|
TECHNETIUM TC 99M OXIDRONATE KIT
|
Facility
OP
|
$315.70
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$104.18 |
| Max. Negotiated Rate |
$293.60 |
| Rate for Payer: Aetna Commercial |
$266.45
|
| Rate for Payer: Aetna Medicare |
$104.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$181.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$197.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$114.60
|
| Rate for Payer: Cash Price |
$195.73
|
| Rate for Payer: Centivo All Commercial |
$161.01
|
| Rate for Payer: Cigna All Commercial |
$272.45
|
| Rate for Payer: CORVEL All Commercial |
$293.60
|
| Rate for Payer: Coventry All Commercial |
$277.82
|
| Rate for Payer: Encore All Commercial |
$290.60
|
| Rate for Payer: Frontpath All Commercial |
$290.44
|
| Rate for Payer: Humana ChoiceCare |
$272.67
|
| Rate for Payer: Humana Medicare |
$161.01
|
| Rate for Payer: Lucent All Commercial |
$161.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$284.13
|
| Rate for Payer: PHCS All Commercial |
$236.78
|
| Rate for Payer: PHP All Commercial |
$239.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.12
|
| Rate for Payer: Sagamore Health Network All Products |
$243.72
|
| Rate for Payer: Signature Care EPO |
$262.03
|
| Rate for Payer: Signature Care PPO |
$277.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$268.34
|
| Rate for Payer: United Healthcare Commercial |
$248.77
|
| Rate for Payer: United Healthcare Medicare |
$104.18
|
|
|
TECHNETIUM TC 99M SULFER COLLOID FILTERED
|
Facility
IP
|
$1,007.60
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
162258
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$755.70 |
| Max. Negotiated Rate |
$937.07 |
| Rate for Payer: Aetna Commercial |
$870.57
|
| Rate for Payer: Cash Price |
$624.71
|
| Rate for Payer: Cigna All Commercial |
$869.56
|
| Rate for Payer: CORVEL All Commercial |
$937.07
|
| Rate for Payer: Coventry All Commercial |
$886.69
|
| Rate for Payer: Encore All Commercial |
$927.50
|
| Rate for Payer: Frontpath All Commercial |
$926.99
|
| Rate for Payer: Humana ChoiceCare |
$870.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.84
|
| Rate for Payer: PHCS All Commercial |
$755.70
|
| Rate for Payer: PHP All Commercial |
$764.16
|
| Rate for Payer: Sagamore Health Network All Products |
$777.87
|
| Rate for Payer: Signature Care EPO |
$836.31
|
| Rate for Payer: Signature Care PPO |
$886.69
|
| Rate for Payer: United Healthcare Commercial |
$793.99
|
|
|
TECHNETIUM TC 99M SULFER COLLOID FILTERED
|
Facility
OP
|
$1,007.60
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
162258
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$332.51 |
| Max. Negotiated Rate |
$937.07 |
| Rate for Payer: Aetna Commercial |
$850.41
|
| Rate for Payer: Aetna Medicare |
$332.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$332.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$578.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$629.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$382.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$365.76
|
| Rate for Payer: Cash Price |
$624.71
|
| Rate for Payer: Centivo All Commercial |
$513.88
|
| Rate for Payer: Cigna All Commercial |
$869.56
|
| Rate for Payer: CORVEL All Commercial |
$937.07
|
| Rate for Payer: Coventry All Commercial |
$886.69
|
| Rate for Payer: Encore All Commercial |
$927.50
|
| Rate for Payer: Frontpath All Commercial |
$926.99
|
| Rate for Payer: Humana ChoiceCare |
$870.26
|
| Rate for Payer: Humana Medicare |
$513.88
|
| Rate for Payer: Lucent All Commercial |
$513.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.84
|
| Rate for Payer: PHCS All Commercial |
$755.70
|
| Rate for Payer: PHP All Commercial |
$764.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$392.96
|
| Rate for Payer: Sagamore Health Network All Products |
$777.87
|
| Rate for Payer: Signature Care EPO |
$836.31
|
| Rate for Payer: Signature Care PPO |
$886.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$856.46
|
| Rate for Payer: United Healthcare Commercial |
$793.99
|
| Rate for Payer: United Healthcare Medicare |
$332.51
|
|
|
TECHNETIUM TC 99M TILMANOCEPT KIT
|
Facility
IP
|
$1,739.10
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4080800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,304.32 |
| Max. Negotiated Rate |
$1,617.36 |
| Rate for Payer: Aetna Commercial |
$1,502.58
|
| Rate for Payer: Cash Price |
$1,078.24
|
| Rate for Payer: Cigna All Commercial |
$1,500.84
|
| Rate for Payer: CORVEL All Commercial |
$1,617.36
|
| Rate for Payer: Coventry All Commercial |
$1,530.41
|
| Rate for Payer: Encore All Commercial |
$1,600.84
|
| Rate for Payer: Frontpath All Commercial |
$1,599.97
|
| Rate for Payer: Humana ChoiceCare |
$1,502.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,565.19
|
| Rate for Payer: PHCS All Commercial |
$1,304.32
|
| Rate for Payer: PHP All Commercial |
$1,318.93
|
| Rate for Payer: Sagamore Health Network All Products |
$1,342.59
|
| Rate for Payer: Signature Care EPO |
$1,443.45
|
| Rate for Payer: Signature Care PPO |
$1,530.41
|
| Rate for Payer: United Healthcare Commercial |
$1,370.41
|
|
|
TECHNETIUM TC 99M TILMANOCEPT KIT
|
Facility
OP
|
$1,739.10
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4080800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$573.90 |
| Max. Negotiated Rate |
$1,617.36 |
| Rate for Payer: Aetna Commercial |
$1,467.80
|
| Rate for Payer: Aetna Medicare |
$573.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$573.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$998.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,087.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$659.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$631.29
|
| Rate for Payer: Cash Price |
$1,078.24
|
| Rate for Payer: Centivo All Commercial |
$886.94
|
| Rate for Payer: Cigna All Commercial |
$1,500.84
|
| Rate for Payer: CORVEL All Commercial |
$1,617.36
|
| Rate for Payer: Coventry All Commercial |
$1,530.41
|
| Rate for Payer: Encore All Commercial |
$1,600.84
|
| Rate for Payer: Frontpath All Commercial |
$1,599.97
|
| Rate for Payer: Humana ChoiceCare |
$1,502.06
|
| Rate for Payer: Humana Medicare |
$886.94
|
| Rate for Payer: Lucent All Commercial |
$886.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,565.19
|
| Rate for Payer: PHCS All Commercial |
$1,304.32
|
| Rate for Payer: PHP All Commercial |
$1,318.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$678.25
|
| Rate for Payer: Sagamore Health Network All Products |
$1,342.59
|
| Rate for Payer: Signature Care EPO |
$1,443.45
|
| Rate for Payer: Signature Care PPO |
$1,530.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,478.24
|
| Rate for Payer: United Healthcare Commercial |
$1,370.41
|
| Rate for Payer: United Healthcare Medicare |
$573.90
|
|
|
TECHNETIUM TO 99M ALBUMIN AGGREGATED
|
Facility
OP
|
$869.55
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
40840064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$286.95 |
| Max. Negotiated Rate |
$808.68 |
| Rate for Payer: Aetna Commercial |
$733.90
|
| Rate for Payer: Aetna Medicare |
$286.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$286.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$499.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$543.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$329.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$315.65
|
| Rate for Payer: Cash Price |
$539.12
|
| Rate for Payer: Centivo All Commercial |
$443.47
|
| Rate for Payer: Cigna All Commercial |
$750.42
|
| Rate for Payer: CORVEL All Commercial |
$808.68
|
| Rate for Payer: Coventry All Commercial |
$765.20
|
| Rate for Payer: Encore All Commercial |
$800.42
|
| Rate for Payer: Frontpath All Commercial |
$799.99
|
| Rate for Payer: Humana ChoiceCare |
$751.03
|
| Rate for Payer: Humana Medicare |
$443.47
|
| Rate for Payer: Lucent All Commercial |
$443.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$782.60
|
| Rate for Payer: PHCS All Commercial |
$652.16
|
| Rate for Payer: PHP All Commercial |
$659.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$339.12
|
| Rate for Payer: Sagamore Health Network All Products |
$671.29
|
| Rate for Payer: Signature Care EPO |
$721.73
|
| Rate for Payer: Signature Care PPO |
$765.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$739.12
|
| Rate for Payer: United Healthcare Commercial |
$685.21
|
| Rate for Payer: United Healthcare Medicare |
$286.95
|
|
|
TECHNETIUM TO 99M ALBUMIN AGGREGATED
|
Facility
IP
|
$869.55
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
40840064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$808.68 |
| Rate for Payer: Aetna Commercial |
$751.29
|
| Rate for Payer: Cash Price |
$539.12
|
| Rate for Payer: Cigna All Commercial |
$750.42
|
| Rate for Payer: CORVEL All Commercial |
$808.68
|
| Rate for Payer: Coventry All Commercial |
$765.20
|
| Rate for Payer: Encore All Commercial |
$800.42
|
| Rate for Payer: Frontpath All Commercial |
$799.99
|
| Rate for Payer: Humana ChoiceCare |
$751.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$782.60
|
| Rate for Payer: PHCS All Commercial |
$652.16
|
| Rate for Payer: PHP All Commercial |
$659.47
|
| Rate for Payer: Sagamore Health Network All Products |
$671.29
|
| Rate for Payer: Signature Care EPO |
$721.73
|
| Rate for Payer: Signature Care PPO |
$765.20
|
| Rate for Payer: United Healthcare Commercial |
$685.21
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
Tendon sheath incision (eg, for trigger finger)
|
Facility
OP
|
$1,728.79
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
CPT-26055
|
|
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
|
|
|
TENECTEPLASE 50 MG IV SOLR
|
Facility
IP
|
$25,985.68
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
184169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19,489.26 |
| Max. Negotiated Rate |
$24,166.68 |
| Rate for Payer: Aetna Commercial |
$22,451.63
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Cigna All Commercial |
$22,425.64
|
| Rate for Payer: CORVEL All Commercial |
$24,166.68
|
| Rate for Payer: Coventry All Commercial |
$22,867.40
|
| Rate for Payer: Encore All Commercial |
$23,919.82
|
| Rate for Payer: Frontpath All Commercial |
$23,906.83
|
| Rate for Payer: Humana ChoiceCare |
$22,443.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,387.11
|
| Rate for Payer: PHCS All Commercial |
$19,489.26
|
| Rate for Payer: PHP All Commercial |
$19,707.54
|
| Rate for Payer: Sagamore Health Network All Products |
$20,060.94
|
| Rate for Payer: Signature Care EPO |
$21,568.11
|
| Rate for Payer: Signature Care PPO |
$22,867.40
|
| Rate for Payer: United Healthcare Commercial |
$20,476.72
|
|
|
TENECTEPLASE 50 MG IV SOLR
|
Facility
OP
|
$25,985.68
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
184169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.94 |
| Max. Negotiated Rate |
$24,166.68 |
| Rate for Payer: Aetna Commercial |
$21,931.91
|
| Rate for Payer: Aetna Medicare |
$8,575.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,575.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14,923.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,243.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$154.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9,861.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,432.80
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Centivo All Commercial |
$13,252.70
|
| Rate for Payer: Cigna All Commercial |
$22,425.64
|
| Rate for Payer: CORVEL All Commercial |
$24,166.68
|
| Rate for Payer: Coventry All Commercial |
$22,867.40
|
| Rate for Payer: Encore All Commercial |
$23,919.82
|
| Rate for Payer: Frontpath All Commercial |
$23,906.83
|
| Rate for Payer: Humana ChoiceCare |
$22,443.83
|
| Rate for Payer: Humana Medicare |
$13,252.70
|
| Rate for Payer: Lucent All Commercial |
$13,252.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,387.11
|
| Rate for Payer: Managed Health Services Medicaid |
$154.94
|
| Rate for Payer: MDWise Medicaid |
$154.94
|
| Rate for Payer: PHCS All Commercial |
$19,489.26
|
| Rate for Payer: PHP All Commercial |
$19,707.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,134.42
|
| Rate for Payer: Sagamore Health Network All Products |
$20,060.94
|
| Rate for Payer: Signature Care EPO |
$21,568.11
|
| Rate for Payer: Signature Care PPO |
$22,867.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22,087.83
|
| Rate for Payer: United Healthcare Commercial |
$20,476.72
|
| Rate for Payer: United Healthcare Medicare |
$8,575.27
|
|
|
TENECTEPLASE FOR STROKE
|
Facility
OP
|
$25,985.68
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
4080184169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.94 |
| Max. Negotiated Rate |
$24,166.68 |
| Rate for Payer: Aetna Commercial |
$21,931.91
|
| Rate for Payer: Aetna Medicare |
$8,575.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,575.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14,923.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16,243.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$154.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9,861.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,432.80
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Centivo All Commercial |
$13,252.70
|
| Rate for Payer: Cigna All Commercial |
$22,425.64
|
| Rate for Payer: CORVEL All Commercial |
$24,166.68
|
| Rate for Payer: Coventry All Commercial |
$22,867.40
|
| Rate for Payer: Encore All Commercial |
$23,919.82
|
| Rate for Payer: Frontpath All Commercial |
$23,906.83
|
| Rate for Payer: Humana ChoiceCare |
$22,443.83
|
| Rate for Payer: Humana Medicare |
$13,252.70
|
| Rate for Payer: Lucent All Commercial |
$13,252.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,387.11
|
| Rate for Payer: Managed Health Services Medicaid |
$154.94
|
| Rate for Payer: MDWise Medicaid |
$154.94
|
| Rate for Payer: PHCS All Commercial |
$19,489.26
|
| Rate for Payer: PHP All Commercial |
$19,707.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,134.42
|
| Rate for Payer: Sagamore Health Network All Products |
$20,060.94
|
| Rate for Payer: Signature Care EPO |
$21,568.11
|
| Rate for Payer: Signature Care PPO |
$22,867.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22,087.83
|
| Rate for Payer: United Healthcare Commercial |
$20,476.72
|
| Rate for Payer: United Healthcare Medicare |
$8,575.27
|
|
|
TENECTEPLASE FOR STROKE
|
Facility
IP
|
$25,985.68
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
4080184169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19,489.26 |
| Max. Negotiated Rate |
$24,166.68 |
| Rate for Payer: Aetna Commercial |
$22,451.63
|
| Rate for Payer: Cash Price |
$16,111.12
|
| Rate for Payer: Cigna All Commercial |
$22,425.64
|
| Rate for Payer: CORVEL All Commercial |
$24,166.68
|
| Rate for Payer: Coventry All Commercial |
$22,867.40
|
| Rate for Payer: Encore All Commercial |
$23,919.82
|
| Rate for Payer: Frontpath All Commercial |
$23,906.83
|
| Rate for Payer: Humana ChoiceCare |
$22,443.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23,387.11
|
| Rate for Payer: PHCS All Commercial |
$19,489.26
|
| Rate for Payer: PHP All Commercial |
$19,707.54
|
| Rate for Payer: Sagamore Health Network All Products |
$20,060.94
|
| Rate for Payer: Signature Care EPO |
$21,568.11
|
| Rate for Payer: Signature Care PPO |
$22,867.40
|
| Rate for Payer: United Healthcare Commercial |
$20,476.72
|
|
|
Tenodesis of long tendon of biceps
|
Facility
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 23430
|
| Hospital Charge Code |
CPT-23430
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment
|
Facility
OP
|
$4,315.74
|
|
|
Service Code
|
CPT 24359
|
| Hospital Charge Code |
CPT-24359
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,315.74 |
| Max. Negotiated Rate |
$4,315.74 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,315.74
|
| Rate for Payer: Managed Health Services Medicaid |
$4,315.74
|
| Rate for Payer: MDWise Medicaid |
$4,315.74
|
|
|
TERAZOSIN 1 MG ORAL CAP
|
Facility
OP
|
$4.66
|
|
|
Service Code
|
NDC 50268076415
|
| Hospital Charge Code |
14550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Aetna Medicare |
$1.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Centivo All Commercial |
$2.38
|
| Rate for Payer: Cigna All Commercial |
$4.02
|
| Rate for Payer: CORVEL All Commercial |
$4.34
|
| Rate for Payer: Coventry All Commercial |
$4.10
|
| Rate for Payer: Encore All Commercial |
$4.29
|
| Rate for Payer: Frontpath All Commercial |
$4.29
|
| Rate for Payer: Humana ChoiceCare |
$4.03
|
| Rate for Payer: Humana Medicare |
$2.38
|
| Rate for Payer: Lucent All Commercial |
$2.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.20
|
| Rate for Payer: PHCS All Commercial |
$3.50
|
| Rate for Payer: PHP All Commercial |
$3.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.82
|
| Rate for Payer: Sagamore Health Network All Products |
$3.60
|
| Rate for Payer: Signature Care EPO |
$3.87
|
| Rate for Payer: Signature Care PPO |
$4.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.96
|
| Rate for Payer: United Healthcare Commercial |
$3.67
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
|
|
TERAZOSIN 1 MG ORAL CAP
|
Facility
IP
|
$4.66
|
|
|
Service Code
|
NDC 50268076415
|
| Hospital Charge Code |
14550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$4.03
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna All Commercial |
$4.02
|
| Rate for Payer: CORVEL All Commercial |
$4.34
|
| Rate for Payer: Coventry All Commercial |
$4.10
|
| Rate for Payer: Encore All Commercial |
$4.29
|
| Rate for Payer: Frontpath All Commercial |
$4.29
|
| Rate for Payer: Humana ChoiceCare |
$4.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.20
|
| Rate for Payer: PHCS All Commercial |
$3.50
|
| Rate for Payer: PHP All Commercial |
$3.54
|
| Rate for Payer: Sagamore Health Network All Products |
$3.60
|
| Rate for Payer: Signature Care EPO |
$3.87
|
| Rate for Payer: Signature Care PPO |
$4.10
|
| Rate for Payer: United Healthcare Commercial |
$3.67
|
|
|
TERBINAFINE HCL 250 MG ORAL TAB
|
Facility
IP
|
$1.67
|
|
|
Service Code
|
NDC 65862007930
|
| Hospital Charge Code |
12724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna All Commercial |
$1.44
|
| Rate for Payer: CORVEL All Commercial |
$1.55
|
| Rate for Payer: Coventry All Commercial |
$1.47
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.50
|
| Rate for Payer: PHCS All Commercial |
$1.25
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1.29
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
|
|
TERBINAFINE HCL 250 MG ORAL TAB
|
Facility
OP
|
$1.67
|
|
|
Service Code
|
NDC 65862007930
|
| Hospital Charge Code |
12724
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.41
|
| Rate for Payer: Aetna Medicare |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Centivo All Commercial |
$0.85
|
| Rate for Payer: Cigna All Commercial |
$1.44
|
| Rate for Payer: CORVEL All Commercial |
$1.55
|
| Rate for Payer: Coventry All Commercial |
$1.47
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.44
|
| Rate for Payer: Humana Medicare |
$0.85
|
| Rate for Payer: Lucent All Commercial |
$0.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.50
|
| Rate for Payer: PHCS All Commercial |
$1.25
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1.29
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.42
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
|
|
TERBUTALINE 1 MG/ML SUBQ SOLN
|
Facility
IP
|
$23.91
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$22.23 |
| Rate for Payer: Aetna Commercial |
$20.65
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cigna All Commercial |
$20.63
|
| Rate for Payer: CORVEL All Commercial |
$22.23
|
| Rate for Payer: Coventry All Commercial |
$21.04
|
| Rate for Payer: Encore All Commercial |
$22.00
|
| Rate for Payer: Frontpath All Commercial |
$21.99
|
| Rate for Payer: Humana ChoiceCare |
$20.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.51
|
| Rate for Payer: PHCS All Commercial |
$17.93
|
| Rate for Payer: PHP All Commercial |
$18.13
|
| Rate for Payer: Sagamore Health Network All Products |
$18.45
|
| Rate for Payer: Signature Care EPO |
$19.84
|
| Rate for Payer: Signature Care PPO |
$21.04
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
|
|
TERBUTALINE 1 MG/ML SUBQ SOLN
|
Facility
OP
|
$23.91
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$22.23 |
| Rate for Payer: Aetna Commercial |
$20.18
|
| Rate for Payer: Aetna Medicare |
$7.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Centivo All Commercial |
$12.19
|
| Rate for Payer: Cigna All Commercial |
$20.63
|
| Rate for Payer: CORVEL All Commercial |
$22.23
|
| Rate for Payer: Coventry All Commercial |
$21.04
|
| Rate for Payer: Encore All Commercial |
$22.00
|
| Rate for Payer: Frontpath All Commercial |
$21.99
|
| Rate for Payer: Humana ChoiceCare |
$20.65
|
| Rate for Payer: Humana Medicare |
$12.19
|
| Rate for Payer: Lucent All Commercial |
$12.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.51
|
| Rate for Payer: PHCS All Commercial |
$17.93
|
| Rate for Payer: PHP All Commercial |
$18.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.32
|
| Rate for Payer: Sagamore Health Network All Products |
$18.45
|
| Rate for Payer: Signature Care EPO |
$19.84
|
| Rate for Payer: Signature Care PPO |
$21.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.32
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare |
$7.89
|
|
|
TERBUTALINE 2.5 MG ORAL TAB
|
Facility
OP
|
$14.83
|
|
|
Service Code
|
NDC 00115261101
|
| Hospital Charge Code |
11508
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$13.79 |
| Rate for Payer: Aetna Commercial |
$12.51
|
| Rate for Payer: Aetna Medicare |
$4.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.38
|
| Rate for Payer: Cash Price |
$9.19
|
| Rate for Payer: Centivo All Commercial |
$7.56
|
| Rate for Payer: Cigna All Commercial |
$12.79
|
| Rate for Payer: CORVEL All Commercial |
$13.79
|
| Rate for Payer: Coventry All Commercial |
$13.05
|
| Rate for Payer: Encore All Commercial |
$13.65
|
| Rate for Payer: Frontpath All Commercial |
$13.64
|
| Rate for Payer: Humana ChoiceCare |
$12.81
|
| Rate for Payer: Humana Medicare |
$7.56
|
| Rate for Payer: Lucent All Commercial |
$7.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.34
|
| Rate for Payer: PHCS All Commercial |
$11.12
|
| Rate for Payer: PHP All Commercial |
$11.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.78
|
| Rate for Payer: Sagamore Health Network All Products |
$11.45
|
| Rate for Payer: Signature Care EPO |
$12.31
|
| Rate for Payer: Signature Care PPO |
$13.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.60
|
| Rate for Payer: United Healthcare Commercial |
$11.68
|
| Rate for Payer: United Healthcare Medicare |
$4.89
|
|
|
TERBUTALINE 2.5 MG ORAL TAB
|
Facility
IP
|
$14.83
|
|
|
Service Code
|
NDC 00115261101
|
| Hospital Charge Code |
11508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$13.79 |
| Rate for Payer: Aetna Commercial |
$12.81
|
| Rate for Payer: Cash Price |
$9.19
|
| Rate for Payer: Cigna All Commercial |
$12.79
|
| Rate for Payer: CORVEL All Commercial |
$13.79
|
| Rate for Payer: Coventry All Commercial |
$13.05
|
| Rate for Payer: Encore All Commercial |
$13.65
|
| Rate for Payer: Frontpath All Commercial |
$13.64
|
| Rate for Payer: Humana ChoiceCare |
$12.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.34
|
| Rate for Payer: PHCS All Commercial |
$11.12
|
| Rate for Payer: PHP All Commercial |
$11.24
|
| Rate for Payer: Sagamore Health Network All Products |
$11.45
|
| Rate for Payer: Signature Care EPO |
$12.31
|
| Rate for Payer: Signature Care PPO |
$13.05
|
| Rate for Payer: United Healthcare Commercial |
$11.68
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL
|
Facility
OP
|
$82.46
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.21 |
| Max. Negotiated Rate |
$76.69 |
| Rate for Payer: Aetna Commercial |
$69.60
|
| Rate for Payer: Aetna Medicare |
$27.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$47.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.93
|
| Rate for Payer: Cash Price |
$51.13
|
| Rate for Payer: Centivo All Commercial |
$42.05
|
| Rate for Payer: Cigna All Commercial |
$71.16
|
| Rate for Payer: CORVEL All Commercial |
$76.69
|
| Rate for Payer: Coventry All Commercial |
$72.56
|
| Rate for Payer: Encore All Commercial |
$75.90
|
| Rate for Payer: Frontpath All Commercial |
$75.86
|
| Rate for Payer: Humana ChoiceCare |
$71.22
|
| Rate for Payer: Humana Medicare |
$42.05
|
| Rate for Payer: Lucent All Commercial |
$42.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.21
|
| Rate for Payer: PHCS All Commercial |
$61.84
|
| Rate for Payer: PHP All Commercial |
$62.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.16
|
| Rate for Payer: Sagamore Health Network All Products |
$63.66
|
| Rate for Payer: Signature Care EPO |
$68.44
|
| Rate for Payer: Signature Care PPO |
$72.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.09
|
| Rate for Payer: United Healthcare Commercial |
$64.98
|
| Rate for Payer: United Healthcare Medicare |
$27.21
|
|
