|
PALIVIZUMAB 100 MG/ML IM SOLN
|
Facility
OP
|
$12,634.37
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
41675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,169.34 |
| Max. Negotiated Rate |
$11,749.96 |
| Rate for Payer: Aetna Commercial |
$10,663.41
|
| Rate for Payer: Aetna Medicare |
$4,169.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,169.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7,255.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,897.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,794.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,586.28
|
| Rate for Payer: Cash Price |
$7,833.31
|
| Rate for Payer: Centivo All Commercial |
$6,443.53
|
| Rate for Payer: Cigna All Commercial |
$10,903.46
|
| Rate for Payer: CORVEL All Commercial |
$11,749.96
|
| Rate for Payer: Coventry All Commercial |
$11,118.25
|
| Rate for Payer: Encore All Commercial |
$11,629.94
|
| Rate for Payer: Frontpath All Commercial |
$11,623.62
|
| Rate for Payer: Humana ChoiceCare |
$10,912.31
|
| Rate for Payer: Humana Medicare |
$6,443.53
|
| Rate for Payer: Lucent All Commercial |
$6,443.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,370.93
|
| Rate for Payer: PHCS All Commercial |
$9,475.78
|
| Rate for Payer: PHP All Commercial |
$9,581.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,927.40
|
| Rate for Payer: Sagamore Health Network All Products |
$9,753.73
|
| Rate for Payer: Signature Care EPO |
$10,486.53
|
| Rate for Payer: Signature Care PPO |
$11,118.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,739.21
|
| Rate for Payer: United Healthcare Commercial |
$9,955.88
|
| Rate for Payer: United Healthcare Medicare |
$4,169.34
|
|
|
PALIVIZUMAB 100 MG/ML IM SOLN
|
Facility
IP
|
$12,634.37
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
41675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,475.78 |
| Max. Negotiated Rate |
$11,749.96 |
| Rate for Payer: Aetna Commercial |
$10,916.10
|
| Rate for Payer: Cash Price |
$7,833.31
|
| Rate for Payer: Cigna All Commercial |
$10,903.46
|
| Rate for Payer: CORVEL All Commercial |
$11,749.96
|
| Rate for Payer: Coventry All Commercial |
$11,118.25
|
| Rate for Payer: Encore All Commercial |
$11,629.94
|
| Rate for Payer: Frontpath All Commercial |
$11,623.62
|
| Rate for Payer: Humana ChoiceCare |
$10,912.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,370.93
|
| Rate for Payer: PHCS All Commercial |
$9,475.78
|
| Rate for Payer: PHP All Commercial |
$9,581.91
|
| Rate for Payer: Sagamore Health Network All Products |
$9,753.73
|
| Rate for Payer: Signature Care EPO |
$10,486.53
|
| Rate for Payer: Signature Care PPO |
$11,118.25
|
| Rate for Payer: United Healthcare Commercial |
$9,955.88
|
|
|
PALIVIZUMAB 50 MG/0.5 ML IM SOLN
|
Facility
IP
|
$6,690.92
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
108060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,018.19 |
| Max. Negotiated Rate |
$6,222.55 |
| Rate for Payer: Aetna Commercial |
$5,780.95
|
| Rate for Payer: Cash Price |
$4,148.37
|
| Rate for Payer: Cigna All Commercial |
$5,774.26
|
| Rate for Payer: CORVEL All Commercial |
$6,222.55
|
| Rate for Payer: Coventry All Commercial |
$5,888.01
|
| Rate for Payer: Encore All Commercial |
$6,158.99
|
| Rate for Payer: Frontpath All Commercial |
$6,155.64
|
| Rate for Payer: Humana ChoiceCare |
$5,778.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,021.82
|
| Rate for Payer: PHCS All Commercial |
$5,018.19
|
| Rate for Payer: PHP All Commercial |
$5,074.39
|
| Rate for Payer: Sagamore Health Network All Products |
$5,165.39
|
| Rate for Payer: Signature Care EPO |
$5,553.46
|
| Rate for Payer: Signature Care PPO |
$5,888.01
|
| Rate for Payer: United Healthcare Commercial |
$5,272.44
|
|
|
PALIVIZUMAB 50 MG/0.5 ML IM SOLN
|
Facility
OP
|
$6,690.92
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
108060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,208.00 |
| Max. Negotiated Rate |
$6,222.55 |
| Rate for Payer: Aetna Commercial |
$5,647.13
|
| Rate for Payer: Aetna Medicare |
$2,208.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,208.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,842.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,182.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,539.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,428.80
|
| Rate for Payer: Cash Price |
$4,148.37
|
| Rate for Payer: Centivo All Commercial |
$3,412.37
|
| Rate for Payer: Cigna All Commercial |
$5,774.26
|
| Rate for Payer: CORVEL All Commercial |
$6,222.55
|
| Rate for Payer: Coventry All Commercial |
$5,888.01
|
| Rate for Payer: Encore All Commercial |
$6,158.99
|
| Rate for Payer: Frontpath All Commercial |
$6,155.64
|
| Rate for Payer: Humana ChoiceCare |
$5,778.94
|
| Rate for Payer: Humana Medicare |
$3,412.37
|
| Rate for Payer: Lucent All Commercial |
$3,412.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,021.82
|
| Rate for Payer: PHCS All Commercial |
$5,018.19
|
| Rate for Payer: PHP All Commercial |
$5,074.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,609.46
|
| Rate for Payer: Sagamore Health Network All Products |
$5,165.39
|
| Rate for Payer: Signature Care EPO |
$5,553.46
|
| Rate for Payer: Signature Care PPO |
$5,888.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,687.28
|
| Rate for Payer: United Healthcare Commercial |
$5,272.44
|
| Rate for Payer: United Healthcare Medicare |
$2,208.00
|
|
|
PANTOPRAZOLE 40 MG IV SOLR
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
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
|
|
|
PANTOPRAZOLE 40 MG IV SOLR
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
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
|
|
|
PANTOPRAZOLE 40 MG ORAL GRPS
|
Facility
OP
|
$48.47
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
89791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$40.91
|
| Rate for Payer: Aetna Medicare |
$15.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.59
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Centivo All Commercial |
$24.72
|
| Rate for Payer: Cigna All Commercial |
$41.83
|
| Rate for Payer: CORVEL All Commercial |
$45.08
|
| Rate for Payer: Coventry All Commercial |
$42.65
|
| Rate for Payer: Encore All Commercial |
$44.61
|
| Rate for Payer: Frontpath All Commercial |
$44.59
|
| Rate for Payer: Humana ChoiceCare |
$41.86
|
| Rate for Payer: Humana Medicare |
$24.72
|
| Rate for Payer: Lucent All Commercial |
$24.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.62
|
| Rate for Payer: PHCS All Commercial |
$36.35
|
| Rate for Payer: PHP All Commercial |
$36.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.90
|
| Rate for Payer: Sagamore Health Network All Products |
$37.42
|
| Rate for Payer: Signature Care EPO |
$40.23
|
| Rate for Payer: Signature Care PPO |
$42.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.20
|
| Rate for Payer: United Healthcare Commercial |
$38.19
|
| Rate for Payer: United Healthcare Medicare |
$15.99
|
|
|
PANTOPRAZOLE 40 MG ORAL GRPS
|
Facility
IP
|
$48.47
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
89791
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.35 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$41.88
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cigna All Commercial |
$41.83
|
| Rate for Payer: CORVEL All Commercial |
$45.08
|
| Rate for Payer: Coventry All Commercial |
$42.65
|
| Rate for Payer: Encore All Commercial |
$44.61
|
| Rate for Payer: Frontpath All Commercial |
$44.59
|
| Rate for Payer: Humana ChoiceCare |
$41.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.62
|
| Rate for Payer: PHCS All Commercial |
$36.35
|
| Rate for Payer: PHP All Commercial |
$36.76
|
| Rate for Payer: Sagamore Health Network All Products |
$37.42
|
| Rate for Payer: Signature Care EPO |
$40.23
|
| Rate for Payer: Signature Care PPO |
$42.65
|
| Rate for Payer: United Healthcare Commercial |
$38.19
|
|
|
PANTOPRAZOLE 40 MG ORAL TBEC
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna All Commercial |
$1.30
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| Rate for Payer: Coventry All Commercial |
$1.33
|
| Rate for Payer: Encore All Commercial |
$1.39
|
| Rate for Payer: Frontpath All Commercial |
$1.39
|
| Rate for Payer: Humana ChoiceCare |
$1.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.36
|
| Rate for Payer: PHCS All Commercial |
$1.13
|
| Rate for Payer: PHP All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.25
|
| Rate for Payer: Signature Care PPO |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.19
|
|
|
PANTOPRAZOLE 40 MG ORAL TBEC
|
Facility
OP
|
$1.51
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Centivo All Commercial |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.30
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| Rate for Payer: Coventry All Commercial |
$1.33
|
| Rate for Payer: Encore All Commercial |
$1.39
|
| Rate for Payer: Frontpath All Commercial |
$1.39
|
| Rate for Payer: Humana ChoiceCare |
$1.31
|
| Rate for Payer: Humana Medicare |
$0.77
|
| Rate for Payer: Lucent All Commercial |
$0.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.36
|
| Rate for Payer: PHCS All Commercial |
$1.13
|
| Rate for Payer: PHP All Commercial |
$1.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.59
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.25
|
| Rate for Payer: Signature Care PPO |
$1.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.19
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
IP
|
$660.00
|
|
|
Service Code
|
NDC 099999994
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$495.00 |
| Max. Negotiated Rate |
$613.80 |
| Rate for Payer: Aetna Commercial |
$570.24
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna All Commercial |
$569.58
|
| Rate for Payer: CORVEL All Commercial |
$613.80
|
| Rate for Payer: Coventry All Commercial |
$580.80
|
| Rate for Payer: Encore All Commercial |
$607.53
|
| Rate for Payer: Frontpath All Commercial |
$607.20
|
| Rate for Payer: Humana ChoiceCare |
$570.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.00
|
| Rate for Payer: PHCS All Commercial |
$495.00
|
| Rate for Payer: PHP All Commercial |
$500.54
|
| Rate for Payer: Sagamore Health Network All Products |
$509.52
|
| Rate for Payer: Signature Care EPO |
$547.80
|
| Rate for Payer: Signature Care PPO |
$580.80
|
| Rate for Payer: United Healthcare Commercial |
$520.08
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
NDC 099999993
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$651.00 |
| Rate for Payer: Aetna Commercial |
$590.80
|
| Rate for Payer: Aetna Medicare |
$231.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$231.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$402.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$437.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$265.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$254.10
|
| Rate for Payer: Cash Price |
$434.00
|
| Rate for Payer: Cash Price |
$434.00
|
| Rate for Payer: Centivo All Commercial |
$357.00
|
| Rate for Payer: Cigna All Commercial |
$604.10
|
| Rate for Payer: CORVEL All Commercial |
$651.00
|
| Rate for Payer: Coventry All Commercial |
$616.00
|
| Rate for Payer: Encore All Commercial |
$644.35
|
| Rate for Payer: Frontpath All Commercial |
$644.00
|
| Rate for Payer: Humana ChoiceCare |
$604.59
|
| Rate for Payer: Humana Medicare |
$357.00
|
| Rate for Payer: Lucent All Commercial |
$357.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$630.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$525.00
|
| Rate for Payer: PHP All Commercial |
$530.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$273.00
|
| Rate for Payer: Sagamore Health Network All Products |
$540.40
|
| Rate for Payer: Signature Care EPO |
$581.00
|
| Rate for Payer: Signature Care PPO |
$616.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$595.00
|
| Rate for Payer: United Healthcare Commercial |
$551.60
|
| Rate for Payer: United Healthcare Medicare |
$231.00
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
OP
|
$660.00
|
|
|
Service Code
|
NDC 099999994
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$613.80 |
| Rate for Payer: Aetna Commercial |
$557.04
|
| Rate for Payer: Aetna Medicare |
$217.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$217.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$379.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$412.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$250.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$239.58
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Centivo All Commercial |
$336.60
|
| Rate for Payer: Cigna All Commercial |
$569.58
|
| Rate for Payer: CORVEL All Commercial |
$613.80
|
| Rate for Payer: Coventry All Commercial |
$580.80
|
| Rate for Payer: Encore All Commercial |
$607.53
|
| Rate for Payer: Frontpath All Commercial |
$607.20
|
| Rate for Payer: Humana ChoiceCare |
$570.04
|
| Rate for Payer: Humana Medicare |
$336.60
|
| Rate for Payer: Lucent All Commercial |
$336.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$495.00
|
| Rate for Payer: PHP All Commercial |
$500.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$257.40
|
| Rate for Payer: Sagamore Health Network All Products |
$509.52
|
| Rate for Payer: Signature Care EPO |
$547.80
|
| Rate for Payer: Signature Care PPO |
$580.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$561.00
|
| Rate for Payer: United Healthcare Commercial |
$520.08
|
| Rate for Payer: United Healthcare Medicare |
$217.80
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
IP
|
$576.00
|
|
|
Service Code
|
NDC 099999995
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$432.00 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna Commercial |
$497.66
|
| Rate for Payer: Cash Price |
$357.12
|
| Rate for Payer: Cigna All Commercial |
$497.09
|
| Rate for Payer: CORVEL All Commercial |
$535.68
|
| Rate for Payer: Coventry All Commercial |
$506.88
|
| Rate for Payer: Encore All Commercial |
$530.21
|
| Rate for Payer: Frontpath All Commercial |
$529.92
|
| Rate for Payer: Humana ChoiceCare |
$497.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$518.40
|
| Rate for Payer: PHCS All Commercial |
$432.00
|
| Rate for Payer: PHP All Commercial |
$436.84
|
| Rate for Payer: Sagamore Health Network All Products |
$444.67
|
| Rate for Payer: Signature Care EPO |
$478.08
|
| Rate for Payer: Signature Care PPO |
$506.88
|
| Rate for Payer: United Healthcare Commercial |
$453.89
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
OP
|
$576.00
|
|
|
Service Code
|
NDC 099999995
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna Commercial |
$486.14
|
| Rate for Payer: Aetna Medicare |
$190.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$190.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$330.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$360.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$218.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$209.09
|
| Rate for Payer: Cash Price |
$357.12
|
| Rate for Payer: Cash Price |
$357.12
|
| Rate for Payer: Centivo All Commercial |
$293.76
|
| Rate for Payer: Cigna All Commercial |
$497.09
|
| Rate for Payer: CORVEL All Commercial |
$535.68
|
| Rate for Payer: Coventry All Commercial |
$506.88
|
| Rate for Payer: Encore All Commercial |
$530.21
|
| Rate for Payer: Frontpath All Commercial |
$529.92
|
| Rate for Payer: Humana ChoiceCare |
$497.49
|
| Rate for Payer: Humana Medicare |
$293.76
|
| Rate for Payer: Lucent All Commercial |
$293.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$518.40
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$432.00
|
| Rate for Payer: PHP All Commercial |
$436.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$224.64
|
| Rate for Payer: Sagamore Health Network All Products |
$444.67
|
| Rate for Payer: Signature Care EPO |
$478.08
|
| Rate for Payer: Signature Care PPO |
$506.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$489.60
|
| Rate for Payer: United Healthcare Commercial |
$453.89
|
| Rate for Payer: United Healthcare Medicare |
$190.08
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
IP
|
$700.00
|
|
|
Service Code
|
NDC 099999993
|
| Hospital Charge Code |
1401000200010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$651.00 |
| Rate for Payer: Aetna Commercial |
$604.80
|
| Rate for Payer: Cash Price |
$434.00
|
| Rate for Payer: Cigna All Commercial |
$604.10
|
| Rate for Payer: CORVEL All Commercial |
$651.00
|
| Rate for Payer: Coventry All Commercial |
$616.00
|
| Rate for Payer: Encore All Commercial |
$644.35
|
| Rate for Payer: Frontpath All Commercial |
$644.00
|
| Rate for Payer: Humana ChoiceCare |
$604.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$630.00
|
| Rate for Payer: PHCS All Commercial |
$525.00
|
| Rate for Payer: PHP All Commercial |
$530.88
|
| Rate for Payer: Sagamore Health Network All Products |
$540.40
|
| Rate for Payer: Signature Care EPO |
$581.00
|
| Rate for Payer: Signature Care PPO |
$616.00
|
| Rate for Payer: United Healthcare Commercial |
$551.60
|
|
|
PAROXETINE HCL 20 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
PAROXETINE HCL 20 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 28124
|
| Hospital Charge Code |
CPT-28124
|
|
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
|
|
|
Partial hymenectomy or revision of hymenal ring
|
Facility
OP
|
$1,242.31
|
|
|
Service Code
|
CPT 56700
|
| Hospital Charge Code |
CPT-56700
|
|
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
|
|
|
PATIENT SUPPLIED MEDICATION
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00000004370
|
| Hospital Charge Code |
900006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
PATIENT SUPPLIED MEDICATION
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00000004370
|
| Hospital Charge Code |
900006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
PB DRYING CAPS
|
Professional
|
$400.00
|
|
|
Service Code
|
CPT V5267
|
| Hospital Charge Code |
zV5267D
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Cash Price |
$248.00
|
| Rate for Payer: PHCS All Commercial |
$300.00
|
| Rate for Payer: Signature Care EPO |
$400.00
|
| Rate for Payer: Signature Care PPO |
$400.00
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP
|
Facility
IP
|
$12.39
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cigna All Commercial |
$10.69
|
| Rate for Payer: CORVEL All Commercial |
$11.52
|
| Rate for Payer: Coventry All Commercial |
$10.90
|
| Rate for Payer: Encore All Commercial |
$11.40
|
| Rate for Payer: Frontpath All Commercial |
$11.40
|
| Rate for Payer: Humana ChoiceCare |
$10.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.15
|
| Rate for Payer: PHCS All Commercial |
$9.29
|
| Rate for Payer: PHP All Commercial |
$9.40
|
| Rate for Payer: Sagamore Health Network All Products |
$9.57
|
| Rate for Payer: Signature Care EPO |
$10.28
|
| Rate for Payer: Signature Care PPO |
$10.90
|
| Rate for Payer: United Healthcare Commercial |
$9.76
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP
|
Facility
OP
|
$12.39
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$10.46
|
| Rate for Payer: Aetna Medicare |
$4.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Centivo All Commercial |
$6.32
|
| Rate for Payer: Cigna All Commercial |
$10.69
|
| Rate for Payer: CORVEL All Commercial |
$11.52
|
| Rate for Payer: Coventry All Commercial |
$10.90
|
| Rate for Payer: Encore All Commercial |
$11.40
|
| Rate for Payer: Frontpath All Commercial |
$11.40
|
| Rate for Payer: Humana ChoiceCare |
$10.70
|
| Rate for Payer: Humana Medicare |
$6.32
|
| Rate for Payer: Lucent All Commercial |
$6.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.15
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$9.29
|
| Rate for Payer: PHP All Commercial |
$9.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.83
|
| Rate for Payer: Sagamore Health Network All Products |
$9.57
|
| Rate for Payer: Signature Care EPO |
$10.28
|
| Rate for Payer: Signature Care PPO |
$10.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.53
|
| Rate for Payer: United Healthcare Commercial |
$9.76
|
| Rate for Payer: United Healthcare Medicare |
$4.09
|
|
