|
Laparoscopy, surgical; cholecystectomy with cholangiography
|
Facility
OP
|
$4,211.34
|
|
|
Service Code
|
CPT 47563
|
| Hospital Charge Code |
CPT-47563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,211.34 |
| Max. Negotiated Rate |
$4,211.34 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,211.34
|
| Rate for Payer: Managed Health Services Medicaid |
$4,211.34
|
| Rate for Payer: MDWise Medicaid |
$4,211.34
|
|
|
Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 44180
|
| Hospital Charge Code |
CPT-44180
|
|
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
|
|
|
Laparoscopy, surgical; repair initial inguinal hernia
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 49650
|
| Hospital Charge Code |
CPT-49650
|
|
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
|
|
|
Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 43281
|
| Hospital Charge Code |
CPT-43281
|
|
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
|
|
|
Laparoscopy, surgical; with biopsy (single or multiple)
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 49321
|
| Hospital Charge Code |
CPT-49321
|
|
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
|
|
|
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 58662
|
| Hospital Charge Code |
CPT-58662
|
|
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
|
|
|
Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 49324
|
| Hospital Charge Code |
CPT-49324
|
|
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
|
|
|
Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 58661
|
| Hospital Charge Code |
CPT-58661
|
|
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
|
|
|
Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;
|
Facility
OP
|
$1,283.57
|
|
|
Service Code
|
CPT 58550
|
| Hospital Charge Code |
CPT-58550
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,283.57 |
| Max. Negotiated Rate |
$1,283.57 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,283.57
|
| Rate for Payer: Managed Health Services Medicaid |
$1,283.57
|
| Rate for Payer: MDWise Medicaid |
$1,283.57
|
|
|
Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 58552
|
| Hospital Charge Code |
CPT-58552
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
LATANOPROST 0.005 % OPHT DROP
|
Facility
IP
|
$41.51
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.13 |
| Max. Negotiated Rate |
$38.60 |
| Rate for Payer: Aetna Commercial |
$35.86
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Cigna All Commercial |
$35.82
|
| Rate for Payer: CORVEL All Commercial |
$38.60
|
| Rate for Payer: Coventry All Commercial |
$36.53
|
| Rate for Payer: Encore All Commercial |
$38.21
|
| Rate for Payer: Frontpath All Commercial |
$38.19
|
| Rate for Payer: Humana ChoiceCare |
$35.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.36
|
| Rate for Payer: PHCS All Commercial |
$31.13
|
| Rate for Payer: PHP All Commercial |
$31.48
|
| Rate for Payer: Sagamore Health Network All Products |
$32.05
|
| Rate for Payer: Signature Care EPO |
$34.45
|
| Rate for Payer: Signature Care PPO |
$36.53
|
| Rate for Payer: United Healthcare Commercial |
$32.71
|
|
|
LATANOPROST 0.005 % OPHT DROP
|
Facility
OP
|
$41.51
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.70 |
| Max. Negotiated Rate |
$38.60 |
| Rate for Payer: Aetna Commercial |
$35.03
|
| Rate for Payer: Aetna Medicare |
$13.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.07
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Centivo All Commercial |
$21.17
|
| Rate for Payer: Cigna All Commercial |
$35.82
|
| Rate for Payer: CORVEL All Commercial |
$38.60
|
| Rate for Payer: Coventry All Commercial |
$36.53
|
| Rate for Payer: Encore All Commercial |
$38.21
|
| Rate for Payer: Frontpath All Commercial |
$38.19
|
| Rate for Payer: Humana ChoiceCare |
$35.85
|
| Rate for Payer: Humana Medicare |
$21.17
|
| Rate for Payer: Lucent All Commercial |
$21.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.36
|
| Rate for Payer: PHCS All Commercial |
$31.13
|
| Rate for Payer: PHP All Commercial |
$31.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.19
|
| Rate for Payer: Sagamore Health Network All Products |
$32.05
|
| Rate for Payer: Signature Care EPO |
$34.45
|
| Rate for Payer: Signature Care PPO |
$36.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.28
|
| Rate for Payer: United Healthcare Commercial |
$32.71
|
| Rate for Payer: United Healthcare Medicare |
$13.70
|
|
|
Lateral retinacular release, open
|
Facility
OP
|
$3,957.76
|
|
|
Service Code
|
CPT 27425
|
| Hospital Charge Code |
CPT-27425
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,957.76 |
| Max. Negotiated Rate |
$3,957.76 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$3,957.76
|
| Rate for Payer: Managed Health Services Medicaid |
$3,957.76
|
| Rate for Payer: MDWise Medicaid |
$3,957.76
|
|
|
LEUPROLIDE 3.75 MG IM SYKT
|
Facility
IP
|
$5,694.50
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,270.88 |
| Max. Negotiated Rate |
$5,295.88 |
| Rate for Payer: Aetna Commercial |
$4,920.05
|
| Rate for Payer: Cash Price |
$3,530.59
|
| Rate for Payer: Cigna All Commercial |
$4,914.35
|
| Rate for Payer: CORVEL All Commercial |
$5,295.88
|
| Rate for Payer: Coventry All Commercial |
$5,011.16
|
| Rate for Payer: Encore All Commercial |
$5,241.79
|
| Rate for Payer: Frontpath All Commercial |
$5,238.94
|
| Rate for Payer: Humana ChoiceCare |
$4,918.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,125.05
|
| Rate for Payer: PHCS All Commercial |
$4,270.88
|
| Rate for Payer: PHP All Commercial |
$4,318.71
|
| Rate for Payer: Sagamore Health Network All Products |
$4,396.15
|
| Rate for Payer: Signature Care EPO |
$4,726.44
|
| Rate for Payer: Signature Care PPO |
$5,011.16
|
| Rate for Payer: United Healthcare Commercial |
$4,487.27
|
|
|
LEUPROLIDE 3.75 MG IM SYKT
|
Facility
OP
|
$5,694.50
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,022.05 |
| Max. Negotiated Rate |
$5,295.88 |
| Rate for Payer: Aetna Commercial |
$4,806.16
|
| Rate for Payer: Aetna Medicare |
$1,879.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,879.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,270.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,559.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,022.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,161.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,067.10
|
| Rate for Payer: Cash Price |
$3,530.59
|
| Rate for Payer: Cash Price |
$3,530.59
|
| Rate for Payer: Centivo All Commercial |
$2,904.20
|
| Rate for Payer: Cigna All Commercial |
$4,914.35
|
| Rate for Payer: CORVEL All Commercial |
$5,295.88
|
| Rate for Payer: Coventry All Commercial |
$5,011.16
|
| Rate for Payer: Encore All Commercial |
$5,241.79
|
| Rate for Payer: Frontpath All Commercial |
$5,238.94
|
| Rate for Payer: Humana ChoiceCare |
$4,918.34
|
| Rate for Payer: Humana Medicare |
$2,904.20
|
| Rate for Payer: Lucent All Commercial |
$2,904.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,125.05
|
| Rate for Payer: Managed Health Services Medicaid |
$1,022.05
|
| Rate for Payer: MDWise Medicaid |
$1,022.05
|
| Rate for Payer: PHCS All Commercial |
$4,270.88
|
| Rate for Payer: PHP All Commercial |
$4,318.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,220.86
|
| Rate for Payer: Sagamore Health Network All Products |
$4,396.15
|
| Rate for Payer: Signature Care EPO |
$4,726.44
|
| Rate for Payer: Signature Care PPO |
$5,011.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,840.32
|
| Rate for Payer: United Healthcare Commercial |
$4,487.27
|
| Rate for Payer: United Healthcare Medicare |
$1,879.18
|
|
|
LEUPROLIDE (3 MONTH) 11.25 MG IM SYKT
|
Facility
IP
|
$17,083.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,812.76 |
| Max. Negotiated Rate |
$15,887.82 |
| Rate for Payer: Aetna Commercial |
$14,760.30
|
| Rate for Payer: Cash Price |
$10,591.88
|
| Rate for Payer: Cigna All Commercial |
$14,743.21
|
| Rate for Payer: CORVEL All Commercial |
$15,887.82
|
| Rate for Payer: Coventry All Commercial |
$15,033.63
|
| Rate for Payer: Encore All Commercial |
$15,725.52
|
| Rate for Payer: Frontpath All Commercial |
$15,716.98
|
| Rate for Payer: Humana ChoiceCare |
$14,755.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,375.31
|
| Rate for Payer: PHCS All Commercial |
$12,812.76
|
| Rate for Payer: PHP All Commercial |
$12,956.26
|
| Rate for Payer: Sagamore Health Network All Products |
$13,188.60
|
| Rate for Payer: Signature Care EPO |
$14,179.45
|
| Rate for Payer: Signature Care PPO |
$15,033.63
|
| Rate for Payer: United Healthcare Commercial |
$13,461.94
|
|
|
LEUPROLIDE (3 MONTH) 11.25 MG IM SYKT
|
Facility
OP
|
$17,083.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,022.05 |
| Max. Negotiated Rate |
$15,887.82 |
| Rate for Payer: Aetna Commercial |
$14,418.62
|
| Rate for Payer: Aetna Medicare |
$5,637.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,637.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,811.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,679.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,022.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,483.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,201.37
|
| Rate for Payer: Cash Price |
$10,591.88
|
| Rate for Payer: Cash Price |
$10,591.88
|
| Rate for Payer: Centivo All Commercial |
$8,712.67
|
| Rate for Payer: Cigna All Commercial |
$14,743.21
|
| Rate for Payer: CORVEL All Commercial |
$15,887.82
|
| Rate for Payer: Coventry All Commercial |
$15,033.63
|
| Rate for Payer: Encore All Commercial |
$15,725.52
|
| Rate for Payer: Frontpath All Commercial |
$15,716.98
|
| Rate for Payer: Humana ChoiceCare |
$14,755.17
|
| Rate for Payer: Humana Medicare |
$8,712.67
|
| Rate for Payer: Lucent All Commercial |
$8,712.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,375.31
|
| Rate for Payer: Managed Health Services Medicaid |
$1,022.05
|
| Rate for Payer: MDWise Medicaid |
$1,022.05
|
| Rate for Payer: PHCS All Commercial |
$12,812.76
|
| Rate for Payer: PHP All Commercial |
$12,956.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,662.63
|
| Rate for Payer: Sagamore Health Network All Products |
$13,188.60
|
| Rate for Payer: Signature Care EPO |
$14,179.45
|
| Rate for Payer: Signature Care PPO |
$15,033.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,521.12
|
| Rate for Payer: United Healthcare Commercial |
$13,461.94
|
| Rate for Payer: United Healthcare Medicare |
$5,637.61
|
|
|
LEUPROLIDE (3 MONTH) 22.5 MG IM SYKT
|
Facility
IP
|
$20,357.61
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15,268.21 |
| Max. Negotiated Rate |
$18,932.58 |
| Rate for Payer: Aetna Commercial |
$17,588.98
|
| Rate for Payer: Cash Price |
$12,621.72
|
| Rate for Payer: Cigna All Commercial |
$17,568.62
|
| Rate for Payer: CORVEL All Commercial |
$18,932.58
|
| Rate for Payer: Coventry All Commercial |
$17,914.70
|
| Rate for Payer: Encore All Commercial |
$18,739.18
|
| Rate for Payer: Frontpath All Commercial |
$18,729.00
|
| Rate for Payer: Humana ChoiceCare |
$17,582.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,321.85
|
| Rate for Payer: PHCS All Commercial |
$15,268.21
|
| Rate for Payer: PHP All Commercial |
$15,439.21
|
| Rate for Payer: Sagamore Health Network All Products |
$15,716.07
|
| Rate for Payer: Signature Care EPO |
$16,896.82
|
| Rate for Payer: Signature Care PPO |
$17,914.70
|
| Rate for Payer: United Healthcare Commercial |
$16,041.80
|
|
|
LEUPROLIDE (3 MONTH) 22.5 MG IM SYKT
|
Facility
OP
|
$20,357.61
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$474.27 |
| Max. Negotiated Rate |
$18,932.58 |
| Rate for Payer: Aetna Commercial |
$17,181.82
|
| Rate for Payer: Aetna Medicare |
$6,718.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,718.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11,691.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,725.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$474.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,725.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,389.81
|
| Rate for Payer: Cash Price |
$12,621.72
|
| Rate for Payer: Cash Price |
$12,621.72
|
| Rate for Payer: Centivo All Commercial |
$10,382.38
|
| Rate for Payer: Cigna All Commercial |
$17,568.62
|
| Rate for Payer: CORVEL All Commercial |
$18,932.58
|
| Rate for Payer: Coventry All Commercial |
$17,914.70
|
| Rate for Payer: Encore All Commercial |
$18,739.18
|
| Rate for Payer: Frontpath All Commercial |
$18,729.00
|
| Rate for Payer: Humana ChoiceCare |
$17,582.87
|
| Rate for Payer: Humana Medicare |
$10,382.38
|
| Rate for Payer: Lucent All Commercial |
$10,382.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,321.85
|
| Rate for Payer: Managed Health Services Medicaid |
$474.27
|
| Rate for Payer: MDWise Medicaid |
$474.27
|
| Rate for Payer: PHCS All Commercial |
$15,268.21
|
| Rate for Payer: PHP All Commercial |
$15,439.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,939.47
|
| Rate for Payer: Sagamore Health Network All Products |
$15,716.07
|
| Rate for Payer: Signature Care EPO |
$16,896.82
|
| Rate for Payer: Signature Care PPO |
$17,914.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,303.97
|
| Rate for Payer: United Healthcare Commercial |
$16,041.80
|
| Rate for Payer: United Healthcare Medicare |
$6,718.01
|
|
|
LEUPROLIDE (4 MONTH) 30 MG IM SYKT
|
Facility
IP
|
$27,143.55
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20,357.66 |
| Max. Negotiated Rate |
$25,243.50 |
| Rate for Payer: Aetna Commercial |
$23,452.03
|
| Rate for Payer: Cash Price |
$16,829.00
|
| Rate for Payer: Cigna All Commercial |
$23,424.88
|
| Rate for Payer: CORVEL All Commercial |
$25,243.50
|
| Rate for Payer: Coventry All Commercial |
$23,886.32
|
| Rate for Payer: Encore All Commercial |
$24,985.64
|
| Rate for Payer: Frontpath All Commercial |
$24,972.07
|
| Rate for Payer: Humana ChoiceCare |
$23,443.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,429.20
|
| Rate for Payer: PHCS All Commercial |
$20,357.66
|
| Rate for Payer: PHP All Commercial |
$20,585.67
|
| Rate for Payer: Sagamore Health Network All Products |
$20,954.82
|
| Rate for Payer: Signature Care EPO |
$22,529.15
|
| Rate for Payer: Signature Care PPO |
$23,886.32
|
| Rate for Payer: United Healthcare Commercial |
$21,389.12
|
|
|
LEUPROLIDE (4 MONTH) 30 MG IM SYKT
|
Facility
OP
|
$27,143.55
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$474.27 |
| Max. Negotiated Rate |
$25,243.50 |
| Rate for Payer: Aetna Commercial |
$22,909.16
|
| Rate for Payer: Aetna Medicare |
$8,957.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,957.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15,588.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,967.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$474.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,300.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,853.11
|
| Rate for Payer: Cash Price |
$16,829.00
|
| Rate for Payer: Cash Price |
$16,829.00
|
| Rate for Payer: Centivo All Commercial |
$13,843.21
|
| Rate for Payer: Cigna All Commercial |
$23,424.88
|
| Rate for Payer: CORVEL All Commercial |
$25,243.50
|
| Rate for Payer: Coventry All Commercial |
$23,886.32
|
| Rate for Payer: Encore All Commercial |
$24,985.64
|
| Rate for Payer: Frontpath All Commercial |
$24,972.07
|
| Rate for Payer: Humana ChoiceCare |
$23,443.88
|
| Rate for Payer: Humana Medicare |
$13,843.21
|
| Rate for Payer: Lucent All Commercial |
$13,843.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,429.20
|
| Rate for Payer: Managed Health Services Medicaid |
$474.27
|
| Rate for Payer: MDWise Medicaid |
$474.27
|
| Rate for Payer: PHCS All Commercial |
$20,357.66
|
| Rate for Payer: PHP All Commercial |
$20,585.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,585.98
|
| Rate for Payer: Sagamore Health Network All Products |
$20,954.82
|
| Rate for Payer: Signature Care EPO |
$22,529.15
|
| Rate for Payer: Signature Care PPO |
$23,886.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23,072.02
|
| Rate for Payer: United Healthcare Commercial |
$21,389.12
|
| Rate for Payer: United Healthcare Medicare |
$8,957.37
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG IM SYKT
|
Facility
IP
|
$40,715.92
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30,536.94 |
| Max. Negotiated Rate |
$37,865.81 |
| Rate for Payer: Aetna Commercial |
$35,178.55
|
| Rate for Payer: Cash Price |
$25,243.87
|
| Rate for Payer: Cigna All Commercial |
$35,137.84
|
| Rate for Payer: CORVEL All Commercial |
$37,865.81
|
| Rate for Payer: Coventry All Commercial |
$35,830.01
|
| Rate for Payer: Encore All Commercial |
$37,479.00
|
| Rate for Payer: Frontpath All Commercial |
$37,458.65
|
| Rate for Payer: Humana ChoiceCare |
$35,166.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36,644.33
|
| Rate for Payer: PHCS All Commercial |
$30,536.94
|
| Rate for Payer: PHP All Commercial |
$30,878.95
|
| Rate for Payer: Sagamore Health Network All Products |
$31,432.69
|
| Rate for Payer: Signature Care EPO |
$33,794.21
|
| Rate for Payer: Signature Care PPO |
$35,830.01
|
| Rate for Payer: United Healthcare Commercial |
$32,084.14
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG IM SYKT
|
Facility
OP
|
$40,715.92
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$474.27 |
| Max. Negotiated Rate |
$37,865.81 |
| Rate for Payer: Aetna Commercial |
$34,364.24
|
| Rate for Payer: Aetna Medicare |
$13,436.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13,436.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23,383.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25,451.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$474.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15,451.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14,779.88
|
| Rate for Payer: Cash Price |
$25,243.87
|
| Rate for Payer: Cash Price |
$25,243.87
|
| Rate for Payer: Centivo All Commercial |
$20,765.12
|
| Rate for Payer: Cigna All Commercial |
$35,137.84
|
| Rate for Payer: CORVEL All Commercial |
$37,865.81
|
| Rate for Payer: Coventry All Commercial |
$35,830.01
|
| Rate for Payer: Encore All Commercial |
$37,479.00
|
| Rate for Payer: Frontpath All Commercial |
$37,458.65
|
| Rate for Payer: Humana ChoiceCare |
$35,166.34
|
| Rate for Payer: Humana Medicare |
$20,765.12
|
| Rate for Payer: Lucent All Commercial |
$20,765.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36,644.33
|
| Rate for Payer: Managed Health Services Medicaid |
$474.27
|
| Rate for Payer: MDWise Medicaid |
$474.27
|
| Rate for Payer: PHCS All Commercial |
$30,536.94
|
| Rate for Payer: PHP All Commercial |
$30,878.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15,879.21
|
| Rate for Payer: Sagamore Health Network All Products |
$31,432.69
|
| Rate for Payer: Signature Care EPO |
$33,794.21
|
| Rate for Payer: Signature Care PPO |
$35,830.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34,608.53
|
| Rate for Payer: United Healthcare Commercial |
$32,084.14
|
| Rate for Payer: United Healthcare Medicare |
$13,436.25
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG SUBQ SYRG
|
Facility
IP
|
$9,485.46
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,114.09 |
| Max. Negotiated Rate |
$8,821.47 |
| Rate for Payer: Aetna Commercial |
$8,195.43
|
| Rate for Payer: Cash Price |
$5,880.98
|
| Rate for Payer: Cigna All Commercial |
$8,185.95
|
| Rate for Payer: CORVEL All Commercial |
$8,821.47
|
| Rate for Payer: Coventry All Commercial |
$8,347.20
|
| Rate for Payer: Encore All Commercial |
$8,731.36
|
| Rate for Payer: Frontpath All Commercial |
$8,726.62
|
| Rate for Payer: Humana ChoiceCare |
$8,192.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,536.91
|
| Rate for Payer: PHCS All Commercial |
$7,114.09
|
| Rate for Payer: PHP All Commercial |
$7,193.77
|
| Rate for Payer: Sagamore Health Network All Products |
$7,322.77
|
| Rate for Payer: Signature Care EPO |
$7,872.93
|
| Rate for Payer: Signature Care PPO |
$8,347.20
|
| Rate for Payer: United Healthcare Commercial |
$7,474.54
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG SUBQ SYRG
|
Facility
OP
|
$9,485.46
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$474.27 |
| Max. Negotiated Rate |
$8,821.47 |
| Rate for Payer: Aetna Commercial |
$8,005.72
|
| Rate for Payer: Aetna Medicare |
$3,130.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,130.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,447.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,929.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$474.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,599.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,443.22
|
| Rate for Payer: Cash Price |
$5,880.98
|
| Rate for Payer: Cash Price |
$5,880.98
|
| Rate for Payer: Centivo All Commercial |
$4,837.58
|
| Rate for Payer: Cigna All Commercial |
$8,185.95
|
| Rate for Payer: CORVEL All Commercial |
$8,821.47
|
| Rate for Payer: Coventry All Commercial |
$8,347.20
|
| Rate for Payer: Encore All Commercial |
$8,731.36
|
| Rate for Payer: Frontpath All Commercial |
$8,726.62
|
| Rate for Payer: Humana ChoiceCare |
$8,192.59
|
| Rate for Payer: Humana Medicare |
$4,837.58
|
| Rate for Payer: Lucent All Commercial |
$4,837.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,536.91
|
| Rate for Payer: Managed Health Services Medicaid |
$474.27
|
| Rate for Payer: MDWise Medicaid |
$474.27
|
| Rate for Payer: PHCS All Commercial |
$7,114.09
|
| Rate for Payer: PHP All Commercial |
$7,193.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,699.33
|
| Rate for Payer: Sagamore Health Network All Products |
$7,322.77
|
| Rate for Payer: Signature Care EPO |
$7,872.93
|
| Rate for Payer: Signature Care PPO |
$8,347.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,062.64
|
| Rate for Payer: United Healthcare Commercial |
$7,474.54
|
| Rate for Payer: United Healthcare Medicare |
$3,130.20
|
|
