|
HONEY 80 % TOP GEL
|
Facility
|
OP
|
$112.42
|
|
|
Service Code
|
NDC 09958003471
|
| Hospital Charge Code |
162300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$94.88
|
| Rate for Payer: Aetna Medicare |
$35.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.57
|
| Rate for Payer: Cash Price |
$67.45
|
| Rate for Payer: Cash Price |
$67.45
|
| Rate for Payer: Centivo All Commercial |
$61.16
|
| Rate for Payer: Cigna All Commercial |
$97.02
|
| Rate for Payer: CORVEL All Commercial |
$104.55
|
| Rate for Payer: Coventry All Commercial |
$98.93
|
| Rate for Payer: Encore All Commercial |
$103.48
|
| Rate for Payer: Frontpath All Commercial |
$103.43
|
| Rate for Payer: Humana ChoiceCare |
$97.10
|
| Rate for Payer: Humana Medicare |
$35.97
|
| Rate for Payer: Lucent All Commercial |
$61.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$84.31
|
| Rate for Payer: PHP All Commercial |
$85.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.84
|
| Rate for Payer: Sagamore Health Network All Products |
$86.79
|
| Rate for Payer: Signature Care EPO |
$93.31
|
| Rate for Payer: Signature Care PPO |
$98.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.56
|
| Rate for Payer: United Healthcare Commercial |
$88.59
|
| Rate for Payer: United Healthcare Medicare |
$35.97
|
|
|
HONEY 80 % TOP GEL
|
Facility
|
IP
|
$112.42
|
|
|
Service Code
|
NDC 09958003471
|
| Hospital Charge Code |
162300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.31 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$97.13
|
| Rate for Payer: Cash Price |
$67.45
|
| Rate for Payer: Cigna All Commercial |
$97.02
|
| Rate for Payer: CORVEL All Commercial |
$104.55
|
| Rate for Payer: Coventry All Commercial |
$98.93
|
| Rate for Payer: Encore All Commercial |
$103.48
|
| Rate for Payer: Frontpath All Commercial |
$103.43
|
| Rate for Payer: Humana ChoiceCare |
$97.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.18
|
| Rate for Payer: PHCS All Commercial |
$84.31
|
| Rate for Payer: PHP All Commercial |
$85.26
|
| Rate for Payer: Sagamore Health Network All Products |
$86.79
|
| Rate for Payer: Signature Care EPO |
$93.31
|
| Rate for Payer: Signature Care PPO |
$98.93
|
| Rate for Payer: United Healthcare Commercial |
$88.59
|
|
|
HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SUSP
|
Facility
|
IP
|
$560.92
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
170975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$420.69 |
| Max. Negotiated Rate |
$521.66 |
| Rate for Payer: Aetna Commercial |
$484.64
|
| Rate for Payer: Cash Price |
$336.55
|
| Rate for Payer: Cigna All Commercial |
$484.08
|
| Rate for Payer: CORVEL All Commercial |
$521.66
|
| Rate for Payer: Coventry All Commercial |
$493.61
|
| Rate for Payer: Encore All Commercial |
$516.33
|
| Rate for Payer: Frontpath All Commercial |
$516.05
|
| Rate for Payer: Humana ChoiceCare |
$484.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$504.83
|
| Rate for Payer: PHCS All Commercial |
$420.69
|
| Rate for Payer: PHP All Commercial |
$425.40
|
| Rate for Payer: Sagamore Health Network All Products |
$433.03
|
| Rate for Payer: Signature Care EPO |
$465.57
|
| Rate for Payer: Signature Care PPO |
$493.61
|
| Rate for Payer: United Healthcare Commercial |
$442.01
|
|
|
HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SUSP
|
Facility
|
OP
|
$560.92
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
170975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$521.66 |
| Rate for Payer: Aetna Commercial |
$473.42
|
| Rate for Payer: Aetna Medicare |
$179.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$322.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$322.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$350.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$322.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$206.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$197.44
|
| Rate for Payer: Cash Price |
$336.55
|
| Rate for Payer: Cash Price |
$336.55
|
| Rate for Payer: Centivo All Commercial |
$305.14
|
| Rate for Payer: Cigna All Commercial |
$484.08
|
| Rate for Payer: CORVEL All Commercial |
$521.66
|
| Rate for Payer: Coventry All Commercial |
$493.61
|
| Rate for Payer: Encore All Commercial |
$516.33
|
| Rate for Payer: Frontpath All Commercial |
$516.05
|
| Rate for Payer: Humana ChoiceCare |
$484.47
|
| Rate for Payer: Humana Medicare |
$179.50
|
| Rate for Payer: Lucent All Commercial |
$305.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$504.83
|
| Rate for Payer: Managed Health Services Medicaid |
$322.20
|
| Rate for Payer: MDWise Medicaid |
$322.20
|
| Rate for Payer: PHCS All Commercial |
$420.69
|
| Rate for Payer: PHP All Commercial |
$425.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$218.76
|
| Rate for Payer: Sagamore Health Network All Products |
$433.03
|
| Rate for Payer: Signature Care EPO |
$465.57
|
| Rate for Payer: Signature Care PPO |
$493.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$476.78
|
| Rate for Payer: United Healthcare Commercial |
$442.01
|
| Rate for Payer: United Healthcare Medicare |
$179.50
|
|
|
HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG
|
Facility
|
IP
|
$628.22
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
170976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$471.16 |
| Max. Negotiated Rate |
$584.24 |
| Rate for Payer: Aetna Commercial |
$542.78
|
| Rate for Payer: Cash Price |
$376.93
|
| Rate for Payer: Cigna All Commercial |
$542.15
|
| Rate for Payer: CORVEL All Commercial |
$584.24
|
| Rate for Payer: Coventry All Commercial |
$552.83
|
| Rate for Payer: Encore All Commercial |
$578.28
|
| Rate for Payer: Frontpath All Commercial |
$577.96
|
| Rate for Payer: Humana ChoiceCare |
$542.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$565.40
|
| Rate for Payer: PHCS All Commercial |
$471.16
|
| Rate for Payer: PHP All Commercial |
$476.44
|
| Rate for Payer: Sagamore Health Network All Products |
$484.99
|
| Rate for Payer: Signature Care EPO |
$521.42
|
| Rate for Payer: Signature Care PPO |
$552.83
|
| Rate for Payer: United Healthcare Commercial |
$495.04
|
|
|
HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG
|
Facility
|
OP
|
$628.22
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
170976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.75 |
| Max. Negotiated Rate |
$584.24 |
| Rate for Payer: Aetna Commercial |
$530.22
|
| Rate for Payer: Aetna Medicare |
$201.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$322.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$194.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$360.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$392.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$322.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$231.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$221.13
|
| Rate for Payer: Cash Price |
$376.93
|
| Rate for Payer: Cash Price |
$376.93
|
| Rate for Payer: Centivo All Commercial |
$341.75
|
| Rate for Payer: Cigna All Commercial |
$542.15
|
| Rate for Payer: CORVEL All Commercial |
$584.24
|
| Rate for Payer: Coventry All Commercial |
$552.83
|
| Rate for Payer: Encore All Commercial |
$578.28
|
| Rate for Payer: Frontpath All Commercial |
$577.96
|
| Rate for Payer: Humana ChoiceCare |
$542.59
|
| Rate for Payer: Humana Medicare |
$201.03
|
| Rate for Payer: Lucent All Commercial |
$341.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$565.40
|
| Rate for Payer: Managed Health Services Medicaid |
$322.20
|
| Rate for Payer: MDWise Medicaid |
$322.20
|
| Rate for Payer: PHCS All Commercial |
$471.16
|
| Rate for Payer: PHP All Commercial |
$476.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$245.01
|
| Rate for Payer: Sagamore Health Network All Products |
$484.99
|
| Rate for Payer: Signature Care EPO |
$521.42
|
| Rate for Payer: Signature Care PPO |
$552.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$533.99
|
| Rate for Payer: United Healthcare Commercial |
$495.04
|
| Rate for Payer: United Healthcare Medicare |
$201.03
|
|
|
HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1240 UNIT) IV SOLR
|
Facility
|
IP
|
$8,407.00
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
168886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,305.25 |
| Max. Negotiated Rate |
$7,818.51 |
| Rate for Payer: Aetna Commercial |
$7,263.65
|
| Rate for Payer: Cash Price |
$5,044.20
|
| Rate for Payer: Cigna All Commercial |
$7,255.24
|
| Rate for Payer: CORVEL All Commercial |
$7,818.51
|
| Rate for Payer: Coventry All Commercial |
$7,398.16
|
| Rate for Payer: Encore All Commercial |
$7,738.64
|
| Rate for Payer: Frontpath All Commercial |
$7,734.44
|
| Rate for Payer: Humana ChoiceCare |
$7,261.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,566.30
|
| Rate for Payer: PHCS All Commercial |
$6,305.25
|
| Rate for Payer: PHP All Commercial |
$6,375.87
|
| Rate for Payer: Sagamore Health Network All Products |
$6,490.20
|
| Rate for Payer: Signature Care EPO |
$6,977.81
|
| Rate for Payer: Signature Care PPO |
$7,398.16
|
| Rate for Payer: United Healthcare Commercial |
$6,624.72
|
|
|
HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1240 UNIT) IV SOLR
|
Facility
|
OP
|
$8,407.00
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
168886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,606.17 |
| Max. Negotiated Rate |
$7,818.51 |
| Rate for Payer: Aetna Commercial |
$7,095.51
|
| Rate for Payer: Aetna Medicare |
$2,690.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,606.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,828.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,255.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,093.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,959.26
|
| Rate for Payer: Cash Price |
$5,044.20
|
| Rate for Payer: Centivo All Commercial |
$4,573.41
|
| Rate for Payer: Cigna All Commercial |
$7,255.24
|
| Rate for Payer: CORVEL All Commercial |
$7,818.51
|
| Rate for Payer: Coventry All Commercial |
$7,398.16
|
| Rate for Payer: Encore All Commercial |
$7,738.64
|
| Rate for Payer: Frontpath All Commercial |
$7,734.44
|
| Rate for Payer: Humana ChoiceCare |
$7,261.13
|
| Rate for Payer: Humana Medicare |
$2,690.24
|
| Rate for Payer: Lucent All Commercial |
$4,573.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,566.30
|
| Rate for Payer: PHCS All Commercial |
$6,305.25
|
| Rate for Payer: PHP All Commercial |
$6,375.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,278.73
|
| Rate for Payer: Sagamore Health Network All Products |
$6,490.20
|
| Rate for Payer: Signature Care EPO |
$6,977.81
|
| Rate for Payer: Signature Care PPO |
$7,398.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,145.95
|
| Rate for Payer: United Healthcare Commercial |
$6,624.72
|
| Rate for Payer: United Healthcare Medicare |
$2,690.24
|
|
|
HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1240 UNIT) IV SOLR (CAMERON)
|
Facility
|
IP
|
$8,407.00
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
1.401E+13
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,305.25 |
| Max. Negotiated Rate |
$7,818.51 |
| Rate for Payer: Aetna Commercial |
$7,263.65
|
| Rate for Payer: Cash Price |
$5,044.20
|
| Rate for Payer: Cigna All Commercial |
$7,255.24
|
| Rate for Payer: CORVEL All Commercial |
$7,818.51
|
| Rate for Payer: Coventry All Commercial |
$7,398.16
|
| Rate for Payer: Encore All Commercial |
$7,738.64
|
| Rate for Payer: Frontpath All Commercial |
$7,734.44
|
| Rate for Payer: Humana ChoiceCare |
$7,261.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,566.30
|
| Rate for Payer: PHCS All Commercial |
$6,305.25
|
| Rate for Payer: PHP All Commercial |
$6,375.87
|
| Rate for Payer: Sagamore Health Network All Products |
$6,490.20
|
| Rate for Payer: Signature Care EPO |
$6,977.81
|
| Rate for Payer: Signature Care PPO |
$7,398.16
|
| Rate for Payer: United Healthcare Commercial |
$6,624.72
|
|
|
HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1240 UNIT) IV SOLR (CAMERON)
|
Facility
|
OP
|
$8,407.00
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
1.401E+13
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,606.17 |
| Max. Negotiated Rate |
$7,818.51 |
| Rate for Payer: Aetna Commercial |
$7,095.51
|
| Rate for Payer: Aetna Medicare |
$2,690.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,606.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,828.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,255.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,093.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,959.26
|
| Rate for Payer: Cash Price |
$5,044.20
|
| Rate for Payer: Centivo All Commercial |
$4,573.41
|
| Rate for Payer: Cigna All Commercial |
$7,255.24
|
| Rate for Payer: CORVEL All Commercial |
$7,818.51
|
| Rate for Payer: Coventry All Commercial |
$7,398.16
|
| Rate for Payer: Encore All Commercial |
$7,738.64
|
| Rate for Payer: Frontpath All Commercial |
$7,734.44
|
| Rate for Payer: Humana ChoiceCare |
$7,261.13
|
| Rate for Payer: Humana Medicare |
$2,690.24
|
| Rate for Payer: Lucent All Commercial |
$4,573.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,566.30
|
| Rate for Payer: PHCS All Commercial |
$6,305.25
|
| Rate for Payer: PHP All Commercial |
$6,375.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,278.73
|
| Rate for Payer: Sagamore Health Network All Products |
$6,490.20
|
| Rate for Payer: Signature Care EPO |
$6,977.81
|
| Rate for Payer: Signature Care PPO |
$7,398.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,145.95
|
| Rate for Payer: United Healthcare Commercial |
$6,624.72
|
| Rate for Payer: United Healthcare Medicare |
$2,690.24
|
|
|
HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IATC SYRG
|
Facility
|
OP
|
$4,065.25
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
163847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,207.50 |
| Max. Negotiated Rate |
$3,780.69 |
| Rate for Payer: Aetna Commercial |
$3,431.07
|
| Rate for Payer: Aetna Medicare |
$1,300.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,207.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,260.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,334.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,541.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,207.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,496.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,430.97
|
| Rate for Payer: Cash Price |
$2,439.15
|
| Rate for Payer: Cash Price |
$2,439.15
|
| Rate for Payer: Centivo All Commercial |
$2,211.50
|
| Rate for Payer: Cigna All Commercial |
$3,508.31
|
| Rate for Payer: CORVEL All Commercial |
$3,780.69
|
| Rate for Payer: Coventry All Commercial |
$3,577.42
|
| Rate for Payer: Encore All Commercial |
$3,742.07
|
| Rate for Payer: Frontpath All Commercial |
$3,740.03
|
| Rate for Payer: Humana ChoiceCare |
$3,511.16
|
| Rate for Payer: Humana Medicare |
$1,300.88
|
| Rate for Payer: Lucent All Commercial |
$2,211.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,658.73
|
| Rate for Payer: Managed Health Services Medicaid |
$1,207.50
|
| Rate for Payer: MDWise Medicaid |
$1,207.50
|
| Rate for Payer: PHCS All Commercial |
$3,048.94
|
| Rate for Payer: PHP All Commercial |
$3,083.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,585.45
|
| Rate for Payer: Sagamore Health Network All Products |
$3,138.38
|
| Rate for Payer: Signature Care EPO |
$3,374.16
|
| Rate for Payer: Signature Care PPO |
$3,577.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,455.47
|
| Rate for Payer: United Healthcare Commercial |
$3,203.42
|
| Rate for Payer: United Healthcare Medicare |
$1,300.88
|
|
|
HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IATC SYRG
|
Facility
|
IP
|
$4,065.25
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
163847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,048.94 |
| Max. Negotiated Rate |
$3,780.69 |
| Rate for Payer: Aetna Commercial |
$3,512.38
|
| Rate for Payer: Cash Price |
$2,439.15
|
| Rate for Payer: Cigna All Commercial |
$3,508.31
|
| Rate for Payer: CORVEL All Commercial |
$3,780.69
|
| Rate for Payer: Coventry All Commercial |
$3,577.42
|
| Rate for Payer: Encore All Commercial |
$3,742.07
|
| Rate for Payer: Frontpath All Commercial |
$3,740.03
|
| Rate for Payer: Humana ChoiceCare |
$3,511.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,658.73
|
| Rate for Payer: PHCS All Commercial |
$3,048.94
|
| Rate for Payer: PHP All Commercial |
$3,083.09
|
| Rate for Payer: Sagamore Health Network All Products |
$3,138.38
|
| Rate for Payer: Signature Care EPO |
$3,374.16
|
| Rate for Payer: Signature Care PPO |
$3,577.42
|
| Rate for Payer: United Healthcare Commercial |
$3,203.42
|
|
|
HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG
|
Facility
|
IP
|
$3,658.59
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
182898
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,743.94 |
| Max. Negotiated Rate |
$3,402.49 |
| Rate for Payer: Aetna Commercial |
$3,161.02
|
| Rate for Payer: Cash Price |
$2,195.15
|
| Rate for Payer: Cigna All Commercial |
$3,157.36
|
| Rate for Payer: CORVEL All Commercial |
$3,402.49
|
| Rate for Payer: Coventry All Commercial |
$3,219.56
|
| Rate for Payer: Encore All Commercial |
$3,367.73
|
| Rate for Payer: Frontpath All Commercial |
$3,365.90
|
| Rate for Payer: Humana ChoiceCare |
$3,159.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,292.73
|
| Rate for Payer: PHCS All Commercial |
$2,743.94
|
| Rate for Payer: PHP All Commercial |
$2,774.67
|
| Rate for Payer: Sagamore Health Network All Products |
$2,824.43
|
| Rate for Payer: Signature Care EPO |
$3,036.63
|
| Rate for Payer: Signature Care PPO |
$3,219.56
|
| Rate for Payer: United Healthcare Commercial |
$2,882.97
|
|
|
HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG
|
Facility
|
OP
|
$3,658.59
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
182898
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$3,402.49 |
| Rate for Payer: Aetna Commercial |
$3,087.85
|
| Rate for Payer: Aetna Medicare |
$1,170.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,134.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,101.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,286.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,346.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,287.82
|
| Rate for Payer: Cash Price |
$2,195.15
|
| Rate for Payer: Cash Price |
$2,195.15
|
| Rate for Payer: Centivo All Commercial |
$1,990.27
|
| Rate for Payer: Cigna All Commercial |
$3,157.36
|
| Rate for Payer: CORVEL All Commercial |
$3,402.49
|
| Rate for Payer: Coventry All Commercial |
$3,219.56
|
| Rate for Payer: Encore All Commercial |
$3,367.73
|
| Rate for Payer: Frontpath All Commercial |
$3,365.90
|
| Rate for Payer: Humana ChoiceCare |
$3,159.92
|
| Rate for Payer: Humana Medicare |
$1,170.75
|
| Rate for Payer: Lucent All Commercial |
$1,990.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,292.73
|
| Rate for Payer: Managed Health Services Medicaid |
$19.51
|
| Rate for Payer: MDWise Medicaid |
$19.51
|
| Rate for Payer: PHCS All Commercial |
$2,743.94
|
| Rate for Payer: PHP All Commercial |
$2,774.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,426.85
|
| Rate for Payer: Sagamore Health Network All Products |
$2,824.43
|
| Rate for Payer: Signature Care EPO |
$3,036.63
|
| Rate for Payer: Signature Care PPO |
$3,219.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,109.80
|
| Rate for Payer: United Healthcare Commercial |
$2,882.97
|
| Rate for Payer: United Healthcare Medicare |
$1,170.75
|
|
|
HYALURONIDASE 150 UNITS/ML INJ SOLN
|
Facility
|
OP
|
$220.70
|
|
|
Service Code
|
HCPCS J3470
|
| Hospital Charge Code |
10201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.42 |
| Max. Negotiated Rate |
$205.25 |
| Rate for Payer: Aetna Commercial |
$186.27
|
| Rate for Payer: Aetna Medicare |
$70.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$68.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$126.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$137.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$81.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$77.68
|
| Rate for Payer: Cash Price |
$132.42
|
| Rate for Payer: Centivo All Commercial |
$120.06
|
| Rate for Payer: Cigna All Commercial |
$190.46
|
| Rate for Payer: CORVEL All Commercial |
$205.25
|
| Rate for Payer: Coventry All Commercial |
$194.21
|
| Rate for Payer: Encore All Commercial |
$203.15
|
| Rate for Payer: Frontpath All Commercial |
$203.04
|
| Rate for Payer: Humana ChoiceCare |
$190.62
|
| Rate for Payer: Humana Medicare |
$70.62
|
| Rate for Payer: Lucent All Commercial |
$120.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$198.63
|
| Rate for Payer: PHCS All Commercial |
$165.52
|
| Rate for Payer: PHP All Commercial |
$167.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$86.07
|
| Rate for Payer: Sagamore Health Network All Products |
$170.38
|
| Rate for Payer: Signature Care EPO |
$183.18
|
| Rate for Payer: Signature Care PPO |
$194.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$187.59
|
| Rate for Payer: United Healthcare Commercial |
$173.91
|
| Rate for Payer: United Healthcare Medicare |
$70.62
|
|
|
HYALURONIDASE 150 UNITS/ML INJ SOLN
|
Facility
|
IP
|
$220.70
|
|
|
Service Code
|
HCPCS J3470
|
| Hospital Charge Code |
10201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$165.52 |
| Max. Negotiated Rate |
$205.25 |
| Rate for Payer: Aetna Commercial |
$190.68
|
| Rate for Payer: Cash Price |
$132.42
|
| Rate for Payer: Cigna All Commercial |
$190.46
|
| Rate for Payer: CORVEL All Commercial |
$205.25
|
| Rate for Payer: Coventry All Commercial |
$194.21
|
| Rate for Payer: Encore All Commercial |
$203.15
|
| Rate for Payer: Frontpath All Commercial |
$203.04
|
| Rate for Payer: Humana ChoiceCare |
$190.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$198.63
|
| Rate for Payer: PHCS All Commercial |
$165.52
|
| Rate for Payer: PHP All Commercial |
$167.38
|
| Rate for Payer: Sagamore Health Network All Products |
$170.38
|
| Rate for Payer: Signature Care EPO |
$183.18
|
| Rate for Payer: Signature Care PPO |
$194.21
|
| Rate for Payer: United Healthcare Commercial |
$173.91
|
|
|
HYDRALAZINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 50111039801
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Centivo All Commercial |
$0.64
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Humana Medicare |
$0.38
|
| Rate for Payer: Lucent All Commercial |
$0.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
HYDRALAZINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 50111039801
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$1.02
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.06
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Sagamore Health Network All Products |
$0.91
|
| Rate for Payer: Signature Care EPO |
$0.98
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$0.93
|
|
|
HYDRALAZINE 20 MG/ML INJ SOLN
|
Facility
|
IP
|
$100.23
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
3697
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.17 |
| Max. Negotiated Rate |
$93.22 |
| Rate for Payer: Aetna Commercial |
$86.60
|
| Rate for Payer: Cash Price |
$60.14
|
| Rate for Payer: Cigna All Commercial |
$86.50
|
| Rate for Payer: CORVEL All Commercial |
$93.22
|
| Rate for Payer: Coventry All Commercial |
$88.21
|
| Rate for Payer: Encore All Commercial |
$92.26
|
| Rate for Payer: Frontpath All Commercial |
$92.21
|
| Rate for Payer: Humana ChoiceCare |
$86.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.21
|
| Rate for Payer: PHCS All Commercial |
$75.17
|
| Rate for Payer: PHP All Commercial |
$76.02
|
| Rate for Payer: Sagamore Health Network All Products |
$77.38
|
| Rate for Payer: Signature Care EPO |
$83.19
|
| Rate for Payer: Signature Care PPO |
$88.21
|
| Rate for Payer: United Healthcare Commercial |
$78.98
|
|
|
HYDRALAZINE 20 MG/ML INJ SOLN
|
Facility
|
OP
|
$100.23
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
3697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.07 |
| Max. Negotiated Rate |
$93.22 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Medicare |
$32.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$57.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.28
|
| Rate for Payer: Cash Price |
$60.14
|
| Rate for Payer: Centivo All Commercial |
$54.53
|
| Rate for Payer: Cigna All Commercial |
$86.50
|
| Rate for Payer: CORVEL All Commercial |
$93.22
|
| Rate for Payer: Coventry All Commercial |
$88.21
|
| Rate for Payer: Encore All Commercial |
$92.26
|
| Rate for Payer: Frontpath All Commercial |
$92.21
|
| Rate for Payer: Humana ChoiceCare |
$86.57
|
| Rate for Payer: Humana Medicare |
$32.07
|
| Rate for Payer: Lucent All Commercial |
$54.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.21
|
| Rate for Payer: PHCS All Commercial |
$75.17
|
| Rate for Payer: PHP All Commercial |
$76.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.09
|
| Rate for Payer: Sagamore Health Network All Products |
$77.38
|
| Rate for Payer: Signature Care EPO |
$83.19
|
| Rate for Payer: Signature Care PPO |
$88.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.20
|
| Rate for Payer: United Healthcare Commercial |
$78.98
|
| Rate for Payer: United Healthcare Medicare |
$32.07
|
|
|
HYDRALAZINE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
HYDRALAZINE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
HYDRALAZINE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 60687082211
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
HYDRALAZINE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 60687082211
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.32
|
| Rate for Payer: CORVEL All Commercial |
$1.42
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1.18
|
| Rate for Payer: Signature Care EPO |
$1.27
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG ORAL TAB
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 69315015501
|
| Hospital Charge Code |
76988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Centivo All Commercial |
$0.65
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.10
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Humana Medicare |
$0.38
|
| Rate for Payer: Lucent All Commercial |
$0.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.08
|
| Rate for Payer: PHCS All Commercial |
$0.90
|
| Rate for Payer: PHP All Commercial |
$0.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.47
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
