|
PHMB 0.1% (PURAPLY AM) 6 X 9 WOUND MATRIX
|
Facility
|
OP
|
$20,520.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$19,083.60 |
| Rate for Payer: Aetna Commercial |
$17,318.88
|
| Rate for Payer: Aetna Medicare |
$6,771.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,771.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11,784.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,827.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,787.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7,448.76
|
| Rate for Payer: Cash Price |
$12,722.40
|
| Rate for Payer: Cash Price |
$12,722.40
|
| Rate for Payer: Centivo All Commercial |
$10,465.20
|
| Rate for Payer: Cigna All Commercial |
$17,708.76
|
| Rate for Payer: CORVEL All Commercial |
$19,083.60
|
| Rate for Payer: Coventry All Commercial |
$18,057.60
|
| Rate for Payer: Encore All Commercial |
$18,888.66
|
| Rate for Payer: Frontpath All Commercial |
$18,878.40
|
| Rate for Payer: Humana ChoiceCare |
$17,723.12
|
| Rate for Payer: Humana Medicare |
$10,465.20
|
| Rate for Payer: Lucent All Commercial |
$10,465.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,468.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$15,390.00
|
| Rate for Payer: PHP All Commercial |
$15,562.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,002.80
|
| Rate for Payer: Sagamore Health Network All Products |
$15,841.44
|
| Rate for Payer: Signature Care EPO |
$17,031.60
|
| Rate for Payer: Signature Care PPO |
$18,057.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,442.00
|
| Rate for Payer: United Healthcare Commercial |
$16,169.76
|
| Rate for Payer: United Healthcare Medicare |
$6,771.60
|
|
|
PHMB 0.1% (PURAPLY AM XT EF) 4.91 X 4.91 WOUND MATRIX
|
Facility
|
OP
|
$11,300.01
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$10,509.01 |
| Rate for Payer: Aetna Commercial |
$9,537.21
|
| Rate for Payer: Aetna Medicare |
$3,729.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,729.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,489.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,063.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,288.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,101.90
|
| Rate for Payer: Cash Price |
$7,006.00
|
| Rate for Payer: Cash Price |
$7,006.00
|
| Rate for Payer: Centivo All Commercial |
$5,763.00
|
| Rate for Payer: Cigna All Commercial |
$9,751.91
|
| Rate for Payer: CORVEL All Commercial |
$10,509.01
|
| Rate for Payer: Coventry All Commercial |
$9,944.01
|
| Rate for Payer: Encore All Commercial |
$10,401.66
|
| Rate for Payer: Frontpath All Commercial |
$10,396.01
|
| Rate for Payer: Humana ChoiceCare |
$9,759.82
|
| Rate for Payer: Humana Medicare |
$5,763.00
|
| Rate for Payer: Lucent All Commercial |
$5,763.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,170.01
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$8,475.01
|
| Rate for Payer: PHP All Commercial |
$8,569.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,407.00
|
| Rate for Payer: Sagamore Health Network All Products |
$8,723.61
|
| Rate for Payer: Signature Care EPO |
$9,379.01
|
| Rate for Payer: Signature Care PPO |
$9,944.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,605.01
|
| Rate for Payer: United Healthcare Commercial |
$8,904.41
|
| Rate for Payer: United Healthcare Medicare |
$3,729.00
|
|
|
PHMB 0.1% (PURAPLY AM XT EF) 4.91 X 4.91 WOUND MATRIX
|
Facility
|
IP
|
$11,300.01
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800596
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,475.01 |
| Max. Negotiated Rate |
$10,509.01 |
| Rate for Payer: Aetna Commercial |
$9,763.21
|
| Rate for Payer: Cash Price |
$7,006.00
|
| Rate for Payer: Cigna All Commercial |
$9,751.91
|
| Rate for Payer: CORVEL All Commercial |
$10,509.01
|
| Rate for Payer: Coventry All Commercial |
$9,944.01
|
| Rate for Payer: Encore All Commercial |
$10,401.66
|
| Rate for Payer: Frontpath All Commercial |
$10,396.01
|
| Rate for Payer: Humana ChoiceCare |
$9,759.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,170.01
|
| Rate for Payer: PHCS All Commercial |
$8,475.01
|
| Rate for Payer: PHP All Commercial |
$8,569.93
|
| Rate for Payer: Sagamore Health Network All Products |
$8,723.61
|
| Rate for Payer: Signature Care EPO |
$9,379.01
|
| Rate for Payer: Signature Care PPO |
$9,944.01
|
| Rate for Payer: United Healthcare Commercial |
$8,904.41
|
|
|
PHMB 0.1% (PURAPLY MZ) 1000 MG WOUND MATRIX
|
Facility
|
IP
|
$9,260.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,945.00 |
| Max. Negotiated Rate |
$8,611.80 |
| Rate for Payer: Aetna Commercial |
$8,000.64
|
| Rate for Payer: Cash Price |
$5,741.20
|
| Rate for Payer: Cigna All Commercial |
$7,991.38
|
| Rate for Payer: CORVEL All Commercial |
$8,611.80
|
| Rate for Payer: Coventry All Commercial |
$8,148.80
|
| Rate for Payer: Encore All Commercial |
$8,523.83
|
| Rate for Payer: Frontpath All Commercial |
$8,519.20
|
| Rate for Payer: Humana ChoiceCare |
$7,997.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,334.00
|
| Rate for Payer: PHCS All Commercial |
$6,945.00
|
| Rate for Payer: PHP All Commercial |
$7,022.78
|
| Rate for Payer: Sagamore Health Network All Products |
$7,148.72
|
| Rate for Payer: Signature Care EPO |
$7,685.80
|
| Rate for Payer: Signature Care PPO |
$8,148.80
|
| Rate for Payer: United Healthcare Commercial |
$7,296.88
|
|
|
PHMB 0.1% (PURAPLY MZ) 1000 MG WOUND MATRIX
|
Facility
|
OP
|
$9,260.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$8,611.80 |
| Rate for Payer: Aetna Commercial |
$7,815.44
|
| Rate for Payer: Aetna Medicare |
$3,055.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,055.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,318.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,788.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,514.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,361.38
|
| Rate for Payer: Cash Price |
$5,741.20
|
| Rate for Payer: Cash Price |
$5,741.20
|
| Rate for Payer: Centivo All Commercial |
$4,722.60
|
| Rate for Payer: Cigna All Commercial |
$7,991.38
|
| Rate for Payer: CORVEL All Commercial |
$8,611.80
|
| Rate for Payer: Coventry All Commercial |
$8,148.80
|
| Rate for Payer: Encore All Commercial |
$8,523.83
|
| Rate for Payer: Frontpath All Commercial |
$8,519.20
|
| Rate for Payer: Humana ChoiceCare |
$7,997.86
|
| Rate for Payer: Humana Medicare |
$4,722.60
|
| Rate for Payer: Lucent All Commercial |
$4,722.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,334.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$6,945.00
|
| Rate for Payer: PHP All Commercial |
$7,022.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,611.40
|
| Rate for Payer: Sagamore Health Network All Products |
$7,148.72
|
| Rate for Payer: Signature Care EPO |
$7,685.80
|
| Rate for Payer: Signature Care PPO |
$8,148.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,871.00
|
| Rate for Payer: United Healthcare Commercial |
$7,296.88
|
| Rate for Payer: United Healthcare Medicare |
$3,055.80
|
|
|
PHMB 0.1% (PURAPLY MZ) 100 MG WOUND MATRIX
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$948.60 |
| Rate for Payer: Aetna Commercial |
$860.88
|
| Rate for Payer: Aetna Medicare |
$336.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$336.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$585.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$637.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$387.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$370.26
|
| Rate for Payer: Cash Price |
$632.40
|
| Rate for Payer: Cash Price |
$632.40
|
| Rate for Payer: Centivo All Commercial |
$520.20
|
| Rate for Payer: Cigna All Commercial |
$880.26
|
| Rate for Payer: CORVEL All Commercial |
$948.60
|
| Rate for Payer: Coventry All Commercial |
$897.60
|
| Rate for Payer: Encore All Commercial |
$938.91
|
| Rate for Payer: Frontpath All Commercial |
$938.40
|
| Rate for Payer: Humana ChoiceCare |
$880.97
|
| Rate for Payer: Humana Medicare |
$520.20
|
| Rate for Payer: Lucent All Commercial |
$520.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$918.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$765.00
|
| Rate for Payer: PHP All Commercial |
$773.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$397.80
|
| Rate for Payer: Sagamore Health Network All Products |
$787.44
|
| Rate for Payer: Signature Care EPO |
$846.60
|
| Rate for Payer: Signature Care PPO |
$897.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$867.00
|
| Rate for Payer: United Healthcare Commercial |
$803.76
|
| Rate for Payer: United Healthcare Medicare |
$336.60
|
|
|
PHMB 0.1% (PURAPLY MZ) 100 MG WOUND MATRIX
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$948.60 |
| Rate for Payer: Aetna Commercial |
$881.28
|
| Rate for Payer: Cash Price |
$632.40
|
| Rate for Payer: Cigna All Commercial |
$880.26
|
| Rate for Payer: CORVEL All Commercial |
$948.60
|
| Rate for Payer: Coventry All Commercial |
$897.60
|
| Rate for Payer: Encore All Commercial |
$938.91
|
| Rate for Payer: Frontpath All Commercial |
$938.40
|
| Rate for Payer: Humana ChoiceCare |
$880.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$918.00
|
| Rate for Payer: PHCS All Commercial |
$765.00
|
| Rate for Payer: PHP All Commercial |
$773.57
|
| Rate for Payer: Sagamore Health Network All Products |
$787.44
|
| Rate for Payer: Signature Care EPO |
$846.60
|
| Rate for Payer: Signature Care PPO |
$897.60
|
| Rate for Payer: United Healthcare Commercial |
$803.76
|
|
|
PHMB 0.1% (PURAPLY MZ) 500 MG WOUND MATRIX
|
Facility
|
IP
|
$4,640.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800598
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,480.00 |
| Max. Negotiated Rate |
$4,315.20 |
| Rate for Payer: Aetna Commercial |
$4,008.96
|
| Rate for Payer: Cash Price |
$2,876.80
|
| Rate for Payer: Cigna All Commercial |
$4,004.32
|
| Rate for Payer: CORVEL All Commercial |
$4,315.20
|
| Rate for Payer: Coventry All Commercial |
$4,083.20
|
| Rate for Payer: Encore All Commercial |
$4,271.12
|
| Rate for Payer: Frontpath All Commercial |
$4,268.80
|
| Rate for Payer: Humana ChoiceCare |
$4,007.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,176.00
|
| Rate for Payer: PHCS All Commercial |
$3,480.00
|
| Rate for Payer: PHP All Commercial |
$3,518.98
|
| Rate for Payer: Sagamore Health Network All Products |
$3,582.08
|
| Rate for Payer: Signature Care EPO |
$3,851.20
|
| Rate for Payer: Signature Care PPO |
$4,083.20
|
| Rate for Payer: United Healthcare Commercial |
$3,656.32
|
|
|
PHMB 0.1% (PURAPLY MZ) 500 MG WOUND MATRIX
|
Facility
|
OP
|
$4,640.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$4,315.20 |
| Rate for Payer: Aetna Commercial |
$3,916.16
|
| Rate for Payer: Aetna Medicare |
$1,531.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,531.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,664.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,900.46
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,760.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,684.32
|
| Rate for Payer: Cash Price |
$2,876.80
|
| Rate for Payer: Cash Price |
$2,876.80
|
| Rate for Payer: Centivo All Commercial |
$2,366.40
|
| Rate for Payer: Cigna All Commercial |
$4,004.32
|
| Rate for Payer: CORVEL All Commercial |
$4,315.20
|
| Rate for Payer: Coventry All Commercial |
$4,083.20
|
| Rate for Payer: Encore All Commercial |
$4,271.12
|
| Rate for Payer: Frontpath All Commercial |
$4,268.80
|
| Rate for Payer: Humana ChoiceCare |
$4,007.57
|
| Rate for Payer: Humana Medicare |
$2,366.40
|
| Rate for Payer: Lucent All Commercial |
$2,366.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,176.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$3,480.00
|
| Rate for Payer: PHP All Commercial |
$3,518.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,809.60
|
| Rate for Payer: Sagamore Health Network All Products |
$3,582.08
|
| Rate for Payer: Signature Care EPO |
$3,851.20
|
| Rate for Payer: Signature Care PPO |
$4,083.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,944.00
|
| Rate for Payer: United Healthcare Commercial |
$3,656.32
|
| Rate for Payer: United Healthcare Medicare |
$1,531.20
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$299.36
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.79 |
| Max. Negotiated Rate |
$278.41 |
| Rate for Payer: Aetna Commercial |
$252.66
|
| Rate for Payer: Aetna Medicare |
$98.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$98.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$171.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$187.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$113.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$108.67
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Centivo All Commercial |
$152.67
|
| Rate for Payer: Cigna All Commercial |
$258.35
|
| Rate for Payer: CORVEL All Commercial |
$278.41
|
| Rate for Payer: Coventry All Commercial |
$263.44
|
| Rate for Payer: Encore All Commercial |
$275.56
|
| Rate for Payer: Frontpath All Commercial |
$275.41
|
| Rate for Payer: Humana ChoiceCare |
$258.56
|
| Rate for Payer: Humana Medicare |
$152.67
|
| Rate for Payer: Lucent All Commercial |
$152.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$269.43
|
| Rate for Payer: PHCS All Commercial |
$224.52
|
| Rate for Payer: PHP All Commercial |
$227.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$116.75
|
| Rate for Payer: Sagamore Health Network All Products |
$231.11
|
| Rate for Payer: Signature Care EPO |
$248.47
|
| Rate for Payer: Signature Care PPO |
$263.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$254.46
|
| Rate for Payer: United Healthcare Commercial |
$235.90
|
| Rate for Payer: United Healthcare Medicare |
$98.79
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$299.36
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$224.52 |
| Max. Negotiated Rate |
$278.41 |
| Rate for Payer: Aetna Commercial |
$258.65
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Cigna All Commercial |
$258.35
|
| Rate for Payer: CORVEL All Commercial |
$278.41
|
| Rate for Payer: Coventry All Commercial |
$263.44
|
| Rate for Payer: Encore All Commercial |
$275.56
|
| Rate for Payer: Frontpath All Commercial |
$275.41
|
| Rate for Payer: Humana ChoiceCare |
$258.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$269.43
|
| Rate for Payer: PHCS All Commercial |
$224.52
|
| Rate for Payer: PHP All Commercial |
$227.04
|
| Rate for Payer: Sagamore Health Network All Products |
$231.11
|
| Rate for Payer: Signature Care EPO |
$248.47
|
| Rate for Payer: Signature Care PPO |
$263.44
|
| Rate for Payer: United Healthcare Commercial |
$235.90
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$158.89
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
6271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.16 |
| Max. Negotiated Rate |
$147.76 |
| Rate for Payer: Aetna Commercial |
$137.28
|
| Rate for Payer: Cash Price |
$98.51
|
| Rate for Payer: Cigna All Commercial |
$137.12
|
| Rate for Payer: CORVEL All Commercial |
$147.76
|
| Rate for Payer: Coventry All Commercial |
$139.82
|
| Rate for Payer: Encore All Commercial |
$146.25
|
| Rate for Payer: Frontpath All Commercial |
$146.18
|
| Rate for Payer: Humana ChoiceCare |
$137.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.00
|
| Rate for Payer: PHCS All Commercial |
$119.16
|
| Rate for Payer: PHP All Commercial |
$120.50
|
| Rate for Payer: Sagamore Health Network All Products |
$122.66
|
| Rate for Payer: Signature Care EPO |
$131.88
|
| Rate for Payer: Signature Care PPO |
$139.82
|
| Rate for Payer: United Healthcare Commercial |
$125.20
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$158.89
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
6271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$147.76 |
| Rate for Payer: Aetna Commercial |
$134.10
|
| Rate for Payer: Aetna Medicare |
$52.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$91.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$99.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.68
|
| Rate for Payer: Cash Price |
$98.51
|
| Rate for Payer: Centivo All Commercial |
$81.03
|
| Rate for Payer: Cigna All Commercial |
$137.12
|
| Rate for Payer: CORVEL All Commercial |
$147.76
|
| Rate for Payer: Coventry All Commercial |
$139.82
|
| Rate for Payer: Encore All Commercial |
$146.25
|
| Rate for Payer: Frontpath All Commercial |
$146.18
|
| Rate for Payer: Humana ChoiceCare |
$137.23
|
| Rate for Payer: Humana Medicare |
$81.03
|
| Rate for Payer: Lucent All Commercial |
$81.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.00
|
| Rate for Payer: PHCS All Commercial |
$119.16
|
| Rate for Payer: PHP All Commercial |
$120.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.97
|
| Rate for Payer: Sagamore Health Network All Products |
$122.66
|
| Rate for Payer: Signature Care EPO |
$131.88
|
| Rate for Payer: Signature Care PPO |
$139.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$135.05
|
| Rate for Payer: United Healthcare Commercial |
$125.20
|
| Rate for Payer: United Healthcare Medicare |
$52.43
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML IV SOLN
|
Facility
|
IP
|
$17,246.32
|
|
|
Service Code
|
HCPCS A9595
|
| Hospital Charge Code |
195262
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$12,934.74 |
| Max. Negotiated Rate |
$16,039.08 |
| Rate for Payer: Aetna Commercial |
$14,900.82
|
| Rate for Payer: Cash Price |
$10,692.72
|
| Rate for Payer: Cigna All Commercial |
$14,883.57
|
| Rate for Payer: CORVEL All Commercial |
$16,039.08
|
| Rate for Payer: Coventry All Commercial |
$15,176.76
|
| Rate for Payer: Encore All Commercial |
$15,875.24
|
| Rate for Payer: Frontpath All Commercial |
$15,866.61
|
| Rate for Payer: Humana ChoiceCare |
$14,895.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,521.69
|
| Rate for Payer: PHCS All Commercial |
$12,934.74
|
| Rate for Payer: PHP All Commercial |
$13,079.61
|
| Rate for Payer: Sagamore Health Network All Products |
$13,314.16
|
| Rate for Payer: Signature Care EPO |
$14,314.45
|
| Rate for Payer: Signature Care PPO |
$15,176.76
|
| Rate for Payer: United Healthcare Commercial |
$13,590.10
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML IV SOLN
|
Facility
|
OP
|
$17,246.32
|
|
|
Service Code
|
HCPCS A9595
|
| Hospital Charge Code |
195262
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$574.88 |
| Max. Negotiated Rate |
$16,039.08 |
| Rate for Payer: Aetna Commercial |
$14,555.89
|
| Rate for Payer: Aetna Medicare |
$5,691.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,691.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,904.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,780.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$574.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,544.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,260.41
|
| Rate for Payer: Cash Price |
$10,692.72
|
| Rate for Payer: Cash Price |
$10,692.72
|
| Rate for Payer: Centivo All Commercial |
$8,795.62
|
| Rate for Payer: Cigna All Commercial |
$14,883.57
|
| Rate for Payer: CORVEL All Commercial |
$16,039.08
|
| Rate for Payer: Coventry All Commercial |
$15,176.76
|
| Rate for Payer: Encore All Commercial |
$15,875.24
|
| Rate for Payer: Frontpath All Commercial |
$15,866.61
|
| Rate for Payer: Humana ChoiceCare |
$14,895.65
|
| Rate for Payer: Humana Medicare |
$8,795.62
|
| Rate for Payer: Lucent All Commercial |
$8,795.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,521.69
|
| Rate for Payer: Managed Health Services Medicaid |
$574.88
|
| Rate for Payer: MDWise Medicaid |
$574.88
|
| Rate for Payer: PHCS All Commercial |
$12,934.74
|
| Rate for Payer: PHP All Commercial |
$13,079.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,726.06
|
| Rate for Payer: Sagamore Health Network All Products |
$13,314.16
|
| Rate for Payer: Signature Care EPO |
$14,314.45
|
| Rate for Payer: Signature Care PPO |
$15,176.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,659.37
|
| Rate for Payer: United Healthcare Commercial |
$13,590.10
|
| Rate for Payer: United Healthcare Medicare |
$5,691.29
|
|
|
PILOCARPINE HCL 2 % OPHT DROP
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$255.75 |
| Rate for Payer: Aetna Commercial |
$232.10
|
| Rate for Payer: Aetna Medicare |
$90.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$90.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$157.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$171.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.82
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Centivo All Commercial |
$140.25
|
| Rate for Payer: Cigna All Commercial |
$237.32
|
| Rate for Payer: CORVEL All Commercial |
$255.75
|
| Rate for Payer: Coventry All Commercial |
$242.00
|
| Rate for Payer: Encore All Commercial |
$253.13
|
| Rate for Payer: Frontpath All Commercial |
$253.00
|
| Rate for Payer: Humana ChoiceCare |
$237.51
|
| Rate for Payer: Humana Medicare |
$140.25
|
| Rate for Payer: Lucent All Commercial |
$140.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$247.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$206.25
|
| Rate for Payer: PHP All Commercial |
$208.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$107.25
|
| Rate for Payer: Sagamore Health Network All Products |
$212.30
|
| Rate for Payer: Signature Care EPO |
$228.25
|
| Rate for Payer: Signature Care PPO |
$242.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$233.75
|
| Rate for Payer: United Healthcare Commercial |
$216.70
|
| Rate for Payer: United Healthcare Medicare |
$90.75
|
|
|
PILOCARPINE HCL 2 % OPHT DROP
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$255.75 |
| Rate for Payer: Aetna Commercial |
$237.60
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cigna All Commercial |
$237.32
|
| Rate for Payer: CORVEL All Commercial |
$255.75
|
| Rate for Payer: Coventry All Commercial |
$242.00
|
| Rate for Payer: Encore All Commercial |
$253.13
|
| Rate for Payer: Frontpath All Commercial |
$253.00
|
| Rate for Payer: Humana ChoiceCare |
$237.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$247.50
|
| Rate for Payer: PHCS All Commercial |
$206.25
|
| Rate for Payer: PHP All Commercial |
$208.56
|
| Rate for Payer: Sagamore Health Network All Products |
$212.30
|
| Rate for Payer: Signature Care EPO |
$228.25
|
| Rate for Payer: Signature Care PPO |
$242.00
|
| Rate for Payer: United Healthcare Commercial |
$216.70
|
|
|
PIOGLITAZONE 15 MG ORAL TAB
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
NDC 60687039101
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$5.76
|
| Rate for Payer: Aetna Medicare |
$2.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Centivo All Commercial |
$3.48
|
| Rate for Payer: Cigna All Commercial |
$5.89
|
| Rate for Payer: CORVEL All Commercial |
$6.35
|
| Rate for Payer: Coventry All Commercial |
$6.01
|
| Rate for Payer: Encore All Commercial |
$6.28
|
| Rate for Payer: Frontpath All Commercial |
$6.28
|
| Rate for Payer: Humana ChoiceCare |
$5.89
|
| Rate for Payer: Humana Medicare |
$3.48
|
| Rate for Payer: Lucent All Commercial |
$3.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.14
|
| Rate for Payer: PHCS All Commercial |
$5.12
|
| Rate for Payer: PHP All Commercial |
$5.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.66
|
| Rate for Payer: Sagamore Health Network All Products |
$5.27
|
| Rate for Payer: Signature Care EPO |
$5.66
|
| Rate for Payer: Signature Care PPO |
$6.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.80
|
| Rate for Payer: United Healthcare Commercial |
$5.38
|
| Rate for Payer: United Healthcare Medicare |
$2.25
|
|
|
PIOGLITAZONE 15 MG ORAL TAB
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 60687039101
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$5.90
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna All Commercial |
$5.89
|
| Rate for Payer: CORVEL All Commercial |
$6.35
|
| Rate for Payer: Coventry All Commercial |
$6.01
|
| Rate for Payer: Encore All Commercial |
$6.28
|
| Rate for Payer: Frontpath All Commercial |
$6.28
|
| Rate for Payer: Humana ChoiceCare |
$5.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.14
|
| Rate for Payer: PHCS All Commercial |
$5.12
|
| Rate for Payer: PHP All Commercial |
$5.18
|
| Rate for Payer: Sagamore Health Network All Products |
$5.27
|
| Rate for Payer: Signature Care EPO |
$5.66
|
| Rate for Payer: Signature Care PPO |
$6.01
|
| Rate for Payer: United Healthcare Commercial |
$5.38
|
|
|
PIPERACILLIN-TAZOBACTAM 2.25 G IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18304
|
|
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
|
|
|
PIPERACILLIN-TAZOBACTAM 2.25 G IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18304
|
|
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
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18303
|
|
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
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18303
|
|
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
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 G IV SOLR
|
Facility
|
IP
|
$31.78
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna Commercial |
$27.46
|
| Rate for Payer: Cash Price |
$19.70
|
| Rate for Payer: Cigna All Commercial |
$27.43
|
| Rate for Payer: CORVEL All Commercial |
$29.56
|
| Rate for Payer: Coventry All Commercial |
$27.97
|
| Rate for Payer: Encore All Commercial |
$29.25
|
| Rate for Payer: Frontpath All Commercial |
$29.24
|
| Rate for Payer: Humana ChoiceCare |
$27.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.60
|
| Rate for Payer: PHCS All Commercial |
$23.84
|
| Rate for Payer: PHP All Commercial |
$24.10
|
| Rate for Payer: Sagamore Health Network All Products |
$24.53
|
| Rate for Payer: Signature Care EPO |
$26.38
|
| Rate for Payer: Signature Care PPO |
$27.97
|
| Rate for Payer: United Healthcare Commercial |
$25.04
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 G IV SOLR
|
Facility
|
OP
|
$31.78
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
18302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna Commercial |
$26.82
|
| Rate for Payer: Aetna Medicare |
$10.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.54
|
| Rate for Payer: Cash Price |
$19.70
|
| Rate for Payer: Centivo All Commercial |
$16.21
|
| Rate for Payer: Cigna All Commercial |
$27.43
|
| Rate for Payer: CORVEL All Commercial |
$29.56
|
| Rate for Payer: Coventry All Commercial |
$27.97
|
| Rate for Payer: Encore All Commercial |
$29.25
|
| Rate for Payer: Frontpath All Commercial |
$29.24
|
| Rate for Payer: Humana ChoiceCare |
$27.45
|
| Rate for Payer: Humana Medicare |
$16.21
|
| Rate for Payer: Lucent All Commercial |
$16.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.60
|
| Rate for Payer: PHCS All Commercial |
$23.84
|
| Rate for Payer: PHP All Commercial |
$24.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.39
|
| Rate for Payer: Sagamore Health Network All Products |
$24.53
|
| Rate for Payer: Signature Care EPO |
$26.38
|
| Rate for Payer: Signature Care PPO |
$27.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.01
|
| Rate for Payer: United Healthcare Commercial |
$25.04
|
| Rate for Payer: United Healthcare Medicare |
$10.49
|
|
