|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 70748017501
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$8.04
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna All Commercial |
$8.03
|
| Rate for Payer: CORVEL All Commercial |
$8.66
|
| Rate for Payer: Coventry All Commercial |
$8.19
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Frontpath All Commercial |
$8.57
|
| Rate for Payer: Humana ChoiceCare |
$8.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.38
|
| Rate for Payer: PHCS All Commercial |
$6.98
|
| Rate for Payer: PHP All Commercial |
$7.06
|
| Rate for Payer: Sagamore Health Network All Products |
$7.19
|
| Rate for Payer: Signature Care EPO |
$7.73
|
| Rate for Payer: Signature Care PPO |
$8.19
|
| Rate for Payer: United Healthcare Commercial |
$7.34
|
|
|
ARFORMOTEROL 15 MCG/2 ML INHL NEBU
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$7.86
|
| Rate for Payer: Aetna Medicare |
$3.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.38
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Centivo All Commercial |
$4.75
|
| Rate for Payer: Cigna All Commercial |
$8.03
|
| Rate for Payer: CORVEL All Commercial |
$8.66
|
| Rate for Payer: Coventry All Commercial |
$8.19
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Frontpath All Commercial |
$8.57
|
| Rate for Payer: Humana ChoiceCare |
$8.04
|
| Rate for Payer: Humana Medicare |
$4.75
|
| Rate for Payer: Lucent All Commercial |
$4.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.38
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$6.98
|
| Rate for Payer: PHP All Commercial |
$7.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.63
|
| Rate for Payer: Sagamore Health Network All Products |
$7.19
|
| Rate for Payer: Signature Care EPO |
$7.73
|
| Rate for Payer: Signature Care PPO |
$8.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.91
|
| Rate for Payer: United Healthcare Commercial |
$7.34
|
| Rate for Payer: United Healthcare Medicare |
$3.07
|
|
|
ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN
|
Facility
|
IP
|
$441.60
|
|
|
Service Code
|
HCPCS C9121
|
| Hospital Charge Code |
109817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$331.20 |
| Max. Negotiated Rate |
$410.69 |
| Rate for Payer: Aetna Commercial |
$381.54
|
| Rate for Payer: Cash Price |
$273.79
|
| Rate for Payer: Cigna All Commercial |
$381.10
|
| Rate for Payer: CORVEL All Commercial |
$410.69
|
| Rate for Payer: Coventry All Commercial |
$388.61
|
| Rate for Payer: Encore All Commercial |
$406.49
|
| Rate for Payer: Frontpath All Commercial |
$406.27
|
| Rate for Payer: Humana ChoiceCare |
$381.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$397.44
|
| Rate for Payer: PHCS All Commercial |
$331.20
|
| Rate for Payer: PHP All Commercial |
$334.91
|
| Rate for Payer: Sagamore Health Network All Products |
$340.92
|
| Rate for Payer: Signature Care EPO |
$366.53
|
| Rate for Payer: Signature Care PPO |
$388.61
|
| Rate for Payer: United Healthcare Commercial |
$347.98
|
|
|
ARGATROBAN IN 0.9 % SOD CHLOR 1 MG/ML IV SOLN
|
Facility
|
OP
|
$441.60
|
|
|
Service Code
|
HCPCS C9121
|
| Hospital Charge Code |
109817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.73 |
| Max. Negotiated Rate |
$410.69 |
| Rate for Payer: Aetna Commercial |
$372.71
|
| Rate for Payer: Aetna Medicare |
$145.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$145.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$253.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$276.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$167.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$160.30
|
| Rate for Payer: Cash Price |
$273.79
|
| Rate for Payer: Centivo All Commercial |
$225.22
|
| Rate for Payer: Cigna All Commercial |
$381.10
|
| Rate for Payer: CORVEL All Commercial |
$410.69
|
| Rate for Payer: Coventry All Commercial |
$388.61
|
| Rate for Payer: Encore All Commercial |
$406.49
|
| Rate for Payer: Frontpath All Commercial |
$406.27
|
| Rate for Payer: Humana ChoiceCare |
$381.41
|
| Rate for Payer: Humana Medicare |
$225.22
|
| Rate for Payer: Lucent All Commercial |
$225.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$397.44
|
| Rate for Payer: PHCS All Commercial |
$331.20
|
| Rate for Payer: PHP All Commercial |
$334.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$172.22
|
| Rate for Payer: Sagamore Health Network All Products |
$340.92
|
| Rate for Payer: Signature Care EPO |
$366.53
|
| Rate for Payer: Signature Care PPO |
$388.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$375.36
|
| Rate for Payer: United Healthcare Commercial |
$347.98
|
| Rate for Payer: United Healthcare Medicare |
$145.73
|
|
|
ARIPIPRAZOLE 300 MG IM SERS
|
Facility
|
IP
|
$7,020.86
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,265.64 |
| Max. Negotiated Rate |
$6,529.40 |
| Rate for Payer: Aetna Commercial |
$6,066.02
|
| Rate for Payer: Cash Price |
$4,352.93
|
| Rate for Payer: Cigna All Commercial |
$6,059.00
|
| Rate for Payer: CORVEL All Commercial |
$6,529.40
|
| Rate for Payer: Coventry All Commercial |
$6,178.36
|
| Rate for Payer: Encore All Commercial |
$6,462.70
|
| Rate for Payer: Frontpath All Commercial |
$6,459.19
|
| Rate for Payer: Humana ChoiceCare |
$6,063.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,318.77
|
| Rate for Payer: PHCS All Commercial |
$5,265.64
|
| Rate for Payer: PHP All Commercial |
$5,324.62
|
| Rate for Payer: Sagamore Health Network All Products |
$5,420.10
|
| Rate for Payer: Signature Care EPO |
$5,827.31
|
| Rate for Payer: Signature Care PPO |
$6,178.36
|
| Rate for Payer: United Healthcare Commercial |
$5,532.44
|
|
|
ARIPIPRAZOLE 300 MG IM SERS
|
Facility
|
OP
|
$7,020.86
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$6,529.40 |
| Rate for Payer: Aetna Commercial |
$5,925.61
|
| Rate for Payer: Aetna Medicare |
$2,316.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,316.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,032.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,388.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$7.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,664.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,548.57
|
| Rate for Payer: Cash Price |
$4,352.93
|
| Rate for Payer: Cash Price |
$4,352.93
|
| Rate for Payer: Centivo All Commercial |
$3,580.64
|
| Rate for Payer: Cigna All Commercial |
$6,059.00
|
| Rate for Payer: CORVEL All Commercial |
$6,529.40
|
| Rate for Payer: Coventry All Commercial |
$6,178.36
|
| Rate for Payer: Encore All Commercial |
$6,462.70
|
| Rate for Payer: Frontpath All Commercial |
$6,459.19
|
| Rate for Payer: Humana ChoiceCare |
$6,063.92
|
| Rate for Payer: Humana Medicare |
$3,580.64
|
| Rate for Payer: Lucent All Commercial |
$3,580.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,318.77
|
| Rate for Payer: Managed Health Services Medicaid |
$7.14
|
| Rate for Payer: MDWise Medicaid |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$5,265.64
|
| Rate for Payer: PHP All Commercial |
$5,324.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,738.14
|
| Rate for Payer: Sagamore Health Network All Products |
$5,420.10
|
| Rate for Payer: Signature Care EPO |
$5,827.31
|
| Rate for Payer: Signature Care PPO |
$6,178.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,967.73
|
| Rate for Payer: United Healthcare Commercial |
$5,532.44
|
| Rate for Payer: United Healthcare Medicare |
$2,316.88
|
|
|
ARIPIPRAZOLE 400 MG IM SERS
|
Facility
|
IP
|
$9,361.17
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,020.88 |
| Max. Negotiated Rate |
$8,705.89 |
| Rate for Payer: Aetna Commercial |
$8,088.05
|
| Rate for Payer: Cash Price |
$5,803.93
|
| Rate for Payer: Cigna All Commercial |
$8,078.69
|
| Rate for Payer: CORVEL All Commercial |
$8,705.89
|
| Rate for Payer: Coventry All Commercial |
$8,237.83
|
| Rate for Payer: Encore All Commercial |
$8,616.96
|
| Rate for Payer: Frontpath All Commercial |
$8,612.28
|
| Rate for Payer: Humana ChoiceCare |
$8,085.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,425.05
|
| Rate for Payer: PHCS All Commercial |
$7,020.88
|
| Rate for Payer: PHP All Commercial |
$7,099.51
|
| Rate for Payer: Sagamore Health Network All Products |
$7,226.82
|
| Rate for Payer: Signature Care EPO |
$7,769.77
|
| Rate for Payer: Signature Care PPO |
$8,237.83
|
| Rate for Payer: United Healthcare Commercial |
$7,376.60
|
|
|
ARIPIPRAZOLE 400 MG IM SERS
|
Facility
|
OP
|
$9,361.17
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
171302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$8,705.89 |
| Rate for Payer: Aetna Commercial |
$7,900.83
|
| Rate for Payer: Aetna Medicare |
$3,089.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,089.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,376.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,851.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$7.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,552.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,398.10
|
| Rate for Payer: Cash Price |
$5,803.93
|
| Rate for Payer: Cash Price |
$5,803.93
|
| Rate for Payer: Centivo All Commercial |
$4,774.20
|
| Rate for Payer: Cigna All Commercial |
$8,078.69
|
| Rate for Payer: CORVEL All Commercial |
$8,705.89
|
| Rate for Payer: Coventry All Commercial |
$8,237.83
|
| Rate for Payer: Encore All Commercial |
$8,616.96
|
| Rate for Payer: Frontpath All Commercial |
$8,612.28
|
| Rate for Payer: Humana ChoiceCare |
$8,085.24
|
| Rate for Payer: Humana Medicare |
$4,774.20
|
| Rate for Payer: Lucent All Commercial |
$4,774.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,425.05
|
| Rate for Payer: Managed Health Services Medicaid |
$7.14
|
| Rate for Payer: MDWise Medicaid |
$7.14
|
| Rate for Payer: PHCS All Commercial |
$7,020.88
|
| Rate for Payer: PHP All Commercial |
$7,099.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,650.86
|
| Rate for Payer: Sagamore Health Network All Products |
$7,226.82
|
| Rate for Payer: Signature Care EPO |
$7,769.77
|
| Rate for Payer: Signature Care PPO |
$8,237.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,956.99
|
| Rate for Payer: United Healthcare Commercial |
$7,376.60
|
| Rate for Payer: United Healthcare Medicare |
$3,089.19
|
|
|
ARIPIPRAZOLE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 65162089709
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna Commercial |
$1.41
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.41
|
| Rate for Payer: CORVEL All Commercial |
$1.52
|
| Rate for Payer: Coventry All Commercial |
$1.44
|
| Rate for Payer: Encore All Commercial |
$1.50
|
| Rate for Payer: Frontpath All Commercial |
$1.50
|
| Rate for Payer: Humana ChoiceCare |
$1.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.47
|
| Rate for Payer: PHCS All Commercial |
$1.22
|
| Rate for Payer: PHP All Commercial |
$1.24
|
| Rate for Payer: Sagamore Health Network All Products |
$1.26
|
| Rate for Payer: Signature Care EPO |
$1.35
|
| Rate for Payer: Signature Care PPO |
$1.44
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
ARIPIPRAZOLE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 65162089709
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna Commercial |
$1.38
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.41
|
| Rate for Payer: CORVEL All Commercial |
$1.52
|
| Rate for Payer: Coventry All Commercial |
$1.44
|
| Rate for Payer: Encore All Commercial |
$1.50
|
| Rate for Payer: Frontpath All Commercial |
$1.50
|
| Rate for Payer: Humana ChoiceCare |
$1.41
|
| Rate for Payer: Humana Medicare |
$0.83
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.47
|
| Rate for Payer: PHCS All Commercial |
$1.22
|
| Rate for Payer: PHP All Commercial |
$1.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.64
|
| Rate for Payer: Sagamore Health Network All Products |
$1.26
|
| Rate for Payer: Signature Care EPO |
$1.35
|
| Rate for Payer: Signature Care PPO |
$1.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
|
|
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
|
Facility
|
OP
|
$285.87
|
|
|
Service Code
|
CPT 20610
|
| Hospital Charge Code |
CPT-20610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.87 |
| Max. Negotiated Rate |
$285.87 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$285.87
|
| Rate for Payer: Managed Health Services Medicaid |
$285.87
|
| Rate for Payer: MDWise Medicaid |
$285.87
|
|
|
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
|
Facility
|
OP
|
$26,103.48
|
|
|
Service Code
|
CPT 27130
|
| Hospital Charge Code |
CPT-27130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$26,103.48 |
| Max. Negotiated Rate |
$26,103.48 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$26,103.48
|
| Rate for Payer: Managed Health Services Medicaid |
$26,103.48
|
| Rate for Payer: MDWise Medicaid |
$26,103.48
|
|
|
Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))
|
Facility
|
OP
|
$26,103.48
|
|
|
Service Code
|
CPT 23472
|
| Hospital Charge Code |
CPT-23472
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$26,103.48 |
| Max. Negotiated Rate |
$26,103.48 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$26,103.48
|
| Rate for Payer: Managed Health Services Medicaid |
$26,103.48
|
| Rate for Payer: MDWise Medicaid |
$26,103.48
|
|
|
Arthroplasty, interposition, intercarpal or carpometacarpal joints
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 25447
|
| Hospital Charge Code |
CPT-25447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
|
Facility
|
OP
|
$26,103.48
|
|
|
Service Code
|
CPT 27447
|
| Hospital Charge Code |
CPT-27447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$26,103.48 |
| Max. Negotiated Rate |
$26,103.48 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$26,103.48
|
| Rate for Payer: Managed Health Services Medicaid |
$26,103.48
|
| Rate for Payer: MDWise Medicaid |
$26,103.48
|
|
|
Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
|
Facility
|
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 27446
|
| Hospital Charge Code |
CPT-27446
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,121.64 |
| Max. Negotiated Rate |
$3,121.64 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,121.64
|
| Rate for Payer: Managed Health Services Medicaid |
$3,121.64
|
| Rate for Payer: MDWise Medicaid |
$3,121.64
|
|
|
Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29888
|
| Hospital Charge Code |
CPT-29888
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 29877
|
| Hospital Charge Code |
CPT-29877
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29874
|
| Hospital Charge Code |
CPT-29874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 29875
|
| Hospital Charge Code |
CPT-29875
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Arthroscopy, knee, surgical; with lateral release
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29873
|
| Hospital Charge Code |
CPT-29873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 29880
|
| Hospital Charge Code |
CPT-29880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 29881
|
| Hospital Charge Code |
CPT-29881
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29883
|
| Hospital Charge Code |
CPT-29883
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)
|
Facility
|
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 29882
|
| Hospital Charge Code |
CPT-29882
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
