|
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREA
|
Facility
OP
|
$11.03
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$9.31
|
| Rate for Payer: Aetna Medicare |
$3.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.00
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Centivo All Commercial |
$5.62
|
| Rate for Payer: Cigna All Commercial |
$9.51
|
| Rate for Payer: CORVEL All Commercial |
$10.25
|
| Rate for Payer: Coventry All Commercial |
$9.70
|
| Rate for Payer: Encore All Commercial |
$10.15
|
| Rate for Payer: Frontpath All Commercial |
$10.14
|
| Rate for Payer: Humana ChoiceCare |
$9.52
|
| Rate for Payer: Humana Medicare |
$5.62
|
| Rate for Payer: Lucent All Commercial |
$5.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.92
|
| Rate for Payer: PHCS All Commercial |
$8.27
|
| Rate for Payer: PHP All Commercial |
$8.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.30
|
| Rate for Payer: Sagamore Health Network All Products |
$8.51
|
| Rate for Payer: Signature Care EPO |
$9.15
|
| Rate for Payer: Signature Care PPO |
$9.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.37
|
| Rate for Payer: United Healthcare Commercial |
$8.69
|
| Rate for Payer: United Healthcare Medicare |
$3.64
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREA
|
Facility
IP
|
$11.03
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$9.53
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna All Commercial |
$9.51
|
| Rate for Payer: CORVEL All Commercial |
$10.25
|
| Rate for Payer: Coventry All Commercial |
$9.70
|
| Rate for Payer: Encore All Commercial |
$10.15
|
| Rate for Payer: Frontpath All Commercial |
$10.14
|
| Rate for Payer: Humana ChoiceCare |
$9.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.92
|
| Rate for Payer: PHCS All Commercial |
$8.27
|
| Rate for Payer: PHP All Commercial |
$8.36
|
| Rate for Payer: Sagamore Health Network All Products |
$8.51
|
| Rate for Payer: Signature Care EPO |
$9.15
|
| Rate for Payer: Signature Care PPO |
$9.70
|
| Rate for Payer: United Healthcare Commercial |
$8.69
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT
|
Facility
OP
|
$27.93
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$23.57
|
| Rate for Payer: Aetna Medicare |
$9.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.14
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Centivo All Commercial |
$14.24
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Humana Medicare |
$14.24
|
| Rate for Payer: Lucent All Commercial |
$14.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.89
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.74
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
| Rate for Payer: United Healthcare Medicare |
$9.22
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT
|
Facility
IP
|
$27.93
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$24.13
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP
|
Facility
IP
|
$80.29
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
11584
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.22 |
| Max. Negotiated Rate |
$74.67 |
| Rate for Payer: Aetna Commercial |
$69.37
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cigna All Commercial |
$69.29
|
| Rate for Payer: CORVEL All Commercial |
$74.67
|
| Rate for Payer: Coventry All Commercial |
$70.66
|
| Rate for Payer: Encore All Commercial |
$73.91
|
| Rate for Payer: Frontpath All Commercial |
$73.87
|
| Rate for Payer: Humana ChoiceCare |
$69.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.26
|
| Rate for Payer: PHCS All Commercial |
$60.22
|
| Rate for Payer: PHP All Commercial |
$60.89
|
| Rate for Payer: Sagamore Health Network All Products |
$61.98
|
| Rate for Payer: Signature Care EPO |
$66.64
|
| Rate for Payer: Signature Care PPO |
$70.66
|
| Rate for Payer: United Healthcare Commercial |
$63.27
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP
|
Facility
OP
|
$80.29
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
11584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$74.67 |
| Rate for Payer: Aetna Commercial |
$67.76
|
| Rate for Payer: Aetna Medicare |
$26.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$46.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.15
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Centivo All Commercial |
$40.95
|
| Rate for Payer: Cigna All Commercial |
$69.29
|
| Rate for Payer: CORVEL All Commercial |
$74.67
|
| Rate for Payer: Coventry All Commercial |
$70.66
|
| Rate for Payer: Encore All Commercial |
$73.91
|
| Rate for Payer: Frontpath All Commercial |
$73.87
|
| Rate for Payer: Humana ChoiceCare |
$69.35
|
| Rate for Payer: Humana Medicare |
$40.95
|
| Rate for Payer: Lucent All Commercial |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$72.26
|
| Rate for Payer: PHCS All Commercial |
$60.22
|
| Rate for Payer: PHP All Commercial |
$60.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.31
|
| Rate for Payer: Sagamore Health Network All Products |
$61.98
|
| Rate for Payer: Signature Care EPO |
$66.64
|
| Rate for Payer: Signature Care PPO |
$70.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$68.25
|
| Rate for Payer: United Healthcare Commercial |
$63.27
|
| Rate for Payer: United Healthcare Medicare |
$26.50
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP
|
Facility
OP
|
$34.92
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$32.47 |
| Rate for Payer: Aetna Commercial |
$29.47
|
| Rate for Payer: Aetna Commercial |
$112.25
|
| Rate for Payer: Aetna Commercial |
$25.14
|
| Rate for Payer: Aetna Medicare |
$43.89
|
| Rate for Payer: Aetna Medicare |
$11.52
|
| Rate for Payer: Aetna Medicare |
$9.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$76.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$83.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.67
|
| Rate for Payer: Cash Price |
$21.65
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Centivo All Commercial |
$67.83
|
| Rate for Payer: Centivo All Commercial |
$15.19
|
| Rate for Payer: Centivo All Commercial |
$17.81
|
| Rate for Payer: Cigna All Commercial |
$30.13
|
| Rate for Payer: Cigna All Commercial |
$25.71
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$27.71
|
| Rate for Payer: CORVEL All Commercial |
$32.47
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Coventry All Commercial |
$30.73
|
| Rate for Payer: Coventry All Commercial |
$26.22
|
| Rate for Payer: Encore All Commercial |
$27.42
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Encore All Commercial |
$32.14
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Frontpath All Commercial |
$27.41
|
| Rate for Payer: Frontpath All Commercial |
$32.12
|
| Rate for Payer: Humana ChoiceCare |
$30.16
|
| Rate for Payer: Humana ChoiceCare |
$25.73
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Humana Medicare |
$15.19
|
| Rate for Payer: Humana Medicare |
$67.83
|
| Rate for Payer: Humana Medicare |
$17.81
|
| Rate for Payer: Lucent All Commercial |
$17.81
|
| Rate for Payer: Lucent All Commercial |
$67.83
|
| Rate for Payer: Lucent All Commercial |
$15.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHCS All Commercial |
$26.19
|
| Rate for Payer: PHCS All Commercial |
$22.34
|
| Rate for Payer: PHP All Commercial |
$22.59
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: PHP All Commercial |
$26.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$51.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.62
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Sagamore Health Network All Products |
$26.96
|
| Rate for Payer: Sagamore Health Network All Products |
$23.00
|
| Rate for Payer: Signature Care EPO |
$24.73
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care EPO |
$28.98
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: Signature Care PPO |
$30.73
|
| Rate for Payer: Signature Care PPO |
$26.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$113.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.68
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
| Rate for Payer: United Healthcare Commercial |
$23.48
|
| Rate for Payer: United Healthcare Commercial |
$27.51
|
| Rate for Payer: United Healthcare Medicare |
$43.89
|
| Rate for Payer: United Healthcare Medicare |
$9.83
|
| Rate for Payer: United Healthcare Medicare |
$11.52
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP
|
Facility
IP
|
$133.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$123.69 |
| Rate for Payer: Aetna Commercial |
$114.91
|
| Rate for Payer: Aetna Commercial |
$25.74
|
| Rate for Payer: Aetna Commercial |
$30.17
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Cash Price |
$21.65
|
| Rate for Payer: Cigna All Commercial |
$30.13
|
| Rate for Payer: Cigna All Commercial |
$25.71
|
| Rate for Payer: Cigna All Commercial |
$114.78
|
| Rate for Payer: CORVEL All Commercial |
$32.47
|
| Rate for Payer: CORVEL All Commercial |
$123.69
|
| Rate for Payer: CORVEL All Commercial |
$27.71
|
| Rate for Payer: Coventry All Commercial |
$117.04
|
| Rate for Payer: Coventry All Commercial |
$26.22
|
| Rate for Payer: Coventry All Commercial |
$30.73
|
| Rate for Payer: Encore All Commercial |
$32.14
|
| Rate for Payer: Encore All Commercial |
$27.42
|
| Rate for Payer: Encore All Commercial |
$122.43
|
| Rate for Payer: Frontpath All Commercial |
$32.12
|
| Rate for Payer: Frontpath All Commercial |
$27.41
|
| Rate for Payer: Frontpath All Commercial |
$122.36
|
| Rate for Payer: Humana ChoiceCare |
$114.87
|
| Rate for Payer: Humana ChoiceCare |
$25.73
|
| Rate for Payer: Humana ChoiceCare |
$30.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.42
|
| Rate for Payer: PHCS All Commercial |
$26.19
|
| Rate for Payer: PHCS All Commercial |
$99.75
|
| Rate for Payer: PHCS All Commercial |
$22.34
|
| Rate for Payer: PHP All Commercial |
$26.48
|
| Rate for Payer: PHP All Commercial |
$22.59
|
| Rate for Payer: PHP All Commercial |
$100.87
|
| Rate for Payer: Sagamore Health Network All Products |
$23.00
|
| Rate for Payer: Sagamore Health Network All Products |
$102.68
|
| Rate for Payer: Sagamore Health Network All Products |
$26.96
|
| Rate for Payer: Signature Care EPO |
$28.98
|
| Rate for Payer: Signature Care EPO |
$110.39
|
| Rate for Payer: Signature Care EPO |
$24.73
|
| Rate for Payer: Signature Care PPO |
$117.04
|
| Rate for Payer: Signature Care PPO |
$26.22
|
| Rate for Payer: Signature Care PPO |
$30.73
|
| Rate for Payer: United Healthcare Commercial |
$104.80
|
| Rate for Payer: United Healthcare Commercial |
$27.51
|
| Rate for Payer: United Healthcare Commercial |
$23.48
|
|
|
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG ORAL TAB
|
Facility
OP
|
$5.13
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$4.33
|
| Rate for Payer: Aetna Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Centivo All Commercial |
$2.62
|
| Rate for Payer: Cigna All Commercial |
$4.43
|
| Rate for Payer: CORVEL All Commercial |
$4.77
|
| Rate for Payer: Coventry All Commercial |
$4.52
|
| Rate for Payer: Encore All Commercial |
$4.72
|
| Rate for Payer: Frontpath All Commercial |
$4.72
|
| Rate for Payer: Humana ChoiceCare |
$4.43
|
| Rate for Payer: Humana Medicare |
$2.62
|
| Rate for Payer: Lucent All Commercial |
$2.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.62
|
| Rate for Payer: PHCS All Commercial |
$3.85
|
| Rate for Payer: PHP All Commercial |
$3.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.00
|
| Rate for Payer: Sagamore Health Network All Products |
$3.96
|
| Rate for Payer: Signature Care EPO |
$4.26
|
| Rate for Payer: Signature Care PPO |
$4.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.36
|
| Rate for Payer: United Healthcare Commercial |
$4.04
|
| Rate for Payer: United Healthcare Medicare |
$1.69
|
|
|
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG ORAL TAB
|
Facility
IP
|
$5.13
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cigna All Commercial |
$4.43
|
| Rate for Payer: CORVEL All Commercial |
$4.77
|
| Rate for Payer: Coventry All Commercial |
$4.52
|
| Rate for Payer: Encore All Commercial |
$4.72
|
| Rate for Payer: Frontpath All Commercial |
$4.72
|
| Rate for Payer: Humana ChoiceCare |
$4.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.62
|
| Rate for Payer: PHCS All Commercial |
$3.85
|
| Rate for Payer: PHP All Commercial |
$3.89
|
| Rate for Payer: Sagamore Health Network All Products |
$3.96
|
| Rate for Payer: Signature Care EPO |
$4.26
|
| Rate for Payer: Signature Care PPO |
$4.52
|
| Rate for Payer: United Healthcare Commercial |
$4.04
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSR
|
Facility
OP
|
$8,585.22
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$853.90 |
| Max. Negotiated Rate |
$7,984.25 |
| Rate for Payer: Aetna Commercial |
$7,245.93
|
| Rate for Payer: Aetna Medicare |
$2,833.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,833.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,930.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,366.62
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$853.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,258.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,116.43
|
| Rate for Payer: Cash Price |
$5,322.84
|
| Rate for Payer: Cash Price |
$5,322.84
|
| Rate for Payer: Centivo All Commercial |
$4,378.46
|
| Rate for Payer: Cigna All Commercial |
$7,409.04
|
| Rate for Payer: CORVEL All Commercial |
$7,984.25
|
| Rate for Payer: Coventry All Commercial |
$7,554.99
|
| Rate for Payer: Encore All Commercial |
$7,902.70
|
| Rate for Payer: Frontpath All Commercial |
$7,898.40
|
| Rate for Payer: Humana ChoiceCare |
$7,415.05
|
| Rate for Payer: Humana Medicare |
$4,378.46
|
| Rate for Payer: Lucent All Commercial |
$4,378.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,726.70
|
| Rate for Payer: Managed Health Services Medicaid |
$853.90
|
| Rate for Payer: MDWise Medicaid |
$853.90
|
| Rate for Payer: PHCS All Commercial |
$6,438.92
|
| Rate for Payer: PHP All Commercial |
$6,511.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,348.24
|
| Rate for Payer: Sagamore Health Network All Products |
$6,627.79
|
| Rate for Payer: Signature Care EPO |
$7,125.73
|
| Rate for Payer: Signature Care PPO |
$7,554.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,297.44
|
| Rate for Payer: United Healthcare Commercial |
$6,765.15
|
| Rate for Payer: United Healthcare Medicare |
$2,833.12
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSR
|
Facility
IP
|
$8,585.22
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,438.92 |
| Max. Negotiated Rate |
$7,984.25 |
| Rate for Payer: Aetna Commercial |
$7,417.63
|
| Rate for Payer: Cash Price |
$5,322.84
|
| Rate for Payer: Cigna All Commercial |
$7,409.04
|
| Rate for Payer: CORVEL All Commercial |
$7,984.25
|
| Rate for Payer: Coventry All Commercial |
$7,554.99
|
| Rate for Payer: Encore All Commercial |
$7,902.70
|
| Rate for Payer: Frontpath All Commercial |
$7,898.40
|
| Rate for Payer: Humana ChoiceCare |
$7,415.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,726.70
|
| Rate for Payer: PHCS All Commercial |
$6,438.92
|
| Rate for Payer: PHP All Commercial |
$6,511.03
|
| Rate for Payer: Sagamore Health Network All Products |
$6,627.79
|
| Rate for Payer: Signature Care EPO |
$7,125.73
|
| Rate for Payer: Signature Care PPO |
$7,554.99
|
| Rate for Payer: United Healthcare Commercial |
$6,765.15
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSR
|
Facility
OP
|
$17,170.44
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
121160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$853.90 |
| Max. Negotiated Rate |
$15,968.51 |
| Rate for Payer: Aetna Commercial |
$14,491.85
|
| Rate for Payer: Aetna Medicare |
$5,666.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,666.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,860.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,733.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$853.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,516.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,232.87
|
| Rate for Payer: Cash Price |
$10,645.67
|
| Rate for Payer: Cash Price |
$10,645.67
|
| Rate for Payer: Centivo All Commercial |
$8,756.92
|
| Rate for Payer: Cigna All Commercial |
$14,818.09
|
| Rate for Payer: CORVEL All Commercial |
$15,968.51
|
| Rate for Payer: Coventry All Commercial |
$15,109.99
|
| Rate for Payer: Encore All Commercial |
$15,805.39
|
| Rate for Payer: Frontpath All Commercial |
$15,796.80
|
| Rate for Payer: Humana ChoiceCare |
$14,830.11
|
| Rate for Payer: Humana Medicare |
$8,756.92
|
| Rate for Payer: Lucent All Commercial |
$8,756.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,453.40
|
| Rate for Payer: Managed Health Services Medicaid |
$853.90
|
| Rate for Payer: MDWise Medicaid |
$853.90
|
| Rate for Payer: PHCS All Commercial |
$12,877.83
|
| Rate for Payer: PHP All Commercial |
$13,022.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,696.47
|
| Rate for Payer: Sagamore Health Network All Products |
$13,255.58
|
| Rate for Payer: Signature Care EPO |
$14,251.47
|
| Rate for Payer: Signature Care PPO |
$15,109.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,594.87
|
| Rate for Payer: United Healthcare Commercial |
$13,530.31
|
| Rate for Payer: United Healthcare Medicare |
$5,666.25
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSR
|
Facility
IP
|
$17,170.44
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
121160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,877.83 |
| Max. Negotiated Rate |
$15,968.51 |
| Rate for Payer: Aetna Commercial |
$14,835.26
|
| Rate for Payer: Cash Price |
$10,645.67
|
| Rate for Payer: Cigna All Commercial |
$14,818.09
|
| Rate for Payer: CORVEL All Commercial |
$15,968.51
|
| Rate for Payer: Coventry All Commercial |
$15,109.99
|
| Rate for Payer: Encore All Commercial |
$15,805.39
|
| Rate for Payer: Frontpath All Commercial |
$15,796.80
|
| Rate for Payer: Humana ChoiceCare |
$14,830.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,453.40
|
| Rate for Payer: PHCS All Commercial |
$12,877.83
|
| Rate for Payer: PHP All Commercial |
$13,022.06
|
| Rate for Payer: Sagamore Health Network All Products |
$13,255.58
|
| Rate for Payer: Signature Care EPO |
$14,251.47
|
| Rate for Payer: Signature Care PPO |
$15,109.99
|
| Rate for Payer: United Healthcare Commercial |
$13,530.31
|
|
|
TROP-CYCLO-PHENYL-KETORO-OFLOX-XYLO 0.06-0.06-0.14-0.03-0.02-1.5 % OPHT DRPS (CAMERON)
|
Facility
OP
|
$600.00
|
|
|
Service Code
|
NDC 9999999882
|
| Hospital Charge Code |
198927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$198.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$198.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$344.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$375.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.80
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Centivo All Commercial |
$306.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Humana Medicare |
$306.00
|
| Rate for Payer: Lucent All Commercial |
$306.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.00
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$510.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
| Rate for Payer: United Healthcare Medicare |
$198.00
|
|
|
TROP-CYCLO-PHENYL-KETORO-OFLOX-XYLO 0.06-0.06-0.14-0.03-0.02-1.5 % OPHT DRPS (CAMERON)
|
Facility
IP
|
$600.00
|
|
|
Service Code
|
NDC 9999999882
|
| Hospital Charge Code |
198927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$518.40
|
| Rate for Payer: Cash Price |
$372.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
OP
|
$70.77
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$65.82 |
| Rate for Payer: Aetna Commercial |
$59.73
|
| Rate for Payer: Aetna Medicare |
$23.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$40.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$44.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.69
|
| Rate for Payer: Cash Price |
$43.88
|
| Rate for Payer: Cash Price |
$43.88
|
| Rate for Payer: Centivo All Commercial |
$36.09
|
| Rate for Payer: Cigna All Commercial |
$61.07
|
| Rate for Payer: CORVEL All Commercial |
$65.82
|
| Rate for Payer: Coventry All Commercial |
$62.28
|
| Rate for Payer: Encore All Commercial |
$65.14
|
| Rate for Payer: Frontpath All Commercial |
$65.11
|
| Rate for Payer: Humana ChoiceCare |
$61.12
|
| Rate for Payer: Humana Medicare |
$36.09
|
| Rate for Payer: Lucent All Commercial |
$36.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.69
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$53.08
|
| Rate for Payer: PHP All Commercial |
$53.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.60
|
| Rate for Payer: Sagamore Health Network All Products |
$54.63
|
| Rate for Payer: Signature Care EPO |
$58.74
|
| Rate for Payer: Signature Care PPO |
$62.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$60.15
|
| Rate for Payer: United Healthcare Commercial |
$55.77
|
| Rate for Payer: United Healthcare Medicare |
$23.35
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
OP
|
$69.09
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$64.25 |
| Rate for Payer: Aetna Commercial |
$58.31
|
| Rate for Payer: Aetna Medicare |
$22.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$39.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.08
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Centivo All Commercial |
$35.24
|
| Rate for Payer: Cigna All Commercial |
$59.62
|
| Rate for Payer: CORVEL All Commercial |
$64.25
|
| Rate for Payer: Coventry All Commercial |
$60.80
|
| Rate for Payer: Encore All Commercial |
$63.60
|
| Rate for Payer: Frontpath All Commercial |
$63.56
|
| Rate for Payer: Humana ChoiceCare |
$59.67
|
| Rate for Payer: Humana Medicare |
$35.24
|
| Rate for Payer: Lucent All Commercial |
$35.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.18
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$51.82
|
| Rate for Payer: PHP All Commercial |
$52.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.95
|
| Rate for Payer: Sagamore Health Network All Products |
$53.34
|
| Rate for Payer: Signature Care EPO |
$57.34
|
| Rate for Payer: Signature Care PPO |
$60.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$58.73
|
| Rate for Payer: United Healthcare Commercial |
$54.44
|
| Rate for Payer: United Healthcare Medicare |
$22.80
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
IP
|
$70.77
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.08 |
| Max. Negotiated Rate |
$65.82 |
| Rate for Payer: Aetna Commercial |
$61.15
|
| Rate for Payer: Cash Price |
$43.88
|
| Rate for Payer: Cigna All Commercial |
$61.07
|
| Rate for Payer: CORVEL All Commercial |
$65.82
|
| Rate for Payer: Coventry All Commercial |
$62.28
|
| Rate for Payer: Encore All Commercial |
$65.14
|
| Rate for Payer: Frontpath All Commercial |
$65.11
|
| Rate for Payer: Humana ChoiceCare |
$61.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.69
|
| Rate for Payer: PHCS All Commercial |
$53.08
|
| Rate for Payer: PHP All Commercial |
$53.67
|
| Rate for Payer: Sagamore Health Network All Products |
$54.63
|
| Rate for Payer: Signature Care EPO |
$58.74
|
| Rate for Payer: Signature Care PPO |
$62.28
|
| Rate for Payer: United Healthcare Commercial |
$55.77
|
|
|
TROPICAMIDE 1 % OPHT DROP
|
Facility
IP
|
$69.09
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.82 |
| Max. Negotiated Rate |
$64.25 |
| Rate for Payer: Aetna Commercial |
$59.69
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Cigna All Commercial |
$59.62
|
| Rate for Payer: CORVEL All Commercial |
$64.25
|
| Rate for Payer: Coventry All Commercial |
$60.80
|
| Rate for Payer: Encore All Commercial |
$63.60
|
| Rate for Payer: Frontpath All Commercial |
$63.56
|
| Rate for Payer: Humana ChoiceCare |
$59.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.18
|
| Rate for Payer: PHCS All Commercial |
$51.82
|
| Rate for Payer: PHP All Commercial |
$52.40
|
| Rate for Payer: Sagamore Health Network All Products |
$53.34
|
| Rate for Payer: Signature Care EPO |
$57.34
|
| Rate for Payer: Signature Care PPO |
$60.80
|
| Rate for Payer: United Healthcare Commercial |
$54.44
|
|
|
TRYPAN BLUE 0.06 % IO SYRG
|
Facility
IP
|
$320.40
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$240.30 |
| Max. Negotiated Rate |
$297.97 |
| Rate for Payer: Aetna Commercial |
$276.83
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Cigna All Commercial |
$276.51
|
| Rate for Payer: CORVEL All Commercial |
$297.97
|
| Rate for Payer: Coventry All Commercial |
$281.95
|
| Rate for Payer: Encore All Commercial |
$294.93
|
| Rate for Payer: Frontpath All Commercial |
$294.77
|
| Rate for Payer: Humana ChoiceCare |
$276.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.36
|
| Rate for Payer: PHCS All Commercial |
$240.30
|
| Rate for Payer: PHP All Commercial |
$242.99
|
| Rate for Payer: Sagamore Health Network All Products |
$247.35
|
| Rate for Payer: Signature Care EPO |
$265.93
|
| Rate for Payer: Signature Care PPO |
$281.95
|
| Rate for Payer: United Healthcare Commercial |
$252.48
|
|
|
TRYPAN BLUE 0.06 % IO SYRG
|
Facility
OP
|
$320.40
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$297.97 |
| Rate for Payer: Aetna Commercial |
$270.42
|
| Rate for Payer: Aetna Medicare |
$105.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$184.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$200.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.31
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Cash Price |
$198.65
|
| Rate for Payer: Centivo All Commercial |
$163.40
|
| Rate for Payer: Cigna All Commercial |
$276.51
|
| Rate for Payer: CORVEL All Commercial |
$297.97
|
| Rate for Payer: Coventry All Commercial |
$281.95
|
| Rate for Payer: Encore All Commercial |
$294.93
|
| Rate for Payer: Frontpath All Commercial |
$294.77
|
| Rate for Payer: Humana ChoiceCare |
$276.73
|
| Rate for Payer: Humana Medicare |
$163.40
|
| Rate for Payer: Lucent All Commercial |
$163.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.36
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$240.30
|
| Rate for Payer: PHP All Commercial |
$242.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.96
|
| Rate for Payer: Sagamore Health Network All Products |
$247.35
|
| Rate for Payer: Signature Care EPO |
$265.93
|
| Rate for Payer: Signature Care PPO |
$281.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$272.34
|
| Rate for Payer: United Healthcare Commercial |
$252.48
|
| Rate for Payer: United Healthcare Medicare |
$105.73
|
|
|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
OP
|
$497.94
|
|
|
Service Code
|
NDC 49281075221
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$463.08 |
| Rate for Payer: Aetna Commercial |
$420.26
|
| Rate for Payer: Aetna Medicare |
$164.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$164.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$285.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$311.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$188.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$180.75
|
| Rate for Payer: Cash Price |
$308.72
|
| Rate for Payer: Cash Price |
$308.72
|
| Rate for Payer: Centivo All Commercial |
$253.95
|
| Rate for Payer: Cigna All Commercial |
$429.72
|
| Rate for Payer: CORVEL All Commercial |
$463.08
|
| Rate for Payer: Coventry All Commercial |
$438.19
|
| Rate for Payer: Encore All Commercial |
$458.35
|
| Rate for Payer: Frontpath All Commercial |
$458.10
|
| Rate for Payer: Humana ChoiceCare |
$430.07
|
| Rate for Payer: Humana Medicare |
$253.95
|
| Rate for Payer: Lucent All Commercial |
$253.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$448.15
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$373.46
|
| Rate for Payer: PHP All Commercial |
$377.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$194.20
|
| Rate for Payer: Sagamore Health Network All Products |
$384.41
|
| Rate for Payer: Signature Care EPO |
$413.29
|
| Rate for Payer: Signature Care PPO |
$438.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$423.25
|
| Rate for Payer: United Healthcare Commercial |
$392.38
|
| Rate for Payer: United Healthcare Medicare |
$164.32
|
|
|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
IP
|
$58.09
|
|
|
Service Code
|
NDC 492810752
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.57 |
| Max. Negotiated Rate |
$54.03 |
| Rate for Payer: Aetna Commercial |
$50.19
|
| Rate for Payer: Cash Price |
$36.02
|
| Rate for Payer: Cigna All Commercial |
$50.13
|
| Rate for Payer: CORVEL All Commercial |
$54.03
|
| Rate for Payer: Coventry All Commercial |
$51.12
|
| Rate for Payer: Encore All Commercial |
$53.47
|
| Rate for Payer: Frontpath All Commercial |
$53.45
|
| Rate for Payer: Humana ChoiceCare |
$50.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.28
|
| Rate for Payer: PHCS All Commercial |
$43.57
|
| Rate for Payer: PHP All Commercial |
$44.06
|
| Rate for Payer: Sagamore Health Network All Products |
$44.85
|
| Rate for Payer: Signature Care EPO |
$48.22
|
| Rate for Payer: Signature Care PPO |
$51.12
|
| Rate for Payer: United Healthcare Commercial |
$45.78
|
|
|
TUBERCULIN PPD 5 TUB. UNIT /0.1 ML IDRM SOLN
|
Facility
OP
|
$58.09
|
|
|
Service Code
|
NDC 492810752
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$54.03 |
| Rate for Payer: Aetna Commercial |
$49.03
|
| Rate for Payer: Aetna Medicare |
$19.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$33.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.09
|
| Rate for Payer: Cash Price |
$36.02
|
| Rate for Payer: Cash Price |
$36.02
|
| Rate for Payer: Centivo All Commercial |
$29.63
|
| Rate for Payer: Cigna All Commercial |
$50.13
|
| Rate for Payer: CORVEL All Commercial |
$54.03
|
| Rate for Payer: Coventry All Commercial |
$51.12
|
| Rate for Payer: Encore All Commercial |
$53.47
|
| Rate for Payer: Frontpath All Commercial |
$53.45
|
| Rate for Payer: Humana ChoiceCare |
$50.17
|
| Rate for Payer: Humana Medicare |
$29.63
|
| Rate for Payer: Lucent All Commercial |
$29.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.28
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$43.57
|
| Rate for Payer: PHP All Commercial |
$44.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.66
|
| Rate for Payer: Sagamore Health Network All Products |
$44.85
|
| Rate for Payer: Signature Care EPO |
$48.22
|
| Rate for Payer: Signature Care PPO |
$51.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$49.38
|
| Rate for Payer: United Healthcare Commercial |
$45.78
|
| Rate for Payer: United Healthcare Medicare |
$19.17
|
|
