|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
OP
|
$5.96
|
|
|
Service Code
|
NDC 68084057211
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$5.03
|
| Rate for Payer: Aetna Medicare |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Centivo All Commercial |
$3.04
|
| Rate for Payer: Cigna All Commercial |
$5.14
|
| Rate for Payer: CORVEL All Commercial |
$5.54
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.48
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Lucent All Commercial |
$3.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.06
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$1.97
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
OP
|
$5.96
|
|
|
Service Code
|
NDC 68084057201
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$5.03
|
| Rate for Payer: Aetna Medicare |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Centivo All Commercial |
$3.04
|
| Rate for Payer: Cigna All Commercial |
$5.14
|
| Rate for Payer: CORVEL All Commercial |
$5.54
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.48
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Lucent All Commercial |
$3.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.06
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$1.97
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
IP
|
$5.96
|
|
|
Service Code
|
NDC 68084057201
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna All Commercial |
$5.14
|
| Rate for Payer: CORVEL All Commercial |
$5.54
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.48
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
|
|
GUAIFENESIN 600 MG ORAL TA12
|
Facility
IP
|
$5.96
|
|
|
Service Code
|
NDC 68084057211
|
| Hospital Charge Code |
168089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna All Commercial |
$5.14
|
| Rate for Payer: CORVEL All Commercial |
$5.54
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.48
|
| Rate for Payer: Humana ChoiceCare |
$5.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.47
|
| Rate for Payer: PHP All Commercial |
$4.52
|
| Rate for Payer: Sagamore Health Network All Products |
$4.60
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
|
|
HAEMPH B POLYSAC CONJ-MENIN PF 7.5 MCG/0.5 ML IM SOLN
|
Facility
OP
|
$187.91
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
10153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.01 |
| Max. Negotiated Rate |
$174.75 |
| Rate for Payer: Aetna Commercial |
$158.59
|
| Rate for Payer: Aetna Medicare |
$62.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$62.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$107.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$117.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.21
|
| Rate for Payer: Cash Price |
$116.50
|
| Rate for Payer: Centivo All Commercial |
$95.83
|
| Rate for Payer: Cigna All Commercial |
$162.16
|
| Rate for Payer: CORVEL All Commercial |
$174.75
|
| Rate for Payer: Coventry All Commercial |
$165.36
|
| Rate for Payer: Encore All Commercial |
$172.97
|
| Rate for Payer: Frontpath All Commercial |
$172.88
|
| Rate for Payer: Humana ChoiceCare |
$162.30
|
| Rate for Payer: Humana Medicare |
$95.83
|
| Rate for Payer: Lucent All Commercial |
$95.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$169.12
|
| Rate for Payer: PHCS All Commercial |
$140.93
|
| Rate for Payer: PHP All Commercial |
$142.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$73.28
|
| Rate for Payer: Sagamore Health Network All Products |
$145.06
|
| Rate for Payer: Signature Care EPO |
$155.96
|
| Rate for Payer: Signature Care PPO |
$165.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$159.72
|
| Rate for Payer: United Healthcare Commercial |
$148.07
|
| Rate for Payer: United Healthcare Medicare |
$62.01
|
|
|
HAEMPH B POLYSAC CONJ-MENIN PF 7.5 MCG/0.5 ML IM SOLN
|
Facility
IP
|
$187.91
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
10153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.93 |
| Max. Negotiated Rate |
$174.75 |
| Rate for Payer: Aetna Commercial |
$162.35
|
| Rate for Payer: Cash Price |
$116.50
|
| Rate for Payer: Cigna All Commercial |
$162.16
|
| Rate for Payer: CORVEL All Commercial |
$174.75
|
| Rate for Payer: Coventry All Commercial |
$165.36
|
| Rate for Payer: Encore All Commercial |
$172.97
|
| Rate for Payer: Frontpath All Commercial |
$172.88
|
| Rate for Payer: Humana ChoiceCare |
$162.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$169.12
|
| Rate for Payer: PHCS All Commercial |
$140.93
|
| Rate for Payer: PHP All Commercial |
$142.51
|
| Rate for Payer: Sagamore Health Network All Products |
$145.06
|
| Rate for Payer: Signature Care EPO |
$155.96
|
| Rate for Payer: Signature Care PPO |
$165.36
|
| Rate for Payer: United Healthcare Commercial |
$148.07
|
|
|
HALOPERIDOL 1 MG ORAL TAB
|
Facility
OP
|
$3.09
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.61
|
| Rate for Payer: Aetna Medicare |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.12
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Centivo All Commercial |
$1.57
|
| Rate for Payer: Cigna All Commercial |
$2.66
|
| Rate for Payer: CORVEL All Commercial |
$2.87
|
| Rate for Payer: Coventry All Commercial |
$2.72
|
| Rate for Payer: Encore All Commercial |
$2.84
|
| Rate for Payer: Frontpath All Commercial |
$2.84
|
| Rate for Payer: Humana ChoiceCare |
$2.67
|
| Rate for Payer: Humana Medicare |
$1.57
|
| Rate for Payer: Lucent All Commercial |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.78
|
| Rate for Payer: PHCS All Commercial |
$2.32
|
| Rate for Payer: PHP All Commercial |
$2.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2.38
|
| Rate for Payer: Signature Care EPO |
$2.56
|
| Rate for Payer: Signature Care PPO |
$2.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.62
|
| Rate for Payer: United Healthcare Commercial |
$2.43
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
|
|
HALOPERIDOL 1 MG ORAL TAB
|
Facility
IP
|
$3.09
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3579
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.67
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna All Commercial |
$2.66
|
| Rate for Payer: CORVEL All Commercial |
$2.87
|
| Rate for Payer: Coventry All Commercial |
$2.72
|
| Rate for Payer: Encore All Commercial |
$2.84
|
| Rate for Payer: Frontpath All Commercial |
$2.84
|
| Rate for Payer: Humana ChoiceCare |
$2.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.78
|
| Rate for Payer: PHCS All Commercial |
$2.32
|
| Rate for Payer: PHP All Commercial |
$2.34
|
| Rate for Payer: Sagamore Health Network All Products |
$2.38
|
| Rate for Payer: Signature Care EPO |
$2.56
|
| Rate for Payer: Signature Care PPO |
$2.72
|
| Rate for Payer: United Healthcare Commercial |
$2.43
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN
|
Facility
IP
|
$495.54
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
10163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$371.66 |
| Max. Negotiated Rate |
$460.85 |
| Rate for Payer: Aetna Commercial |
$428.15
|
| Rate for Payer: Cash Price |
$307.23
|
| Rate for Payer: Cigna All Commercial |
$427.65
|
| Rate for Payer: CORVEL All Commercial |
$460.85
|
| Rate for Payer: Coventry All Commercial |
$436.08
|
| Rate for Payer: Encore All Commercial |
$456.14
|
| Rate for Payer: Frontpath All Commercial |
$455.90
|
| Rate for Payer: Humana ChoiceCare |
$428.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.99
|
| Rate for Payer: PHCS All Commercial |
$371.66
|
| Rate for Payer: PHP All Commercial |
$375.82
|
| Rate for Payer: Sagamore Health Network All Products |
$382.56
|
| Rate for Payer: Signature Care EPO |
$411.30
|
| Rate for Payer: Signature Care PPO |
$436.08
|
| Rate for Payer: United Healthcare Commercial |
$390.49
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN
|
Facility
OP
|
$495.54
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
10163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.53 |
| Max. Negotiated Rate |
$460.85 |
| Rate for Payer: Aetna Commercial |
$418.24
|
| Rate for Payer: Aetna Medicare |
$163.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$163.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$284.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$309.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$188.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$179.88
|
| Rate for Payer: Cash Price |
$307.23
|
| Rate for Payer: Centivo All Commercial |
$252.73
|
| Rate for Payer: Cigna All Commercial |
$427.65
|
| Rate for Payer: CORVEL All Commercial |
$460.85
|
| Rate for Payer: Coventry All Commercial |
$436.08
|
| Rate for Payer: Encore All Commercial |
$456.14
|
| Rate for Payer: Frontpath All Commercial |
$455.90
|
| Rate for Payer: Humana ChoiceCare |
$428.00
|
| Rate for Payer: Humana Medicare |
$252.73
|
| Rate for Payer: Lucent All Commercial |
$252.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$445.99
|
| Rate for Payer: PHCS All Commercial |
$371.66
|
| Rate for Payer: PHP All Commercial |
$375.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$193.26
|
| Rate for Payer: Sagamore Health Network All Products |
$382.56
|
| Rate for Payer: Signature Care EPO |
$411.30
|
| Rate for Payer: Signature Care PPO |
$436.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$421.21
|
| Rate for Payer: United Healthcare Commercial |
$390.49
|
| Rate for Payer: United Healthcare Medicare |
$163.53
|
|
|
HALOPERIDOL LACTATE 5 MG/ML INJ SOLN
|
Facility
OP
|
$21.05
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$19.58 |
| Rate for Payer: Aetna Commercial |
$17.77
|
| Rate for Payer: Aetna Medicare |
$6.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.64
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Centivo All Commercial |
$10.73
|
| Rate for Payer: Cigna All Commercial |
$18.17
|
| Rate for Payer: CORVEL All Commercial |
$19.58
|
| Rate for Payer: Coventry All Commercial |
$18.52
|
| Rate for Payer: Encore All Commercial |
$19.38
|
| Rate for Payer: Frontpath All Commercial |
$19.37
|
| Rate for Payer: Humana ChoiceCare |
$18.18
|
| Rate for Payer: Humana Medicare |
$10.73
|
| Rate for Payer: Lucent All Commercial |
$10.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.94
|
| Rate for Payer: PHCS All Commercial |
$15.79
|
| Rate for Payer: PHP All Commercial |
$15.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.21
|
| Rate for Payer: Sagamore Health Network All Products |
$16.25
|
| Rate for Payer: Signature Care EPO |
$17.47
|
| Rate for Payer: Signature Care PPO |
$18.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.89
|
| Rate for Payer: United Healthcare Commercial |
$16.59
|
| Rate for Payer: United Healthcare Medicare |
$6.95
|
|
|
HALOPERIDOL LACTATE 5 MG/ML INJ SOLN
|
Facility
IP
|
$21.05
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3584
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$19.58 |
| Rate for Payer: Aetna Commercial |
$18.19
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna All Commercial |
$18.17
|
| Rate for Payer: CORVEL All Commercial |
$19.58
|
| Rate for Payer: Coventry All Commercial |
$18.52
|
| Rate for Payer: Encore All Commercial |
$19.38
|
| Rate for Payer: Frontpath All Commercial |
$19.37
|
| Rate for Payer: Humana ChoiceCare |
$18.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.94
|
| Rate for Payer: PHCS All Commercial |
$15.79
|
| Rate for Payer: PHP All Commercial |
$15.96
|
| Rate for Payer: Sagamore Health Network All Products |
$16.25
|
| Rate for Payer: Signature Care EPO |
$17.47
|
| Rate for Payer: Signature Care PPO |
$18.52
|
| Rate for Payer: United Healthcare Commercial |
$16.59
|
|
|
HC 14FR FIRM INTUB STYLET
|
Facility
IP
|
$12.80
|
|
| Hospital Charge Code |
41608050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Aetna Commercial |
$11.06
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Cigna All Commercial |
$11.05
|
| Rate for Payer: CORVEL All Commercial |
$11.90
|
| Rate for Payer: Coventry All Commercial |
$11.26
|
| Rate for Payer: Encore All Commercial |
$11.78
|
| Rate for Payer: Frontpath All Commercial |
$11.78
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.52
|
| Rate for Payer: PHCS All Commercial |
$9.60
|
| Rate for Payer: PHP All Commercial |
$9.71
|
| Rate for Payer: Sagamore Health Network All Products |
$9.88
|
| Rate for Payer: Signature Care EPO |
$10.62
|
| Rate for Payer: Signature Care PPO |
$11.26
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
|
|
HC 14FR FIRM INTUB STYLET
|
Facility
OP
|
$12.80
|
|
| Hospital Charge Code |
41608050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Medicare |
$4.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Centivo All Commercial |
$6.53
|
| Rate for Payer: Cigna All Commercial |
$11.05
|
| Rate for Payer: CORVEL All Commercial |
$11.90
|
| Rate for Payer: Coventry All Commercial |
$11.26
|
| Rate for Payer: Encore All Commercial |
$11.78
|
| Rate for Payer: Frontpath All Commercial |
$11.78
|
| Rate for Payer: Humana ChoiceCare |
$11.06
|
| Rate for Payer: Humana Medicare |
$6.53
|
| Rate for Payer: Lucent All Commercial |
$6.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.52
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$9.60
|
| Rate for Payer: PHP All Commercial |
$9.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.99
|
| Rate for Payer: Sagamore Health Network All Products |
$9.88
|
| Rate for Payer: Signature Care EPO |
$10.62
|
| Rate for Payer: Signature Care PPO |
$11.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.88
|
| Rate for Payer: United Healthcare Commercial |
$10.09
|
| Rate for Payer: United Healthcare Medicare |
$4.22
|
|
|
HC 17 HYDROXYPROGESTRERONE-16 & YOUNGER
|
Facility
IP
|
$175.99
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
63001574
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.99 |
| Max. Negotiated Rate |
$163.67 |
| Rate for Payer: Aetna Commercial |
$152.06
|
| Rate for Payer: Cash Price |
$109.11
|
| Rate for Payer: Cigna All Commercial |
$151.88
|
| Rate for Payer: CORVEL All Commercial |
$163.67
|
| Rate for Payer: Coventry All Commercial |
$154.87
|
| Rate for Payer: Encore All Commercial |
$162.00
|
| Rate for Payer: Frontpath All Commercial |
$161.91
|
| Rate for Payer: Humana ChoiceCare |
$152.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.39
|
| Rate for Payer: PHCS All Commercial |
$131.99
|
| Rate for Payer: PHP All Commercial |
$133.47
|
| Rate for Payer: Sagamore Health Network All Products |
$135.86
|
| Rate for Payer: Signature Care EPO |
$146.07
|
| Rate for Payer: Signature Care PPO |
$154.87
|
| Rate for Payer: United Healthcare Commercial |
$138.68
|
|
|
HC 17 HYDROXYPROGESTRERONE-16 & YOUNGER
|
Facility
OP
|
$175.99
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
63001574
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$163.67 |
| Rate for Payer: Aetna Commercial |
$148.54
|
| Rate for Payer: Aetna Medicare |
$58.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$58.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$80.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$80.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$27.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$66.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$63.88
|
| Rate for Payer: Cash Price |
$109.11
|
| Rate for Payer: Cash Price |
$109.11
|
| Rate for Payer: Centivo All Commercial |
$89.76
|
| Rate for Payer: Cigna All Commercial |
$151.88
|
| Rate for Payer: CORVEL All Commercial |
$163.67
|
| Rate for Payer: Coventry All Commercial |
$154.87
|
| Rate for Payer: Encore All Commercial |
$162.00
|
| Rate for Payer: Frontpath All Commercial |
$161.91
|
| Rate for Payer: Humana ChoiceCare |
$152.00
|
| Rate for Payer: Humana Medicare |
$89.76
|
| Rate for Payer: Lucent All Commercial |
$89.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$158.39
|
| Rate for Payer: Managed Health Services Medicaid |
$27.17
|
| Rate for Payer: MDWise Medicaid |
$27.17
|
| Rate for Payer: PHCS All Commercial |
$131.99
|
| Rate for Payer: PHP All Commercial |
$133.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$68.64
|
| Rate for Payer: Sagamore Health Network All Products |
$135.86
|
| Rate for Payer: Signature Care EPO |
$146.07
|
| Rate for Payer: Signature Care PPO |
$154.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$149.59
|
| Rate for Payer: United Healthcare Commercial |
$138.68
|
| Rate for Payer: United Healthcare Medicare |
$58.08
|
|
|
HC 17 HYDROXYPROGESTRERONE-ADULTS
|
Facility
OP
|
$235.62
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
63001575
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$219.13 |
| Rate for Payer: Aetna Commercial |
$198.86
|
| Rate for Payer: Aetna Medicare |
$77.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$77.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$108.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$108.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$27.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$85.53
|
| Rate for Payer: Cash Price |
$146.08
|
| Rate for Payer: Cash Price |
$146.08
|
| Rate for Payer: Centivo All Commercial |
$120.17
|
| Rate for Payer: Cigna All Commercial |
$203.34
|
| Rate for Payer: CORVEL All Commercial |
$219.13
|
| Rate for Payer: Coventry All Commercial |
$207.35
|
| Rate for Payer: Encore All Commercial |
$216.89
|
| Rate for Payer: Frontpath All Commercial |
$216.77
|
| Rate for Payer: Humana ChoiceCare |
$203.50
|
| Rate for Payer: Humana Medicare |
$120.17
|
| Rate for Payer: Lucent All Commercial |
$120.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.06
|
| Rate for Payer: Managed Health Services Medicaid |
$27.17
|
| Rate for Payer: MDWise Medicaid |
$27.17
|
| Rate for Payer: PHCS All Commercial |
$176.72
|
| Rate for Payer: PHP All Commercial |
$178.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$91.89
|
| Rate for Payer: Sagamore Health Network All Products |
$181.90
|
| Rate for Payer: Signature Care EPO |
$195.56
|
| Rate for Payer: Signature Care PPO |
$207.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$200.28
|
| Rate for Payer: United Healthcare Commercial |
$185.67
|
| Rate for Payer: United Healthcare Medicare |
$77.75
|
|
|
HC 17 HYDROXYPROGESTRERONE-ADULTS
|
Facility
IP
|
$235.62
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
63001575
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.72 |
| Max. Negotiated Rate |
$219.13 |
| Rate for Payer: Aetna Commercial |
$203.58
|
| Rate for Payer: Cash Price |
$146.08
|
| Rate for Payer: Cigna All Commercial |
$203.34
|
| Rate for Payer: CORVEL All Commercial |
$219.13
|
| Rate for Payer: Coventry All Commercial |
$207.35
|
| Rate for Payer: Encore All Commercial |
$216.89
|
| Rate for Payer: Frontpath All Commercial |
$216.77
|
| Rate for Payer: Humana ChoiceCare |
$203.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.06
|
| Rate for Payer: PHCS All Commercial |
$176.72
|
| Rate for Payer: PHP All Commercial |
$178.69
|
| Rate for Payer: Sagamore Health Network All Products |
$181.90
|
| Rate for Payer: Signature Care EPO |
$195.56
|
| Rate for Payer: Signature Care PPO |
$207.35
|
| Rate for Payer: United Healthcare Commercial |
$185.67
|
|
|
HC 17 KETOSTEROIDS
|
Facility
OP
|
$175.09
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
63001616
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$162.84 |
| Rate for Payer: Aetna Commercial |
$147.78
|
| Rate for Payer: Aetna Medicare |
$57.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$100.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$12.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$66.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$63.56
|
| Rate for Payer: Cash Price |
$108.56
|
| Rate for Payer: Cash Price |
$108.56
|
| Rate for Payer: Centivo All Commercial |
$89.30
|
| Rate for Payer: Cigna All Commercial |
$151.11
|
| Rate for Payer: CORVEL All Commercial |
$162.84
|
| Rate for Payer: Coventry All Commercial |
$154.08
|
| Rate for Payer: Encore All Commercial |
$161.17
|
| Rate for Payer: Frontpath All Commercial |
$161.09
|
| Rate for Payer: Humana ChoiceCare |
$151.23
|
| Rate for Payer: Humana Medicare |
$89.30
|
| Rate for Payer: Lucent All Commercial |
$89.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$157.58
|
| Rate for Payer: Managed Health Services Medicaid |
$12.80
|
| Rate for Payer: MDWise Medicaid |
$12.80
|
| Rate for Payer: PHCS All Commercial |
$131.32
|
| Rate for Payer: PHP All Commercial |
$132.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$68.29
|
| Rate for Payer: Sagamore Health Network All Products |
$135.17
|
| Rate for Payer: Signature Care EPO |
$145.33
|
| Rate for Payer: Signature Care PPO |
$154.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$148.83
|
| Rate for Payer: United Healthcare Commercial |
$137.97
|
| Rate for Payer: United Healthcare Medicare |
$57.78
|
|
|
HC 17 KETOSTEROIDS
|
Facility
IP
|
$175.09
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
63001616
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.32 |
| Max. Negotiated Rate |
$162.84 |
| Rate for Payer: Aetna Commercial |
$151.28
|
| Rate for Payer: Cash Price |
$108.56
|
| Rate for Payer: Cigna All Commercial |
$151.11
|
| Rate for Payer: CORVEL All Commercial |
$162.84
|
| Rate for Payer: Coventry All Commercial |
$154.08
|
| Rate for Payer: Encore All Commercial |
$161.17
|
| Rate for Payer: Frontpath All Commercial |
$161.09
|
| Rate for Payer: Humana ChoiceCare |
$151.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$157.58
|
| Rate for Payer: PHCS All Commercial |
$131.32
|
| Rate for Payer: PHP All Commercial |
$132.79
|
| Rate for Payer: Sagamore Health Network All Products |
$135.17
|
| Rate for Payer: Signature Care EPO |
$145.33
|
| Rate for Payer: Signature Care PPO |
$154.08
|
| Rate for Payer: United Healthcare Commercial |
$137.97
|
|
|
HC 24 HR CREATININE
|
Facility
OP
|
$106.52
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
63001523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$99.06 |
| Rate for Payer: Aetna Commercial |
$89.90
|
| Rate for Payer: Aetna Medicare |
$35.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$48.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$48.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$5.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.67
|
| Rate for Payer: Cash Price |
$66.04
|
| Rate for Payer: Cash Price |
$66.04
|
| Rate for Payer: Centivo All Commercial |
$54.32
|
| Rate for Payer: Cigna All Commercial |
$91.93
|
| Rate for Payer: CORVEL All Commercial |
$99.06
|
| Rate for Payer: Coventry All Commercial |
$93.74
|
| Rate for Payer: Encore All Commercial |
$98.05
|
| Rate for Payer: Frontpath All Commercial |
$98.00
|
| Rate for Payer: Humana ChoiceCare |
$92.00
|
| Rate for Payer: Humana Medicare |
$54.32
|
| Rate for Payer: Lucent All Commercial |
$54.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.87
|
| Rate for Payer: Managed Health Services Medicaid |
$5.18
|
| Rate for Payer: MDWise Medicaid |
$5.18
|
| Rate for Payer: PHCS All Commercial |
$79.89
|
| Rate for Payer: PHP All Commercial |
$80.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.54
|
| Rate for Payer: Sagamore Health Network All Products |
$82.23
|
| Rate for Payer: Signature Care EPO |
$88.41
|
| Rate for Payer: Signature Care PPO |
$93.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.54
|
| Rate for Payer: United Healthcare Commercial |
$83.94
|
| Rate for Payer: United Healthcare Medicare |
$35.15
|
|
|
HC 24 HR CREATININE
|
Facility
IP
|
$106.52
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
63001523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.89 |
| Max. Negotiated Rate |
$99.06 |
| Rate for Payer: Aetna Commercial |
$92.03
|
| Rate for Payer: Cash Price |
$66.04
|
| Rate for Payer: Cigna All Commercial |
$91.93
|
| Rate for Payer: CORVEL All Commercial |
$99.06
|
| Rate for Payer: Coventry All Commercial |
$93.74
|
| Rate for Payer: Encore All Commercial |
$98.05
|
| Rate for Payer: Frontpath All Commercial |
$98.00
|
| Rate for Payer: Humana ChoiceCare |
$92.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.87
|
| Rate for Payer: PHCS All Commercial |
$79.89
|
| Rate for Payer: PHP All Commercial |
$80.78
|
| Rate for Payer: Sagamore Health Network All Products |
$82.23
|
| Rate for Payer: Signature Care EPO |
$88.41
|
| Rate for Payer: Signature Care PPO |
$93.74
|
| Rate for Payer: United Healthcare Commercial |
$83.94
|
|
|
HC 24 HR POTASSIUM
|
Facility
OP
|
$100.42
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
63001662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna Commercial |
$84.75
|
| Rate for Payer: Aetna Medicare |
$33.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$57.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.45
|
| Rate for Payer: Cash Price |
$62.26
|
| Rate for Payer: Cash Price |
$62.26
|
| Rate for Payer: Centivo All Commercial |
$51.21
|
| Rate for Payer: Cigna All Commercial |
$86.66
|
| Rate for Payer: CORVEL All Commercial |
$93.39
|
| Rate for Payer: Coventry All Commercial |
$88.37
|
| Rate for Payer: Encore All Commercial |
$92.44
|
| Rate for Payer: Frontpath All Commercial |
$92.39
|
| Rate for Payer: Humana ChoiceCare |
$86.73
|
| Rate for Payer: Humana Medicare |
$51.21
|
| Rate for Payer: Lucent All Commercial |
$51.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.38
|
| Rate for Payer: Managed Health Services Medicaid |
$4.70
|
| Rate for Payer: MDWise Medicaid |
$4.70
|
| Rate for Payer: PHCS All Commercial |
$75.31
|
| Rate for Payer: PHP All Commercial |
$76.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.16
|
| Rate for Payer: Sagamore Health Network All Products |
$77.52
|
| Rate for Payer: Signature Care EPO |
$83.35
|
| Rate for Payer: Signature Care PPO |
$88.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.36
|
| Rate for Payer: United Healthcare Commercial |
$79.13
|
| Rate for Payer: United Healthcare Medicare |
$33.14
|
|
|
HC 24 HR POTASSIUM
|
Facility
IP
|
$100.42
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
63001662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.31 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Cash Price |
$62.26
|
| Rate for Payer: Cigna All Commercial |
$86.66
|
| Rate for Payer: CORVEL All Commercial |
$93.39
|
| Rate for Payer: Coventry All Commercial |
$88.37
|
| Rate for Payer: Encore All Commercial |
$92.44
|
| Rate for Payer: Frontpath All Commercial |
$92.39
|
| Rate for Payer: Humana ChoiceCare |
$86.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.38
|
| Rate for Payer: PHCS All Commercial |
$75.31
|
| Rate for Payer: PHP All Commercial |
$76.16
|
| Rate for Payer: Sagamore Health Network All Products |
$77.52
|
| Rate for Payer: Signature Care EPO |
$83.35
|
| Rate for Payer: Signature Care PPO |
$88.37
|
| Rate for Payer: United Healthcare Commercial |
$79.13
|
|
|
HC 24 HR SODIUM
|
Facility
IP
|
$99.86
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
63001678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.89 |
| Max. Negotiated Rate |
$92.87 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Cash Price |
$61.91
|
| Rate for Payer: Cigna All Commercial |
$86.18
|
| Rate for Payer: CORVEL All Commercial |
$92.87
|
| Rate for Payer: Coventry All Commercial |
$87.88
|
| Rate for Payer: Encore All Commercial |
$91.92
|
| Rate for Payer: Frontpath All Commercial |
$91.87
|
| Rate for Payer: Humana ChoiceCare |
$86.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.87
|
| Rate for Payer: PHCS All Commercial |
$74.89
|
| Rate for Payer: PHP All Commercial |
$75.73
|
| Rate for Payer: Sagamore Health Network All Products |
$77.09
|
| Rate for Payer: Signature Care EPO |
$82.88
|
| Rate for Payer: Signature Care PPO |
$87.88
|
| Rate for Payer: United Healthcare Commercial |
$78.69
|
|
