|
MS-DRG 42.00: VEIN LIGATION AND STRIPPING
|
Facility
|
IP
|
$27,649.77
|
|
|
Service Code
|
MSDRG 263
|
| Min. Negotiated Rate |
$15,093.73 |
| Max. Negotiated Rate |
$27,649.77 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$23,441.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27,649.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15,093.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19,713.44
|
|
|
MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$22,015.90
|
|
|
Service Code
|
MSDRG 032
|
| Min. Negotiated Rate |
$12,018.26 |
| Max. Negotiated Rate |
$22,015.90 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18,665.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22,015.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12,018.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15,696.66
|
|
|
MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$43,200.90
|
|
|
Service Code
|
MSDRG 031
|
| Min. Negotiated Rate |
$23,582.94 |
| Max. Negotiated Rate |
$43,200.90 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36,625.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43,200.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23,582.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30,800.91
|
|
|
MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$16,448.01
|
|
|
Service Code
|
MSDRG 033
|
| Min. Negotiated Rate |
$8,978.80 |
| Max. Negotiated Rate |
$16,448.01 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13,944.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,448.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,978.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11,726.92
|
|
|
MS-DRG 42.00: VIRAL ILLNESS WITH MCC
|
Facility
|
IP
|
$15,215.05
|
|
|
Service Code
|
MSDRG 865
|
| Min. Negotiated Rate |
$8,305.75 |
| Max. Negotiated Rate |
$15,215.05 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12,899.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15,215.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,305.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,847.86
|
|
|
MS-DRG 42.00: VIRAL ILLNESS WITHOUT MCC
|
Facility
|
IP
|
$9,121.40
|
|
|
Service Code
|
MSDRG 866
|
| Min. Negotiated Rate |
$4,979.28 |
| Max. Negotiated Rate |
$9,121.40 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7,733.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,121.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,979.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,503.28
|
|
|
MS-DRG 42.00: VIRAL MENINGITIS WITH CC/MCC
|
Facility
|
IP
|
$17,756.22
|
|
|
Service Code
|
MSDRG 075
|
| Min. Negotiated Rate |
$9,692.94 |
| Max. Negotiated Rate |
$17,756.22 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15,053.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17,756.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9,692.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,659.64
|
|
|
MS-DRG 42.00: VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$9,452.32
|
|
|
Service Code
|
MSDRG 076
|
| Min. Negotiated Rate |
$5,159.93 |
| Max. Negotiated Rate |
$9,452.32 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8,013.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,452.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,159.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,739.22
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$30,397.12
|
|
|
Service Code
|
MSDRG 464
|
| Min. Negotiated Rate |
$16,593.48 |
| Max. Negotiated Rate |
$30,397.12 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$25,770.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30,397.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16,593.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21,672.21
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$55,678.91
|
|
|
Service Code
|
MSDRG 463
|
| Min. Negotiated Rate |
$30,394.56 |
| Max. Negotiated Rate |
$55,678.91 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47,204.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$55,678.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30,394.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39,697.35
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$17,897.45
|
|
|
Service Code
|
MSDRG 465
|
| Min. Negotiated Rate |
$9,770.04 |
| Max. Negotiated Rate |
$17,897.45 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15,173.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17,897.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9,770.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,760.33
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITH CC
|
Facility
|
IP
|
$19,562.36
|
|
|
Service Code
|
MSDRG 902
|
| Min. Negotiated Rate |
$10,678.90 |
| Max. Negotiated Rate |
$19,562.36 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16,585.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19,562.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,678.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,947.36
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITH MCC
|
Facility
|
IP
|
$45,674.02
|
|
|
Service Code
|
MSDRG 901
|
| Min. Negotiated Rate |
$24,932.99 |
| Max. Negotiated Rate |
$45,674.02 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$38,722.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45,674.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24,932.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32,564.17
|
|
|
MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$12,567.70
|
|
|
Service Code
|
MSDRG 903
|
| Min. Negotiated Rate |
$6,860.58 |
| Max. Negotiated Rate |
$12,567.70 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10,654.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,567.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,860.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,960.39
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
NDC 77333086125
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 77333086110
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.30
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.84
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 77333086125
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.30
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Centivo All Commercial |
$0.84
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG ORAL TAB
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
NDC 77333086110
|
| Hospital Charge Code |
120459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna All Commercial |
$1.33
|
| Rate for Payer: CORVEL All Commercial |
$1.43
|
| Rate for Payer: Coventry All Commercial |
$1.36
|
| Rate for Payer: Encore All Commercial |
$1.42
|
| Rate for Payer: Frontpath All Commercial |
$1.42
|
| Rate for Payer: Humana ChoiceCare |
$1.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.39
|
| Rate for Payer: PHCS All Commercial |
$1.16
|
| Rate for Payer: PHP All Commercial |
$1.17
|
| Rate for Payer: Sagamore Health Network All Products |
$1.19
|
| Rate for Payer: Signature Care EPO |
$1.28
|
| Rate for Payer: Signature Care PPO |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQD
|
Facility
|
OP
|
$54.52
|
|
|
Service Code
|
NDC 00005434462
|
| Hospital Charge Code |
121122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$50.70 |
| Rate for Payer: Aetna Commercial |
$46.01
|
| Rate for Payer: Aetna Medicare |
$17.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$31.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$34.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.19
|
| Rate for Payer: Cash Price |
$32.71
|
| Rate for Payer: Centivo All Commercial |
$29.66
|
| Rate for Payer: Cigna All Commercial |
$47.05
|
| Rate for Payer: CORVEL All Commercial |
$50.70
|
| Rate for Payer: Coventry All Commercial |
$47.97
|
| Rate for Payer: Encore All Commercial |
$50.18
|
| Rate for Payer: Frontpath All Commercial |
$50.15
|
| Rate for Payer: Humana ChoiceCare |
$47.09
|
| Rate for Payer: Humana Medicare |
$17.45
|
| Rate for Payer: Lucent All Commercial |
$29.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.06
|
| Rate for Payer: PHCS All Commercial |
$40.89
|
| Rate for Payer: PHP All Commercial |
$41.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.26
|
| Rate for Payer: Sagamore Health Network All Products |
$42.09
|
| Rate for Payer: Signature Care EPO |
$45.25
|
| Rate for Payer: Signature Care PPO |
$47.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.34
|
| Rate for Payer: United Healthcare Commercial |
$42.96
|
| Rate for Payer: United Healthcare Medicare |
$17.45
|
|
|
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQD
|
Facility
|
IP
|
$54.52
|
|
|
Service Code
|
NDC 00005434462
|
| Hospital Charge Code |
121122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.89 |
| Max. Negotiated Rate |
$50.70 |
| Rate for Payer: Aetna Commercial |
$47.10
|
| Rate for Payer: Cash Price |
$32.71
|
| Rate for Payer: Cigna All Commercial |
$47.05
|
| Rate for Payer: CORVEL All Commercial |
$50.70
|
| Rate for Payer: Coventry All Commercial |
$47.97
|
| Rate for Payer: Encore All Commercial |
$50.18
|
| Rate for Payer: Frontpath All Commercial |
$50.15
|
| Rate for Payer: Humana ChoiceCare |
$47.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$49.06
|
| Rate for Payer: PHCS All Commercial |
$40.89
|
| Rate for Payer: PHP All Commercial |
$41.34
|
| Rate for Payer: Sagamore Health Network All Products |
$42.09
|
| Rate for Payer: Signature Care EPO |
$45.25
|
| Rate for Payer: Signature Care PPO |
$47.97
|
| Rate for Payer: United Healthcare Commercial |
$42.96
|
|
|
MUPIROCIN 2 % TOP OINT
|
Facility
|
IP
|
$33.26
|
|
|
Service Code
|
NDC 51672131200
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.95 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.74
|
| Rate for Payer: Cash Price |
$19.96
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
|
|
MUPIROCIN 2 % TOP OINT
|
Facility
|
OP
|
$33.26
|
|
|
Service Code
|
NDC 51672131200
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Aetna Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.79
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.71
|
| Rate for Payer: Cash Price |
$19.96
|
| Rate for Payer: Cash Price |
$19.96
|
| Rate for Payer: Centivo All Commercial |
$18.10
|
| Rate for Payer: Cigna All Commercial |
$28.71
|
| Rate for Payer: CORVEL All Commercial |
$30.94
|
| Rate for Payer: Coventry All Commercial |
$29.27
|
| Rate for Payer: Encore All Commercial |
$30.62
|
| Rate for Payer: Frontpath All Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$28.73
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Lucent All Commercial |
$18.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.94
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$24.95
|
| Rate for Payer: PHP All Commercial |
$25.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.97
|
| Rate for Payer: Sagamore Health Network All Products |
$25.68
|
| Rate for Payer: Signature Care EPO |
$27.61
|
| Rate for Payer: Signature Care PPO |
$29.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.27
|
| Rate for Payer: United Healthcare Commercial |
$26.21
|
| Rate for Payer: United Healthcare Medicare |
$10.64
|
|
|
MUPIROCIN CALCIUM 2 % TOP CREA
|
Facility
|
IP
|
$1,225.73
|
|
|
Service Code
|
NDC 68462056417
|
| Hospital Charge Code |
22251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$919.29 |
| Max. Negotiated Rate |
$1,139.92 |
| Rate for Payer: Aetna Commercial |
$1,059.03
|
| Rate for Payer: Cash Price |
$735.44
|
| Rate for Payer: Cigna All Commercial |
$1,057.80
|
| Rate for Payer: CORVEL All Commercial |
$1,139.92
|
| Rate for Payer: Coventry All Commercial |
$1,078.64
|
| Rate for Payer: Encore All Commercial |
$1,128.28
|
| Rate for Payer: Frontpath All Commercial |
$1,127.67
|
| Rate for Payer: Humana ChoiceCare |
$1,058.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,103.15
|
| Rate for Payer: PHCS All Commercial |
$919.29
|
| Rate for Payer: PHP All Commercial |
$929.59
|
| Rate for Payer: Sagamore Health Network All Products |
$946.26
|
| Rate for Payer: Signature Care EPO |
$1,017.35
|
| Rate for Payer: Signature Care PPO |
$1,078.64
|
| Rate for Payer: United Healthcare Commercial |
$965.87
|
|
|
MUPIROCIN CALCIUM 2 % TOP CREA
|
Facility
|
OP
|
$1,225.73
|
|
|
Service Code
|
NDC 68462056417
|
| Hospital Charge Code |
22251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$379.97 |
| Max. Negotiated Rate |
$1,139.92 |
| Rate for Payer: Aetna Commercial |
$1,034.51
|
| Rate for Payer: Aetna Medicare |
$392.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$379.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$703.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$766.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$451.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$431.46
|
| Rate for Payer: Cash Price |
$735.44
|
| Rate for Payer: Centivo All Commercial |
$666.79
|
| Rate for Payer: Cigna All Commercial |
$1,057.80
|
| Rate for Payer: CORVEL All Commercial |
$1,139.92
|
| Rate for Payer: Coventry All Commercial |
$1,078.64
|
| Rate for Payer: Encore All Commercial |
$1,128.28
|
| Rate for Payer: Frontpath All Commercial |
$1,127.67
|
| Rate for Payer: Humana ChoiceCare |
$1,058.66
|
| Rate for Payer: Humana Medicare |
$392.23
|
| Rate for Payer: Lucent All Commercial |
$666.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,103.15
|
| Rate for Payer: PHCS All Commercial |
$919.29
|
| Rate for Payer: PHP All Commercial |
$929.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$478.03
|
| Rate for Payer: Sagamore Health Network All Products |
$946.26
|
| Rate for Payer: Signature Care EPO |
$1,017.35
|
| Rate for Payer: Signature Care PPO |
$1,078.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,041.87
|
| Rate for Payer: United Healthcare Commercial |
$965.87
|
| Rate for Payer: United Healthcare Medicare |
$392.23
|
|
|
MVI, ADULT NO.4, VIT K, 1 OF 2 3,300 UNIT- 150 MCG/5 ML IV SOLN
|
Facility
|
OP
|
$33.71
|
|
|
Service Code
|
NDC 54643786208
|
| Hospital Charge Code |
182456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Medicare |
$10.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.86
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Centivo All Commercial |
$18.34
|
| Rate for Payer: Cigna All Commercial |
$29.09
|
| Rate for Payer: CORVEL All Commercial |
$31.35
|
| Rate for Payer: Coventry All Commercial |
$29.66
|
| Rate for Payer: Encore All Commercial |
$31.03
|
| Rate for Payer: Frontpath All Commercial |
$31.01
|
| Rate for Payer: Humana ChoiceCare |
$29.11
|
| Rate for Payer: Humana Medicare |
$10.79
|
| Rate for Payer: Lucent All Commercial |
$18.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.33
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$25.28
|
| Rate for Payer: PHP All Commercial |
$25.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.14
|
| Rate for Payer: Sagamore Health Network All Products |
$26.02
|
| Rate for Payer: Signature Care EPO |
$27.98
|
| Rate for Payer: Signature Care PPO |
$29.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.65
|
| Rate for Payer: United Healthcare Commercial |
$26.56
|
| Rate for Payer: United Healthcare Medicare |
$10.79
|
|
