|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN
|
Facility
OP
|
$185.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.22 |
| Max. Negotiated Rate |
$172.52 |
| Rate for Payer: Aetna Commercial |
$156.56
|
| Rate for Payer: Aetna Medicare |
$61.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$61.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$106.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$115.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.34
|
| Rate for Payer: Cash Price |
$115.01
|
| Rate for Payer: Centivo All Commercial |
$94.60
|
| Rate for Payer: Cigna All Commercial |
$160.09
|
| Rate for Payer: CORVEL All Commercial |
$172.52
|
| Rate for Payer: Coventry All Commercial |
$163.24
|
| Rate for Payer: Encore All Commercial |
$170.75
|
| Rate for Payer: Frontpath All Commercial |
$170.66
|
| Rate for Payer: Humana ChoiceCare |
$160.22
|
| Rate for Payer: Humana Medicare |
$94.60
|
| Rate for Payer: Lucent All Commercial |
$94.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.95
|
| Rate for Payer: PHCS All Commercial |
$139.12
|
| Rate for Payer: PHP All Commercial |
$140.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.34
|
| Rate for Payer: Sagamore Health Network All Products |
$143.21
|
| Rate for Payer: Signature Care EPO |
$153.96
|
| Rate for Payer: Signature Care PPO |
$163.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$157.68
|
| Rate for Payer: United Healthcare Commercial |
$146.17
|
| Rate for Payer: United Healthcare Medicare |
$61.22
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 10 ML VIAL
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
140165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$302.40
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 10 ML VIAL
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
140165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$295.40
|
| Rate for Payer: Aetna Medicare |
$115.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$115.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$201.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$127.05
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Centivo All Commercial |
$178.50
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Humana Medicare |
$178.50
|
| Rate for Payer: Lucent All Commercial |
$178.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.50
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$297.50
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
| Rate for Payer: United Healthcare Medicare |
$115.50
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 15 ML VIAL
|
Facility
OP
|
$540.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$502.20 |
| Rate for Payer: Aetna Commercial |
$455.76
|
| Rate for Payer: Aetna Medicare |
$178.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$178.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$310.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$337.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$204.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$196.02
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Centivo All Commercial |
$275.40
|
| Rate for Payer: Cigna All Commercial |
$466.02
|
| Rate for Payer: CORVEL All Commercial |
$502.20
|
| Rate for Payer: Coventry All Commercial |
$475.20
|
| Rate for Payer: Encore All Commercial |
$497.07
|
| Rate for Payer: Frontpath All Commercial |
$496.80
|
| Rate for Payer: Humana ChoiceCare |
$466.40
|
| Rate for Payer: Humana Medicare |
$275.40
|
| Rate for Payer: Lucent All Commercial |
$275.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.00
|
| Rate for Payer: PHCS All Commercial |
$405.00
|
| Rate for Payer: PHP All Commercial |
$409.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$210.60
|
| Rate for Payer: Sagamore Health Network All Products |
$416.88
|
| Rate for Payer: Signature Care EPO |
$448.20
|
| Rate for Payer: Signature Care PPO |
$475.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$459.00
|
| Rate for Payer: United Healthcare Commercial |
$425.52
|
| Rate for Payer: United Healthcare Medicare |
$178.20
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 15 ML VIAL
|
Facility
IP
|
$540.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$405.00 |
| Max. Negotiated Rate |
$502.20 |
| Rate for Payer: Aetna Commercial |
$466.56
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Cigna All Commercial |
$466.02
|
| Rate for Payer: CORVEL All Commercial |
$502.20
|
| Rate for Payer: Coventry All Commercial |
$475.20
|
| Rate for Payer: Encore All Commercial |
$497.07
|
| Rate for Payer: Frontpath All Commercial |
$496.80
|
| Rate for Payer: Humana ChoiceCare |
$466.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.00
|
| Rate for Payer: PHCS All Commercial |
$405.00
|
| Rate for Payer: PHP All Commercial |
$409.54
|
| Rate for Payer: Sagamore Health Network All Products |
$416.88
|
| Rate for Payer: Signature Care EPO |
$448.20
|
| Rate for Payer: Signature Care PPO |
$475.20
|
| Rate for Payer: United Healthcare Commercial |
$425.52
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 20 ML VIAL
|
Facility
IP
|
$600.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1402165683
|
|
Hospital Revenue Code
|
255
|
| 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
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 20 ML VIAL
|
Facility
OP
|
$600.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1402165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.00 |
| 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 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: 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: 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
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG
|
Facility
OP
|
$330.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
166052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.90 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$278.52
|
| Rate for Payer: Aetna Medicare |
$108.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$189.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$119.79
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Centivo All Commercial |
$168.30
|
| Rate for Payer: Cigna All Commercial |
$284.79
|
| Rate for Payer: CORVEL All Commercial |
$306.90
|
| Rate for Payer: Coventry All Commercial |
$290.40
|
| Rate for Payer: Encore All Commercial |
$303.76
|
| Rate for Payer: Frontpath All Commercial |
$303.60
|
| Rate for Payer: Humana ChoiceCare |
$285.02
|
| Rate for Payer: Humana Medicare |
$168.30
|
| Rate for Payer: Lucent All Commercial |
$168.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.00
|
| Rate for Payer: PHCS All Commercial |
$247.50
|
| Rate for Payer: PHP All Commercial |
$250.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.70
|
| Rate for Payer: Sagamore Health Network All Products |
$254.76
|
| Rate for Payer: Signature Care EPO |
$273.90
|
| Rate for Payer: Signature Care PPO |
$290.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$280.50
|
| Rate for Payer: United Healthcare Commercial |
$260.04
|
| Rate for Payer: United Healthcare Medicare |
$108.90
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG
|
Facility
IP
|
$330.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
166052
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$285.12
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna All Commercial |
$284.79
|
| Rate for Payer: CORVEL All Commercial |
$306.90
|
| Rate for Payer: Coventry All Commercial |
$290.40
|
| Rate for Payer: Encore All Commercial |
$303.76
|
| Rate for Payer: Frontpath All Commercial |
$303.60
|
| Rate for Payer: Humana ChoiceCare |
$285.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.00
|
| Rate for Payer: PHCS All Commercial |
$247.50
|
| Rate for Payer: PHP All Commercial |
$250.27
|
| Rate for Payer: Sagamore Health Network All Products |
$254.76
|
| Rate for Payer: Signature Care EPO |
$273.90
|
| Rate for Payer: Signature Care PPO |
$290.40
|
| Rate for Payer: United Healthcare Commercial |
$260.04
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG - 20 ML
|
Facility
OP
|
$550.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401166052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.50 |
| Max. Negotiated Rate |
$511.50 |
| Rate for Payer: Aetna Commercial |
$464.20
|
| Rate for Payer: Aetna Medicare |
$181.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$181.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$315.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$343.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$208.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$199.65
|
| Rate for Payer: Cash Price |
$341.00
|
| Rate for Payer: Centivo All Commercial |
$280.50
|
| Rate for Payer: Cigna All Commercial |
$474.65
|
| Rate for Payer: CORVEL All Commercial |
$511.50
|
| Rate for Payer: Coventry All Commercial |
$484.00
|
| Rate for Payer: Encore All Commercial |
$506.28
|
| Rate for Payer: Frontpath All Commercial |
$506.00
|
| Rate for Payer: Humana ChoiceCare |
$475.04
|
| Rate for Payer: Humana Medicare |
$280.50
|
| Rate for Payer: Lucent All Commercial |
$280.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.00
|
| Rate for Payer: PHCS All Commercial |
$412.50
|
| Rate for Payer: PHP All Commercial |
$417.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$214.50
|
| Rate for Payer: Sagamore Health Network All Products |
$424.60
|
| Rate for Payer: Signature Care EPO |
$456.50
|
| Rate for Payer: Signature Care PPO |
$484.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$467.50
|
| Rate for Payer: United Healthcare Commercial |
$433.40
|
| Rate for Payer: United Healthcare Medicare |
$181.50
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG - 20 ML
|
Facility
IP
|
$550.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401166052
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$412.50 |
| Max. Negotiated Rate |
$511.50 |
| Rate for Payer: Aetna Commercial |
$475.20
|
| Rate for Payer: Cash Price |
$341.00
|
| Rate for Payer: Cigna All Commercial |
$474.65
|
| Rate for Payer: CORVEL All Commercial |
$511.50
|
| Rate for Payer: Coventry All Commercial |
$484.00
|
| Rate for Payer: Encore All Commercial |
$506.28
|
| Rate for Payer: Frontpath All Commercial |
$506.00
|
| Rate for Payer: Humana ChoiceCare |
$475.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.00
|
| Rate for Payer: PHCS All Commercial |
$412.50
|
| Rate for Payer: PHP All Commercial |
$417.12
|
| Rate for Payer: Sagamore Health Network All Products |
$424.60
|
| Rate for Payer: Signature Care EPO |
$456.50
|
| Rate for Payer: Signature Care PPO |
$484.00
|
| Rate for Payer: United Healthcare Commercial |
$433.40
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 10 ML VIAL
|
Facility
OP
|
$331.02
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
40810100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.24 |
| Max. Negotiated Rate |
$307.85 |
| Rate for Payer: Aetna Commercial |
$279.38
|
| Rate for Payer: Aetna Medicare |
$109.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$109.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$190.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.16
|
| Rate for Payer: Cash Price |
$205.23
|
| Rate for Payer: Centivo All Commercial |
$168.82
|
| Rate for Payer: Cigna All Commercial |
$285.67
|
| Rate for Payer: CORVEL All Commercial |
$307.85
|
| Rate for Payer: Coventry All Commercial |
$291.30
|
| Rate for Payer: Encore All Commercial |
$304.70
|
| Rate for Payer: Frontpath All Commercial |
$304.54
|
| Rate for Payer: Humana ChoiceCare |
$285.90
|
| Rate for Payer: Humana Medicare |
$168.82
|
| Rate for Payer: Lucent All Commercial |
$168.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.92
|
| Rate for Payer: PHCS All Commercial |
$248.26
|
| Rate for Payer: PHP All Commercial |
$251.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$129.10
|
| Rate for Payer: Sagamore Health Network All Products |
$255.55
|
| Rate for Payer: Signature Care EPO |
$274.75
|
| Rate for Payer: Signature Care PPO |
$291.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$281.37
|
| Rate for Payer: United Healthcare Commercial |
$260.84
|
| Rate for Payer: United Healthcare Medicare |
$109.24
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 10 ML VIAL
|
Facility
IP
|
$331.02
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
40810100
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$248.26 |
| Max. Negotiated Rate |
$307.85 |
| Rate for Payer: Aetna Commercial |
$286.00
|
| Rate for Payer: Cash Price |
$205.23
|
| Rate for Payer: Cigna All Commercial |
$285.67
|
| Rate for Payer: CORVEL All Commercial |
$307.85
|
| Rate for Payer: Coventry All Commercial |
$291.30
|
| Rate for Payer: Encore All Commercial |
$304.70
|
| Rate for Payer: Frontpath All Commercial |
$304.54
|
| Rate for Payer: Humana ChoiceCare |
$285.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.92
|
| Rate for Payer: PHCS All Commercial |
$248.26
|
| Rate for Payer: PHP All Commercial |
$251.05
|
| Rate for Payer: Sagamore Health Network All Products |
$255.55
|
| Rate for Payer: Signature Care EPO |
$274.75
|
| Rate for Payer: Signature Care PPO |
$291.30
|
| Rate for Payer: United Healthcare Commercial |
$260.84
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 15 ML VIAL
|
Facility
IP
|
$484.38
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101001
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$363.28 |
| Max. Negotiated Rate |
$450.47 |
| Rate for Payer: Aetna Commercial |
$418.50
|
| Rate for Payer: Cash Price |
$300.32
|
| Rate for Payer: Cigna All Commercial |
$418.02
|
| Rate for Payer: CORVEL All Commercial |
$450.47
|
| Rate for Payer: Coventry All Commercial |
$426.25
|
| Rate for Payer: Encore All Commercial |
$445.87
|
| Rate for Payer: Frontpath All Commercial |
$445.63
|
| Rate for Payer: Humana ChoiceCare |
$418.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$435.94
|
| Rate for Payer: PHCS All Commercial |
$363.28
|
| Rate for Payer: PHP All Commercial |
$367.35
|
| Rate for Payer: Sagamore Health Network All Products |
$373.94
|
| Rate for Payer: Signature Care EPO |
$402.04
|
| Rate for Payer: Signature Care PPO |
$426.25
|
| Rate for Payer: United Healthcare Commercial |
$381.69
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 15 ML VIAL
|
Facility
OP
|
$484.38
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$159.85 |
| Max. Negotiated Rate |
$450.47 |
| Rate for Payer: Aetna Commercial |
$408.82
|
| Rate for Payer: Aetna Medicare |
$159.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$159.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$278.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$302.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$183.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$175.83
|
| Rate for Payer: Cash Price |
$300.32
|
| Rate for Payer: Centivo All Commercial |
$247.03
|
| Rate for Payer: Cigna All Commercial |
$418.02
|
| Rate for Payer: CORVEL All Commercial |
$450.47
|
| Rate for Payer: Coventry All Commercial |
$426.25
|
| Rate for Payer: Encore All Commercial |
$445.87
|
| Rate for Payer: Frontpath All Commercial |
$445.63
|
| Rate for Payer: Humana ChoiceCare |
$418.36
|
| Rate for Payer: Humana Medicare |
$247.03
|
| Rate for Payer: Lucent All Commercial |
$247.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$435.94
|
| Rate for Payer: PHCS All Commercial |
$363.28
|
| Rate for Payer: PHP All Commercial |
$367.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$188.91
|
| Rate for Payer: Sagamore Health Network All Products |
$373.94
|
| Rate for Payer: Signature Care EPO |
$402.04
|
| Rate for Payer: Signature Care PPO |
$426.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$411.72
|
| Rate for Payer: United Healthcare Commercial |
$381.69
|
| Rate for Payer: United Healthcare Medicare |
$159.85
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 20 ML VIAL
|
Facility
IP
|
$598.20
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$448.65 |
| Max. Negotiated Rate |
$556.33 |
| Rate for Payer: Aetna Commercial |
$516.84
|
| Rate for Payer: Cash Price |
$370.88
|
| Rate for Payer: Cigna All Commercial |
$516.25
|
| Rate for Payer: CORVEL All Commercial |
$556.33
|
| Rate for Payer: Coventry All Commercial |
$526.42
|
| Rate for Payer: Encore All Commercial |
$550.64
|
| Rate for Payer: Frontpath All Commercial |
$550.34
|
| Rate for Payer: Humana ChoiceCare |
$516.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.38
|
| Rate for Payer: PHCS All Commercial |
$448.65
|
| Rate for Payer: PHP All Commercial |
$453.67
|
| Rate for Payer: Sagamore Health Network All Products |
$461.81
|
| Rate for Payer: Signature Care EPO |
$496.51
|
| Rate for Payer: Signature Care PPO |
$526.42
|
| Rate for Payer: United Healthcare Commercial |
$471.38
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 20 ML VIAL
|
Facility
OP
|
$598.20
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.41 |
| Max. Negotiated Rate |
$556.33 |
| Rate for Payer: Aetna Commercial |
$504.88
|
| Rate for Payer: Aetna Medicare |
$197.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$197.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$343.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$373.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.15
|
| Rate for Payer: Cash Price |
$370.88
|
| Rate for Payer: Centivo All Commercial |
$305.08
|
| Rate for Payer: Cigna All Commercial |
$516.25
|
| Rate for Payer: CORVEL All Commercial |
$556.33
|
| Rate for Payer: Coventry All Commercial |
$526.42
|
| Rate for Payer: Encore All Commercial |
$550.64
|
| Rate for Payer: Frontpath All Commercial |
$550.34
|
| Rate for Payer: Humana ChoiceCare |
$516.67
|
| Rate for Payer: Humana Medicare |
$305.08
|
| Rate for Payer: Lucent All Commercial |
$305.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.38
|
| Rate for Payer: PHCS All Commercial |
$448.65
|
| Rate for Payer: PHP All Commercial |
$453.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$233.30
|
| Rate for Payer: Sagamore Health Network All Products |
$461.81
|
| Rate for Payer: Signature Care EPO |
$496.51
|
| Rate for Payer: Signature Care PPO |
$526.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$508.47
|
| Rate for Payer: United Healthcare Commercial |
$471.38
|
| Rate for Payer: United Healthcare Medicare |
$197.41
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 5 ML VIAL
|
Facility
OP
|
$196.84
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.96 |
| Max. Negotiated Rate |
$183.06 |
| Rate for Payer: Aetna Commercial |
$166.13
|
| Rate for Payer: Aetna Medicare |
$64.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$113.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$123.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$74.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$71.45
|
| Rate for Payer: Cash Price |
$122.04
|
| Rate for Payer: Centivo All Commercial |
$100.39
|
| Rate for Payer: Cigna All Commercial |
$169.87
|
| Rate for Payer: CORVEL All Commercial |
$183.06
|
| Rate for Payer: Coventry All Commercial |
$173.22
|
| Rate for Payer: Encore All Commercial |
$181.19
|
| Rate for Payer: Frontpath All Commercial |
$181.09
|
| Rate for Payer: Humana ChoiceCare |
$170.01
|
| Rate for Payer: Humana Medicare |
$100.39
|
| Rate for Payer: Lucent All Commercial |
$100.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.16
|
| Rate for Payer: PHCS All Commercial |
$147.63
|
| Rate for Payer: PHP All Commercial |
$149.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.77
|
| Rate for Payer: Sagamore Health Network All Products |
$151.96
|
| Rate for Payer: Signature Care EPO |
$163.38
|
| Rate for Payer: Signature Care PPO |
$173.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$167.31
|
| Rate for Payer: United Healthcare Commercial |
$155.11
|
| Rate for Payer: United Healthcare Medicare |
$64.96
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 5 ML VIAL
|
Facility
IP
|
$196.84
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$147.63 |
| Max. Negotiated Rate |
$183.06 |
| Rate for Payer: Aetna Commercial |
$170.07
|
| Rate for Payer: Cash Price |
$122.04
|
| Rate for Payer: Cigna All Commercial |
$169.87
|
| Rate for Payer: CORVEL All Commercial |
$183.06
|
| Rate for Payer: Coventry All Commercial |
$173.22
|
| Rate for Payer: Encore All Commercial |
$181.19
|
| Rate for Payer: Frontpath All Commercial |
$181.09
|
| Rate for Payer: Humana ChoiceCare |
$170.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.16
|
| Rate for Payer: PHCS All Commercial |
$147.63
|
| Rate for Payer: PHP All Commercial |
$149.28
|
| Rate for Payer: Sagamore Health Network All Products |
$151.96
|
| Rate for Payer: Signature Care EPO |
$163.38
|
| Rate for Payer: Signature Care PPO |
$173.22
|
| Rate for Payer: United Healthcare Commercial |
$155.11
|
|
|
GADOTERIDOL 279.3 MG/ML IV SYRG 17 ML SYRINGE
|
Facility
IP
|
$524.28
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4081142261
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$393.21 |
| Max. Negotiated Rate |
$487.58 |
| Rate for Payer: Aetna Commercial |
$452.98
|
| Rate for Payer: Cash Price |
$325.05
|
| Rate for Payer: Cigna All Commercial |
$452.45
|
| Rate for Payer: CORVEL All Commercial |
$487.58
|
| Rate for Payer: Coventry All Commercial |
$461.37
|
| Rate for Payer: Encore All Commercial |
$482.60
|
| Rate for Payer: Frontpath All Commercial |
$482.34
|
| Rate for Payer: Humana ChoiceCare |
$452.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$471.85
|
| Rate for Payer: PHCS All Commercial |
$393.21
|
| Rate for Payer: PHP All Commercial |
$397.61
|
| Rate for Payer: Sagamore Health Network All Products |
$404.74
|
| Rate for Payer: Signature Care EPO |
$435.15
|
| Rate for Payer: Signature Care PPO |
$461.37
|
| Rate for Payer: United Healthcare Commercial |
$413.13
|
|
|
GADOTERIDOL 279.3 MG/ML IV SYRG 17 ML SYRINGE
|
Facility
OP
|
$524.28
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4081142261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.01 |
| Max. Negotiated Rate |
$487.58 |
| Rate for Payer: Aetna Commercial |
$442.49
|
| Rate for Payer: Aetna Medicare |
$173.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$301.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$327.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$198.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$190.31
|
| Rate for Payer: Cash Price |
$325.05
|
| Rate for Payer: Centivo All Commercial |
$267.38
|
| Rate for Payer: Cigna All Commercial |
$452.45
|
| Rate for Payer: CORVEL All Commercial |
$487.58
|
| Rate for Payer: Coventry All Commercial |
$461.37
|
| Rate for Payer: Encore All Commercial |
$482.60
|
| Rate for Payer: Frontpath All Commercial |
$482.34
|
| Rate for Payer: Humana ChoiceCare |
$452.82
|
| Rate for Payer: Humana Medicare |
$267.38
|
| Rate for Payer: Lucent All Commercial |
$267.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$471.85
|
| Rate for Payer: PHCS All Commercial |
$393.21
|
| Rate for Payer: PHP All Commercial |
$397.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$204.47
|
| Rate for Payer: Sagamore Health Network All Products |
$404.74
|
| Rate for Payer: Signature Care EPO |
$435.15
|
| Rate for Payer: Signature Care PPO |
$461.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$445.64
|
| Rate for Payer: United Healthcare Commercial |
$413.13
|
| Rate for Payer: United Healthcare Medicare |
$173.01
|
|
|
GADOXETATE 2.5 MMOL/10 ML IV SOLN 10 ML VIAL
|
Facility
IP
|
$709.80
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$532.35 |
| Max. Negotiated Rate |
$660.11 |
| Rate for Payer: Aetna Commercial |
$613.27
|
| Rate for Payer: Cash Price |
$440.08
|
| Rate for Payer: Cigna All Commercial |
$612.56
|
| Rate for Payer: CORVEL All Commercial |
$660.11
|
| Rate for Payer: Coventry All Commercial |
$624.62
|
| Rate for Payer: Encore All Commercial |
$653.37
|
| Rate for Payer: Frontpath All Commercial |
$653.02
|
| Rate for Payer: Humana ChoiceCare |
$613.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$638.82
|
| Rate for Payer: PHCS All Commercial |
$532.35
|
| Rate for Payer: PHP All Commercial |
$538.31
|
| Rate for Payer: Sagamore Health Network All Products |
$547.97
|
| Rate for Payer: Signature Care EPO |
$589.13
|
| Rate for Payer: Signature Care PPO |
$624.62
|
| Rate for Payer: United Healthcare Commercial |
$559.32
|
|
|
GADOXETATE 2.5 MMOL/10 ML IV SOLN 10 ML VIAL
|
Facility
OP
|
$709.80
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.23 |
| Max. Negotiated Rate |
$660.11 |
| Rate for Payer: Aetna Commercial |
$599.07
|
| Rate for Payer: Aetna Medicare |
$234.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$234.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$407.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$443.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$269.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$257.66
|
| Rate for Payer: Cash Price |
$440.08
|
| Rate for Payer: Centivo All Commercial |
$362.00
|
| Rate for Payer: Cigna All Commercial |
$612.56
|
| Rate for Payer: CORVEL All Commercial |
$660.11
|
| Rate for Payer: Coventry All Commercial |
$624.62
|
| Rate for Payer: Encore All Commercial |
$653.37
|
| Rate for Payer: Frontpath All Commercial |
$653.02
|
| Rate for Payer: Humana ChoiceCare |
$613.05
|
| Rate for Payer: Humana Medicare |
$362.00
|
| Rate for Payer: Lucent All Commercial |
$362.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$638.82
|
| Rate for Payer: PHCS All Commercial |
$532.35
|
| Rate for Payer: PHP All Commercial |
$538.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$276.82
|
| Rate for Payer: Sagamore Health Network All Products |
$547.97
|
| Rate for Payer: Signature Care EPO |
$589.13
|
| Rate for Payer: Signature Care PPO |
$624.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$603.33
|
| Rate for Payer: United Healthcare Commercial |
$559.32
|
| Rate for Payer: United Healthcare Medicare |
$234.23
|
|
|
GELATIN ABSORBABLE MM POWD
|
Facility
IP
|
$535.63
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$401.72 |
| Max. Negotiated Rate |
$498.14 |
| Rate for Payer: Aetna Commercial |
$462.79
|
| Rate for Payer: Cash Price |
$332.09
|
| Rate for Payer: Cigna All Commercial |
$462.25
|
| Rate for Payer: CORVEL All Commercial |
$498.14
|
| Rate for Payer: Coventry All Commercial |
$471.36
|
| Rate for Payer: Encore All Commercial |
$493.05
|
| Rate for Payer: Frontpath All Commercial |
$492.78
|
| Rate for Payer: Humana ChoiceCare |
$462.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$482.07
|
| Rate for Payer: PHCS All Commercial |
$401.72
|
| Rate for Payer: PHP All Commercial |
$406.22
|
| Rate for Payer: Sagamore Health Network All Products |
$413.51
|
| Rate for Payer: Signature Care EPO |
$444.57
|
| Rate for Payer: Signature Care PPO |
$471.36
|
| Rate for Payer: United Healthcare Commercial |
$422.08
|
|
|
GELATIN ABSORBABLE MM POWD
|
Facility
OP
|
$535.63
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$498.14 |
| Rate for Payer: Aetna Commercial |
$452.07
|
| Rate for Payer: Aetna Medicare |
$176.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$176.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$307.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$334.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$203.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$194.43
|
| Rate for Payer: Cash Price |
$332.09
|
| Rate for Payer: Cash Price |
$332.09
|
| Rate for Payer: Centivo All Commercial |
$273.17
|
| Rate for Payer: Cigna All Commercial |
$462.25
|
| Rate for Payer: CORVEL All Commercial |
$498.14
|
| Rate for Payer: Coventry All Commercial |
$471.36
|
| Rate for Payer: Encore All Commercial |
$493.05
|
| Rate for Payer: Frontpath All Commercial |
$492.78
|
| Rate for Payer: Humana ChoiceCare |
$462.63
|
| Rate for Payer: Humana Medicare |
$273.17
|
| Rate for Payer: Lucent All Commercial |
$273.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$482.07
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$401.72
|
| Rate for Payer: PHP All Commercial |
$406.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$208.90
|
| Rate for Payer: Sagamore Health Network All Products |
$413.51
|
| Rate for Payer: Signature Care EPO |
$444.57
|
| Rate for Payer: Signature Care PPO |
$471.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$455.29
|
| Rate for Payer: United Healthcare Commercial |
$422.08
|
| Rate for Payer: United Healthcare Medicare |
$176.76
|
|
