|
HEPARIN, PORCINE (PF) 100 UNITS/ML IV SYRG
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
117963
|
|
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 |
$11.16
|
| 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
|
|
|
HEPARIN, PORCINE (PF) 10 UNITS/ML IV SYRG
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
105460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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: 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 |
$5.94
|
|
|
HEPARIN, PORCINE (PF) 10 UNITS/ML IV SYRG
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
105460
|
|
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 |
$11.16
|
| 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
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SOLN
|
Facility
OP
|
$37.58
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
121687
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$31.72
|
| Rate for Payer: Aetna Medicare |
$12.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.64
|
| Rate for Payer: Cash Price |
$23.30
|
| Rate for Payer: Centivo All Commercial |
$19.17
|
| Rate for Payer: Cigna All Commercial |
$32.43
|
| Rate for Payer: CORVEL All Commercial |
$34.95
|
| Rate for Payer: Coventry All Commercial |
$33.07
|
| Rate for Payer: Encore All Commercial |
$34.59
|
| Rate for Payer: Frontpath All Commercial |
$34.57
|
| Rate for Payer: Humana ChoiceCare |
$32.46
|
| Rate for Payer: Humana Medicare |
$19.17
|
| Rate for Payer: Lucent All Commercial |
$19.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.82
|
| Rate for Payer: PHCS All Commercial |
$28.18
|
| Rate for Payer: PHP All Commercial |
$28.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.66
|
| Rate for Payer: Sagamore Health Network All Products |
$29.01
|
| Rate for Payer: Signature Care EPO |
$31.19
|
| Rate for Payer: Signature Care PPO |
$33.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.94
|
| Rate for Payer: United Healthcare Commercial |
$29.61
|
| Rate for Payer: United Healthcare Medicare |
$12.40
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SOLN
|
Facility
IP
|
$37.58
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
121687
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.18 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$32.47
|
| Rate for Payer: Cash Price |
$23.30
|
| Rate for Payer: Cigna All Commercial |
$32.43
|
| Rate for Payer: CORVEL All Commercial |
$34.95
|
| Rate for Payer: Coventry All Commercial |
$33.07
|
| Rate for Payer: Encore All Commercial |
$34.59
|
| Rate for Payer: Frontpath All Commercial |
$34.57
|
| Rate for Payer: Humana ChoiceCare |
$32.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.82
|
| Rate for Payer: PHCS All Commercial |
$28.18
|
| Rate for Payer: PHP All Commercial |
$28.50
|
| Rate for Payer: Sagamore Health Network All Products |
$29.01
|
| Rate for Payer: Signature Care EPO |
$31.19
|
| Rate for Payer: Signature Care PPO |
$33.07
|
| Rate for Payer: United Healthcare Commercial |
$29.61
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
IP
|
$37.58
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
1401000117969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.18 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$32.47
|
| Rate for Payer: Cash Price |
$23.30
|
| Rate for Payer: Cigna All Commercial |
$32.43
|
| Rate for Payer: CORVEL All Commercial |
$34.95
|
| Rate for Payer: Coventry All Commercial |
$33.07
|
| Rate for Payer: Encore All Commercial |
$34.59
|
| Rate for Payer: Frontpath All Commercial |
$34.57
|
| Rate for Payer: Humana ChoiceCare |
$32.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.82
|
| Rate for Payer: PHCS All Commercial |
$28.18
|
| Rate for Payer: PHP All Commercial |
$28.50
|
| Rate for Payer: Sagamore Health Network All Products |
$29.01
|
| Rate for Payer: Signature Care EPO |
$31.19
|
| Rate for Payer: Signature Care PPO |
$33.07
|
| Rate for Payer: United Healthcare Commercial |
$29.61
|
|
|
HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
OP
|
$37.58
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
1401000117969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$31.72
|
| Rate for Payer: Aetna Medicare |
$12.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.64
|
| Rate for Payer: Cash Price |
$23.30
|
| Rate for Payer: Centivo All Commercial |
$19.17
|
| Rate for Payer: Cigna All Commercial |
$32.43
|
| Rate for Payer: CORVEL All Commercial |
$34.95
|
| Rate for Payer: Coventry All Commercial |
$33.07
|
| Rate for Payer: Encore All Commercial |
$34.59
|
| Rate for Payer: Frontpath All Commercial |
$34.57
|
| Rate for Payer: Humana ChoiceCare |
$32.46
|
| Rate for Payer: Humana Medicare |
$19.17
|
| Rate for Payer: Lucent All Commercial |
$19.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.82
|
| Rate for Payer: PHCS All Commercial |
$28.18
|
| Rate for Payer: PHP All Commercial |
$28.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.66
|
| Rate for Payer: Sagamore Health Network All Products |
$29.01
|
| Rate for Payer: Signature Care EPO |
$31.19
|
| Rate for Payer: Signature Care PPO |
$33.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.94
|
| Rate for Payer: United Healthcare Commercial |
$29.61
|
| Rate for Payer: United Healthcare Medicare |
$12.40
|
|
|
HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML IM SYRG
|
Facility
OP
|
$598.87
|
|
|
Service Code
|
HCPCS 90636
|
| Hospital Charge Code |
118915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.90 |
| Max. Negotiated Rate |
$556.95 |
| Rate for Payer: Aetna Commercial |
$505.45
|
| Rate for Payer: Aetna Medicare |
$197.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$197.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$343.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$374.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$125.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.39
|
| Rate for Payer: Cash Price |
$371.30
|
| Rate for Payer: Cash Price |
$371.30
|
| Rate for Payer: Centivo All Commercial |
$305.42
|
| Rate for Payer: Cigna All Commercial |
$516.82
|
| Rate for Payer: CORVEL All Commercial |
$556.95
|
| Rate for Payer: Coventry All Commercial |
$527.01
|
| Rate for Payer: Encore All Commercial |
$551.26
|
| Rate for Payer: Frontpath All Commercial |
$550.96
|
| Rate for Payer: Humana ChoiceCare |
$517.24
|
| Rate for Payer: Humana Medicare |
$305.42
|
| Rate for Payer: Lucent All Commercial |
$305.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.98
|
| Rate for Payer: Managed Health Services Medicaid |
$125.90
|
| Rate for Payer: MDWise Medicaid |
$125.90
|
| Rate for Payer: PHCS All Commercial |
$449.15
|
| Rate for Payer: PHP All Commercial |
$454.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$233.56
|
| Rate for Payer: Sagamore Health Network All Products |
$462.33
|
| Rate for Payer: Signature Care EPO |
$497.06
|
| Rate for Payer: Signature Care PPO |
$527.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$509.04
|
| Rate for Payer: United Healthcare Commercial |
$471.91
|
| Rate for Payer: United Healthcare Medicare |
$197.63
|
|
|
HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML IM SYRG
|
Facility
IP
|
$598.87
|
|
|
Service Code
|
HCPCS 90636
|
| Hospital Charge Code |
118915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$449.15 |
| Max. Negotiated Rate |
$556.95 |
| Rate for Payer: Aetna Commercial |
$517.42
|
| Rate for Payer: Cash Price |
$371.30
|
| Rate for Payer: Cigna All Commercial |
$516.82
|
| Rate for Payer: CORVEL All Commercial |
$556.95
|
| Rate for Payer: Coventry All Commercial |
$527.01
|
| Rate for Payer: Encore All Commercial |
$551.26
|
| Rate for Payer: Frontpath All Commercial |
$550.96
|
| Rate for Payer: Humana ChoiceCare |
$517.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.98
|
| Rate for Payer: PHCS All Commercial |
$449.15
|
| Rate for Payer: PHP All Commercial |
$454.18
|
| Rate for Payer: Sagamore Health Network All Products |
$462.33
|
| Rate for Payer: Signature Care EPO |
$497.06
|
| Rate for Payer: Signature Care PPO |
$527.01
|
| Rate for Payer: United Healthcare Commercial |
$471.91
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML IM SYRG
|
Facility
OP
|
$471.82
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
118741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.70 |
| Max. Negotiated Rate |
$438.79 |
| Rate for Payer: Aetna Commercial |
$398.22
|
| Rate for Payer: Aetna Medicare |
$155.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$155.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$270.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$294.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$179.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$171.27
|
| Rate for Payer: Cash Price |
$292.53
|
| Rate for Payer: Centivo All Commercial |
$240.63
|
| Rate for Payer: Cigna All Commercial |
$407.18
|
| Rate for Payer: CORVEL All Commercial |
$438.79
|
| Rate for Payer: Coventry All Commercial |
$415.20
|
| Rate for Payer: Encore All Commercial |
$434.31
|
| Rate for Payer: Frontpath All Commercial |
$434.08
|
| Rate for Payer: Humana ChoiceCare |
$407.51
|
| Rate for Payer: Humana Medicare |
$240.63
|
| Rate for Payer: Lucent All Commercial |
$240.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$424.64
|
| Rate for Payer: PHCS All Commercial |
$353.87
|
| Rate for Payer: PHP All Commercial |
$357.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$184.01
|
| Rate for Payer: Sagamore Health Network All Products |
$364.25
|
| Rate for Payer: Signature Care EPO |
$391.61
|
| Rate for Payer: Signature Care PPO |
$415.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$401.05
|
| Rate for Payer: United Healthcare Commercial |
$371.80
|
| Rate for Payer: United Healthcare Medicare |
$155.70
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML IM SYRG
|
Facility
IP
|
$471.82
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
118741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$353.87 |
| Max. Negotiated Rate |
$438.79 |
| Rate for Payer: Aetna Commercial |
$407.65
|
| Rate for Payer: Cash Price |
$292.53
|
| Rate for Payer: Cigna All Commercial |
$407.18
|
| Rate for Payer: CORVEL All Commercial |
$438.79
|
| Rate for Payer: Coventry All Commercial |
$415.20
|
| Rate for Payer: Encore All Commercial |
$434.31
|
| Rate for Payer: Frontpath All Commercial |
$434.08
|
| Rate for Payer: Humana ChoiceCare |
$407.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$424.64
|
| Rate for Payer: PHCS All Commercial |
$353.87
|
| Rate for Payer: PHP All Commercial |
$357.83
|
| Rate for Payer: Sagamore Health Network All Products |
$364.25
|
| Rate for Payer: Signature Care EPO |
$391.61
|
| Rate for Payer: Signature Care PPO |
$415.20
|
| Rate for Payer: United Healthcare Commercial |
$371.80
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRG
|
Facility
OP
|
$252.63
|
|
|
Service Code
|
HCPCS 90633
|
| Hospital Charge Code |
91033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.37 |
| Max. Negotiated Rate |
$234.95 |
| Rate for Payer: Aetna Commercial |
$213.22
|
| Rate for Payer: Aetna Medicare |
$83.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$83.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$145.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$157.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$95.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$91.70
|
| Rate for Payer: Cash Price |
$156.63
|
| Rate for Payer: Centivo All Commercial |
$128.84
|
| Rate for Payer: Cigna All Commercial |
$218.02
|
| Rate for Payer: CORVEL All Commercial |
$234.95
|
| Rate for Payer: Coventry All Commercial |
$222.31
|
| Rate for Payer: Encore All Commercial |
$232.55
|
| Rate for Payer: Frontpath All Commercial |
$232.42
|
| Rate for Payer: Humana ChoiceCare |
$218.20
|
| Rate for Payer: Humana Medicare |
$128.84
|
| Rate for Payer: Lucent All Commercial |
$128.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$227.37
|
| Rate for Payer: PHCS All Commercial |
$189.47
|
| Rate for Payer: PHP All Commercial |
$191.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$98.53
|
| Rate for Payer: Sagamore Health Network All Products |
$195.03
|
| Rate for Payer: Signature Care EPO |
$209.68
|
| Rate for Payer: Signature Care PPO |
$222.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$214.74
|
| Rate for Payer: United Healthcare Commercial |
$199.07
|
| Rate for Payer: United Healthcare Medicare |
$83.37
|
|
|
HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRG
|
Facility
IP
|
$252.63
|
|
|
Service Code
|
HCPCS 90633
|
| Hospital Charge Code |
91033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$189.47 |
| Max. Negotiated Rate |
$234.95 |
| Rate for Payer: Aetna Commercial |
$218.27
|
| Rate for Payer: Cash Price |
$156.63
|
| Rate for Payer: Cigna All Commercial |
$218.02
|
| Rate for Payer: CORVEL All Commercial |
$234.95
|
| Rate for Payer: Coventry All Commercial |
$222.31
|
| Rate for Payer: Encore All Commercial |
$232.55
|
| Rate for Payer: Frontpath All Commercial |
$232.42
|
| Rate for Payer: Humana ChoiceCare |
$218.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$227.37
|
| Rate for Payer: PHCS All Commercial |
$189.47
|
| Rate for Payer: PHP All Commercial |
$191.59
|
| Rate for Payer: Sagamore Health Network All Products |
$195.03
|
| Rate for Payer: Signature Care EPO |
$209.68
|
| Rate for Payer: Signature Care PPO |
$222.31
|
| Rate for Payer: United Healthcare Commercial |
$199.07
|
|
|
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN
|
Facility
IP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
118498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,000.55 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,304.63
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
|
|
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN
|
Facility
OP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
118498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.00 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,251.29
|
| Rate for Payer: Aetna Medicare |
$880.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$880.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,531.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,667.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$149.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,012.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$968.27
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Centivo All Commercial |
$1,360.37
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Humana Medicare |
$1,360.37
|
| Rate for Payer: Lucent All Commercial |
$1,360.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: Managed Health Services Medicaid |
$149.00
|
| Rate for Payer: MDWise Medicaid |
$149.00
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,040.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,267.29
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
| Rate for Payer: United Healthcare Medicare |
$880.24
|
|
|
HEPATITIS B IMMUNE GLOBULIN SYRINGE (CAMERON)
|
Facility
IP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
1401000118499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,000.55 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,304.63
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
|
|
HEPATITIS B IMMUNE GLOBULIN SYRINGE (CAMERON)
|
Facility
OP
|
$2,667.40
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
1401000118499
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.00 |
| Max. Negotiated Rate |
$2,480.68 |
| Rate for Payer: Aetna Commercial |
$2,251.29
|
| Rate for Payer: Aetna Medicare |
$880.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$880.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,531.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,667.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$149.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,012.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$968.27
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Cash Price |
$1,653.79
|
| Rate for Payer: Centivo All Commercial |
$1,360.37
|
| Rate for Payer: Cigna All Commercial |
$2,301.97
|
| Rate for Payer: CORVEL All Commercial |
$2,480.68
|
| Rate for Payer: Coventry All Commercial |
$2,347.31
|
| Rate for Payer: Encore All Commercial |
$2,455.34
|
| Rate for Payer: Frontpath All Commercial |
$2,454.01
|
| Rate for Payer: Humana ChoiceCare |
$2,303.83
|
| Rate for Payer: Humana Medicare |
$1,360.37
|
| Rate for Payer: Lucent All Commercial |
$1,360.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,400.66
|
| Rate for Payer: Managed Health Services Medicaid |
$149.00
|
| Rate for Payer: MDWise Medicaid |
$149.00
|
| Rate for Payer: PHCS All Commercial |
$2,000.55
|
| Rate for Payer: PHP All Commercial |
$2,022.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,040.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,059.23
|
| Rate for Payer: Signature Care EPO |
$2,213.94
|
| Rate for Payer: Signature Care PPO |
$2,347.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,267.29
|
| Rate for Payer: United Healthcare Commercial |
$2,101.91
|
| Rate for Payer: United Healthcare Medicare |
$880.24
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG
|
Facility
OP
|
$188.98
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
118672
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.36 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna Commercial |
$159.50
|
| Rate for Payer: Aetna Medicare |
$62.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$62.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$108.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$118.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.60
|
| Rate for Payer: Cash Price |
$117.17
|
| Rate for Payer: Centivo All Commercial |
$96.38
|
| Rate for Payer: Cigna All Commercial |
$163.09
|
| Rate for Payer: CORVEL All Commercial |
$175.75
|
| Rate for Payer: Coventry All Commercial |
$166.30
|
| Rate for Payer: Encore All Commercial |
$173.96
|
| Rate for Payer: Frontpath All Commercial |
$173.86
|
| Rate for Payer: Humana ChoiceCare |
$163.22
|
| Rate for Payer: Humana Medicare |
$96.38
|
| Rate for Payer: Lucent All Commercial |
$96.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$170.08
|
| Rate for Payer: PHCS All Commercial |
$141.73
|
| Rate for Payer: PHP All Commercial |
$143.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$73.70
|
| Rate for Payer: Sagamore Health Network All Products |
$145.89
|
| Rate for Payer: Signature Care EPO |
$156.85
|
| Rate for Payer: Signature Care PPO |
$166.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$160.63
|
| Rate for Payer: United Healthcare Commercial |
$148.92
|
| Rate for Payer: United Healthcare Medicare |
$62.36
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG
|
Facility
IP
|
$188.98
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
118672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.73 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna Commercial |
$163.28
|
| Rate for Payer: Cash Price |
$117.17
|
| Rate for Payer: Cigna All Commercial |
$163.09
|
| Rate for Payer: CORVEL All Commercial |
$175.75
|
| Rate for Payer: Coventry All Commercial |
$166.30
|
| Rate for Payer: Encore All Commercial |
$173.96
|
| Rate for Payer: Frontpath All Commercial |
$173.86
|
| Rate for Payer: Humana ChoiceCare |
$163.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$170.08
|
| Rate for Payer: PHCS All Commercial |
$141.73
|
| Rate for Payer: PHP All Commercial |
$143.32
|
| Rate for Payer: Sagamore Health Network All Products |
$145.89
|
| Rate for Payer: Signature Care EPO |
$156.85
|
| Rate for Payer: Signature Care PPO |
$166.30
|
| Rate for Payer: United Healthcare Commercial |
$148.92
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SYRG
|
Facility
OP
|
$395.70
|
|
|
Service Code
|
HCPCS 90746
|
| Hospital Charge Code |
118608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.58 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$333.97
|
| Rate for Payer: Aetna Medicare |
$130.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$130.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$227.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$247.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$150.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$143.64
|
| Rate for Payer: Cash Price |
$245.33
|
| Rate for Payer: Centivo All Commercial |
$201.81
|
| Rate for Payer: Cigna All Commercial |
$341.49
|
| Rate for Payer: CORVEL All Commercial |
$368.00
|
| Rate for Payer: Coventry All Commercial |
$348.22
|
| Rate for Payer: Encore All Commercial |
$364.24
|
| Rate for Payer: Frontpath All Commercial |
$364.04
|
| Rate for Payer: Humana ChoiceCare |
$341.77
|
| Rate for Payer: Humana Medicare |
$201.81
|
| Rate for Payer: Lucent All Commercial |
$201.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$356.13
|
| Rate for Payer: PHCS All Commercial |
$296.78
|
| Rate for Payer: PHP All Commercial |
$300.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$154.32
|
| Rate for Payer: Sagamore Health Network All Products |
$305.48
|
| Rate for Payer: Signature Care EPO |
$328.43
|
| Rate for Payer: Signature Care PPO |
$348.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$336.34
|
| Rate for Payer: United Healthcare Commercial |
$311.81
|
| Rate for Payer: United Healthcare Medicare |
$130.58
|
|
|
HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SYRG
|
Facility
IP
|
$395.70
|
|
|
Service Code
|
HCPCS 90746
|
| Hospital Charge Code |
118608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$296.78 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$341.88
|
| Rate for Payer: Cash Price |
$245.33
|
| Rate for Payer: Cigna All Commercial |
$341.49
|
| Rate for Payer: CORVEL All Commercial |
$368.00
|
| Rate for Payer: Coventry All Commercial |
$348.22
|
| Rate for Payer: Encore All Commercial |
$364.24
|
| Rate for Payer: Frontpath All Commercial |
$364.04
|
| Rate for Payer: Humana ChoiceCare |
$341.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$356.13
|
| Rate for Payer: PHCS All Commercial |
$296.78
|
| Rate for Payer: PHP All Commercial |
$300.10
|
| Rate for Payer: Sagamore Health Network All Products |
$305.48
|
| Rate for Payer: Signature Care EPO |
$328.43
|
| Rate for Payer: Signature Care PPO |
$348.22
|
| Rate for Payer: United Healthcare Commercial |
$311.81
|
|
|
HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRG
|
Facility
OP
|
$558.69
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
34550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.33 |
| Max. Negotiated Rate |
$519.58 |
| Rate for Payer: Aetna Commercial |
$471.53
|
| Rate for Payer: Aetna Medicare |
$184.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$184.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$320.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$349.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$93.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$212.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$202.80
|
| Rate for Payer: Cash Price |
$346.39
|
| Rate for Payer: Cash Price |
$346.39
|
| Rate for Payer: Centivo All Commercial |
$284.93
|
| Rate for Payer: Cigna All Commercial |
$482.15
|
| Rate for Payer: CORVEL All Commercial |
$519.58
|
| Rate for Payer: Coventry All Commercial |
$491.65
|
| Rate for Payer: Encore All Commercial |
$514.27
|
| Rate for Payer: Frontpath All Commercial |
$513.99
|
| Rate for Payer: Humana ChoiceCare |
$482.54
|
| Rate for Payer: Humana Medicare |
$284.93
|
| Rate for Payer: Lucent All Commercial |
$284.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$502.82
|
| Rate for Payer: Managed Health Services Medicaid |
$93.33
|
| Rate for Payer: MDWise Medicaid |
$93.33
|
| Rate for Payer: PHCS All Commercial |
$419.02
|
| Rate for Payer: PHP All Commercial |
$423.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$217.89
|
| Rate for Payer: Sagamore Health Network All Products |
$431.31
|
| Rate for Payer: Signature Care EPO |
$463.71
|
| Rate for Payer: Signature Care PPO |
$491.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$474.89
|
| Rate for Payer: United Healthcare Commercial |
$440.25
|
| Rate for Payer: United Healthcare Medicare |
$184.37
|
|
|
HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRG
|
Facility
IP
|
$558.69
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
34550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$419.02 |
| Max. Negotiated Rate |
$519.58 |
| Rate for Payer: Aetna Commercial |
$482.71
|
| Rate for Payer: Cash Price |
$346.39
|
| Rate for Payer: Cigna All Commercial |
$482.15
|
| Rate for Payer: CORVEL All Commercial |
$519.58
|
| Rate for Payer: Coventry All Commercial |
$491.65
|
| Rate for Payer: Encore All Commercial |
$514.27
|
| Rate for Payer: Frontpath All Commercial |
$513.99
|
| Rate for Payer: Humana ChoiceCare |
$482.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$502.82
|
| Rate for Payer: PHCS All Commercial |
$419.02
|
| Rate for Payer: PHP All Commercial |
$423.71
|
| Rate for Payer: Sagamore Health Network All Products |
$431.31
|
| Rate for Payer: Signature Care EPO |
$463.71
|
| Rate for Payer: Signature Care PPO |
$491.65
|
| Rate for Payer: United Healthcare Commercial |
$440.25
|
|
|
HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$72.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.74
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Centivo All Commercial |
$64.26
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Humana Medicare |
$64.26
|
| Rate for Payer: Lucent All Commercial |
$64.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.14
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
| Rate for Payer: United Healthcare Medicare |
$41.58
|
|
|
HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
|
