|
INDOCYANINE GREEN 25 MG INJ SOLR
|
Facility
OP
|
$999.20
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$929.26 |
| Rate for Payer: Aetna Commercial |
$843.32
|
| Rate for Payer: Aetna Medicare |
$329.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$329.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$573.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$624.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$379.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$362.71
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: Centivo All Commercial |
$509.59
|
| Rate for Payer: Cigna All Commercial |
$862.31
|
| Rate for Payer: CORVEL All Commercial |
$929.26
|
| Rate for Payer: Coventry All Commercial |
$879.30
|
| Rate for Payer: Encore All Commercial |
$919.76
|
| Rate for Payer: Frontpath All Commercial |
$919.26
|
| Rate for Payer: Humana ChoiceCare |
$863.01
|
| Rate for Payer: Humana Medicare |
$509.59
|
| Rate for Payer: Lucent All Commercial |
$509.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$899.28
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$749.40
|
| Rate for Payer: PHP All Commercial |
$757.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$389.69
|
| Rate for Payer: Sagamore Health Network All Products |
$771.38
|
| Rate for Payer: Signature Care EPO |
$829.34
|
| Rate for Payer: Signature Care PPO |
$879.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$849.32
|
| Rate for Payer: United Healthcare Commercial |
$787.37
|
| Rate for Payer: United Healthcare Medicare |
$329.74
|
|
|
INDOMETHACIN 25 MG ORAL CAP
|
Facility
IP
|
$1.72
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Aetna Commercial |
$1.48
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna All Commercial |
$1.48
|
| Rate for Payer: CORVEL All Commercial |
$1.59
|
| Rate for Payer: Coventry All Commercial |
$1.51
|
| Rate for Payer: Encore All Commercial |
$1.58
|
| Rate for Payer: Frontpath All Commercial |
$1.58
|
| Rate for Payer: Humana ChoiceCare |
$1.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.54
|
| Rate for Payer: PHCS All Commercial |
$1.29
|
| Rate for Payer: PHP All Commercial |
$1.30
|
| Rate for Payer: Sagamore Health Network All Products |
$1.32
|
| Rate for Payer: Signature Care EPO |
$1.42
|
| Rate for Payer: Signature Care PPO |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
|
|
INDOMETHACIN 25 MG ORAL CAP
|
Facility
OP
|
$1.72
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Aetna Commercial |
$1.45
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Centivo All Commercial |
$0.87
|
| Rate for Payer: Cigna All Commercial |
$1.48
|
| Rate for Payer: CORVEL All Commercial |
$1.59
|
| Rate for Payer: Coventry All Commercial |
$1.51
|
| Rate for Payer: Encore All Commercial |
$1.58
|
| Rate for Payer: Frontpath All Commercial |
$1.58
|
| Rate for Payer: Humana ChoiceCare |
$1.48
|
| Rate for Payer: Humana Medicare |
$0.87
|
| Rate for Payer: Lucent All Commercial |
$0.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.54
|
| Rate for Payer: PHCS All Commercial |
$1.29
|
| Rate for Payer: PHP All Commercial |
$1.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.67
|
| Rate for Payer: Sagamore Health Network All Products |
$1.32
|
| Rate for Payer: Signature Care EPO |
$1.42
|
| Rate for Payer: Signature Care PPO |
$1.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
INFLIXIMAB 100 MG IV SOLR
|
Facility
IP
|
$1,851.56
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,388.67 |
| Max. Negotiated Rate |
$1,721.95 |
| Rate for Payer: Aetna Commercial |
$1,599.75
|
| Rate for Payer: Cash Price |
$1,147.97
|
| Rate for Payer: Cigna All Commercial |
$1,597.90
|
| Rate for Payer: CORVEL All Commercial |
$1,721.95
|
| Rate for Payer: Coventry All Commercial |
$1,629.37
|
| Rate for Payer: Encore All Commercial |
$1,704.36
|
| Rate for Payer: Frontpath All Commercial |
$1,703.44
|
| Rate for Payer: Humana ChoiceCare |
$1,599.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,666.40
|
| Rate for Payer: PHCS All Commercial |
$1,388.67
|
| Rate for Payer: PHP All Commercial |
$1,404.22
|
| Rate for Payer: Sagamore Health Network All Products |
$1,429.40
|
| Rate for Payer: Signature Care EPO |
$1,536.79
|
| Rate for Payer: Signature Care PPO |
$1,629.37
|
| Rate for Payer: United Healthcare Commercial |
$1,459.03
|
|
|
INFLIXIMAB 100 MG IV SOLR
|
Facility
OP
|
$1,851.56
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.88 |
| Max. Negotiated Rate |
$1,721.95 |
| Rate for Payer: Aetna Commercial |
$1,562.72
|
| Rate for Payer: Aetna Medicare |
$611.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$611.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,063.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,157.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$49.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$702.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$672.12
|
| Rate for Payer: Cash Price |
$1,147.97
|
| Rate for Payer: Cash Price |
$1,147.97
|
| Rate for Payer: Centivo All Commercial |
$944.30
|
| Rate for Payer: Cigna All Commercial |
$1,597.90
|
| Rate for Payer: CORVEL All Commercial |
$1,721.95
|
| Rate for Payer: Coventry All Commercial |
$1,629.37
|
| Rate for Payer: Encore All Commercial |
$1,704.36
|
| Rate for Payer: Frontpath All Commercial |
$1,703.44
|
| Rate for Payer: Humana ChoiceCare |
$1,599.19
|
| Rate for Payer: Humana Medicare |
$944.30
|
| Rate for Payer: Lucent All Commercial |
$944.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,666.40
|
| Rate for Payer: Managed Health Services Medicaid |
$49.88
|
| Rate for Payer: MDWise Medicaid |
$49.88
|
| Rate for Payer: PHCS All Commercial |
$1,388.67
|
| Rate for Payer: PHP All Commercial |
$1,404.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$722.11
|
| Rate for Payer: Sagamore Health Network All Products |
$1,429.40
|
| Rate for Payer: Signature Care EPO |
$1,536.79
|
| Rate for Payer: Signature Care PPO |
$1,629.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,573.83
|
| Rate for Payer: United Healthcare Commercial |
$1,459.03
|
| Rate for Payer: United Healthcare Medicare |
$611.01
|
|
|
INFLIXIMAB-AXXQ 100 MG IV SOLR
|
Facility
OP
|
$1,911.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
191220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$1,777.23 |
| Rate for Payer: Aetna Commercial |
$1,612.88
|
| Rate for Payer: Aetna Medicare |
$630.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$630.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,097.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,194.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$52.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$725.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$693.69
|
| Rate for Payer: Cash Price |
$1,184.82
|
| Rate for Payer: Cash Price |
$1,184.82
|
| Rate for Payer: Centivo All Commercial |
$974.61
|
| Rate for Payer: Cigna All Commercial |
$1,649.19
|
| Rate for Payer: CORVEL All Commercial |
$1,777.23
|
| Rate for Payer: Coventry All Commercial |
$1,681.68
|
| Rate for Payer: Encore All Commercial |
$1,759.08
|
| Rate for Payer: Frontpath All Commercial |
$1,758.12
|
| Rate for Payer: Humana ChoiceCare |
$1,650.53
|
| Rate for Payer: Humana Medicare |
$974.61
|
| Rate for Payer: Lucent All Commercial |
$974.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,719.90
|
| Rate for Payer: Managed Health Services Medicaid |
$52.50
|
| Rate for Payer: MDWise Medicaid |
$52.50
|
| Rate for Payer: PHCS All Commercial |
$1,433.25
|
| Rate for Payer: PHP All Commercial |
$1,449.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$745.29
|
| Rate for Payer: Sagamore Health Network All Products |
$1,475.29
|
| Rate for Payer: Signature Care EPO |
$1,586.13
|
| Rate for Payer: Signature Care PPO |
$1,681.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,624.35
|
| Rate for Payer: United Healthcare Commercial |
$1,505.87
|
| Rate for Payer: United Healthcare Medicare |
$630.63
|
|
|
INFLIXIMAB-AXXQ 100 MG IV SOLR
|
Facility
IP
|
$1,911.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
191220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,433.25 |
| Max. Negotiated Rate |
$1,777.23 |
| Rate for Payer: Aetna Commercial |
$1,651.10
|
| Rate for Payer: Cash Price |
$1,184.82
|
| Rate for Payer: Cigna All Commercial |
$1,649.19
|
| Rate for Payer: CORVEL All Commercial |
$1,777.23
|
| Rate for Payer: Coventry All Commercial |
$1,681.68
|
| Rate for Payer: Encore All Commercial |
$1,759.08
|
| Rate for Payer: Frontpath All Commercial |
$1,758.12
|
| Rate for Payer: Humana ChoiceCare |
$1,650.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,719.90
|
| Rate for Payer: PHCS All Commercial |
$1,433.25
|
| Rate for Payer: PHP All Commercial |
$1,449.30
|
| Rate for Payer: Sagamore Health Network All Products |
$1,475.29
|
| Rate for Payer: Signature Care EPO |
$1,586.13
|
| Rate for Payer: Signature Care PPO |
$1,681.68
|
| Rate for Payer: United Healthcare Commercial |
$1,505.87
|
|
|
INFLIXIMAB-DYYB 100 MG IV SOLR
|
Facility
IP
|
$3,690.48
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
179180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,767.86 |
| Max. Negotiated Rate |
$3,432.15 |
| Rate for Payer: Aetna Commercial |
$3,188.57
|
| Rate for Payer: Cash Price |
$2,288.10
|
| Rate for Payer: Cigna All Commercial |
$3,184.88
|
| Rate for Payer: CORVEL All Commercial |
$3,432.15
|
| Rate for Payer: Coventry All Commercial |
$3,247.62
|
| Rate for Payer: Encore All Commercial |
$3,397.09
|
| Rate for Payer: Frontpath All Commercial |
$3,395.24
|
| Rate for Payer: Humana ChoiceCare |
$3,187.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,321.43
|
| Rate for Payer: PHCS All Commercial |
$2,767.86
|
| Rate for Payer: PHP All Commercial |
$2,798.86
|
| Rate for Payer: Sagamore Health Network All Products |
$2,849.05
|
| Rate for Payer: Signature Care EPO |
$3,063.10
|
| Rate for Payer: Signature Care PPO |
$3,247.62
|
| Rate for Payer: United Healthcare Commercial |
$2,908.10
|
|
|
INFLIXIMAB-DYYB 100 MG IV SOLR
|
Facility
OP
|
$3,690.48
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
179180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.36 |
| Max. Negotiated Rate |
$3,432.15 |
| Rate for Payer: Aetna Commercial |
$3,114.77
|
| Rate for Payer: Aetna Medicare |
$1,217.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,217.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,119.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,306.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$99.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,400.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,339.64
|
| Rate for Payer: Cash Price |
$2,288.10
|
| Rate for Payer: Cash Price |
$2,288.10
|
| Rate for Payer: Centivo All Commercial |
$1,882.14
|
| Rate for Payer: Cigna All Commercial |
$3,184.88
|
| Rate for Payer: CORVEL All Commercial |
$3,432.15
|
| Rate for Payer: Coventry All Commercial |
$3,247.62
|
| Rate for Payer: Encore All Commercial |
$3,397.09
|
| Rate for Payer: Frontpath All Commercial |
$3,395.24
|
| Rate for Payer: Humana ChoiceCare |
$3,187.47
|
| Rate for Payer: Humana Medicare |
$1,882.14
|
| Rate for Payer: Lucent All Commercial |
$1,882.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,321.43
|
| Rate for Payer: Managed Health Services Medicaid |
$99.36
|
| Rate for Payer: MDWise Medicaid |
$99.36
|
| Rate for Payer: PHCS All Commercial |
$2,767.86
|
| Rate for Payer: PHP All Commercial |
$2,798.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,439.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,849.05
|
| Rate for Payer: Signature Care EPO |
$3,063.10
|
| Rate for Payer: Signature Care PPO |
$3,247.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,136.91
|
| Rate for Payer: United Healthcare Commercial |
$2,908.10
|
| Rate for Payer: United Healthcare Medicare |
$1,217.86
|
|
|
Injection procedure for cystography or voiding urethrocystography
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
CPT-51600
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection procedure for elbow arthrography
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 24220
|
| Hospital Charge Code |
CPT-24220
|
|
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
|
|
|
Injection procedure for hip arthrography; without anesthesia
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 27093
|
| Hospital Charge Code |
CPT-27093
|
|
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
|
|
|
Injection procedure for myelography and/or computed tomography, lumbar
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
CPT-62284
|
|
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
|
|
|
Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
CPT-23350
|
|
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
|
|
|
Injection procedure for wrist arthrography
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
CPT-25246
|
|
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
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64415
|
| Hospital Charge Code |
CPT-64415
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64447
|
| Hospital Charge Code |
CPT-64447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
CPT-64450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64484
|
| Hospital Charge Code |
CPT-64484
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
CPT-64483
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
CPT-64494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
CPT-64493
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,242.31 |
| Max. Negotiated Rate |
$1,242.31 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,242.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,242.31
|
| Rate for Payer: MDWise Medicaid |
$1,242.31
|
|
|
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 62323
|
| Hospital Charge Code |
CPT-62323
|
|
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
|
|
|
Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
|
Facility
OP
|
$285.87
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
CPT-20550
|
|
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
|
|
|
INPATIENT APRDRG 0011: LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT
|
Facility
IP
|
$80,860.90
|
|
|
Service Code
|
APR-DRG 0011
|
| Hospital Charge Code |
APRDRG 0011
|
| Min. Negotiated Rate |
$46,131.95 |
| Max. Negotiated Rate |
$80,860.90 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$46,131.95
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$80,860.90
|
| Rate for Payer: Managed Health Services Medicaid |
$80,860.90
|
| Rate for Payer: MDWise Medicaid |
$80,860.90
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$46,131.95
|
|
