|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN
|
Facility
|
IP
|
$18.48
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$17.19 |
| Rate for Payer: Aetna Commercial |
$15.97
|
| Rate for Payer: Cash Price |
$11.09
|
| Rate for Payer: Cigna All Commercial |
$15.95
|
| Rate for Payer: CORVEL All Commercial |
$17.19
|
| Rate for Payer: Coventry All Commercial |
$16.26
|
| Rate for Payer: Encore All Commercial |
$17.01
|
| Rate for Payer: Frontpath All Commercial |
$17.00
|
| Rate for Payer: Humana ChoiceCare |
$15.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.63
|
| Rate for Payer: PHCS All Commercial |
$13.86
|
| Rate for Payer: PHP All Commercial |
$14.02
|
| Rate for Payer: Sagamore Health Network All Products |
$14.27
|
| Rate for Payer: Signature Care EPO |
$15.34
|
| Rate for Payer: Signature Care PPO |
$16.26
|
| Rate for Payer: United Healthcare Commercial |
$14.56
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN
|
Facility
|
OP
|
$18.48
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$17.19 |
| Rate for Payer: Aetna Commercial |
$15.60
|
| Rate for Payer: Aetna Medicare |
$5.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.50
|
| Rate for Payer: Cash Price |
$11.09
|
| Rate for Payer: Centivo All Commercial |
$10.05
|
| Rate for Payer: Cigna All Commercial |
$15.95
|
| Rate for Payer: CORVEL All Commercial |
$17.19
|
| Rate for Payer: Coventry All Commercial |
$16.26
|
| Rate for Payer: Encore All Commercial |
$17.01
|
| Rate for Payer: Frontpath All Commercial |
$17.00
|
| Rate for Payer: Humana ChoiceCare |
$15.96
|
| Rate for Payer: Humana Medicare |
$5.91
|
| Rate for Payer: Lucent All Commercial |
$10.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.63
|
| Rate for Payer: PHCS All Commercial |
$13.86
|
| Rate for Payer: PHP All Commercial |
$14.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.21
|
| Rate for Payer: Sagamore Health Network All Products |
$14.27
|
| Rate for Payer: Signature Care EPO |
$15.34
|
| Rate for Payer: Signature Care PPO |
$16.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.71
|
| Rate for Payer: United Healthcare Commercial |
$14.56
|
| Rate for Payer: United Healthcare Medicare |
$5.91
|
|
|
MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
119529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.25
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Centivo All Commercial |
$26.66
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana Medicare |
$15.68
|
| Rate for Payer: Lucent All Commercial |
$26.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Medicare |
$15.68
|
|
|
MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
119529
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
|
IP
|
$23.80
|
|
|
Service Code
|
NDC 63323010701
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
|
IP
|
$23.80
|
|
|
Service Code
|
NDC 63323010705
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
|
OP
|
$23.80
|
|
|
Service Code
|
NDC 63323010701
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.09
|
| Rate for Payer: Aetna Medicare |
$7.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.38
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Centivo All Commercial |
$12.95
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Humana Medicare |
$7.62
|
| Rate for Payer: Lucent All Commercial |
$12.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.28
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.23
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$7.62
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
|
OP
|
$23.80
|
|
|
Service Code
|
NDC 63323010705
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Aetna Commercial |
$20.09
|
| Rate for Payer: Aetna Medicare |
$7.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.38
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Centivo All Commercial |
$12.95
|
| Rate for Payer: Cigna All Commercial |
$20.54
|
| Rate for Payer: CORVEL All Commercial |
$22.13
|
| Rate for Payer: Coventry All Commercial |
$20.94
|
| Rate for Payer: Encore All Commercial |
$21.91
|
| Rate for Payer: Frontpath All Commercial |
$21.90
|
| Rate for Payer: Humana ChoiceCare |
$20.56
|
| Rate for Payer: Humana Medicare |
$7.62
|
| Rate for Payer: Lucent All Commercial |
$12.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.42
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$17.85
|
| Rate for Payer: PHP All Commercial |
$18.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.28
|
| Rate for Payer: Sagamore Health Network All Products |
$18.37
|
| Rate for Payer: Signature Care EPO |
$19.75
|
| Rate for Payer: Signature Care PPO |
$20.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.23
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$7.62
|
|
|
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
|
Facility
|
IP
|
$4,366.01
|
|
|
Service Code
|
APR-DRG 7513
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,366.01 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
|
Facility
|
IP
|
$8,342.97
|
|
|
Service Code
|
APR-DRG 7514
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$8,342.97 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
|
Facility
|
IP
|
$2,161.39
|
|
|
Service Code
|
APR-DRG 7512
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,161.39 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
|
Facility
|
IP
|
$1,599.43
|
|
|
Service Code
|
APR-DRG 7511
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$1,599.43 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
MANNITOL 20 % 20 % IV SOLP
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$123.69 |
| Rate for Payer: Aetna Commercial |
$114.91
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
|
|
MANNITOL 20 % 20 % IV SOLP
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.23 |
| Max. Negotiated Rate |
$123.69 |
| Rate for Payer: Aetna Commercial |
$112.25
|
| Rate for Payer: Aetna Medicare |
$42.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$76.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$83.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$48.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Centivo All Commercial |
$72.35
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Humana Medicare |
$42.56
|
| Rate for Payer: Lucent All Commercial |
$72.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$51.87
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$113.05
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
| Rate for Payer: United Healthcare Medicare |
$42.56
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SUBQ SOLR
|
Facility
|
IP
|
$510.20
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$382.65 |
| Max. Negotiated Rate |
$474.49 |
| Rate for Payer: Aetna Commercial |
$440.82
|
| Rate for Payer: Cash Price |
$306.12
|
| Rate for Payer: Cigna All Commercial |
$440.31
|
| Rate for Payer: CORVEL All Commercial |
$474.49
|
| Rate for Payer: Coventry All Commercial |
$448.98
|
| Rate for Payer: Encore All Commercial |
$469.64
|
| Rate for Payer: Frontpath All Commercial |
$469.39
|
| Rate for Payer: Humana ChoiceCare |
$440.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$459.18
|
| Rate for Payer: PHCS All Commercial |
$382.65
|
| Rate for Payer: PHP All Commercial |
$386.94
|
| Rate for Payer: Sagamore Health Network All Products |
$393.88
|
| Rate for Payer: Signature Care EPO |
$423.47
|
| Rate for Payer: Signature Care PPO |
$448.98
|
| Rate for Payer: United Healthcare Commercial |
$402.04
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SUBQ SOLR
|
Facility
|
OP
|
$510.20
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.16 |
| Max. Negotiated Rate |
$474.49 |
| Rate for Payer: Aetna Commercial |
$430.61
|
| Rate for Payer: Aetna Medicare |
$163.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$158.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$293.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$318.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$187.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$179.59
|
| Rate for Payer: Cash Price |
$306.12
|
| Rate for Payer: Centivo All Commercial |
$277.55
|
| Rate for Payer: Cigna All Commercial |
$440.31
|
| Rate for Payer: CORVEL All Commercial |
$474.49
|
| Rate for Payer: Coventry All Commercial |
$448.98
|
| Rate for Payer: Encore All Commercial |
$469.64
|
| Rate for Payer: Frontpath All Commercial |
$469.39
|
| Rate for Payer: Humana ChoiceCare |
$440.66
|
| Rate for Payer: Humana Medicare |
$163.27
|
| Rate for Payer: Lucent All Commercial |
$277.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$459.18
|
| Rate for Payer: PHCS All Commercial |
$382.65
|
| Rate for Payer: PHP All Commercial |
$386.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$198.98
|
| Rate for Payer: Sagamore Health Network All Products |
$393.88
|
| Rate for Payer: Signature Care EPO |
$423.47
|
| Rate for Payer: Signature Care PPO |
$448.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$433.67
|
| Rate for Payer: United Healthcare Commercial |
$402.04
|
| Rate for Payer: United Healthcare Medicare |
$163.27
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR
|
Facility
|
IP
|
$536.35
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
198256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$402.26 |
| Max. Negotiated Rate |
$498.81 |
| Rate for Payer: Aetna Commercial |
$463.41
|
| Rate for Payer: Cash Price |
$321.81
|
| Rate for Payer: Cigna All Commercial |
$462.87
|
| Rate for Payer: CORVEL All Commercial |
$498.81
|
| Rate for Payer: Coventry All Commercial |
$471.99
|
| Rate for Payer: Encore All Commercial |
$493.71
|
| Rate for Payer: Frontpath All Commercial |
$493.44
|
| Rate for Payer: Humana ChoiceCare |
$463.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$482.72
|
| Rate for Payer: PHCS All Commercial |
$402.26
|
| Rate for Payer: PHP All Commercial |
$406.77
|
| Rate for Payer: Sagamore Health Network All Products |
$414.06
|
| Rate for Payer: Signature Care EPO |
$445.17
|
| Rate for Payer: Signature Care PPO |
$471.99
|
| Rate for Payer: United Healthcare Commercial |
$422.65
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR
|
Facility
|
OP
|
$536.35
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
198256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.27 |
| Max. Negotiated Rate |
$498.81 |
| Rate for Payer: Aetna Commercial |
$452.68
|
| Rate for Payer: Aetna Medicare |
$171.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$166.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$308.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$335.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$197.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$188.80
|
| Rate for Payer: Cash Price |
$321.81
|
| Rate for Payer: Centivo All Commercial |
$291.78
|
| Rate for Payer: Cigna All Commercial |
$462.87
|
| Rate for Payer: CORVEL All Commercial |
$498.81
|
| Rate for Payer: Coventry All Commercial |
$471.99
|
| Rate for Payer: Encore All Commercial |
$493.71
|
| Rate for Payer: Frontpath All Commercial |
$493.44
|
| Rate for Payer: Humana ChoiceCare |
$463.25
|
| Rate for Payer: Humana Medicare |
$171.63
|
| Rate for Payer: Lucent All Commercial |
$291.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$482.72
|
| Rate for Payer: PHCS All Commercial |
$402.26
|
| Rate for Payer: PHP All Commercial |
$406.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$209.18
|
| Rate for Payer: Sagamore Health Network All Products |
$414.06
|
| Rate for Payer: Signature Care EPO |
$445.17
|
| Rate for Payer: Signature Care PPO |
$471.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$455.90
|
| Rate for Payer: United Healthcare Commercial |
$422.65
|
| Rate for Payer: United Healthcare Medicare |
$171.63
|
|
|
MEASLES,MUMPS,RUB,VARICEL(PF) 10EXP3-4.3-3- 3.99 TCID50/0.5 SUBQ SUSR
|
Facility
|
OP
|
$1,035.60
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
42622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$288.92 |
| Max. Negotiated Rate |
$963.11 |
| Rate for Payer: Aetna Commercial |
$874.05
|
| Rate for Payer: Aetna Medicare |
$331.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$288.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$321.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$594.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$647.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$288.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$381.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$364.53
|
| Rate for Payer: Cash Price |
$621.36
|
| Rate for Payer: Cash Price |
$621.36
|
| Rate for Payer: Centivo All Commercial |
$563.37
|
| Rate for Payer: Cigna All Commercial |
$893.73
|
| Rate for Payer: CORVEL All Commercial |
$963.11
|
| Rate for Payer: Coventry All Commercial |
$911.33
|
| Rate for Payer: Encore All Commercial |
$953.27
|
| Rate for Payer: Frontpath All Commercial |
$952.76
|
| Rate for Payer: Humana ChoiceCare |
$894.45
|
| Rate for Payer: Humana Medicare |
$331.39
|
| Rate for Payer: Lucent All Commercial |
$563.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$932.04
|
| Rate for Payer: Managed Health Services Medicaid |
$288.92
|
| Rate for Payer: MDWise Medicaid |
$288.92
|
| Rate for Payer: PHCS All Commercial |
$776.70
|
| Rate for Payer: PHP All Commercial |
$785.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$403.89
|
| Rate for Payer: Sagamore Health Network All Products |
$799.49
|
| Rate for Payer: Signature Care EPO |
$859.55
|
| Rate for Payer: Signature Care PPO |
$911.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$880.26
|
| Rate for Payer: United Healthcare Commercial |
$816.06
|
| Rate for Payer: United Healthcare Medicare |
$331.39
|
|
|
MEASLES,MUMPS,RUB,VARICEL(PF) 10EXP3-4.3-3- 3.99 TCID50/0.5 SUBQ SUSR
|
Facility
|
IP
|
$1,035.60
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
42622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$776.70 |
| Max. Negotiated Rate |
$963.11 |
| Rate for Payer: Aetna Commercial |
$894.76
|
| Rate for Payer: Cash Price |
$621.36
|
| Rate for Payer: Cigna All Commercial |
$893.73
|
| Rate for Payer: CORVEL All Commercial |
$963.11
|
| Rate for Payer: Coventry All Commercial |
$911.33
|
| Rate for Payer: Encore All Commercial |
$953.27
|
| Rate for Payer: Frontpath All Commercial |
$952.76
|
| Rate for Payer: Humana ChoiceCare |
$894.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$932.04
|
| Rate for Payer: PHCS All Commercial |
$776.70
|
| Rate for Payer: PHP All Commercial |
$785.40
|
| Rate for Payer: Sagamore Health Network All Products |
$799.49
|
| Rate for Payer: Signature Care EPO |
$859.55
|
| Rate for Payer: Signature Care PPO |
$911.33
|
| Rate for Payer: United Healthcare Commercial |
$816.06
|
|
|
MECLIZINE 12.5 MG ORAL TAB
|
Facility
|
IP
|
$2.43
|
|
|
Service Code
|
NDC 50268052211
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna All Commercial |
$2.10
|
| Rate for Payer: CORVEL All Commercial |
$2.26
|
| Rate for Payer: Coventry All Commercial |
$2.14
|
| Rate for Payer: Encore All Commercial |
$2.24
|
| Rate for Payer: Frontpath All Commercial |
$2.23
|
| Rate for Payer: Humana ChoiceCare |
$2.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.19
|
| Rate for Payer: PHCS All Commercial |
$1.82
|
| Rate for Payer: PHP All Commercial |
$1.84
|
| Rate for Payer: Sagamore Health Network All Products |
$1.88
|
| Rate for Payer: Signature Care EPO |
$2.02
|
| Rate for Payer: Signature Care PPO |
$2.14
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
|
|
MECLIZINE 12.5 MG ORAL TAB
|
Facility
|
OP
|
$2.43
|
|
|
Service Code
|
NDC 50268052215
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Centivo All Commercial |
$1.32
|
| Rate for Payer: Cigna All Commercial |
$2.10
|
| Rate for Payer: CORVEL All Commercial |
$2.26
|
| Rate for Payer: Coventry All Commercial |
$2.14
|
| Rate for Payer: Encore All Commercial |
$2.24
|
| Rate for Payer: Frontpath All Commercial |
$2.23
|
| Rate for Payer: Humana ChoiceCare |
$2.10
|
| Rate for Payer: Humana Medicare |
$0.78
|
| Rate for Payer: Lucent All Commercial |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.19
|
| Rate for Payer: PHCS All Commercial |
$1.82
|
| Rate for Payer: PHP All Commercial |
$1.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.95
|
| Rate for Payer: Sagamore Health Network All Products |
$1.88
|
| Rate for Payer: Signature Care EPO |
$2.02
|
| Rate for Payer: Signature Care PPO |
$2.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.06
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
| Rate for Payer: United Healthcare Medicare |
$0.78
|
|
|
MECLIZINE 12.5 MG ORAL TAB
|
Facility
|
IP
|
$2.43
|
|
|
Service Code
|
NDC 50268052215
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna All Commercial |
$2.10
|
| Rate for Payer: CORVEL All Commercial |
$2.26
|
| Rate for Payer: Coventry All Commercial |
$2.14
|
| Rate for Payer: Encore All Commercial |
$2.24
|
| Rate for Payer: Frontpath All Commercial |
$2.23
|
| Rate for Payer: Humana ChoiceCare |
$2.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.19
|
| Rate for Payer: PHCS All Commercial |
$1.82
|
| Rate for Payer: PHP All Commercial |
$1.84
|
| Rate for Payer: Sagamore Health Network All Products |
$1.88
|
| Rate for Payer: Signature Care EPO |
$2.02
|
| Rate for Payer: Signature Care PPO |
$2.14
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
|
|
MECLIZINE 12.5 MG ORAL TAB
|
Facility
|
OP
|
$2.43
|
|
|
Service Code
|
NDC 50268052211
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Centivo All Commercial |
$1.32
|
| Rate for Payer: Cigna All Commercial |
$2.10
|
| Rate for Payer: CORVEL All Commercial |
$2.26
|
| Rate for Payer: Coventry All Commercial |
$2.14
|
| Rate for Payer: Encore All Commercial |
$2.24
|
| Rate for Payer: Frontpath All Commercial |
$2.23
|
| Rate for Payer: Humana ChoiceCare |
$2.10
|
| Rate for Payer: Humana Medicare |
$0.78
|
| Rate for Payer: Lucent All Commercial |
$1.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.19
|
| Rate for Payer: PHCS All Commercial |
$1.82
|
| Rate for Payer: PHP All Commercial |
$1.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.95
|
| Rate for Payer: Sagamore Health Network All Products |
$1.88
|
| Rate for Payer: Signature Care EPO |
$2.02
|
| Rate for Payer: Signature Care PPO |
$2.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.06
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
| Rate for Payer: United Healthcare Medicare |
$0.78
|
|
|
MEDROXYPROGESTERONE 150 MG/ML IM S.O.
|
Facility
|
OP
|
$401.76
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
420792
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.55 |
| Max. Negotiated Rate |
$373.64 |
| Rate for Payer: Aetna Commercial |
$339.09
|
| Rate for Payer: Aetna Medicare |
$128.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$124.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$230.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$251.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$147.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$141.42
|
| Rate for Payer: Cash Price |
$241.06
|
| Rate for Payer: Centivo All Commercial |
$218.56
|
| Rate for Payer: Cigna All Commercial |
$346.72
|
| Rate for Payer: CORVEL All Commercial |
$373.64
|
| Rate for Payer: Coventry All Commercial |
$353.55
|
| Rate for Payer: Encore All Commercial |
$369.82
|
| Rate for Payer: Frontpath All Commercial |
$369.62
|
| Rate for Payer: Humana ChoiceCare |
$347.00
|
| Rate for Payer: Humana Medicare |
$128.56
|
| Rate for Payer: Lucent All Commercial |
$218.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$361.58
|
| Rate for Payer: PHCS All Commercial |
$301.32
|
| Rate for Payer: PHP All Commercial |
$304.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$156.69
|
| Rate for Payer: Sagamore Health Network All Products |
$310.16
|
| Rate for Payer: Signature Care EPO |
$333.46
|
| Rate for Payer: Signature Care PPO |
$353.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$341.50
|
| Rate for Payer: United Healthcare Commercial |
$316.59
|
| Rate for Payer: United Healthcare Medicare |
$128.56
|
|
