|
PEGFILGRASTIM 6 MG/0.6 ML SUBQ SYRG
|
Facility
OP
|
$15,816.96
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$561.57 |
| Max. Negotiated Rate |
$14,709.77 |
| Rate for Payer: Aetna Commercial |
$13,349.51
|
| Rate for Payer: Aetna Medicare |
$5,219.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,219.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,083.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,887.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$561.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,002.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,741.55
|
| Rate for Payer: Cash Price |
$9,806.51
|
| Rate for Payer: Cash Price |
$9,806.51
|
| Rate for Payer: Centivo All Commercial |
$8,066.65
|
| Rate for Payer: Cigna All Commercial |
$13,650.03
|
| Rate for Payer: CORVEL All Commercial |
$14,709.77
|
| Rate for Payer: Coventry All Commercial |
$13,918.92
|
| Rate for Payer: Encore All Commercial |
$14,559.51
|
| Rate for Payer: Frontpath All Commercial |
$14,551.60
|
| Rate for Payer: Humana ChoiceCare |
$13,661.10
|
| Rate for Payer: Humana Medicare |
$8,066.65
|
| Rate for Payer: Lucent All Commercial |
$8,066.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,235.26
|
| Rate for Payer: Managed Health Services Medicaid |
$561.57
|
| Rate for Payer: MDWise Medicaid |
$561.57
|
| Rate for Payer: PHCS All Commercial |
$11,862.72
|
| Rate for Payer: PHP All Commercial |
$11,995.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,168.61
|
| Rate for Payer: Sagamore Health Network All Products |
$12,210.69
|
| Rate for Payer: Signature Care EPO |
$13,128.07
|
| Rate for Payer: Signature Care PPO |
$13,918.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,444.41
|
| Rate for Payer: United Healthcare Commercial |
$12,463.76
|
| Rate for Payer: United Healthcare Medicare |
$5,219.60
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBQ SYRG
|
Facility
IP
|
$15,816.96
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,862.72 |
| Max. Negotiated Rate |
$14,709.77 |
| Rate for Payer: Aetna Commercial |
$13,665.85
|
| Rate for Payer: Cash Price |
$9,806.51
|
| Rate for Payer: Cigna All Commercial |
$13,650.03
|
| Rate for Payer: CORVEL All Commercial |
$14,709.77
|
| Rate for Payer: Coventry All Commercial |
$13,918.92
|
| Rate for Payer: Encore All Commercial |
$14,559.51
|
| Rate for Payer: Frontpath All Commercial |
$14,551.60
|
| Rate for Payer: Humana ChoiceCare |
$13,661.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,235.26
|
| Rate for Payer: PHCS All Commercial |
$11,862.72
|
| Rate for Payer: PHP All Commercial |
$11,995.58
|
| Rate for Payer: Sagamore Health Network All Products |
$12,210.69
|
| Rate for Payer: Signature Care EPO |
$13,128.07
|
| Rate for Payer: Signature Care PPO |
$13,918.92
|
| Rate for Payer: United Healthcare Commercial |
$12,463.76
|
|
|
PEMBROLIZUMAB 25 MG/ML IV SOLN
|
Facility
IP
|
$19,840.38
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
171368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,880.28 |
| Max. Negotiated Rate |
$18,451.55 |
| Rate for Payer: Aetna Commercial |
$17,142.09
|
| Rate for Payer: Cash Price |
$12,301.04
|
| Rate for Payer: Cigna All Commercial |
$17,122.25
|
| Rate for Payer: CORVEL All Commercial |
$18,451.55
|
| Rate for Payer: Coventry All Commercial |
$17,459.53
|
| Rate for Payer: Encore All Commercial |
$18,263.07
|
| Rate for Payer: Frontpath All Commercial |
$18,253.15
|
| Rate for Payer: Humana ChoiceCare |
$17,136.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,856.34
|
| Rate for Payer: PHCS All Commercial |
$14,880.28
|
| Rate for Payer: PHP All Commercial |
$15,046.94
|
| Rate for Payer: Sagamore Health Network All Products |
$15,316.77
|
| Rate for Payer: Signature Care EPO |
$16,467.52
|
| Rate for Payer: Signature Care PPO |
$17,459.53
|
| Rate for Payer: United Healthcare Commercial |
$15,634.22
|
|
|
PEMBROLIZUMAB 25 MG/ML IV SOLN
|
Facility
OP
|
$19,840.38
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
171368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.21 |
| Max. Negotiated Rate |
$18,451.55 |
| Rate for Payer: Aetna Commercial |
$16,745.28
|
| Rate for Payer: Aetna Medicare |
$6,547.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,547.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11,394.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,402.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$57.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,529.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,202.06
|
| Rate for Payer: Cash Price |
$12,301.04
|
| Rate for Payer: Cash Price |
$12,301.04
|
| Rate for Payer: Centivo All Commercial |
$10,118.59
|
| Rate for Payer: Cigna All Commercial |
$17,122.25
|
| Rate for Payer: CORVEL All Commercial |
$18,451.55
|
| Rate for Payer: Coventry All Commercial |
$17,459.53
|
| Rate for Payer: Encore All Commercial |
$18,263.07
|
| Rate for Payer: Frontpath All Commercial |
$18,253.15
|
| Rate for Payer: Humana ChoiceCare |
$17,136.14
|
| Rate for Payer: Humana Medicare |
$10,118.59
|
| Rate for Payer: Lucent All Commercial |
$10,118.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,856.34
|
| Rate for Payer: Managed Health Services Medicaid |
$57.21
|
| Rate for Payer: MDWise Medicaid |
$57.21
|
| Rate for Payer: PHCS All Commercial |
$14,880.28
|
| Rate for Payer: PHP All Commercial |
$15,046.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,737.75
|
| Rate for Payer: Sagamore Health Network All Products |
$15,316.77
|
| Rate for Payer: Signature Care EPO |
$16,467.52
|
| Rate for Payer: Signature Care PPO |
$17,459.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16,864.32
|
| Rate for Payer: United Healthcare Commercial |
$15,634.22
|
| Rate for Payer: United Healthcare Medicare |
$6,547.33
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG
|
Facility
OP
|
$1,051.74
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
108049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$347.08 |
| Max. Negotiated Rate |
$978.12 |
| Rate for Payer: Aetna Commercial |
$887.67
|
| Rate for Payer: Aetna Medicare |
$347.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$347.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$604.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$657.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$399.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$381.78
|
| Rate for Payer: Cash Price |
$652.08
|
| Rate for Payer: Centivo All Commercial |
$536.39
|
| Rate for Payer: Cigna All Commercial |
$907.66
|
| Rate for Payer: CORVEL All Commercial |
$978.12
|
| Rate for Payer: Coventry All Commercial |
$925.53
|
| Rate for Payer: Encore All Commercial |
$968.13
|
| Rate for Payer: Frontpath All Commercial |
$967.60
|
| Rate for Payer: Humana ChoiceCare |
$908.39
|
| Rate for Payer: Humana Medicare |
$536.39
|
| Rate for Payer: Lucent All Commercial |
$536.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$946.57
|
| Rate for Payer: PHCS All Commercial |
$788.81
|
| Rate for Payer: PHP All Commercial |
$797.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$410.18
|
| Rate for Payer: Sagamore Health Network All Products |
$811.95
|
| Rate for Payer: Signature Care EPO |
$872.95
|
| Rate for Payer: Signature Care PPO |
$925.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$893.98
|
| Rate for Payer: United Healthcare Commercial |
$828.77
|
| Rate for Payer: United Healthcare Medicare |
$347.08
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG
|
Facility
IP
|
$1,051.74
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
108049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$788.81 |
| Max. Negotiated Rate |
$978.12 |
| Rate for Payer: Aetna Commercial |
$908.71
|
| Rate for Payer: Cash Price |
$652.08
|
| Rate for Payer: Cigna All Commercial |
$907.66
|
| Rate for Payer: CORVEL All Commercial |
$978.12
|
| Rate for Payer: Coventry All Commercial |
$925.53
|
| Rate for Payer: Encore All Commercial |
$968.13
|
| Rate for Payer: Frontpath All Commercial |
$967.60
|
| Rate for Payer: Humana ChoiceCare |
$908.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$946.57
|
| Rate for Payer: PHCS All Commercial |
$788.81
|
| Rate for Payer: PHP All Commercial |
$797.64
|
| Rate for Payer: Sagamore Health Network All Products |
$811.95
|
| Rate for Payer: Signature Care EPO |
$872.95
|
| Rate for Payer: Signature Care PPO |
$925.53
|
| Rate for Payer: United Healthcare Commercial |
$828.77
|
|
|
PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 ML(600K/600K) IM SYRG
|
Facility
OP
|
$1,047.91
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
108051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$345.81 |
| Max. Negotiated Rate |
$974.56 |
| Rate for Payer: Aetna Commercial |
$884.44
|
| Rate for Payer: Aetna Medicare |
$345.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$345.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$601.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$655.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$397.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$380.39
|
| Rate for Payer: Cash Price |
$649.70
|
| Rate for Payer: Centivo All Commercial |
$534.43
|
| Rate for Payer: Cigna All Commercial |
$904.35
|
| Rate for Payer: CORVEL All Commercial |
$974.56
|
| Rate for Payer: Coventry All Commercial |
$922.16
|
| Rate for Payer: Encore All Commercial |
$964.60
|
| Rate for Payer: Frontpath All Commercial |
$964.08
|
| Rate for Payer: Humana ChoiceCare |
$905.08
|
| Rate for Payer: Humana Medicare |
$534.43
|
| Rate for Payer: Lucent All Commercial |
$534.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$943.12
|
| Rate for Payer: PHCS All Commercial |
$785.93
|
| Rate for Payer: PHP All Commercial |
$794.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$408.68
|
| Rate for Payer: Sagamore Health Network All Products |
$808.99
|
| Rate for Payer: Signature Care EPO |
$869.77
|
| Rate for Payer: Signature Care PPO |
$922.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$890.72
|
| Rate for Payer: United Healthcare Commercial |
$825.75
|
| Rate for Payer: United Healthcare Medicare |
$345.81
|
|
|
PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 ML(600K/600K) IM SYRG
|
Facility
IP
|
$1,047.91
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
108051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$785.93 |
| Max. Negotiated Rate |
$974.56 |
| Rate for Payer: Aetna Commercial |
$905.39
|
| Rate for Payer: Cash Price |
$649.70
|
| Rate for Payer: Cigna All Commercial |
$904.35
|
| Rate for Payer: CORVEL All Commercial |
$974.56
|
| Rate for Payer: Coventry All Commercial |
$922.16
|
| Rate for Payer: Encore All Commercial |
$964.60
|
| Rate for Payer: Frontpath All Commercial |
$964.08
|
| Rate for Payer: Humana ChoiceCare |
$905.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$943.12
|
| Rate for Payer: PHCS All Commercial |
$785.93
|
| Rate for Payer: PHP All Commercial |
$794.73
|
| Rate for Payer: Sagamore Health Network All Products |
$808.99
|
| Rate for Payer: Signature Care EPO |
$869.77
|
| Rate for Payer: Signature Care PPO |
$922.16
|
| Rate for Payer: United Healthcare Commercial |
$825.75
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNITS INJ SOLR
|
Facility
IP
|
$181.02
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.76 |
| Max. Negotiated Rate |
$168.35 |
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Cash Price |
$112.23
|
| Rate for Payer: Cigna All Commercial |
$156.22
|
| Rate for Payer: CORVEL All Commercial |
$168.35
|
| Rate for Payer: Coventry All Commercial |
$159.30
|
| Rate for Payer: Encore All Commercial |
$166.63
|
| Rate for Payer: Frontpath All Commercial |
$166.54
|
| Rate for Payer: Humana ChoiceCare |
$156.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$162.92
|
| Rate for Payer: PHCS All Commercial |
$135.76
|
| Rate for Payer: PHP All Commercial |
$137.29
|
| Rate for Payer: Sagamore Health Network All Products |
$139.75
|
| Rate for Payer: Signature Care EPO |
$150.25
|
| Rate for Payer: Signature Care PPO |
$159.30
|
| Rate for Payer: United Healthcare Commercial |
$142.64
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNITS INJ SOLR
|
Facility
OP
|
$181.02
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.74 |
| Max. Negotiated Rate |
$168.35 |
| Rate for Payer: Aetna Commercial |
$152.78
|
| Rate for Payer: Aetna Medicare |
$59.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$103.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$113.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.71
|
| Rate for Payer: Cash Price |
$112.23
|
| Rate for Payer: Centivo All Commercial |
$92.32
|
| Rate for Payer: Cigna All Commercial |
$156.22
|
| Rate for Payer: CORVEL All Commercial |
$168.35
|
| Rate for Payer: Coventry All Commercial |
$159.30
|
| Rate for Payer: Encore All Commercial |
$166.63
|
| Rate for Payer: Frontpath All Commercial |
$166.54
|
| Rate for Payer: Humana ChoiceCare |
$156.35
|
| Rate for Payer: Humana Medicare |
$92.32
|
| Rate for Payer: Lucent All Commercial |
$92.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$162.92
|
| Rate for Payer: PHCS All Commercial |
$135.76
|
| Rate for Payer: PHP All Commercial |
$137.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$70.60
|
| Rate for Payer: Sagamore Health Network All Products |
$139.75
|
| Rate for Payer: Signature Care EPO |
$150.25
|
| Rate for Payer: Signature Care PPO |
$159.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$153.87
|
| Rate for Payer: United Healthcare Commercial |
$142.64
|
| Rate for Payer: United Healthcare Medicare |
$59.74
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNITS INJ SOLR
|
Facility
IP
|
$29.20
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Aetna Commercial |
$25.23
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNITS INJ SOLR
|
Facility
OP
|
$29.20
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Aetna Commercial |
$24.65
|
| Rate for Payer: Aetna Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.60
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Centivo All Commercial |
$14.89
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Humana Medicare |
$14.89
|
| Rate for Payer: Lucent All Commercial |
$14.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.39
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
|
|
PENICILLIN G POT IN DEXTROSE 3 MILLION UNIT/50 ML IV PGBK
|
Facility
IP
|
$79.80
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
15960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.85 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$68.95
|
| Rate for Payer: Cash Price |
$49.48
|
| Rate for Payer: Cigna All Commercial |
$68.87
|
| Rate for Payer: CORVEL All Commercial |
$74.21
|
| Rate for Payer: Coventry All Commercial |
$70.22
|
| Rate for Payer: Encore All Commercial |
$73.46
|
| Rate for Payer: Frontpath All Commercial |
$73.42
|
| Rate for Payer: Humana ChoiceCare |
$68.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.82
|
| Rate for Payer: PHCS All Commercial |
$59.85
|
| Rate for Payer: PHP All Commercial |
$60.52
|
| Rate for Payer: Sagamore Health Network All Products |
$61.61
|
| Rate for Payer: Signature Care EPO |
$66.23
|
| Rate for Payer: Signature Care PPO |
$70.22
|
| Rate for Payer: United Healthcare Commercial |
$62.88
|
|
|
PENICILLIN G POT IN DEXTROSE 3 MILLION UNIT/50 ML IV PGBK
|
Facility
OP
|
$79.80
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
15960
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.33 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$67.35
|
| Rate for Payer: Aetna Medicare |
$26.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$45.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.97
|
| Rate for Payer: Cash Price |
$49.48
|
| Rate for Payer: Centivo All Commercial |
$40.70
|
| Rate for Payer: Cigna All Commercial |
$68.87
|
| Rate for Payer: CORVEL All Commercial |
$74.21
|
| Rate for Payer: Coventry All Commercial |
$70.22
|
| Rate for Payer: Encore All Commercial |
$73.46
|
| Rate for Payer: Frontpath All Commercial |
$73.42
|
| Rate for Payer: Humana ChoiceCare |
$68.92
|
| Rate for Payer: Humana Medicare |
$40.70
|
| Rate for Payer: Lucent All Commercial |
$40.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.82
|
| Rate for Payer: PHCS All Commercial |
$59.85
|
| Rate for Payer: PHP All Commercial |
$60.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.12
|
| Rate for Payer: Sagamore Health Network All Products |
$61.61
|
| Rate for Payer: Signature Care EPO |
$66.23
|
| Rate for Payer: Signature Care PPO |
$70.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.83
|
| Rate for Payer: United Healthcare Commercial |
$62.88
|
| Rate for Payer: United Healthcare Medicare |
$26.33
|
|
|
PENICILLIN SKIN TEST (CAMERON)
|
Facility
OP
|
$29.20
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
14010006086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$24.65
|
| Rate for Payer: Aetna Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.60
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Centivo All Commercial |
$14.89
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Humana Medicare |
$14.89
|
| Rate for Payer: Lucent All Commercial |
$14.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.39
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
|
|
PENICILLIN SKIN TEST (CAMERON)
|
Facility
IP
|
$29.20
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
14010006086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Aetna Commercial |
$25.23
|
| Rate for Payer: Cash Price |
$18.11
|
| Rate for Payer: Cigna All Commercial |
$25.20
|
| Rate for Payer: CORVEL All Commercial |
$27.16
|
| Rate for Payer: Coventry All Commercial |
$25.70
|
| Rate for Payer: Encore All Commercial |
$26.88
|
| Rate for Payer: Frontpath All Commercial |
$26.87
|
| Rate for Payer: Humana ChoiceCare |
$25.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.28
|
| Rate for Payer: PHCS All Commercial |
$21.90
|
| Rate for Payer: PHP All Commercial |
$22.15
|
| Rate for Payer: Sagamore Health Network All Products |
$22.55
|
| Rate for Payer: Signature Care EPO |
$24.24
|
| Rate for Payer: Signature Care PPO |
$25.70
|
| Rate for Payer: United Healthcare Commercial |
$23.01
|
|
|
PENICILLIN V POTASSIUM 250 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
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
|
|
|
PENTAMIDINE 300 MG INHL SOLR
|
Facility
OP
|
$532.20
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$494.95 |
| Rate for Payer: Aetna Commercial |
$449.18
|
| Rate for Payer: Aetna Medicare |
$175.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$175.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$305.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$332.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$94.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$201.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$193.19
|
| Rate for Payer: Cash Price |
$329.96
|
| Rate for Payer: Cash Price |
$329.96
|
| Rate for Payer: Centivo All Commercial |
$271.42
|
| Rate for Payer: Cigna All Commercial |
$459.29
|
| Rate for Payer: CORVEL All Commercial |
$494.95
|
| Rate for Payer: Coventry All Commercial |
$468.34
|
| Rate for Payer: Encore All Commercial |
$489.89
|
| Rate for Payer: Frontpath All Commercial |
$489.62
|
| Rate for Payer: Humana ChoiceCare |
$459.66
|
| Rate for Payer: Humana Medicare |
$271.42
|
| Rate for Payer: Lucent All Commercial |
$271.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.98
|
| Rate for Payer: Managed Health Services Medicaid |
$94.50
|
| Rate for Payer: MDWise Medicaid |
$94.50
|
| Rate for Payer: PHCS All Commercial |
$399.15
|
| Rate for Payer: PHP All Commercial |
$403.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$207.56
|
| Rate for Payer: Sagamore Health Network All Products |
$410.86
|
| Rate for Payer: Signature Care EPO |
$441.73
|
| Rate for Payer: Signature Care PPO |
$468.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$452.37
|
| Rate for Payer: United Healthcare Commercial |
$419.37
|
| Rate for Payer: United Healthcare Medicare |
$175.63
|
|
|
PENTAMIDINE 300 MG INHL SOLR
|
Facility
IP
|
$532.20
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$399.15 |
| Max. Negotiated Rate |
$494.95 |
| Rate for Payer: Aetna Commercial |
$459.82
|
| Rate for Payer: Cash Price |
$329.96
|
| Rate for Payer: Cigna All Commercial |
$459.29
|
| Rate for Payer: CORVEL All Commercial |
$494.95
|
| Rate for Payer: Coventry All Commercial |
$468.34
|
| Rate for Payer: Encore All Commercial |
$489.89
|
| Rate for Payer: Frontpath All Commercial |
$489.62
|
| Rate for Payer: Humana ChoiceCare |
$459.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.98
|
| Rate for Payer: PHCS All Commercial |
$399.15
|
| Rate for Payer: PHP All Commercial |
$403.62
|
| Rate for Payer: Sagamore Health Network All Products |
$410.86
|
| Rate for Payer: Signature Care EPO |
$441.73
|
| Rate for Payer: Signature Care PPO |
$468.34
|
| Rate for Payer: United Healthcare Commercial |
$419.37
|
|
|
PENTOXIFYLLINE 400 MG ORAL TBER
|
Facility
IP
|
$1.35
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.19
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| 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 |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
|
|
PENTOXIFYLLINE 400 MG ORAL TBER
|
Facility
OP
|
$1.35
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.14
|
| Rate for Payer: Aetna Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.78
|
| 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 |
$0.84
|
| Rate for Payer: Centivo All Commercial |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$1.17
|
| Rate for Payer: CORVEL All Commercial |
$1.26
|
| Rate for Payer: Coventry All Commercial |
$1.19
|
| Rate for Payer: Encore All Commercial |
$1.24
|
| Rate for Payer: Frontpath All Commercial |
$1.24
|
| Rate for Payer: Humana ChoiceCare |
$1.17
|
| Rate for Payer: Humana Medicare |
$0.69
|
| Rate for Payer: Lucent All Commercial |
$0.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.22
|
| 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 |
$0.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1.04
|
| Rate for Payer: Signature Care EPO |
$1.12
|
| Rate for Payer: Signature Care PPO |
$1.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
|
|
Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 25606
|
| Hospital Charge Code |
CPT-25606
|
|
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
|
|
|
Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 24538
|
| Hospital Charge Code |
CPT-24538
|
|
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
|
|
|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP
|
Facility
OP
|
$781.25
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.81 |
| Max. Negotiated Rate |
$726.56 |
| Rate for Payer: Aetna Commercial |
$659.38
|
| Rate for Payer: Aetna Medicare |
$257.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$257.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$448.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$488.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$296.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$283.59
|
| Rate for Payer: Cash Price |
$484.38
|
| Rate for Payer: Centivo All Commercial |
$398.44
|
| Rate for Payer: Cigna All Commercial |
$674.22
|
| Rate for Payer: CORVEL All Commercial |
$726.56
|
| Rate for Payer: Coventry All Commercial |
$687.50
|
| Rate for Payer: Encore All Commercial |
$719.14
|
| Rate for Payer: Frontpath All Commercial |
$718.75
|
| Rate for Payer: Humana ChoiceCare |
$674.77
|
| Rate for Payer: Humana Medicare |
$398.44
|
| Rate for Payer: Lucent All Commercial |
$398.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$703.12
|
| Rate for Payer: PHCS All Commercial |
$585.94
|
| Rate for Payer: PHP All Commercial |
$592.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$304.69
|
| Rate for Payer: Sagamore Health Network All Products |
$603.12
|
| Rate for Payer: Signature Care EPO |
$648.44
|
| Rate for Payer: Signature Care PPO |
$687.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$664.06
|
| Rate for Payer: United Healthcare Commercial |
$615.62
|
| Rate for Payer: United Healthcare Medicare |
$257.81
|
|
