|
ONABOTULINUMTOXINA 100 UNITS INJ SOLR
|
Facility
IP
|
$2,584.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
32700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,938.00 |
| Max. Negotiated Rate |
$2,403.12 |
| Rate for Payer: Aetna Commercial |
$2,232.58
|
| Rate for Payer: Cash Price |
$1,602.08
|
| Rate for Payer: Cigna All Commercial |
$2,229.99
|
| Rate for Payer: CORVEL All Commercial |
$2,403.12
|
| Rate for Payer: Coventry All Commercial |
$2,273.92
|
| Rate for Payer: Encore All Commercial |
$2,378.57
|
| Rate for Payer: Frontpath All Commercial |
$2,377.28
|
| Rate for Payer: Humana ChoiceCare |
$2,231.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,325.60
|
| Rate for Payer: PHCS All Commercial |
$1,938.00
|
| Rate for Payer: PHP All Commercial |
$1,959.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1,994.85
|
| Rate for Payer: Signature Care EPO |
$2,144.72
|
| Rate for Payer: Signature Care PPO |
$2,273.92
|
| Rate for Payer: United Healthcare Commercial |
$2,036.19
|
|
|
ONDANSETRON 4 MG ODT #4 ED PACK (CAMERON)
|
Facility
OP
|
$5.38
|
|
|
Service Code
|
NDC 684620157
|
| Hospital Charge Code |
1401000800199
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.54
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Centivo All Commercial |
$2.74
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Humana Medicare |
$2.74
|
| Rate for Payer: Lucent All Commercial |
$2.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.10
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.57
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
| Rate for Payer: United Healthcare Medicare |
$1.77
|
|
|
ONDANSETRON 4 MG ODT #4 ED PACK (CAMERON)
|
Facility
IP
|
$5.38
|
|
|
Service Code
|
NDC 684620157
|
| Hospital Charge Code |
1401000800199
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cigna All Commercial |
$4.64
|
| Rate for Payer: CORVEL All Commercial |
$5.00
|
| Rate for Payer: Coventry All Commercial |
$4.73
|
| Rate for Payer: Encore All Commercial |
$4.95
|
| Rate for Payer: Frontpath All Commercial |
$4.95
|
| Rate for Payer: Humana ChoiceCare |
$4.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.84
|
| Rate for Payer: PHCS All Commercial |
$4.03
|
| Rate for Payer: PHP All Commercial |
$4.08
|
| Rate for Payer: Sagamore Health Network All Products |
$4.15
|
| Rate for Payer: Signature Care EPO |
$4.46
|
| Rate for Payer: Signature Care PPO |
$4.73
|
| Rate for Payer: United Healthcare Commercial |
$4.24
|
|
|
ONDANSETRON 4 MG ORAL TBDL
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Centivo All Commercial |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$1.16
|
| Rate for Payer: CORVEL All Commercial |
$1.25
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.16
|
| Rate for Payer: Humana Medicare |
$0.69
|
| Rate for Payer: Lucent All Commercial |
$0.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.21
|
| Rate for Payer: PHCS All Commercial |
$1.01
|
| Rate for Payer: PHP All Commercial |
$1.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.04
|
| Rate for Payer: Signature Care EPO |
$1.12
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
ONDANSETRON 4 MG ORAL TBDL
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.16
|
| Rate for Payer: CORVEL All Commercial |
$1.25
|
| Rate for Payer: Coventry All Commercial |
$1.18
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.21
|
| Rate for Payer: PHCS All Commercial |
$1.01
|
| Rate for Payer: PHP All Commercial |
$1.02
|
| Rate for Payer: Sagamore Health Network All Products |
$1.04
|
| Rate for Payer: Signature Care EPO |
$1.12
|
| Rate for Payer: Signature Care PPO |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
|
|
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
105614
|
|
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
|
|
|
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
105614
|
|
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
|
|
|
Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 26746
|
| Hospital Charge Code |
CPT-26746
|
|
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
|
|
|
Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27814
|
| Hospital Charge Code |
CPT-27814
|
|
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
|
|
|
Open treatment of clavicular fracture, includes internal fixation, when performed
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 23515
|
| Hospital Charge Code |
CPT-23515
|
|
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
|
|
|
Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 26765
|
| Hospital Charge Code |
CPT-26765
|
|
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
|
|
|
Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 25607
|
| Hospital Charge Code |
CPT-25607
|
|
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
|
|
|
Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 25608
|
| Hospital Charge Code |
CPT-25608
|
|
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
|
|
|
Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments
|
Facility
OP
|
$3,121.64
|
|
|
Service Code
|
CPT 25609
|
| Hospital Charge Code |
CPT-25609
|
|
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
|
|
|
Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 27829
|
| Hospital Charge Code |
CPT-27829
|
|
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
|
|
|
Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 27828
|
| Hospital Charge Code |
CPT-27828
|
|
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
|
|
|
Open treatment of humeral shaft fracture with plate/screws, with or without cerclage
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 24515
|
| Hospital Charge Code |
CPT-24515
|
|
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
|
|
|
Open treatment of medial malleolus fracture, includes internal fixation, when performed
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27766
|
| Hospital Charge Code |
CPT-27766
|
|
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
|
|
|
Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 26615
|
| Hospital Charge Code |
CPT-26615
|
|
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
|
|
|
Open treatment of metatarsal fracture, includes internal fixation, when performed, each
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 28485
|
| Hospital Charge Code |
CPT-28485
|
|
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
|
|
|
Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed;
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 23615
|
| Hospital Charge Code |
CPT-23615
|
|
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
|
|
|
Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 25575
|
| Hospital Charge Code |
CPT-25575
|
|
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
|
|
|
Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed;
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 24665
|
| Hospital Charge Code |
CPT-24665
|
|
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
|
|
|
Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27823
|
| Hospital Charge Code |
CPT-27823
|
|
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
|
|
|
Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27822
|
| Hospital Charge Code |
CPT-27822
|
|
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
|
|
