|
LOSARTAN 50 MG ORAL TAB
|
Facility
IP
|
$1.67
|
|
|
Service Code
|
NDC 68084034701
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna Commercial |
$1.45
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna All Commercial |
$1.44
|
| Rate for Payer: CORVEL All Commercial |
$1.56
|
| Rate for Payer: Coventry All Commercial |
$1.47
|
| Rate for Payer: Encore All Commercial |
$1.54
|
| Rate for Payer: Frontpath All Commercial |
$1.54
|
| Rate for Payer: Humana ChoiceCare |
$1.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.51
|
| Rate for Payer: PHCS All Commercial |
$1.25
|
| Rate for Payer: PHP All Commercial |
$1.27
|
| Rate for Payer: Sagamore Health Network All Products |
$1.29
|
| Rate for Payer: Signature Care EPO |
$1.39
|
| Rate for Payer: Signature Care PPO |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
|
|
LUBIPROSTONE 8 MCG ORAL CAP
|
Facility
IP
|
$41.07
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$38.19 |
| Rate for Payer: Aetna Commercial |
$35.48
|
| Rate for Payer: Cash Price |
$25.46
|
| Rate for Payer: Cigna All Commercial |
$35.44
|
| Rate for Payer: CORVEL All Commercial |
$38.19
|
| Rate for Payer: Coventry All Commercial |
$36.14
|
| Rate for Payer: Encore All Commercial |
$37.80
|
| Rate for Payer: Frontpath All Commercial |
$37.78
|
| Rate for Payer: Humana ChoiceCare |
$35.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.96
|
| Rate for Payer: PHCS All Commercial |
$30.80
|
| Rate for Payer: PHP All Commercial |
$31.15
|
| Rate for Payer: Sagamore Health Network All Products |
$31.71
|
| Rate for Payer: Signature Care EPO |
$34.09
|
| Rate for Payer: Signature Care PPO |
$36.14
|
| Rate for Payer: United Healthcare Commercial |
$32.36
|
|
|
LUBIPROSTONE 8 MCG ORAL CAP
|
Facility
OP
|
$41.07
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.55 |
| Max. Negotiated Rate |
$38.19 |
| Rate for Payer: Aetna Commercial |
$34.66
|
| Rate for Payer: Aetna Medicare |
$13.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.91
|
| Rate for Payer: Cash Price |
$25.46
|
| Rate for Payer: Centivo All Commercial |
$20.95
|
| Rate for Payer: Cigna All Commercial |
$35.44
|
| Rate for Payer: CORVEL All Commercial |
$38.19
|
| Rate for Payer: Coventry All Commercial |
$36.14
|
| Rate for Payer: Encore All Commercial |
$37.80
|
| Rate for Payer: Frontpath All Commercial |
$37.78
|
| Rate for Payer: Humana ChoiceCare |
$35.47
|
| Rate for Payer: Humana Medicare |
$20.95
|
| Rate for Payer: Lucent All Commercial |
$20.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.96
|
| Rate for Payer: PHCS All Commercial |
$30.80
|
| Rate for Payer: PHP All Commercial |
$31.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.02
|
| Rate for Payer: Sagamore Health Network All Products |
$31.71
|
| Rate for Payer: Signature Care EPO |
$34.09
|
| Rate for Payer: Signature Care PPO |
$36.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34.91
|
| Rate for Payer: United Healthcare Commercial |
$32.36
|
| Rate for Payer: United Healthcare Medicare |
$13.55
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP
|
Facility
IP
|
$12.60
|
|
|
Service Code
|
NDC 00904684673
|
| Hospital Charge Code |
111171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$11.72 |
| Rate for Payer: Aetna Commercial |
$10.89
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cigna All Commercial |
$10.87
|
| Rate for Payer: CORVEL All Commercial |
$11.72
|
| Rate for Payer: Coventry All Commercial |
$11.09
|
| Rate for Payer: Encore All Commercial |
$11.60
|
| Rate for Payer: Frontpath All Commercial |
$11.59
|
| Rate for Payer: Humana ChoiceCare |
$10.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.34
|
| Rate for Payer: PHCS All Commercial |
$9.45
|
| Rate for Payer: PHP All Commercial |
$9.56
|
| Rate for Payer: Sagamore Health Network All Products |
$9.73
|
| Rate for Payer: Signature Care EPO |
$10.46
|
| Rate for Payer: Signature Care PPO |
$11.09
|
| Rate for Payer: United Healthcare Commercial |
$9.93
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP
|
Facility
OP
|
$12.60
|
|
|
Service Code
|
NDC 00904684673
|
| Hospital Charge Code |
111171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$10.63
|
| Rate for Payer: Aetna Medicare |
$4.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.57
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Centivo All Commercial |
$6.43
|
| Rate for Payer: Cigna All Commercial |
$10.87
|
| Rate for Payer: CORVEL All Commercial |
$11.72
|
| Rate for Payer: Coventry All Commercial |
$11.09
|
| Rate for Payer: Encore All Commercial |
$11.60
|
| Rate for Payer: Frontpath All Commercial |
$11.59
|
| Rate for Payer: Humana ChoiceCare |
$10.88
|
| Rate for Payer: Humana Medicare |
$6.43
|
| Rate for Payer: Lucent All Commercial |
$6.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.34
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$9.45
|
| Rate for Payer: PHP All Commercial |
$9.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.91
|
| Rate for Payer: Sagamore Health Network All Products |
$9.73
|
| Rate for Payer: Signature Care EPO |
$10.46
|
| Rate for Payer: Signature Care PPO |
$11.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.71
|
| Rate for Payer: United Healthcare Commercial |
$9.93
|
| Rate for Payer: United Healthcare Medicare |
$4.16
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) ORAL TAB
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna All Commercial |
$0.59
|
| Rate for Payer: CORVEL All Commercial |
$0.64
|
| Rate for Payer: Coventry All Commercial |
$0.60
|
| Rate for Payer: Encore All Commercial |
$0.63
|
| Rate for Payer: Frontpath All Commercial |
$0.63
|
| Rate for Payer: Humana ChoiceCare |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.62
|
| Rate for Payer: PHCS All Commercial |
$0.51
|
| Rate for Payer: PHP All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$0.53
|
| Rate for Payer: Signature Care EPO |
$0.57
|
| Rate for Payer: Signature Care PPO |
$0.60
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) ORAL TAB
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.58
|
| Rate for Payer: Aetna Medicare |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Centivo All Commercial |
$0.35
|
| Rate for Payer: Cigna All Commercial |
$0.59
|
| Rate for Payer: CORVEL All Commercial |
$0.64
|
| Rate for Payer: Coventry All Commercial |
$0.60
|
| Rate for Payer: Encore All Commercial |
$0.63
|
| Rate for Payer: Frontpath All Commercial |
$0.63
|
| Rate for Payer: Humana ChoiceCare |
$0.59
|
| Rate for Payer: Humana Medicare |
$0.35
|
| Rate for Payer: Lucent All Commercial |
$0.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.62
|
| Rate for Payer: PHCS All Commercial |
$0.51
|
| Rate for Payer: PHP All Commercial |
$0.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.27
|
| Rate for Payer: Sagamore Health Network All Products |
$0.53
|
| Rate for Payer: Signature Care EPO |
$0.57
|
| Rate for Payer: Signature Care PPO |
$0.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
|
|
MAGNESIUM SULFATE 1 GRAM/100 ML IVPB
|
Facility
IP
|
$30.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
16162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$26.61
|
| Rate for Payer: Cash Price |
$19.10
|
| Rate for Payer: Cigna All Commercial |
$26.58
|
| Rate for Payer: CORVEL All Commercial |
$28.64
|
| Rate for Payer: Coventry All Commercial |
$27.10
|
| Rate for Payer: Encore All Commercial |
$28.35
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Humana ChoiceCare |
$26.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.72
|
| Rate for Payer: PHCS All Commercial |
$23.10
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Signature Care EPO |
$25.56
|
| Rate for Payer: Signature Care PPO |
$27.10
|
| Rate for Payer: United Healthcare Commercial |
$24.27
|
|
|
MAGNESIUM SULFATE 1 GRAM/100 ML IVPB
|
Facility
OP
|
$30.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
16162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$26.00
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.18
|
| Rate for Payer: Cash Price |
$19.10
|
| Rate for Payer: Centivo All Commercial |
$15.71
|
| Rate for Payer: Cigna All Commercial |
$26.58
|
| Rate for Payer: CORVEL All Commercial |
$28.64
|
| Rate for Payer: Coventry All Commercial |
$27.10
|
| Rate for Payer: Encore All Commercial |
$28.35
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Humana ChoiceCare |
$26.60
|
| Rate for Payer: Humana Medicare |
$15.71
|
| Rate for Payer: Lucent All Commercial |
$15.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.72
|
| Rate for Payer: PHCS All Commercial |
$23.10
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.01
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Signature Care EPO |
$25.56
|
| Rate for Payer: Signature Care PPO |
$27.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$24.27
|
| Rate for Payer: United Healthcare Medicare |
$10.16
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
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
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
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
|
|
|
MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP
|
Facility
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
119529
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP
|
Facility
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
119529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.79
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Centivo All Commercial |
$24.99
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana Medicare |
$24.99
|
| Rate for Payer: Lucent All Commercial |
$24.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Medicare |
$16.17
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
OP
|
$38.50
|
|
|
Service Code
|
NDC 00409673013
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.98
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Centivo All Commercial |
$19.64
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$19.64
|
| Rate for Payer: Lucent All Commercial |
$19.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.72
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
|
|
MAGNESIUM SULFATE IN WATER 4 GRAM/50 ML (8 %) IV PGBK
|
Facility
IP
|
$38.50
|
|
|
Service Code
|
NDC 00409673013
|
| Hospital Charge Code |
4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
|
|
Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 27570
|
| Hospital Charge Code |
CPT-27570
|
|
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
|
|
|
Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 23700
|
| Hospital Charge Code |
CPT-23700
|
|
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
|
|
|
MANNITOL 20 % 20 % IV SOLP
|
Facility
IP
|
$133.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$123.69 |
| Rate for Payer: Aetna Commercial |
$114.91
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
|
|
MANNITOL 20 % 20 % IV SOLP
|
Facility
OP
|
$133.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.89 |
| Max. Negotiated Rate |
$123.69 |
| Rate for Payer: Aetna Commercial |
$112.25
|
| Rate for Payer: Aetna Medicare |
$43.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$76.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$83.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.28
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Centivo All Commercial |
$67.83
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Humana Medicare |
$67.83
|
| Rate for Payer: Lucent All Commercial |
$67.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$51.87
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$113.05
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
| Rate for Payer: United Healthcare Medicare |
$43.89
|
|
|
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
CPT-19301
|
|
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
|
|
|
Mastectomy, simple, complete
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
CPT-19303
|
|
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
|
|
|
Mastotomy with exploration or drainage of abscess, deep
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 19020
|
| Hospital Charge Code |
CPT-19020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,728.79 |
| Max. Negotiated Rate |
$1,728.79 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,728.79
|
| Rate for Payer: Managed Health Services Medicaid |
$1,728.79
|
| Rate for Payer: MDWise Medicaid |
$1,728.79
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SUBQ SOLR
|
Facility
OP
|
$501.40
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.46 |
| Max. Negotiated Rate |
$466.30 |
| Rate for Payer: Aetna Commercial |
$423.18
|
| Rate for Payer: Aetna Medicare |
$165.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$165.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$287.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$313.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$190.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$182.01
|
| Rate for Payer: Cash Price |
$310.87
|
| Rate for Payer: Centivo All Commercial |
$255.72
|
| Rate for Payer: Cigna All Commercial |
$432.71
|
| Rate for Payer: CORVEL All Commercial |
$466.30
|
| Rate for Payer: Coventry All Commercial |
$441.23
|
| Rate for Payer: Encore All Commercial |
$461.54
|
| Rate for Payer: Frontpath All Commercial |
$461.29
|
| Rate for Payer: Humana ChoiceCare |
$433.06
|
| Rate for Payer: Humana Medicare |
$255.72
|
| Rate for Payer: Lucent All Commercial |
$255.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$451.26
|
| Rate for Payer: PHCS All Commercial |
$376.05
|
| Rate for Payer: PHP All Commercial |
$380.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$195.55
|
| Rate for Payer: Sagamore Health Network All Products |
$387.08
|
| Rate for Payer: Signature Care EPO |
$416.16
|
| Rate for Payer: Signature Care PPO |
$441.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$426.19
|
| Rate for Payer: United Healthcare Commercial |
$395.10
|
| Rate for Payer: United Healthcare Medicare |
$165.46
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SUBQ SOLR
|
Facility
IP
|
$501.40
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$376.05 |
| Max. Negotiated Rate |
$466.30 |
| Rate for Payer: Aetna Commercial |
$433.21
|
| Rate for Payer: Cash Price |
$310.87
|
| Rate for Payer: Cigna All Commercial |
$432.71
|
| Rate for Payer: CORVEL All Commercial |
$466.30
|
| Rate for Payer: Coventry All Commercial |
$441.23
|
| Rate for Payer: Encore All Commercial |
$461.54
|
| Rate for Payer: Frontpath All Commercial |
$461.29
|
| Rate for Payer: Humana ChoiceCare |
$433.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$451.26
|
| Rate for Payer: PHCS All Commercial |
$376.05
|
| Rate for Payer: PHP All Commercial |
$380.26
|
| Rate for Payer: Sagamore Health Network All Products |
$387.08
|
| Rate for Payer: Signature Care EPO |
$416.16
|
| Rate for Payer: Signature Care PPO |
$441.23
|
| Rate for Payer: United Healthcare Commercial |
$395.10
|
|
|
MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR
|
Facility
OP
|
$527.08
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
198256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.94 |
| Max. Negotiated Rate |
$490.18 |
| Rate for Payer: Aetna Commercial |
$444.85
|
| Rate for Payer: Aetna Medicare |
$173.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$302.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$329.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$200.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$191.33
|
| Rate for Payer: Cash Price |
$326.79
|
| Rate for Payer: Centivo All Commercial |
$268.81
|
| Rate for Payer: Cigna All Commercial |
$454.87
|
| Rate for Payer: CORVEL All Commercial |
$490.18
|
| Rate for Payer: Coventry All Commercial |
$463.83
|
| Rate for Payer: Encore All Commercial |
$485.17
|
| Rate for Payer: Frontpath All Commercial |
$484.91
|
| Rate for Payer: Humana ChoiceCare |
$455.24
|
| Rate for Payer: Humana Medicare |
$268.81
|
| Rate for Payer: Lucent All Commercial |
$268.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$474.37
|
| Rate for Payer: PHCS All Commercial |
$395.31
|
| Rate for Payer: PHP All Commercial |
$399.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$205.56
|
| Rate for Payer: Sagamore Health Network All Products |
$406.90
|
| Rate for Payer: Signature Care EPO |
$437.47
|
| Rate for Payer: Signature Care PPO |
$463.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$448.01
|
| Rate for Payer: United Healthcare Commercial |
$415.34
|
| Rate for Payer: United Healthcare Medicare |
$173.94
|
|
