.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.70
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Centivo All Commercial |
$41.73
|
| Rate for Payer: Cigna All Commercial |
$70.62
|
| Rate for Payer: CORVEL All Commercial |
$76.10
|
| Rate for Payer: Coventry All Commercial |
$72.01
|
| Rate for Payer: Encore All Commercial |
$75.32
|
| Rate for Payer: Frontpath All Commercial |
$75.28
|
| Rate for Payer: Humana ChoiceCare |
$70.68
|
| Rate for Payer: Humana Medicare |
$41.73
|
| Rate for Payer: Lucent All Commercial |
$41.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.65
|
| Rate for Payer: PHCS All Commercial |
$61.37
|
| Rate for Payer: PHP All Commercial |
$62.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.91
|
| Rate for Payer: Sagamore Health Network All Products |
$63.17
|
| Rate for Payer: Signature Care EPO |
$67.92
|
| Rate for Payer: Signature Care PPO |
$72.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$69.56
|
| Rate for Payer: United Healthcare Commercial |
$64.48
|
| Rate for Payer: United Healthcare Medicare |
$27.00
|
|
|
ESTRADIOL 0.5 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 42806008701
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
ESTRADIOL 0.5 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 42806008701
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
ETHYL CHLORIDE 100 % TOP SPRA
|
Facility
IP
|
$228.98
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.74 |
| Max. Negotiated Rate |
$212.96 |
| Rate for Payer: Aetna Commercial |
$197.84
|
| Rate for Payer: Cash Price |
$141.97
|
| Rate for Payer: Cigna All Commercial |
$197.61
|
| Rate for Payer: CORVEL All Commercial |
$212.96
|
| Rate for Payer: Coventry All Commercial |
$201.51
|
| Rate for Payer: Encore All Commercial |
$210.78
|
| Rate for Payer: Frontpath All Commercial |
$210.67
|
| Rate for Payer: Humana ChoiceCare |
$197.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$206.09
|
| Rate for Payer: PHCS All Commercial |
$171.74
|
| Rate for Payer: PHP All Commercial |
$173.66
|
| Rate for Payer: Sagamore Health Network All Products |
$176.78
|
| Rate for Payer: Signature Care EPO |
$190.06
|
| Rate for Payer: Signature Care PPO |
$201.51
|
| Rate for Payer: United Healthcare Commercial |
$180.44
|
|
|
ETHYL CHLORIDE 100 % TOP SPRA
|
Facility
OP
|
$228.98
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.56 |
| Max. Negotiated Rate |
$212.96 |
| Rate for Payer: Aetna Commercial |
$193.26
|
| Rate for Payer: Aetna Medicare |
$75.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$75.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$131.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$143.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$86.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.12
|
| Rate for Payer: Cash Price |
$141.97
|
| Rate for Payer: Centivo All Commercial |
$116.78
|
| Rate for Payer: Cigna All Commercial |
$197.61
|
| Rate for Payer: CORVEL All Commercial |
$212.96
|
| Rate for Payer: Coventry All Commercial |
$201.51
|
| Rate for Payer: Encore All Commercial |
$210.78
|
| Rate for Payer: Frontpath All Commercial |
$210.67
|
| Rate for Payer: Humana ChoiceCare |
$197.77
|
| Rate for Payer: Humana Medicare |
$116.78
|
| Rate for Payer: Lucent All Commercial |
$116.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$206.09
|
| Rate for Payer: PHCS All Commercial |
$171.74
|
| Rate for Payer: PHP All Commercial |
$173.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$89.30
|
| Rate for Payer: Sagamore Health Network All Products |
$176.78
|
| Rate for Payer: Signature Care EPO |
$190.06
|
| Rate for Payer: Signature Care PPO |
$201.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$194.64
|
| Rate for Payer: United Healthcare Commercial |
$180.44
|
| Rate for Payer: United Healthcare Medicare |
$75.56
|
|
|
ETOMIDATE 2 MG/ML IV SOLN
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$24.19
|
| Rate for Payer: Cash Price |
$17.36
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
|
|
ETOMIDATE 2 MG/ML IV SOLN
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$17.36
|
| Rate for Payer: Centivo All Commercial |
$14.28
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana Medicare |
$14.28
|
| Rate for Payer: Lucent All Commercial |
$14.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.92
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
|
|
ETONOGESTREL 68 MG SDRM IMPL
|
Facility
IP
|
$2,543.82
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
77012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,907.86 |
| Max. Negotiated Rate |
$2,365.75 |
| Rate for Payer: Aetna Commercial |
$2,197.86
|
| Rate for Payer: Cash Price |
$1,577.17
|
| Rate for Payer: Cigna All Commercial |
$2,195.31
|
| Rate for Payer: CORVEL All Commercial |
$2,365.75
|
| Rate for Payer: Coventry All Commercial |
$2,238.56
|
| Rate for Payer: Encore All Commercial |
$2,341.58
|
| Rate for Payer: Frontpath All Commercial |
$2,340.31
|
| Rate for Payer: Humana ChoiceCare |
$2,197.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,289.43
|
| Rate for Payer: PHCS All Commercial |
$1,907.86
|
| Rate for Payer: PHP All Commercial |
$1,929.23
|
| Rate for Payer: Sagamore Health Network All Products |
$1,963.83
|
| Rate for Payer: Signature Care EPO |
$2,111.37
|
| Rate for Payer: Signature Care PPO |
$2,238.56
|
| Rate for Payer: United Healthcare Commercial |
$2,004.53
|
|
|
ETONOGESTREL 68 MG SDRM IMPL
|
Facility
OP
|
$2,543.82
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
77012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$839.46 |
| Max. Negotiated Rate |
$2,365.75 |
| Rate for Payer: Aetna Commercial |
$2,146.98
|
| Rate for Payer: Aetna Medicare |
$839.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$839.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,460.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,590.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,082.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$965.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$923.41
|
| Rate for Payer: Cash Price |
$1,577.17
|
| Rate for Payer: Cash Price |
$1,577.17
|
| Rate for Payer: Centivo All Commercial |
$1,297.35
|
| Rate for Payer: Cigna All Commercial |
$2,195.31
|
| Rate for Payer: CORVEL All Commercial |
$2,365.75
|
| Rate for Payer: Coventry All Commercial |
$2,238.56
|
| Rate for Payer: Encore All Commercial |
$2,341.58
|
| Rate for Payer: Frontpath All Commercial |
$2,340.31
|
| Rate for Payer: Humana ChoiceCare |
$2,197.09
|
| Rate for Payer: Humana Medicare |
$1,297.35
|
| Rate for Payer: Lucent All Commercial |
$1,297.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,289.43
|
| Rate for Payer: Managed Health Services Medicaid |
$1,082.17
|
| Rate for Payer: MDWise Medicaid |
$1,082.17
|
| Rate for Payer: PHCS All Commercial |
$1,907.86
|
| Rate for Payer: PHP All Commercial |
$1,929.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$992.09
|
| Rate for Payer: Sagamore Health Network All Products |
$1,963.83
|
| Rate for Payer: Signature Care EPO |
$2,111.37
|
| Rate for Payer: Signature Care PPO |
$2,238.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,162.24
|
| Rate for Payer: United Healthcare Commercial |
$2,004.53
|
| Rate for Payer: United Healthcare Medicare |
$839.46
|
|
|
ETONOGESTREL IMPLANT SYSTEM
|
Professional
|
$1,125.25
|
|
|
Service Code
|
CPT J7307
|
| Hospital Charge Code |
zJ7307
|
| Min. Negotiated Rate |
$1,048.78 |
| Max. Negotiated Rate |
$1,125.25 |
| Rate for Payer: Humana ChoiceCare |
$1,119.79
|
| Rate for Payer: PHP All Commercial |
$1,048.78
|
| Rate for Payer: United Healthcare Commercial |
$1,125.25
|
|
|
EUCALYPTUS-MENTHOL MM LOZG
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 41528000066
|
| Hospital Charge Code |
14294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna Commercial |
$0.40
|
| Rate for Payer: Aetna Medicare |
$0.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Centivo All Commercial |
$0.24
|
| Rate for Payer: Cigna All Commercial |
$0.40
|
| Rate for Payer: CORVEL All Commercial |
$0.44
|
| Rate for Payer: Coventry All Commercial |
$0.41
|
| Rate for Payer: Encore All Commercial |
$0.43
|
| Rate for Payer: Frontpath All Commercial |
$0.43
|
| Rate for Payer: Humana ChoiceCare |
$0.41
|
| Rate for Payer: Humana Medicare |
$0.24
|
| Rate for Payer: Lucent All Commercial |
$0.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.42
|
| Rate for Payer: PHCS All Commercial |
$0.35
|
| Rate for Payer: PHP All Commercial |
$0.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.18
|
| Rate for Payer: Sagamore Health Network All Products |
$0.36
|
| Rate for Payer: Signature Care EPO |
$0.39
|
| Rate for Payer: Signature Care PPO |
$0.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
|
|
EUCALYPTUS-MENTHOL MM LOZG
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 41528000066
|
| Hospital Charge Code |
14294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna All Commercial |
$0.40
|
| Rate for Payer: CORVEL All Commercial |
$0.44
|
| Rate for Payer: Coventry All Commercial |
$0.41
|
| Rate for Payer: Encore All Commercial |
$0.43
|
| Rate for Payer: Frontpath All Commercial |
$0.43
|
| Rate for Payer: Humana ChoiceCare |
$0.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.42
|
| Rate for Payer: PHCS All Commercial |
$0.35
|
| Rate for Payer: PHP All Commercial |
$0.36
|
| Rate for Payer: Sagamore Health Network All Products |
$0.36
|
| Rate for Payer: Signature Care EPO |
$0.39
|
| Rate for Payer: Signature Care PPO |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
|
|
EUFLEXXA INJ PER DOSE
|
Professional
|
$336.12
|
|
|
Service Code
|
CPT J7323
|
| Hospital Charge Code |
zJ7323
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$336.12 |
| Rate for Payer: Humana ChoiceCare |
$129.58
|
| Rate for Payer: PHP All Commercial |
$336.12
|
|
|
Exchange of intraocular lens
|
Facility
OP
|
$4,211.34
|
|
|
Service Code
|
CPT 66986
|
| Hospital Charge Code |
CPT-66986
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,211.34 |
| Max. Negotiated Rate |
$4,211.34 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,211.34
|
| Rate for Payer: Managed Health Services Medicaid |
$4,211.34
|
| Rate for Payer: MDWise Medicaid |
$4,211.34
|
|
|
Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 67961
|
| Hospital Charge Code |
CPT-67961
|
|
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
|
|
|
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm
|
Facility
OP
|
$648.18
|
|
|
Service Code
|
CPT 11421
|
| Hospital Charge Code |
CPT-11421
|
|
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
|
|
|
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm
|
Facility
OP
|
$648.18
|
|
|
Service Code
|
CPT 11422
|
| Hospital Charge Code |
CPT-11422
|
|
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
|
|
