|
PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP
|
Facility
|
OP
|
$14.81
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna Commercial |
$12.50
|
| Rate for Payer: Aetna Medicare |
$4.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.21
|
| Rate for Payer: Cash Price |
$8.88
|
| Rate for Payer: Cash Price |
$8.88
|
| Rate for Payer: Centivo All Commercial |
$8.05
|
| Rate for Payer: Cigna All Commercial |
$12.78
|
| Rate for Payer: CORVEL All Commercial |
$13.77
|
| Rate for Payer: Coventry All Commercial |
$13.03
|
| Rate for Payer: Encore All Commercial |
$13.63
|
| Rate for Payer: Frontpath All Commercial |
$13.62
|
| Rate for Payer: Humana ChoiceCare |
$12.79
|
| Rate for Payer: Humana Medicare |
$4.74
|
| Rate for Payer: Lucent All Commercial |
$8.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.32
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$11.10
|
| Rate for Payer: PHP All Commercial |
$11.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.77
|
| Rate for Payer: Sagamore Health Network All Products |
$11.43
|
| Rate for Payer: Signature Care EPO |
$12.29
|
| Rate for Payer: Signature Care PPO |
$13.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.58
|
| Rate for Payer: United Healthcare Commercial |
$11.67
|
| Rate for Payer: United Healthcare Medicare |
$4.74
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBQ SYRG
|
Facility
|
OP
|
$15,816.96
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$561.57 |
| Max. Negotiated Rate |
$14,709.77 |
| Rate for Payer: Aetna Commercial |
$13,349.51
|
| Rate for Payer: Aetna Medicare |
$5,061.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$561.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,903.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9,083.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,887.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$561.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,820.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,567.57
|
| Rate for Payer: Cash Price |
$9,490.17
|
| Rate for Payer: Cash Price |
$9,490.17
|
| Rate for Payer: Centivo All Commercial |
$8,604.42
|
| Rate for Payer: Cigna All Commercial |
$13,650.03
|
| Rate for Payer: CORVEL All Commercial |
$14,709.77
|
| Rate for Payer: Coventry All Commercial |
$13,918.92
|
| Rate for Payer: Encore All Commercial |
$14,559.51
|
| Rate for Payer: Frontpath All Commercial |
$14,551.60
|
| Rate for Payer: Humana ChoiceCare |
$13,661.10
|
| Rate for Payer: Humana Medicare |
$5,061.43
|
| Rate for Payer: Lucent All Commercial |
$8,604.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,235.26
|
| Rate for Payer: Managed Health Services Medicaid |
$561.57
|
| Rate for Payer: MDWise Medicaid |
$561.57
|
| Rate for Payer: PHCS All Commercial |
$11,862.72
|
| Rate for Payer: PHP All Commercial |
$11,995.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,168.61
|
| Rate for Payer: Sagamore Health Network All Products |
$12,210.69
|
| Rate for Payer: Signature Care EPO |
$13,128.07
|
| Rate for Payer: Signature Care PPO |
$13,918.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,444.41
|
| Rate for Payer: United Healthcare Commercial |
$12,463.76
|
| Rate for Payer: United Healthcare Medicare |
$5,061.43
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBQ SYRG
|
Facility
|
IP
|
$15,816.96
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,862.72 |
| Max. Negotiated Rate |
$14,709.77 |
| Rate for Payer: Aetna Commercial |
$13,665.85
|
| Rate for Payer: Cash Price |
$9,490.17
|
| Rate for Payer: Cigna All Commercial |
$13,650.03
|
| Rate for Payer: CORVEL All Commercial |
$14,709.77
|
| Rate for Payer: Coventry All Commercial |
$13,918.92
|
| Rate for Payer: Encore All Commercial |
$14,559.51
|
| Rate for Payer: Frontpath All Commercial |
$14,551.60
|
| Rate for Payer: Humana ChoiceCare |
$13,661.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,235.26
|
| Rate for Payer: PHCS All Commercial |
$11,862.72
|
| Rate for Payer: PHP All Commercial |
$11,995.58
|
| Rate for Payer: Sagamore Health Network All Products |
$12,210.69
|
| Rate for Payer: Signature Care EPO |
$13,128.07
|
| Rate for Payer: Signature Care PPO |
$13,918.92
|
| Rate for Payer: United Healthcare Commercial |
$12,463.76
|
|
|
PEMBROLIZUMAB 25 MG/ML IV SOLN
|
Facility
|
OP
|
$20,642.02
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
171368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.93 |
| Max. Negotiated Rate |
$19,197.08 |
| Rate for Payer: Aetna Commercial |
$17,421.86
|
| Rate for Payer: Aetna Medicare |
$6,605.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$61.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,399.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11,854.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,903.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$61.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,596.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,265.99
|
| Rate for Payer: Cash Price |
$12,385.21
|
| Rate for Payer: Cash Price |
$12,385.21
|
| Rate for Payer: Centivo All Commercial |
$11,229.26
|
| Rate for Payer: Cigna All Commercial |
$17,814.06
|
| Rate for Payer: CORVEL All Commercial |
$19,197.08
|
| Rate for Payer: Coventry All Commercial |
$18,164.98
|
| Rate for Payer: Encore All Commercial |
$19,000.98
|
| Rate for Payer: Frontpath All Commercial |
$18,990.66
|
| Rate for Payer: Humana ChoiceCare |
$17,828.51
|
| Rate for Payer: Humana Medicare |
$6,605.45
|
| Rate for Payer: Lucent All Commercial |
$11,229.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,577.82
|
| Rate for Payer: Managed Health Services Medicaid |
$61.93
|
| Rate for Payer: MDWise Medicaid |
$61.93
|
| Rate for Payer: PHCS All Commercial |
$15,481.51
|
| Rate for Payer: PHP All Commercial |
$15,654.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,050.39
|
| Rate for Payer: Sagamore Health Network All Products |
$15,935.64
|
| Rate for Payer: Signature Care EPO |
$17,132.88
|
| Rate for Payer: Signature Care PPO |
$18,164.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,545.72
|
| Rate for Payer: United Healthcare Commercial |
$16,265.91
|
| Rate for Payer: United Healthcare Medicare |
$6,605.45
|
|
|
PEMBROLIZUMAB 25 MG/ML IV SOLN
|
Facility
|
IP
|
$20,642.02
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
171368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15,481.51 |
| Max. Negotiated Rate |
$19,197.08 |
| Rate for Payer: Aetna Commercial |
$17,834.71
|
| Rate for Payer: Cash Price |
$12,385.21
|
| Rate for Payer: Cigna All Commercial |
$17,814.06
|
| Rate for Payer: CORVEL All Commercial |
$19,197.08
|
| Rate for Payer: Coventry All Commercial |
$18,164.98
|
| Rate for Payer: Encore All Commercial |
$19,000.98
|
| Rate for Payer: Frontpath All Commercial |
$18,990.66
|
| Rate for Payer: Humana ChoiceCare |
$17,828.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,577.82
|
| Rate for Payer: PHCS All Commercial |
$15,481.51
|
| Rate for Payer: PHP All Commercial |
$15,654.91
|
| Rate for Payer: Sagamore Health Network All Products |
$15,935.64
|
| Rate for Payer: Signature Care EPO |
$17,132.88
|
| Rate for Payer: Signature Care PPO |
$18,164.98
|
| Rate for Payer: United Healthcare Commercial |
$16,265.91
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG
|
Facility
|
IP
|
$1,257.83
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
108049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$943.37 |
| Max. Negotiated Rate |
$1,169.78 |
| Rate for Payer: Aetna Commercial |
$1,086.77
|
| Rate for Payer: Cash Price |
$754.70
|
| Rate for Payer: Cigna All Commercial |
$1,085.51
|
| Rate for Payer: CORVEL All Commercial |
$1,169.78
|
| Rate for Payer: Coventry All Commercial |
$1,106.89
|
| Rate for Payer: Encore All Commercial |
$1,157.83
|
| Rate for Payer: Frontpath All Commercial |
$1,157.21
|
| Rate for Payer: Humana ChoiceCare |
$1,086.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,132.05
|
| Rate for Payer: PHCS All Commercial |
$943.37
|
| Rate for Payer: PHP All Commercial |
$953.94
|
| Rate for Payer: Sagamore Health Network All Products |
$971.05
|
| Rate for Payer: Signature Care EPO |
$1,044.00
|
| Rate for Payer: Signature Care PPO |
$1,106.89
|
| Rate for Payer: United Healthcare Commercial |
$991.17
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG
|
Facility
|
OP
|
$1,257.83
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
108049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$389.93 |
| Max. Negotiated Rate |
$1,169.78 |
| Rate for Payer: Aetna Commercial |
$1,061.61
|
| Rate for Payer: Aetna Medicare |
$402.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$389.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$722.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$786.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$462.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$442.76
|
| Rate for Payer: Cash Price |
$754.70
|
| Rate for Payer: Centivo All Commercial |
$684.26
|
| Rate for Payer: Cigna All Commercial |
$1,085.51
|
| Rate for Payer: CORVEL All Commercial |
$1,169.78
|
| Rate for Payer: Coventry All Commercial |
$1,106.89
|
| Rate for Payer: Encore All Commercial |
$1,157.83
|
| Rate for Payer: Frontpath All Commercial |
$1,157.21
|
| Rate for Payer: Humana ChoiceCare |
$1,086.39
|
| Rate for Payer: Humana Medicare |
$402.51
|
| Rate for Payer: Lucent All Commercial |
$684.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,132.05
|
| Rate for Payer: PHCS All Commercial |
$943.37
|
| Rate for Payer: PHP All Commercial |
$953.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$490.55
|
| Rate for Payer: Sagamore Health Network All Products |
$971.05
|
| Rate for Payer: Signature Care EPO |
$1,044.00
|
| Rate for Payer: Signature Care PPO |
$1,106.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,069.16
|
| Rate for Payer: United Healthcare Commercial |
$991.17
|
| Rate for Payer: United Healthcare Medicare |
$402.51
|
|
|
PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 ML(600K/600K) IM SYRG
|
Facility
|
IP
|
$1,035.76
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
108051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$776.82 |
| Max. Negotiated Rate |
$963.26 |
| Rate for Payer: Aetna Commercial |
$894.90
|
| Rate for Payer: Cash Price |
$621.46
|
| Rate for Payer: Cigna All Commercial |
$893.86
|
| Rate for Payer: CORVEL All Commercial |
$963.26
|
| Rate for Payer: Coventry All Commercial |
$911.47
|
| Rate for Payer: Encore All Commercial |
$953.42
|
| Rate for Payer: Frontpath All Commercial |
$952.90
|
| Rate for Payer: Humana ChoiceCare |
$894.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$932.18
|
| Rate for Payer: PHCS All Commercial |
$776.82
|
| Rate for Payer: PHP All Commercial |
$785.52
|
| Rate for Payer: Sagamore Health Network All Products |
$799.61
|
| Rate for Payer: Signature Care EPO |
$859.68
|
| Rate for Payer: Signature Care PPO |
$911.47
|
| Rate for Payer: United Healthcare Commercial |
$816.18
|
|
|
PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 ML(600K/600K) IM SYRG
|
Facility
|
OP
|
$1,035.76
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
108051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$321.09 |
| Max. Negotiated Rate |
$963.26 |
| Rate for Payer: Aetna Commercial |
$874.18
|
| Rate for Payer: Aetna Medicare |
$331.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$321.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$594.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$647.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$381.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$364.59
|
| Rate for Payer: Cash Price |
$621.46
|
| Rate for Payer: Centivo All Commercial |
$563.45
|
| Rate for Payer: Cigna All Commercial |
$893.86
|
| Rate for Payer: CORVEL All Commercial |
$963.26
|
| Rate for Payer: Coventry All Commercial |
$911.47
|
| Rate for Payer: Encore All Commercial |
$953.42
|
| Rate for Payer: Frontpath All Commercial |
$952.90
|
| Rate for Payer: Humana ChoiceCare |
$894.59
|
| Rate for Payer: Humana Medicare |
$331.44
|
| Rate for Payer: Lucent All Commercial |
$563.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$932.18
|
| Rate for Payer: PHCS All Commercial |
$776.82
|
| Rate for Payer: PHP All Commercial |
$785.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$403.95
|
| Rate for Payer: Sagamore Health Network All Products |
$799.61
|
| Rate for Payer: Signature Care EPO |
$859.68
|
| Rate for Payer: Signature Care PPO |
$911.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$880.40
|
| Rate for Payer: United Healthcare Commercial |
$816.18
|
| Rate for Payer: United Healthcare Medicare |
$331.44
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNITS INJ SOLR
|
Facility
|
OP
|
$178.92
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$166.40 |
| Rate for Payer: Aetna Commercial |
$151.01
|
| Rate for Payer: Aetna Medicare |
$57.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$55.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$102.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$111.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$65.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$62.98
|
| Rate for Payer: Cash Price |
$107.35
|
| Rate for Payer: Centivo All Commercial |
$97.33
|
| Rate for Payer: Cigna All Commercial |
$154.41
|
| Rate for Payer: CORVEL All Commercial |
$166.40
|
| Rate for Payer: Coventry All Commercial |
$157.45
|
| Rate for Payer: Encore All Commercial |
$164.70
|
| Rate for Payer: Frontpath All Commercial |
$164.61
|
| Rate for Payer: Humana ChoiceCare |
$154.53
|
| Rate for Payer: Humana Medicare |
$57.25
|
| Rate for Payer: Lucent All Commercial |
$97.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$161.03
|
| Rate for Payer: PHCS All Commercial |
$134.19
|
| Rate for Payer: PHP All Commercial |
$135.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$69.78
|
| Rate for Payer: Sagamore Health Network All Products |
$138.13
|
| Rate for Payer: Signature Care EPO |
$148.50
|
| Rate for Payer: Signature Care PPO |
$157.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$152.08
|
| Rate for Payer: United Healthcare Commercial |
$140.99
|
| Rate for Payer: United Healthcare Medicare |
$57.25
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNITS INJ SOLR
|
Facility
|
IP
|
$178.92
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$134.19 |
| Max. Negotiated Rate |
$166.40 |
| Rate for Payer: Aetna Commercial |
$154.59
|
| Rate for Payer: Cash Price |
$107.35
|
| Rate for Payer: Cigna All Commercial |
$154.41
|
| Rate for Payer: CORVEL All Commercial |
$166.40
|
| Rate for Payer: Coventry All Commercial |
$157.45
|
| Rate for Payer: Encore All Commercial |
$164.70
|
| Rate for Payer: Frontpath All Commercial |
$164.61
|
| Rate for Payer: Humana ChoiceCare |
$154.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$161.03
|
| Rate for Payer: PHCS All Commercial |
$134.19
|
| Rate for Payer: PHP All Commercial |
$135.69
|
| Rate for Payer: Sagamore Health Network All Products |
$138.13
|
| Rate for Payer: Signature Care EPO |
$148.50
|
| Rate for Payer: Signature Care PPO |
$157.45
|
| Rate for Payer: United Healthcare Commercial |
$140.99
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNITS INJ SOLR
|
Facility
|
IP
|
$28.86
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.65 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.94
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cigna All Commercial |
$24.91
|
| Rate for Payer: CORVEL All Commercial |
$26.84
|
| Rate for Payer: Coventry All Commercial |
$25.40
|
| Rate for Payer: Encore All Commercial |
$26.57
|
| Rate for Payer: Frontpath All Commercial |
$26.55
|
| Rate for Payer: Humana ChoiceCare |
$24.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.97
|
| Rate for Payer: PHCS All Commercial |
$21.65
|
| Rate for Payer: PHP All Commercial |
$21.89
|
| Rate for Payer: Sagamore Health Network All Products |
$22.28
|
| Rate for Payer: Signature Care EPO |
$23.95
|
| Rate for Payer: Signature Care PPO |
$25.40
|
| Rate for Payer: United Healthcare Commercial |
$22.74
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNITS INJ SOLR
|
Facility
|
OP
|
$28.86
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.36
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Centivo All Commercial |
$15.70
|
| Rate for Payer: Cigna All Commercial |
$24.91
|
| Rate for Payer: CORVEL All Commercial |
$26.84
|
| Rate for Payer: Coventry All Commercial |
$25.40
|
| Rate for Payer: Encore All Commercial |
$26.57
|
| Rate for Payer: Frontpath All Commercial |
$26.55
|
| Rate for Payer: Humana ChoiceCare |
$24.93
|
| Rate for Payer: Humana Medicare |
$9.24
|
| Rate for Payer: Lucent All Commercial |
$15.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.97
|
| Rate for Payer: PHCS All Commercial |
$21.65
|
| Rate for Payer: PHP All Commercial |
$21.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.26
|
| Rate for Payer: Sagamore Health Network All Products |
$22.28
|
| Rate for Payer: Signature Care EPO |
$23.95
|
| Rate for Payer: Signature Care PPO |
$25.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.53
|
| Rate for Payer: United Healthcare Commercial |
$22.74
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
|
|
PENICILLIN G POT IN DEXTROSE 3 MILLION UNIT/50 ML IV PGBK
|
Facility
|
IP
|
$79.80
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
15960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.85 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$68.95
|
| Rate for Payer: Cash Price |
$47.88
|
| Rate for Payer: Cigna All Commercial |
$68.87
|
| Rate for Payer: CORVEL All Commercial |
$74.21
|
| Rate for Payer: Coventry All Commercial |
$70.22
|
| Rate for Payer: Encore All Commercial |
$73.46
|
| Rate for Payer: Frontpath All Commercial |
$73.42
|
| Rate for Payer: Humana ChoiceCare |
$68.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.82
|
| Rate for Payer: PHCS All Commercial |
$59.85
|
| Rate for Payer: PHP All Commercial |
$60.52
|
| Rate for Payer: Sagamore Health Network All Products |
$61.61
|
| Rate for Payer: Signature Care EPO |
$66.23
|
| Rate for Payer: Signature Care PPO |
$70.22
|
| Rate for Payer: United Healthcare Commercial |
$62.88
|
|
|
PENICILLIN G POT IN DEXTROSE 3 MILLION UNIT/50 ML IV PGBK
|
Facility
|
OP
|
$79.80
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
15960
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.74 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$67.35
|
| Rate for Payer: Aetna Medicare |
$25.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.09
|
| Rate for Payer: Cash Price |
$47.88
|
| Rate for Payer: Centivo All Commercial |
$43.41
|
| Rate for Payer: Cigna All Commercial |
$68.87
|
| Rate for Payer: CORVEL All Commercial |
$74.21
|
| Rate for Payer: Coventry All Commercial |
$70.22
|
| Rate for Payer: Encore All Commercial |
$73.46
|
| Rate for Payer: Frontpath All Commercial |
$73.42
|
| Rate for Payer: Humana ChoiceCare |
$68.92
|
| Rate for Payer: Humana Medicare |
$25.54
|
| Rate for Payer: Lucent All Commercial |
$43.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.82
|
| Rate for Payer: PHCS All Commercial |
$59.85
|
| Rate for Payer: PHP All Commercial |
$60.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.12
|
| Rate for Payer: Sagamore Health Network All Products |
$61.61
|
| Rate for Payer: Signature Care EPO |
$66.23
|
| Rate for Payer: Signature Care PPO |
$70.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.83
|
| Rate for Payer: United Healthcare Commercial |
$62.88
|
| Rate for Payer: United Healthcare Medicare |
$25.54
|
|
|
PENICILLIN SKIN TEST (CAMERON)
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
14010006086
|
|
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
|
|
|
PENICILLIN SKIN TEST (CAMERON)
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
14010006086
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$9.56
|
| 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 Hoosier Healthwise/HIP |
$9.56
|
| 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: 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: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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
|
|
|
PENICILLIN V POTASSIUM 250 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
PENICILLIN V POTASSIUM 250 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
PENTAMIDINE 300 MG INHL SOLR
|
Facility
|
IP
|
$546.35
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$409.76 |
| Max. Negotiated Rate |
$508.11 |
| Rate for Payer: Aetna Commercial |
$472.05
|
| Rate for Payer: Cash Price |
$327.81
|
| Rate for Payer: Cigna All Commercial |
$471.50
|
| Rate for Payer: CORVEL All Commercial |
$508.11
|
| Rate for Payer: Coventry All Commercial |
$480.79
|
| Rate for Payer: Encore All Commercial |
$502.92
|
| Rate for Payer: Frontpath All Commercial |
$502.64
|
| Rate for Payer: Humana ChoiceCare |
$471.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$491.71
|
| Rate for Payer: PHCS All Commercial |
$409.76
|
| Rate for Payer: PHP All Commercial |
$414.35
|
| Rate for Payer: Sagamore Health Network All Products |
$421.78
|
| Rate for Payer: Signature Care EPO |
$453.47
|
| Rate for Payer: Signature Care PPO |
$480.79
|
| Rate for Payer: United Healthcare Commercial |
$430.52
|
|
|
PENTAMIDINE 300 MG INHL SOLR
|
Facility
|
OP
|
$546.35
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$508.11 |
| Rate for Payer: Aetna Commercial |
$461.12
|
| Rate for Payer: Aetna Medicare |
$174.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$94.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$169.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$313.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$341.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$94.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$201.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$192.32
|
| Rate for Payer: Cash Price |
$327.81
|
| Rate for Payer: Cash Price |
$327.81
|
| Rate for Payer: Centivo All Commercial |
$297.21
|
| Rate for Payer: Cigna All Commercial |
$471.50
|
| Rate for Payer: CORVEL All Commercial |
$508.11
|
| Rate for Payer: Coventry All Commercial |
$480.79
|
| Rate for Payer: Encore All Commercial |
$502.92
|
| Rate for Payer: Frontpath All Commercial |
$502.64
|
| Rate for Payer: Humana ChoiceCare |
$471.88
|
| Rate for Payer: Humana Medicare |
$174.83
|
| Rate for Payer: Lucent All Commercial |
$297.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$491.71
|
| Rate for Payer: Managed Health Services Medicaid |
$94.50
|
| Rate for Payer: MDWise Medicaid |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$409.76
|
| Rate for Payer: PHP All Commercial |
$414.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$213.08
|
| Rate for Payer: Sagamore Health Network All Products |
$421.78
|
| Rate for Payer: Signature Care EPO |
$453.47
|
| Rate for Payer: Signature Care PPO |
$480.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$464.40
|
| Rate for Payer: United Healthcare Commercial |
$430.52
|
| Rate for Payer: United Healthcare Medicare |
$174.83
|
|
|
PENTOXIFYLLINE 400 MG ORAL TBER
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna All Commercial |
$1.31
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| 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 |
$1.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.26
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
PENTOXIFYLLINE 400 MG ORAL TBER
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| 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 |
$0.87
|
| 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 |
$0.53
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.31
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| 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 |
$1.31
|
| 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 |
$1.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.59
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.26
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP
|
Facility
|
IP
|
$602.11
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$451.58 |
| Max. Negotiated Rate |
$559.96 |
| Rate for Payer: Aetna Commercial |
$520.22
|
| Rate for Payer: Cash Price |
$361.27
|
| Rate for Payer: Cigna All Commercial |
$519.62
|
| Rate for Payer: CORVEL All Commercial |
$559.96
|
| Rate for Payer: Coventry All Commercial |
$529.86
|
| Rate for Payer: Encore All Commercial |
$554.24
|
| Rate for Payer: Frontpath All Commercial |
$553.94
|
| Rate for Payer: Humana ChoiceCare |
$520.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$541.90
|
| Rate for Payer: PHCS All Commercial |
$451.58
|
| Rate for Payer: PHP All Commercial |
$456.64
|
| Rate for Payer: Sagamore Health Network All Products |
$464.83
|
| Rate for Payer: Signature Care EPO |
$499.75
|
| Rate for Payer: Signature Care PPO |
$529.86
|
| Rate for Payer: United Healthcare Commercial |
$474.46
|
|
|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP
|
Facility
|
OP
|
$602.11
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.65 |
| Max. Negotiated Rate |
$559.96 |
| Rate for Payer: Aetna Commercial |
$508.18
|
| Rate for Payer: Aetna Medicare |
$192.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$186.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$345.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$376.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$221.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$211.94
|
| Rate for Payer: Cash Price |
$361.27
|
| Rate for Payer: Centivo All Commercial |
$327.55
|
| Rate for Payer: Cigna All Commercial |
$519.62
|
| Rate for Payer: CORVEL All Commercial |
$559.96
|
| Rate for Payer: Coventry All Commercial |
$529.86
|
| Rate for Payer: Encore All Commercial |
$554.24
|
| Rate for Payer: Frontpath All Commercial |
$553.94
|
| Rate for Payer: Humana ChoiceCare |
$520.04
|
| Rate for Payer: Humana Medicare |
$192.68
|
| Rate for Payer: Lucent All Commercial |
$327.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$541.90
|
| Rate for Payer: PHCS All Commercial |
$451.58
|
| Rate for Payer: PHP All Commercial |
$456.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.82
|
| Rate for Payer: Sagamore Health Network All Products |
$464.83
|
| Rate for Payer: Signature Care EPO |
$499.75
|
| Rate for Payer: Signature Care PPO |
$529.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$511.79
|
| Rate for Payer: United Healthcare Commercial |
$474.46
|
| Rate for Payer: United Healthcare Medicare |
$192.68
|
|
