|
HEPARIN, PORCINE (PF) 100 UNITS/ML IV SYRG
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
117963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
HEPARIN, PORCINE (PF) 10 UNITS/ML IV SYRG
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
105460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
HEPARIN, PORCINE (PF) 10 UNITS/ML IV SYRG
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
105460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SOLN
|
Facility
|
IP
|
$37.15
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
121687
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.86 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$32.09
|
| Rate for Payer: Cash Price |
$22.29
|
| Rate for Payer: Cigna All Commercial |
$32.06
|
| Rate for Payer: CORVEL All Commercial |
$34.55
|
| Rate for Payer: Coventry All Commercial |
$32.69
|
| Rate for Payer: Encore All Commercial |
$34.19
|
| Rate for Payer: Frontpath All Commercial |
$34.17
|
| Rate for Payer: Humana ChoiceCare |
$32.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.43
|
| Rate for Payer: PHCS All Commercial |
$27.86
|
| Rate for Payer: PHP All Commercial |
$28.17
|
| Rate for Payer: Sagamore Health Network All Products |
$28.68
|
| Rate for Payer: Signature Care EPO |
$30.83
|
| Rate for Payer: Signature Care PPO |
$32.69
|
| Rate for Payer: United Healthcare Commercial |
$29.27
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SOLN
|
Facility
|
OP
|
$37.15
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
121687
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$11.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.08
|
| Rate for Payer: Cash Price |
$22.29
|
| Rate for Payer: Centivo All Commercial |
$20.21
|
| Rate for Payer: Cigna All Commercial |
$32.06
|
| Rate for Payer: CORVEL All Commercial |
$34.55
|
| Rate for Payer: Coventry All Commercial |
$32.69
|
| Rate for Payer: Encore All Commercial |
$34.19
|
| Rate for Payer: Frontpath All Commercial |
$34.17
|
| Rate for Payer: Humana ChoiceCare |
$32.08
|
| Rate for Payer: Humana Medicare |
$11.89
|
| Rate for Payer: Lucent All Commercial |
$20.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.43
|
| Rate for Payer: PHCS All Commercial |
$27.86
|
| Rate for Payer: PHP All Commercial |
$28.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.49
|
| Rate for Payer: Sagamore Health Network All Products |
$28.68
|
| Rate for Payer: Signature Care EPO |
$30.83
|
| Rate for Payer: Signature Care PPO |
$32.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.57
|
| Rate for Payer: United Healthcare Commercial |
$29.27
|
| Rate for Payer: United Healthcare Medicare |
$11.89
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
|
OP
|
$37.15
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$11.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.08
|
| Rate for Payer: Cash Price |
$22.29
|
| Rate for Payer: Centivo All Commercial |
$20.21
|
| Rate for Payer: Cigna All Commercial |
$32.06
|
| Rate for Payer: CORVEL All Commercial |
$34.55
|
| Rate for Payer: Coventry All Commercial |
$32.69
|
| Rate for Payer: Encore All Commercial |
$34.19
|
| Rate for Payer: Frontpath All Commercial |
$34.17
|
| Rate for Payer: Humana ChoiceCare |
$32.08
|
| Rate for Payer: Humana Medicare |
$11.89
|
| Rate for Payer: Lucent All Commercial |
$20.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.43
|
| Rate for Payer: PHCS All Commercial |
$27.86
|
| Rate for Payer: PHP All Commercial |
$28.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.49
|
| Rate for Payer: Sagamore Health Network All Products |
$28.68
|
| Rate for Payer: Signature Care EPO |
$30.83
|
| Rate for Payer: Signature Care PPO |
$32.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.57
|
| Rate for Payer: United Healthcare Commercial |
$29.27
|
| Rate for Payer: United Healthcare Medicare |
$11.89
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
|
IP
|
$37.15
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.86 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$32.09
|
| Rate for Payer: Cash Price |
$22.29
|
| Rate for Payer: Cigna All Commercial |
$32.06
|
| Rate for Payer: CORVEL All Commercial |
$34.55
|
| Rate for Payer: Coventry All Commercial |
$32.69
|
| Rate for Payer: Encore All Commercial |
$34.19
|
| Rate for Payer: Frontpath All Commercial |
$34.17
|
| Rate for Payer: Humana ChoiceCare |
$32.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.43
|
| Rate for Payer: PHCS All Commercial |
$27.86
|
| Rate for Payer: PHP All Commercial |
$28.17
|
| Rate for Payer: Sagamore Health Network All Products |
$28.68
|
| Rate for Payer: Signature Care EPO |
$30.83
|
| Rate for Payer: Signature Care PPO |
$32.69
|
| Rate for Payer: United Healthcare Commercial |
$29.27
|
|
|
HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML IM SYRG
|
Facility
|
OP
|
$621.24
|
|
|
Service Code
|
HCPCS 90636
|
| Hospital Charge Code |
118915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.48 |
| Max. Negotiated Rate |
$577.75 |
| Rate for Payer: Aetna Commercial |
$524.33
|
| Rate for Payer: Aetna Medicare |
$198.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$137.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$192.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$356.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$388.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$137.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$228.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$218.68
|
| Rate for Payer: Cash Price |
$372.74
|
| Rate for Payer: Cash Price |
$372.74
|
| Rate for Payer: Centivo All Commercial |
$337.95
|
| Rate for Payer: Cigna All Commercial |
$536.13
|
| Rate for Payer: CORVEL All Commercial |
$577.75
|
| Rate for Payer: Coventry All Commercial |
$546.69
|
| Rate for Payer: Encore All Commercial |
$571.85
|
| Rate for Payer: Frontpath All Commercial |
$571.54
|
| Rate for Payer: Humana ChoiceCare |
$536.56
|
| Rate for Payer: Humana Medicare |
$198.80
|
| Rate for Payer: Lucent All Commercial |
$337.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$559.12
|
| Rate for Payer: Managed Health Services Medicaid |
$137.48
|
| Rate for Payer: MDWise Medicaid |
$137.48
|
| Rate for Payer: PHCS All Commercial |
$465.93
|
| Rate for Payer: PHP All Commercial |
$471.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$242.28
|
| Rate for Payer: Sagamore Health Network All Products |
$479.60
|
| Rate for Payer: Signature Care EPO |
$515.63
|
| Rate for Payer: Signature Care PPO |
$546.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$528.05
|
| Rate for Payer: United Healthcare Commercial |
$489.54
|
| Rate for Payer: United Healthcare Medicare |
$198.80
|
|
|
HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML IM SYRG
|
Facility
|
IP
|
$621.24
|
|
|
Service Code
|
HCPCS 90636
|
| Hospital Charge Code |
118915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$465.93 |
| Max. Negotiated Rate |
$577.75 |
| Rate for Payer: Aetna Commercial |
$536.75
|
| Rate for Payer: Cash Price |
$372.74
|
| Rate for Payer: Cigna All Commercial |
$536.13
|
| Rate for Payer: CORVEL All Commercial |
$577.75
|
| Rate for Payer: Coventry All Commercial |
$546.69
|
| Rate for Payer: Encore All Commercial |
$571.85
|
| Rate for Payer: Frontpath All Commercial |
$571.54
|
| Rate for Payer: Humana ChoiceCare |
$536.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$559.12
|
| Rate for Payer: PHCS All Commercial |
$465.93
|
| Rate for Payer: PHP All Commercial |
$471.15
|
| Rate for Payer: Sagamore Health Network All Products |
$479.60
|
| Rate for Payer: Signature Care EPO |
$515.63
|
| Rate for Payer: Signature Care PPO |
$546.69
|
| Rate for Payer: United Healthcare Commercial |
$489.54
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML IM SYRG
|
Facility
|
OP
|
$484.88
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
118741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.31 |
| Max. Negotiated Rate |
$450.94 |
| Rate for Payer: Aetna Commercial |
$409.24
|
| Rate for Payer: Aetna Medicare |
$155.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$150.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$278.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$303.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$178.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$170.68
|
| Rate for Payer: Cash Price |
$290.93
|
| Rate for Payer: Centivo All Commercial |
$263.77
|
| Rate for Payer: Cigna All Commercial |
$418.45
|
| Rate for Payer: CORVEL All Commercial |
$450.94
|
| Rate for Payer: Coventry All Commercial |
$426.69
|
| Rate for Payer: Encore All Commercial |
$446.33
|
| Rate for Payer: Frontpath All Commercial |
$446.09
|
| Rate for Payer: Humana ChoiceCare |
$418.79
|
| Rate for Payer: Humana Medicare |
$155.16
|
| Rate for Payer: Lucent All Commercial |
$263.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$436.39
|
| Rate for Payer: PHCS All Commercial |
$363.66
|
| Rate for Payer: PHP All Commercial |
$367.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$189.10
|
| Rate for Payer: Sagamore Health Network All Products |
$374.33
|
| Rate for Payer: Signature Care EPO |
$402.45
|
| Rate for Payer: Signature Care PPO |
$426.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$412.15
|
| Rate for Payer: United Healthcare Commercial |
$382.08
|
| Rate for Payer: United Healthcare Medicare |
$155.16
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML IM SYRG
|
Facility
|
IP
|
$484.88
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
118741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$363.66 |
| Max. Negotiated Rate |
$450.94 |
| Rate for Payer: Aetna Commercial |
$418.93
|
| Rate for Payer: Cash Price |
$290.93
|
| Rate for Payer: Cigna All Commercial |
$418.45
|
| Rate for Payer: CORVEL All Commercial |
$450.94
|
| Rate for Payer: Coventry All Commercial |
$426.69
|
| Rate for Payer: Encore All Commercial |
$446.33
|
| Rate for Payer: Frontpath All Commercial |
$446.09
|
| Rate for Payer: Humana ChoiceCare |
$418.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$436.39
|
| Rate for Payer: PHCS All Commercial |
$363.66
|
| Rate for Payer: PHP All Commercial |
$367.73
|
| Rate for Payer: Sagamore Health Network All Products |
$374.33
|
| Rate for Payer: Signature Care EPO |
$402.45
|
| Rate for Payer: Signature Care PPO |
$426.69
|
| Rate for Payer: United Healthcare Commercial |
$382.08
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRG
|
Facility
|
IP
|
$257.10
|
|
|
Service Code
|
HCPCS 90633
|
| Hospital Charge Code |
91033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$192.82 |
| Max. Negotiated Rate |
$239.10 |
| Rate for Payer: Aetna Commercial |
$222.13
|
| Rate for Payer: Cash Price |
$154.26
|
| Rate for Payer: Cigna All Commercial |
$221.87
|
| Rate for Payer: CORVEL All Commercial |
$239.10
|
| Rate for Payer: Coventry All Commercial |
$226.24
|
| Rate for Payer: Encore All Commercial |
$236.66
|
| Rate for Payer: Frontpath All Commercial |
$236.53
|
| Rate for Payer: Humana ChoiceCare |
$222.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$231.39
|
| Rate for Payer: PHCS All Commercial |
$192.82
|
| Rate for Payer: PHP All Commercial |
$194.98
|
| Rate for Payer: Sagamore Health Network All Products |
$198.48
|
| Rate for Payer: Signature Care EPO |
$213.39
|
| Rate for Payer: Signature Care PPO |
$226.24
|
| Rate for Payer: United Healthcare Commercial |
$202.59
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRG
|
Facility
|
OP
|
$257.10
|
|
|
Service Code
|
HCPCS 90633
|
| Hospital Charge Code |
91033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.70 |
| Max. Negotiated Rate |
$239.10 |
| Rate for Payer: Aetna Commercial |
$216.99
|
| Rate for Payer: Aetna Medicare |
$82.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$79.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$147.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$160.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$94.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$90.50
|
| Rate for Payer: Cash Price |
$154.26
|
| Rate for Payer: Centivo All Commercial |
$139.86
|
| Rate for Payer: Cigna All Commercial |
$221.87
|
| Rate for Payer: CORVEL All Commercial |
$239.10
|
| Rate for Payer: Coventry All Commercial |
$226.24
|
| Rate for Payer: Encore All Commercial |
$236.66
|
| Rate for Payer: Frontpath All Commercial |
$236.53
|
| Rate for Payer: Humana ChoiceCare |
$222.05
|
| Rate for Payer: Humana Medicare |
$82.27
|
| Rate for Payer: Lucent All Commercial |
$139.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$231.39
|
| Rate for Payer: PHCS All Commercial |
$192.82
|
| Rate for Payer: PHP All Commercial |
$194.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$100.27
|
| Rate for Payer: Sagamore Health Network All Products |
$198.48
|
| Rate for Payer: Signature Care EPO |
$213.39
|
| Rate for Payer: Signature Care PPO |
$226.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$218.53
|
| Rate for Payer: United Healthcare Commercial |
$202.59
|
| Rate for Payer: United Healthcare Medicare |
$82.27
|
|
|
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN
|
Facility
|
OP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
118498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.98 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,251.29
|
| Rate for Payer: Aetna Medicare |
$853.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$165.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$826.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,531.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,667.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$165.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$981.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$938.92
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Centivo All Commercial |
$1,451.07
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Humana Medicare |
$853.57
|
| Rate for Payer: Lucent All Commercial |
$1,451.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: Managed Health Services Medicaid |
$165.98
|
| Rate for Payer: MDWise Medicaid |
$165.98
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,040.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,267.29
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
| Rate for Payer: United Healthcare Medicare |
$853.57
|
|
|
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN
|
Facility
|
IP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
118498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,000.55 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,304.63
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
|
|
HEPATITIS B IMMUNE GLOBULIN SYRINGE (CAMERON)
|
Facility
|
IP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,000.55 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,304.63
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
|
|
HEPATITIS B IMMUNE GLOBULIN SYRINGE (CAMERON)
|
Facility
|
OP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.98 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,251.29
|
| Rate for Payer: Aetna Medicare |
$853.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$165.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$826.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,531.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,667.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$165.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$981.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$938.92
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Cash Price |
$1,600.44
|
| Rate for Payer: Centivo All Commercial |
$1,451.07
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Humana Medicare |
$853.57
|
| Rate for Payer: Lucent All Commercial |
$1,451.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: Managed Health Services Medicaid |
$165.98
|
| Rate for Payer: MDWise Medicaid |
$165.98
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,040.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,267.29
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
| Rate for Payer: United Healthcare Medicare |
$853.57
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG
|
Facility
|
OP
|
$192.30
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
118672
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.61 |
| Max. Negotiated Rate |
$178.84 |
| Rate for Payer: Aetna Commercial |
$162.30
|
| Rate for Payer: Aetna Medicare |
$61.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$120.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.69
|
| Rate for Payer: Cash Price |
$115.38
|
| Rate for Payer: Centivo All Commercial |
$104.61
|
| Rate for Payer: Cigna All Commercial |
$165.95
|
| Rate for Payer: CORVEL All Commercial |
$178.84
|
| Rate for Payer: Coventry All Commercial |
$169.22
|
| Rate for Payer: Encore All Commercial |
$177.01
|
| Rate for Payer: Frontpath All Commercial |
$176.91
|
| Rate for Payer: Humana ChoiceCare |
$166.09
|
| Rate for Payer: Humana Medicare |
$61.54
|
| Rate for Payer: Lucent All Commercial |
$104.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.07
|
| Rate for Payer: PHCS All Commercial |
$144.22
|
| Rate for Payer: PHP All Commercial |
$145.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$75.00
|
| Rate for Payer: Sagamore Health Network All Products |
$148.45
|
| Rate for Payer: Signature Care EPO |
$159.61
|
| Rate for Payer: Signature Care PPO |
$169.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$163.45
|
| Rate for Payer: United Healthcare Commercial |
$151.53
|
| Rate for Payer: United Healthcare Medicare |
$61.54
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG
|
Facility
|
IP
|
$192.30
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
118672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.22 |
| Max. Negotiated Rate |
$178.84 |
| Rate for Payer: Aetna Commercial |
$166.14
|
| Rate for Payer: Cash Price |
$115.38
|
| Rate for Payer: Cigna All Commercial |
$165.95
|
| Rate for Payer: CORVEL All Commercial |
$178.84
|
| Rate for Payer: Coventry All Commercial |
$169.22
|
| Rate for Payer: Encore All Commercial |
$177.01
|
| Rate for Payer: Frontpath All Commercial |
$176.91
|
| Rate for Payer: Humana ChoiceCare |
$166.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.07
|
| Rate for Payer: PHCS All Commercial |
$144.22
|
| Rate for Payer: PHP All Commercial |
$145.84
|
| Rate for Payer: Sagamore Health Network All Products |
$148.45
|
| Rate for Payer: Signature Care EPO |
$159.61
|
| Rate for Payer: Signature Care PPO |
$169.22
|
| Rate for Payer: United Healthcare Commercial |
$151.53
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SYRG
|
Facility
|
OP
|
$406.63
|
|
|
Service Code
|
HCPCS 90746
|
| Hospital Charge Code |
118608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.06 |
| Max. Negotiated Rate |
$378.17 |
| Rate for Payer: Aetna Commercial |
$343.20
|
| Rate for Payer: Aetna Medicare |
$130.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$126.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$233.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$254.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$149.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$143.13
|
| Rate for Payer: Cash Price |
$243.98
|
| Rate for Payer: Centivo All Commercial |
$221.21
|
| Rate for Payer: Cigna All Commercial |
$350.92
|
| Rate for Payer: CORVEL All Commercial |
$378.17
|
| Rate for Payer: Coventry All Commercial |
$357.84
|
| Rate for Payer: Encore All Commercial |
$374.30
|
| Rate for Payer: Frontpath All Commercial |
$374.10
|
| Rate for Payer: Humana ChoiceCare |
$351.21
|
| Rate for Payer: Humana Medicare |
$130.12
|
| Rate for Payer: Lucent All Commercial |
$221.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$365.97
|
| Rate for Payer: PHCS All Commercial |
$304.97
|
| Rate for Payer: PHP All Commercial |
$308.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$158.59
|
| Rate for Payer: Sagamore Health Network All Products |
$313.92
|
| Rate for Payer: Signature Care EPO |
$337.50
|
| Rate for Payer: Signature Care PPO |
$357.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$345.64
|
| Rate for Payer: United Healthcare Commercial |
$320.43
|
| Rate for Payer: United Healthcare Medicare |
$130.12
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SYRG
|
Facility
|
IP
|
$406.63
|
|
|
Service Code
|
HCPCS 90746
|
| Hospital Charge Code |
118608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$304.97 |
| Max. Negotiated Rate |
$378.17 |
| Rate for Payer: Aetna Commercial |
$351.33
|
| Rate for Payer: Cash Price |
$243.98
|
| Rate for Payer: Cigna All Commercial |
$350.92
|
| Rate for Payer: CORVEL All Commercial |
$378.17
|
| Rate for Payer: Coventry All Commercial |
$357.84
|
| Rate for Payer: Encore All Commercial |
$374.30
|
| Rate for Payer: Frontpath All Commercial |
$374.10
|
| Rate for Payer: Humana ChoiceCare |
$351.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$365.97
|
| Rate for Payer: PHCS All Commercial |
$304.97
|
| Rate for Payer: PHP All Commercial |
$308.39
|
| Rate for Payer: Sagamore Health Network All Products |
$313.92
|
| Rate for Payer: Signature Care EPO |
$337.50
|
| Rate for Payer: Signature Care PPO |
$357.84
|
| Rate for Payer: United Healthcare Commercial |
$320.43
|
|
|
HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRG
|
Facility
|
OP
|
$584.27
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
34550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$543.37 |
| Rate for Payer: Aetna Commercial |
$493.12
|
| Rate for Payer: Aetna Medicare |
$186.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$104.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$181.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$335.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$365.23
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$104.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$215.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$205.66
|
| Rate for Payer: Cash Price |
$350.56
|
| Rate for Payer: Cash Price |
$350.56
|
| Rate for Payer: Centivo All Commercial |
$317.84
|
| Rate for Payer: Cigna All Commercial |
$504.22
|
| Rate for Payer: CORVEL All Commercial |
$543.37
|
| Rate for Payer: Coventry All Commercial |
$514.16
|
| Rate for Payer: Encore All Commercial |
$537.82
|
| Rate for Payer: Frontpath All Commercial |
$537.53
|
| Rate for Payer: Humana ChoiceCare |
$504.63
|
| Rate for Payer: Humana Medicare |
$186.97
|
| Rate for Payer: Lucent All Commercial |
$317.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$525.84
|
| Rate for Payer: Managed Health Services Medicaid |
$104.86
|
| Rate for Payer: MDWise Medicaid |
$104.86
|
| Rate for Payer: PHCS All Commercial |
$438.20
|
| Rate for Payer: PHP All Commercial |
$443.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$227.86
|
| Rate for Payer: Sagamore Health Network All Products |
$451.05
|
| Rate for Payer: Signature Care EPO |
$484.94
|
| Rate for Payer: Signature Care PPO |
$514.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$496.63
|
| Rate for Payer: United Healthcare Commercial |
$460.40
|
| Rate for Payer: United Healthcare Medicare |
$186.97
|
|
|
HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRG
|
Facility
|
IP
|
$584.27
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
34550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$438.20 |
| Max. Negotiated Rate |
$543.37 |
| Rate for Payer: Aetna Commercial |
$504.81
|
| Rate for Payer: Cash Price |
$350.56
|
| Rate for Payer: Cigna All Commercial |
$504.22
|
| Rate for Payer: CORVEL All Commercial |
$543.37
|
| Rate for Payer: Coventry All Commercial |
$514.16
|
| Rate for Payer: Encore All Commercial |
$537.82
|
| Rate for Payer: Frontpath All Commercial |
$537.53
|
| Rate for Payer: Humana ChoiceCare |
$504.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$525.84
|
| Rate for Payer: PHCS All Commercial |
$438.20
|
| Rate for Payer: PHP All Commercial |
$443.11
|
| Rate for Payer: Sagamore Health Network All Products |
$451.05
|
| Rate for Payer: Signature Care EPO |
$484.94
|
| Rate for Payer: Signature Care PPO |
$514.16
|
| Rate for Payer: United Healthcare Commercial |
$460.40
|
|
|
HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN
|
Facility
|
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.83 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$132.93
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$90.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.44
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Centivo All Commercial |
$85.68
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Humana Medicare |
$50.40
|
| Rate for Payer: Lucent All Commercial |
$85.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.42
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.88
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
| Rate for Payer: United Healthcare Medicare |
$50.40
|
|
|
HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN
|
Facility
|
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.12 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$136.08
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna All Commercial |
$135.92
|
| Rate for Payer: CORVEL All Commercial |
$146.47
|
| Rate for Payer: Coventry All Commercial |
$138.60
|
| Rate for Payer: Encore All Commercial |
$144.98
|
| Rate for Payer: Frontpath All Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$136.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.75
|
| Rate for Payer: PHCS All Commercial |
$118.12
|
| Rate for Payer: PHP All Commercial |
$119.45
|
| Rate for Payer: Sagamore Health Network All Products |
$121.59
|
| Rate for Payer: Signature Care EPO |
$130.72
|
| Rate for Payer: Signature Care PPO |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$124.11
|
|
