|
KETAMINE 50 MG/ML INJ SOLN FOR ANE ORDER SET (CAMERON)
|
Facility
|
OP
|
$19.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$18.10 |
| Rate for Payer: Aetna Commercial |
$16.42
|
| Rate for Payer: Aetna Medicare |
$6.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.85
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Centivo All Commercial |
$10.59
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Humana Medicare |
$6.23
|
| Rate for Payer: Lucent All Commercial |
$10.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.59
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.54
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
| Rate for Payer: United Healthcare Medicare |
$6.23
|
|
|
KETAMINE 50 MG/ML INJ SOLN FOR ANE ORDER SET (CAMERON)
|
Facility
|
IP
|
$19.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$18.10 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
|
|
KETAMINE IN STERILE WATER 50 MG/ML INJ SYRG
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 69374051101
|
| Hospital Charge Code |
188192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$27.22
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
KETAMINE IN STERILE WATER 50 MG/ML INJ SYRG
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
NDC 69374051101
|
| Hospital Charge Code |
188192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$26.59
|
| Rate for Payer: Aetna Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.09
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Centivo All Commercial |
$17.14
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana Medicare |
$10.08
|
| Rate for Payer: Lucent All Commercial |
$17.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.29
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.77
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Medicare |
$10.08
|
|
|
KETOCONAZOLE 2 % TOP CREA
|
Facility
|
OP
|
$68.04
|
|
|
Service Code
|
NDC 00168009930
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.09 |
| Max. Negotiated Rate |
$63.28 |
| Rate for Payer: Aetna Commercial |
$57.43
|
| Rate for Payer: Aetna Medicare |
$21.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$39.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.95
|
| Rate for Payer: Cash Price |
$40.82
|
| Rate for Payer: Centivo All Commercial |
$37.01
|
| Rate for Payer: Cigna All Commercial |
$58.72
|
| Rate for Payer: CORVEL All Commercial |
$63.28
|
| Rate for Payer: Coventry All Commercial |
$59.88
|
| Rate for Payer: Encore All Commercial |
$62.63
|
| Rate for Payer: Frontpath All Commercial |
$62.60
|
| Rate for Payer: Humana ChoiceCare |
$58.77
|
| Rate for Payer: Humana Medicare |
$21.77
|
| Rate for Payer: Lucent All Commercial |
$37.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.24
|
| Rate for Payer: PHCS All Commercial |
$51.03
|
| Rate for Payer: PHP All Commercial |
$51.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$52.53
|
| Rate for Payer: Signature Care EPO |
$56.47
|
| Rate for Payer: Signature Care PPO |
$59.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$57.83
|
| Rate for Payer: United Healthcare Commercial |
$53.62
|
| Rate for Payer: United Healthcare Medicare |
$21.77
|
|
|
KETOCONAZOLE 2 % TOP CREA
|
Facility
|
IP
|
$68.04
|
|
|
Service Code
|
NDC 00168009930
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.03 |
| Max. Negotiated Rate |
$63.28 |
| Rate for Payer: Aetna Commercial |
$58.79
|
| Rate for Payer: Cash Price |
$40.82
|
| Rate for Payer: Cigna All Commercial |
$58.72
|
| Rate for Payer: CORVEL All Commercial |
$63.28
|
| Rate for Payer: Coventry All Commercial |
$59.88
|
| Rate for Payer: Encore All Commercial |
$62.63
|
| Rate for Payer: Frontpath All Commercial |
$62.60
|
| Rate for Payer: Humana ChoiceCare |
$58.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.24
|
| Rate for Payer: PHCS All Commercial |
$51.03
|
| Rate for Payer: PHP All Commercial |
$51.60
|
| Rate for Payer: Sagamore Health Network All Products |
$52.53
|
| Rate for Payer: Signature Care EPO |
$56.47
|
| Rate for Payer: Signature Care PPO |
$59.88
|
| Rate for Payer: United Healthcare Commercial |
$53.62
|
|
|
KETOCONAZOLE 2 % TOP SHAM
|
Facility
|
IP
|
$143.64
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
14132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.73 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Aetna Commercial |
$124.10
|
| Rate for Payer: Cash Price |
$86.18
|
| Rate for Payer: Cigna All Commercial |
$123.96
|
| Rate for Payer: CORVEL All Commercial |
$133.59
|
| Rate for Payer: Coventry All Commercial |
$126.40
|
| Rate for Payer: Encore All Commercial |
$132.22
|
| Rate for Payer: Frontpath All Commercial |
$132.15
|
| Rate for Payer: Humana ChoiceCare |
$124.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.28
|
| Rate for Payer: PHCS All Commercial |
$107.73
|
| Rate for Payer: PHP All Commercial |
$108.94
|
| Rate for Payer: Sagamore Health Network All Products |
$110.89
|
| Rate for Payer: Signature Care EPO |
$119.22
|
| Rate for Payer: Signature Care PPO |
$126.40
|
| Rate for Payer: United Healthcare Commercial |
$113.19
|
|
|
KETOCONAZOLE 2 % TOP SHAM
|
Facility
|
OP
|
$143.64
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
14132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Aetna Commercial |
$121.23
|
| Rate for Payer: Aetna Medicare |
$45.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.79
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.56
|
| Rate for Payer: Cash Price |
$86.18
|
| Rate for Payer: Cash Price |
$86.18
|
| Rate for Payer: Centivo All Commercial |
$78.14
|
| Rate for Payer: Cigna All Commercial |
$123.96
|
| Rate for Payer: CORVEL All Commercial |
$133.59
|
| Rate for Payer: Coventry All Commercial |
$126.40
|
| Rate for Payer: Encore All Commercial |
$132.22
|
| Rate for Payer: Frontpath All Commercial |
$132.15
|
| Rate for Payer: Humana ChoiceCare |
$124.06
|
| Rate for Payer: Humana Medicare |
$45.96
|
| Rate for Payer: Lucent All Commercial |
$78.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.28
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$107.73
|
| Rate for Payer: PHP All Commercial |
$108.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.02
|
| Rate for Payer: Sagamore Health Network All Products |
$110.89
|
| Rate for Payer: Signature Care EPO |
$119.22
|
| Rate for Payer: Signature Care PPO |
$126.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$122.09
|
| Rate for Payer: United Healthcare Commercial |
$113.19
|
| Rate for Payer: United Healthcare Medicare |
$45.96
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
OP
|
$56.70
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
19733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$47.85
|
| Rate for Payer: Aetna Medicare |
$18.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$32.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.96
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Centivo All Commercial |
$30.84
|
| Rate for Payer: Cigna All Commercial |
$48.93
|
| Rate for Payer: CORVEL All Commercial |
$52.73
|
| Rate for Payer: Coventry All Commercial |
$49.90
|
| Rate for Payer: Encore All Commercial |
$52.19
|
| Rate for Payer: Frontpath All Commercial |
$52.16
|
| Rate for Payer: Humana ChoiceCare |
$48.97
|
| Rate for Payer: Humana Medicare |
$18.14
|
| Rate for Payer: Lucent All Commercial |
$30.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.03
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$42.52
|
| Rate for Payer: PHP All Commercial |
$43.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.11
|
| Rate for Payer: Sagamore Health Network All Products |
$43.77
|
| Rate for Payer: Signature Care EPO |
$47.06
|
| Rate for Payer: Signature Care PPO |
$49.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.20
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare |
$18.14
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
IP
|
$56.70
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
19733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.52 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$48.99
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cigna All Commercial |
$48.93
|
| Rate for Payer: CORVEL All Commercial |
$52.73
|
| Rate for Payer: Coventry All Commercial |
$49.90
|
| Rate for Payer: Encore All Commercial |
$52.19
|
| Rate for Payer: Frontpath All Commercial |
$52.16
|
| Rate for Payer: Humana ChoiceCare |
$48.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.03
|
| Rate for Payer: PHCS All Commercial |
$42.52
|
| Rate for Payer: PHP All Commercial |
$43.00
|
| Rate for Payer: Sagamore Health Network All Products |
$43.77
|
| Rate for Payer: Signature Care EPO |
$47.06
|
| Rate for Payer: Signature Care PPO |
$49.90
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
|
|
KETOROLAC 10 MG ORAL TAB
|
Facility
|
IP
|
$10.63
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
10371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.18
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
|
|
KETOROLAC 10 MG ORAL TAB
|
Facility
|
OP
|
$10.63
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
10371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$8.97
|
| Rate for Payer: Aetna Medicare |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.74
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Centivo All Commercial |
$5.78
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Humana Medicare |
$3.40
|
| Rate for Payer: Lucent All Commercial |
$5.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.14
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.03
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
| Rate for Payer: United Healthcare Medicare |
$3.40
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22473
|
|
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 |
$10.80
|
| 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
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
|
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR
|
Facility
|
OP
|
$10,500.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
178918
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,255.00 |
| Max. Negotiated Rate |
$9,765.00 |
| Rate for Payer: Aetna Commercial |
$8,862.00
|
| Rate for Payer: Aetna Medicare |
$3,360.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,255.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,030.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,563.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,864.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,696.00
|
| Rate for Payer: Cash Price |
$6,300.00
|
| Rate for Payer: Centivo All Commercial |
$5,712.00
|
| Rate for Payer: Cigna All Commercial |
$9,061.50
|
| Rate for Payer: CORVEL All Commercial |
$9,765.00
|
| Rate for Payer: Coventry All Commercial |
$9,240.00
|
| Rate for Payer: Encore All Commercial |
$9,665.25
|
| Rate for Payer: Frontpath All Commercial |
$9,660.00
|
| Rate for Payer: Humana ChoiceCare |
$9,068.85
|
| Rate for Payer: Humana Medicare |
$3,360.00
|
| Rate for Payer: Lucent All Commercial |
$5,712.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,450.00
|
| Rate for Payer: PHCS All Commercial |
$7,875.00
|
| Rate for Payer: PHP All Commercial |
$7,963.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,095.00
|
| Rate for Payer: Sagamore Health Network All Products |
$8,106.00
|
| Rate for Payer: Signature Care EPO |
$8,715.00
|
| Rate for Payer: Signature Care PPO |
$9,240.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,925.00
|
| Rate for Payer: United Healthcare Commercial |
$8,274.00
|
| Rate for Payer: United Healthcare Medicare |
$3,360.00
|
|
|
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR
|
Facility
|
IP
|
$10,500.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
178918
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7,875.00 |
| Max. Negotiated Rate |
$9,765.00 |
| Rate for Payer: Aetna Commercial |
$9,072.00
|
| Rate for Payer: Cash Price |
$6,300.00
|
| Rate for Payer: Cigna All Commercial |
$9,061.50
|
| Rate for Payer: CORVEL All Commercial |
$9,765.00
|
| Rate for Payer: Coventry All Commercial |
$9,240.00
|
| Rate for Payer: Encore All Commercial |
$9,665.25
|
| Rate for Payer: Frontpath All Commercial |
$9,660.00
|
| Rate for Payer: Humana ChoiceCare |
$9,068.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,450.00
|
| Rate for Payer: PHCS All Commercial |
$7,875.00
|
| Rate for Payer: PHP All Commercial |
$7,963.20
|
| Rate for Payer: Sagamore Health Network All Products |
$8,106.00
|
| Rate for Payer: Signature Care EPO |
$8,715.00
|
| Rate for Payer: Signature Care PPO |
$9,240.00
|
| Rate for Payer: United Healthcare Commercial |
$8,274.00
|
|
|
KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR
|
Facility
|
OP
|
$307.72
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
121547
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$95.39 |
| Max. Negotiated Rate |
$286.18 |
| Rate for Payer: Aetna Commercial |
$259.72
|
| Rate for Payer: Aetna Medicare |
$98.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$176.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$192.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$113.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$108.32
|
| Rate for Payer: Cash Price |
$184.63
|
| Rate for Payer: Centivo All Commercial |
$167.40
|
| Rate for Payer: Cigna All Commercial |
$265.56
|
| Rate for Payer: CORVEL All Commercial |
$286.18
|
| Rate for Payer: Coventry All Commercial |
$270.79
|
| Rate for Payer: Encore All Commercial |
$283.26
|
| Rate for Payer: Frontpath All Commercial |
$283.10
|
| Rate for Payer: Humana ChoiceCare |
$265.78
|
| Rate for Payer: Humana Medicare |
$98.47
|
| Rate for Payer: Lucent All Commercial |
$167.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.95
|
| Rate for Payer: PHCS All Commercial |
$230.79
|
| Rate for Payer: PHP All Commercial |
$233.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$120.01
|
| Rate for Payer: Sagamore Health Network All Products |
$237.56
|
| Rate for Payer: Signature Care EPO |
$255.41
|
| Rate for Payer: Signature Care PPO |
$270.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$261.56
|
| Rate for Payer: United Healthcare Commercial |
$242.48
|
| Rate for Payer: United Healthcare Medicare |
$98.47
|
|
|
KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR
|
Facility
|
IP
|
$307.72
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
121547
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$286.18 |
| Rate for Payer: Aetna Commercial |
$265.87
|
| Rate for Payer: Cash Price |
$184.63
|
| Rate for Payer: Cigna All Commercial |
$265.56
|
| Rate for Payer: CORVEL All Commercial |
$286.18
|
| Rate for Payer: Coventry All Commercial |
$270.79
|
| Rate for Payer: Encore All Commercial |
$283.26
|
| Rate for Payer: Frontpath All Commercial |
$283.10
|
| Rate for Payer: Humana ChoiceCare |
$265.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.95
|
| Rate for Payer: PHCS All Commercial |
$230.79
|
| Rate for Payer: PHP All Commercial |
$233.37
|
| Rate for Payer: Sagamore Health Network All Products |
$237.56
|
| Rate for Payer: Signature Care EPO |
$255.41
|
| Rate for Payer: Signature Care PPO |
$270.79
|
| Rate for Payer: United Healthcare Commercial |
$242.48
|
|
|
KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR
|
Facility
|
OP
|
$1,734.56
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
121541
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$537.71 |
| Max. Negotiated Rate |
$1,613.14 |
| Rate for Payer: Aetna Commercial |
$1,463.97
|
| Rate for Payer: Aetna Medicare |
$555.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$537.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$996.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,084.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$638.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$610.57
|
| Rate for Payer: Cash Price |
$1,040.74
|
| Rate for Payer: Centivo All Commercial |
$943.60
|
| Rate for Payer: Cigna All Commercial |
$1,496.93
|
| Rate for Payer: CORVEL All Commercial |
$1,613.14
|
| Rate for Payer: Coventry All Commercial |
$1,526.41
|
| Rate for Payer: Encore All Commercial |
$1,596.66
|
| Rate for Payer: Frontpath All Commercial |
$1,595.80
|
| Rate for Payer: Humana ChoiceCare |
$1,498.14
|
| Rate for Payer: Humana Medicare |
$555.06
|
| Rate for Payer: Lucent All Commercial |
$943.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,561.10
|
| Rate for Payer: PHCS All Commercial |
$1,300.92
|
| Rate for Payer: PHP All Commercial |
$1,315.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$676.48
|
| Rate for Payer: Sagamore Health Network All Products |
$1,339.08
|
| Rate for Payer: Signature Care EPO |
$1,439.68
|
| Rate for Payer: Signature Care PPO |
$1,526.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,474.38
|
| Rate for Payer: United Healthcare Commercial |
$1,366.83
|
| Rate for Payer: United Healthcare Medicare |
$555.06
|
|
|
KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR
|
Facility
|
IP
|
$1,734.56
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
121541
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,300.92 |
| Max. Negotiated Rate |
$1,613.14 |
| Rate for Payer: Aetna Commercial |
$1,498.66
|
| Rate for Payer: Cash Price |
$1,040.74
|
| Rate for Payer: Cigna All Commercial |
$1,496.93
|
| Rate for Payer: CORVEL All Commercial |
$1,613.14
|
| Rate for Payer: Coventry All Commercial |
$1,526.41
|
| Rate for Payer: Encore All Commercial |
$1,596.66
|
| Rate for Payer: Frontpath All Commercial |
$1,595.80
|
| Rate for Payer: Humana ChoiceCare |
$1,498.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,561.10
|
| Rate for Payer: PHCS All Commercial |
$1,300.92
|
| Rate for Payer: PHP All Commercial |
$1,315.49
|
| Rate for Payer: Sagamore Health Network All Products |
$1,339.08
|
| Rate for Payer: Signature Care EPO |
$1,439.68
|
| Rate for Payer: Signature Care PPO |
$1,526.41
|
| Rate for Payer: United Healthcare Commercial |
$1,366.83
|
|
|
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR
|
Facility
|
IP
|
$90,405.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
197065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67,803.75 |
| Max. Negotiated Rate |
$84,076.65 |
| Rate for Payer: Aetna Commercial |
$78,109.92
|
| Rate for Payer: Cash Price |
$54,243.00
|
| Rate for Payer: Cigna All Commercial |
$78,019.51
|
| Rate for Payer: CORVEL All Commercial |
$84,076.65
|
| Rate for Payer: Coventry All Commercial |
$79,556.40
|
| Rate for Payer: Encore All Commercial |
$83,217.80
|
| Rate for Payer: Frontpath All Commercial |
$83,172.60
|
| Rate for Payer: Humana ChoiceCare |
$78,082.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81,364.50
|
| Rate for Payer: PHCS All Commercial |
$67,803.75
|
| Rate for Payer: PHP All Commercial |
$68,563.15
|
| Rate for Payer: Sagamore Health Network All Products |
$69,792.66
|
| Rate for Payer: Signature Care EPO |
$75,036.15
|
| Rate for Payer: Signature Care PPO |
$79,556.40
|
| Rate for Payer: United Healthcare Commercial |
$71,239.14
|
|
|
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR
|
Facility
|
OP
|
$90,405.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
197065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,084.86 |
| Max. Negotiated Rate |
$84,076.65 |
| Rate for Payer: Aetna Commercial |
$76,301.82
|
| Rate for Payer: Aetna Medicare |
$28,929.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,084.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28,025.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$51,919.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56,512.17
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,084.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$33,269.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31,822.56
|
| Rate for Payer: Cash Price |
$54,243.00
|
| Rate for Payer: Cash Price |
$54,243.00
|
| Rate for Payer: Centivo All Commercial |
$49,180.32
|
| Rate for Payer: Cigna All Commercial |
$78,019.51
|
| Rate for Payer: CORVEL All Commercial |
$84,076.65
|
| Rate for Payer: Coventry All Commercial |
$79,556.40
|
| Rate for Payer: Encore All Commercial |
$83,217.80
|
| Rate for Payer: Frontpath All Commercial |
$83,172.60
|
| Rate for Payer: Humana ChoiceCare |
$78,082.80
|
| Rate for Payer: Humana Medicare |
$28,929.60
|
| Rate for Payer: Lucent All Commercial |
$49,180.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81,364.50
|
| Rate for Payer: Managed Health Services Medicaid |
$1,084.86
|
| Rate for Payer: MDWise Medicaid |
$1,084.86
|
| Rate for Payer: PHCS All Commercial |
$67,803.75
|
| Rate for Payer: PHP All Commercial |
$68,563.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35,257.95
|
| Rate for Payer: Sagamore Health Network All Products |
$69,792.66
|
| Rate for Payer: Signature Care EPO |
$75,036.15
|
| Rate for Payer: Signature Care PPO |
$79,556.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$76,844.25
|
| Rate for Payer: United Healthcare Commercial |
$71,239.14
|
| Rate for Payer: United Healthcare Medicare |
$28,929.60
|
|
|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR
|
Facility
|
IP
|
$330.30
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$247.72 |
| Max. Negotiated Rate |
$307.18 |
| Rate for Payer: Aetna Commercial |
$285.38
|
| Rate for Payer: Cash Price |
$198.18
|
| Rate for Payer: Cigna All Commercial |
$285.05
|
| Rate for Payer: CORVEL All Commercial |
$307.18
|
| Rate for Payer: Coventry All Commercial |
$290.66
|
| Rate for Payer: Encore All Commercial |
$304.04
|
| Rate for Payer: Frontpath All Commercial |
$303.88
|
| Rate for Payer: Humana ChoiceCare |
$285.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.27
|
| Rate for Payer: PHCS All Commercial |
$247.72
|
| Rate for Payer: PHP All Commercial |
$250.50
|
| Rate for Payer: Sagamore Health Network All Products |
$254.99
|
| Rate for Payer: Signature Care EPO |
$274.15
|
| Rate for Payer: Signature Care PPO |
$290.66
|
| Rate for Payer: United Healthcare Commercial |
$260.28
|
|
|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR
|
Facility
|
OP
|
$330.30
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$102.39 |
| Max. Negotiated Rate |
$307.18 |
| Rate for Payer: Aetna Commercial |
$278.77
|
| Rate for Payer: Aetna Medicare |
$105.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$297.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$189.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$297.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.27
|
| Rate for Payer: Cash Price |
$198.18
|
| Rate for Payer: Centivo All Commercial |
$179.68
|
| Rate for Payer: Cigna All Commercial |
$285.05
|
| Rate for Payer: CORVEL All Commercial |
$307.18
|
| Rate for Payer: Coventry All Commercial |
$290.66
|
| Rate for Payer: Encore All Commercial |
$304.04
|
| Rate for Payer: Frontpath All Commercial |
$303.88
|
| Rate for Payer: Humana ChoiceCare |
$285.28
|
| Rate for Payer: Humana Medicare |
$105.70
|
| Rate for Payer: Lucent All Commercial |
$179.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.27
|
| Rate for Payer: Managed Health Services Medicaid |
$297.27
|
| Rate for Payer: MDWise Medicaid |
$297.27
|
| Rate for Payer: PHCS All Commercial |
$247.72
|
| Rate for Payer: PHP All Commercial |
$250.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.82
|
| Rate for Payer: Sagamore Health Network All Products |
$254.99
|
| Rate for Payer: Signature Care EPO |
$274.15
|
| Rate for Payer: Signature Care PPO |
$290.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$280.75
|
| Rate for Payer: United Healthcare Commercial |
$260.28
|
| Rate for Payer: United Healthcare Medicare |
$105.70
|
|
|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR STRESS DOSE
|
Facility
|
IP
|
$330.30
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
140171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$247.72 |
| Max. Negotiated Rate |
$307.18 |
| Rate for Payer: Aetna Commercial |
$285.38
|
| Rate for Payer: Cash Price |
$198.18
|
| Rate for Payer: Cigna All Commercial |
$285.05
|
| Rate for Payer: CORVEL All Commercial |
$307.18
|
| Rate for Payer: Coventry All Commercial |
$290.66
|
| Rate for Payer: Encore All Commercial |
$304.04
|
| Rate for Payer: Frontpath All Commercial |
$303.88
|
| Rate for Payer: Humana ChoiceCare |
$285.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.27
|
| Rate for Payer: PHCS All Commercial |
$247.72
|
| Rate for Payer: PHP All Commercial |
$250.50
|
| Rate for Payer: Sagamore Health Network All Products |
$254.99
|
| Rate for Payer: Signature Care EPO |
$274.15
|
| Rate for Payer: Signature Care PPO |
$290.66
|
| Rate for Payer: United Healthcare Commercial |
$260.28
|
|
