|
TECHNETIUM TC 99M MERTIATIDE
|
Facility
|
OP
|
$1,755.84
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
40840068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$544.31 |
| Max. Negotiated Rate |
$1,632.93 |
| Rate for Payer: Aetna Commercial |
$1,481.93
|
| Rate for Payer: Aetna Medicare |
$561.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,580.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$544.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,008.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,097.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,580.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$646.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$618.06
|
| Rate for Payer: Cash Price |
$1,053.50
|
| Rate for Payer: Centivo All Commercial |
$955.18
|
| Rate for Payer: Cigna All Commercial |
$1,515.29
|
| Rate for Payer: CORVEL All Commercial |
$1,632.93
|
| Rate for Payer: Coventry All Commercial |
$1,545.14
|
| Rate for Payer: Encore All Commercial |
$1,616.25
|
| Rate for Payer: Frontpath All Commercial |
$1,615.37
|
| Rate for Payer: Humana ChoiceCare |
$1,516.52
|
| Rate for Payer: Humana Medicare |
$561.87
|
| Rate for Payer: Lucent All Commercial |
$955.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,580.26
|
| Rate for Payer: Managed Health Services Medicaid |
$1,580.26
|
| Rate for Payer: MDWise Medicaid |
$1,580.26
|
| Rate for Payer: PHCS All Commercial |
$1,316.88
|
| Rate for Payer: PHP All Commercial |
$1,331.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$684.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1,355.51
|
| Rate for Payer: Signature Care EPO |
$1,457.35
|
| Rate for Payer: Signature Care PPO |
$1,545.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,492.46
|
| Rate for Payer: United Healthcare Commercial |
$1,383.60
|
| Rate for Payer: United Healthcare Medicare |
$561.87
|
|
|
TECHNETIUM TC 99M MERTIATIDE
|
Facility
|
IP
|
$1,755.84
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
40840068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,316.88 |
| Max. Negotiated Rate |
$1,632.93 |
| Rate for Payer: Aetna Commercial |
$1,517.05
|
| Rate for Payer: Cash Price |
$1,053.50
|
| Rate for Payer: Cigna All Commercial |
$1,515.29
|
| Rate for Payer: CORVEL All Commercial |
$1,632.93
|
| Rate for Payer: Coventry All Commercial |
$1,545.14
|
| Rate for Payer: Encore All Commercial |
$1,616.25
|
| Rate for Payer: Frontpath All Commercial |
$1,615.37
|
| Rate for Payer: Humana ChoiceCare |
$1,516.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,580.26
|
| Rate for Payer: PHCS All Commercial |
$1,316.88
|
| Rate for Payer: PHP All Commercial |
$1,331.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1,355.51
|
| Rate for Payer: Signature Care EPO |
$1,457.35
|
| Rate for Payer: Signature Care PPO |
$1,545.14
|
| Rate for Payer: United Healthcare Commercial |
$1,383.60
|
|
|
TECHNETIUM TC 99M OXIDRONATE KIT
|
Facility
|
IP
|
$359.64
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$269.73 |
| Max. Negotiated Rate |
$334.47 |
| Rate for Payer: Aetna Commercial |
$310.73
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cigna All Commercial |
$310.37
|
| Rate for Payer: CORVEL All Commercial |
$334.47
|
| Rate for Payer: Coventry All Commercial |
$316.48
|
| Rate for Payer: Encore All Commercial |
$331.05
|
| Rate for Payer: Frontpath All Commercial |
$330.87
|
| Rate for Payer: Humana ChoiceCare |
$310.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.68
|
| Rate for Payer: PHCS All Commercial |
$269.73
|
| Rate for Payer: PHP All Commercial |
$272.75
|
| Rate for Payer: Sagamore Health Network All Products |
$277.64
|
| Rate for Payer: Signature Care EPO |
$298.50
|
| Rate for Payer: Signature Care PPO |
$316.48
|
| Rate for Payer: United Healthcare Commercial |
$283.40
|
|
|
TECHNETIUM TC 99M OXIDRONATE KIT
|
Facility
|
OP
|
$359.64
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$111.49 |
| Max. Negotiated Rate |
$334.47 |
| Rate for Payer: Aetna Commercial |
$303.54
|
| Rate for Payer: Aetna Medicare |
$115.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$111.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$206.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$224.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.59
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Centivo All Commercial |
$195.64
|
| Rate for Payer: Cigna All Commercial |
$310.37
|
| Rate for Payer: CORVEL All Commercial |
$334.47
|
| Rate for Payer: Coventry All Commercial |
$316.48
|
| Rate for Payer: Encore All Commercial |
$331.05
|
| Rate for Payer: Frontpath All Commercial |
$330.87
|
| Rate for Payer: Humana ChoiceCare |
$310.62
|
| Rate for Payer: Humana Medicare |
$115.08
|
| Rate for Payer: Lucent All Commercial |
$195.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$323.68
|
| Rate for Payer: PHCS All Commercial |
$269.73
|
| Rate for Payer: PHP All Commercial |
$272.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$140.26
|
| Rate for Payer: Sagamore Health Network All Products |
$277.64
|
| Rate for Payer: Signature Care EPO |
$298.50
|
| Rate for Payer: Signature Care PPO |
$316.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.69
|
| Rate for Payer: United Healthcare Commercial |
$283.40
|
| Rate for Payer: United Healthcare Medicare |
$115.08
|
|
|
TECHNETIUM TC 99M SULFER COLLOID FILTERED
|
Facility
|
OP
|
$1,170.40
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
162258
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$362.82 |
| Max. Negotiated Rate |
$1,088.47 |
| Rate for Payer: Aetna Commercial |
$987.82
|
| Rate for Payer: Aetna Medicare |
$374.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$362.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$672.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$731.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$430.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$411.98
|
| Rate for Payer: Cash Price |
$702.24
|
| Rate for Payer: Centivo All Commercial |
$636.70
|
| Rate for Payer: Cigna All Commercial |
$1,010.06
|
| Rate for Payer: CORVEL All Commercial |
$1,088.47
|
| Rate for Payer: Coventry All Commercial |
$1,029.95
|
| Rate for Payer: Encore All Commercial |
$1,077.35
|
| Rate for Payer: Frontpath All Commercial |
$1,076.77
|
| Rate for Payer: Humana ChoiceCare |
$1,010.87
|
| Rate for Payer: Humana Medicare |
$374.53
|
| Rate for Payer: Lucent All Commercial |
$636.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,053.36
|
| Rate for Payer: PHCS All Commercial |
$877.80
|
| Rate for Payer: PHP All Commercial |
$887.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$456.46
|
| Rate for Payer: Sagamore Health Network All Products |
$903.55
|
| Rate for Payer: Signature Care EPO |
$971.43
|
| Rate for Payer: Signature Care PPO |
$1,029.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$994.84
|
| Rate for Payer: United Healthcare Commercial |
$922.28
|
| Rate for Payer: United Healthcare Medicare |
$374.53
|
|
|
TECHNETIUM TC 99M SULFER COLLOID FILTERED
|
Facility
|
IP
|
$1,170.40
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
162258
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$877.80 |
| Max. Negotiated Rate |
$1,088.47 |
| Rate for Payer: Aetna Commercial |
$1,011.23
|
| Rate for Payer: Cash Price |
$702.24
|
| Rate for Payer: Cigna All Commercial |
$1,010.06
|
| Rate for Payer: CORVEL All Commercial |
$1,088.47
|
| Rate for Payer: Coventry All Commercial |
$1,029.95
|
| Rate for Payer: Encore All Commercial |
$1,077.35
|
| Rate for Payer: Frontpath All Commercial |
$1,076.77
|
| Rate for Payer: Humana ChoiceCare |
$1,010.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,053.36
|
| Rate for Payer: PHCS All Commercial |
$877.80
|
| Rate for Payer: PHP All Commercial |
$887.63
|
| Rate for Payer: Sagamore Health Network All Products |
$903.55
|
| Rate for Payer: Signature Care EPO |
$971.43
|
| Rate for Payer: Signature Care PPO |
$1,029.95
|
| Rate for Payer: United Healthcare Commercial |
$922.28
|
|
|
TECHNETIUM TC 99M TILMANOCEPT KIT
|
Facility
|
OP
|
$3,190.52
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4080800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$989.06 |
| Max. Negotiated Rate |
$2,967.18 |
| Rate for Payer: Aetna Commercial |
$2,692.80
|
| Rate for Payer: Aetna Medicare |
$1,020.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$989.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,832.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,994.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,174.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,123.06
|
| Rate for Payer: Cash Price |
$1,914.31
|
| Rate for Payer: Centivo All Commercial |
$1,735.64
|
| Rate for Payer: Cigna All Commercial |
$2,753.42
|
| Rate for Payer: CORVEL All Commercial |
$2,967.18
|
| Rate for Payer: Coventry All Commercial |
$2,807.66
|
| Rate for Payer: Encore All Commercial |
$2,936.87
|
| Rate for Payer: Frontpath All Commercial |
$2,935.28
|
| Rate for Payer: Humana ChoiceCare |
$2,755.65
|
| Rate for Payer: Humana Medicare |
$1,020.97
|
| Rate for Payer: Lucent All Commercial |
$1,735.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,871.47
|
| Rate for Payer: PHCS All Commercial |
$2,392.89
|
| Rate for Payer: PHP All Commercial |
$2,419.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,244.30
|
| Rate for Payer: Sagamore Health Network All Products |
$2,463.08
|
| Rate for Payer: Signature Care EPO |
$2,648.13
|
| Rate for Payer: Signature Care PPO |
$2,807.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,711.94
|
| Rate for Payer: United Healthcare Commercial |
$2,514.13
|
| Rate for Payer: United Healthcare Medicare |
$1,020.97
|
|
|
TECHNETIUM TC 99M TILMANOCEPT KIT
|
Facility
|
IP
|
$3,190.52
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
4080800676
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,392.89 |
| Max. Negotiated Rate |
$2,967.18 |
| Rate for Payer: Aetna Commercial |
$2,756.61
|
| Rate for Payer: Cash Price |
$1,914.31
|
| Rate for Payer: Cigna All Commercial |
$2,753.42
|
| Rate for Payer: CORVEL All Commercial |
$2,967.18
|
| Rate for Payer: Coventry All Commercial |
$2,807.66
|
| Rate for Payer: Encore All Commercial |
$2,936.87
|
| Rate for Payer: Frontpath All Commercial |
$2,935.28
|
| Rate for Payer: Humana ChoiceCare |
$2,755.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,871.47
|
| Rate for Payer: PHCS All Commercial |
$2,392.89
|
| Rate for Payer: PHP All Commercial |
$2,419.69
|
| Rate for Payer: Sagamore Health Network All Products |
$2,463.08
|
| Rate for Payer: Signature Care EPO |
$2,648.13
|
| Rate for Payer: Signature Care PPO |
$2,807.66
|
| Rate for Payer: United Healthcare Commercial |
$2,514.13
|
|
|
TECHNETIUM TO 99M ALBUMIN AGGREGATED
|
Facility
|
IP
|
$1,003.95
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
40840064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$752.96 |
| Max. Negotiated Rate |
$933.67 |
| Rate for Payer: Aetna Commercial |
$867.41
|
| Rate for Payer: Cash Price |
$602.37
|
| Rate for Payer: Cigna All Commercial |
$866.41
|
| Rate for Payer: CORVEL All Commercial |
$933.67
|
| Rate for Payer: Coventry All Commercial |
$883.48
|
| Rate for Payer: Encore All Commercial |
$924.14
|
| Rate for Payer: Frontpath All Commercial |
$923.63
|
| Rate for Payer: Humana ChoiceCare |
$867.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$903.55
|
| Rate for Payer: PHCS All Commercial |
$752.96
|
| Rate for Payer: PHP All Commercial |
$761.40
|
| Rate for Payer: Sagamore Health Network All Products |
$775.05
|
| Rate for Payer: Signature Care EPO |
$833.28
|
| Rate for Payer: Signature Care PPO |
$883.48
|
| Rate for Payer: United Healthcare Commercial |
$791.11
|
|
|
TECHNETIUM TO 99M ALBUMIN AGGREGATED
|
Facility
|
OP
|
$1,003.95
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
40840064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$311.22 |
| Max. Negotiated Rate |
$933.67 |
| Rate for Payer: Aetna Commercial |
$847.33
|
| Rate for Payer: Aetna Medicare |
$321.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$311.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$576.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$627.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$369.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$353.39
|
| Rate for Payer: Cash Price |
$602.37
|
| Rate for Payer: Centivo All Commercial |
$546.15
|
| Rate for Payer: Cigna All Commercial |
$866.41
|
| Rate for Payer: CORVEL All Commercial |
$933.67
|
| Rate for Payer: Coventry All Commercial |
$883.48
|
| Rate for Payer: Encore All Commercial |
$924.14
|
| Rate for Payer: Frontpath All Commercial |
$923.63
|
| Rate for Payer: Humana ChoiceCare |
$867.11
|
| Rate for Payer: Humana Medicare |
$321.26
|
| Rate for Payer: Lucent All Commercial |
$546.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$903.55
|
| Rate for Payer: PHCS All Commercial |
$752.96
|
| Rate for Payer: PHP All Commercial |
$761.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$391.54
|
| Rate for Payer: Sagamore Health Network All Products |
$775.05
|
| Rate for Payer: Signature Care EPO |
$833.28
|
| Rate for Payer: Signature Care PPO |
$883.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$853.36
|
| Rate for Payer: United Healthcare Commercial |
$791.11
|
| Rate for Payer: United Healthcare Medicare |
$321.26
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
|
IP
|
$4.14
|
|
|
Service Code
|
NDC 50268077915
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna All Commercial |
$3.58
|
| Rate for Payer: CORVEL All Commercial |
$3.85
|
| Rate for Payer: Coventry All Commercial |
$3.65
|
| Rate for Payer: Encore All Commercial |
$3.81
|
| Rate for Payer: Frontpath All Commercial |
$3.81
|
| Rate for Payer: Humana ChoiceCare |
$3.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.73
|
| Rate for Payer: PHCS All Commercial |
$3.11
|
| Rate for Payer: PHP All Commercial |
$3.14
|
| Rate for Payer: Sagamore Health Network All Products |
$3.20
|
| Rate for Payer: Signature Care EPO |
$3.44
|
| Rate for Payer: Signature Care PPO |
$3.65
|
| Rate for Payer: United Healthcare Commercial |
$3.27
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
|
IP
|
$4.14
|
|
|
Service Code
|
NDC 50268077911
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna All Commercial |
$3.58
|
| Rate for Payer: CORVEL All Commercial |
$3.85
|
| Rate for Payer: Coventry All Commercial |
$3.65
|
| Rate for Payer: Encore All Commercial |
$3.81
|
| Rate for Payer: Frontpath All Commercial |
$3.81
|
| Rate for Payer: Humana ChoiceCare |
$3.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.73
|
| Rate for Payer: PHCS All Commercial |
$3.11
|
| Rate for Payer: PHP All Commercial |
$3.14
|
| Rate for Payer: Sagamore Health Network All Products |
$3.20
|
| Rate for Payer: Signature Care EPO |
$3.44
|
| Rate for Payer: Signature Care PPO |
$3.65
|
| Rate for Payer: United Healthcare Commercial |
$3.27
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
|
OP
|
$4.14
|
|
|
Service Code
|
NDC 50268077911
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna Medicare |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.46
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Centivo All Commercial |
$2.25
|
| Rate for Payer: Cigna All Commercial |
$3.58
|
| Rate for Payer: CORVEL All Commercial |
$3.85
|
| Rate for Payer: Coventry All Commercial |
$3.65
|
| Rate for Payer: Encore All Commercial |
$3.81
|
| Rate for Payer: Frontpath All Commercial |
$3.81
|
| Rate for Payer: Humana ChoiceCare |
$3.58
|
| Rate for Payer: Humana Medicare |
$1.33
|
| Rate for Payer: Lucent All Commercial |
$2.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.73
|
| Rate for Payer: PHCS All Commercial |
$3.11
|
| Rate for Payer: PHP All Commercial |
$3.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.62
|
| Rate for Payer: Sagamore Health Network All Products |
$3.20
|
| Rate for Payer: Signature Care EPO |
$3.44
|
| Rate for Payer: Signature Care PPO |
$3.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.27
|
| Rate for Payer: United Healthcare Medicare |
$1.33
|
|
|
TEMAZEPAM 15 MG ORAL CAP
|
Facility
|
OP
|
$4.14
|
|
|
Service Code
|
NDC 50268077915
|
| Hospital Charge Code |
7753
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna Medicare |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.46
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Centivo All Commercial |
$2.25
|
| Rate for Payer: Cigna All Commercial |
$3.58
|
| Rate for Payer: CORVEL All Commercial |
$3.85
|
| Rate for Payer: Coventry All Commercial |
$3.65
|
| Rate for Payer: Encore All Commercial |
$3.81
|
| Rate for Payer: Frontpath All Commercial |
$3.81
|
| Rate for Payer: Humana ChoiceCare |
$3.58
|
| Rate for Payer: Humana Medicare |
$1.33
|
| Rate for Payer: Lucent All Commercial |
$2.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.73
|
| Rate for Payer: PHCS All Commercial |
$3.11
|
| Rate for Payer: PHP All Commercial |
$3.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.62
|
| Rate for Payer: Sagamore Health Network All Products |
$3.20
|
| Rate for Payer: Signature Care EPO |
$3.44
|
| Rate for Payer: Signature Care PPO |
$3.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.27
|
| Rate for Payer: United Healthcare Medicare |
$1.33
|
|
|
TENECTEPLASE 50 MG IV SOLR
|
Facility
|
OP
|
$27,225.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
184169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$25,319.60 |
| Rate for Payer: Aetna Commercial |
$22,978.22
|
| Rate for Payer: Aetna Medicare |
$8,712.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$174.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,439.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15,635.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17,018.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$174.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,018.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,583.33
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Centivo All Commercial |
$14,810.61
|
| Rate for Payer: Cigna All Commercial |
$23,495.50
|
| Rate for Payer: CORVEL All Commercial |
$25,319.60
|
| Rate for Payer: Coventry All Commercial |
$23,958.33
|
| Rate for Payer: Encore All Commercial |
$25,060.96
|
| Rate for Payer: Frontpath All Commercial |
$25,047.35
|
| Rate for Payer: Humana ChoiceCare |
$23,514.56
|
| Rate for Payer: Humana Medicare |
$8,712.12
|
| Rate for Payer: Lucent All Commercial |
$14,810.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,502.84
|
| Rate for Payer: Managed Health Services Medicaid |
$174.24
|
| Rate for Payer: MDWise Medicaid |
$174.24
|
| Rate for Payer: PHCS All Commercial |
$20,419.03
|
| Rate for Payer: PHP All Commercial |
$20,647.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,617.90
|
| Rate for Payer: Sagamore Health Network All Products |
$21,017.99
|
| Rate for Payer: Signature Care EPO |
$22,597.07
|
| Rate for Payer: Signature Care PPO |
$23,958.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23,141.57
|
| Rate for Payer: United Healthcare Commercial |
$21,453.60
|
| Rate for Payer: United Healthcare Medicare |
$8,712.12
|
|
|
TENECTEPLASE 50 MG IV SOLR
|
Facility
|
IP
|
$27,225.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
184169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20,419.03 |
| Max. Negotiated Rate |
$25,319.60 |
| Rate for Payer: Aetna Commercial |
$23,522.73
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Cigna All Commercial |
$23,495.50
|
| Rate for Payer: CORVEL All Commercial |
$25,319.60
|
| Rate for Payer: Coventry All Commercial |
$23,958.33
|
| Rate for Payer: Encore All Commercial |
$25,060.96
|
| Rate for Payer: Frontpath All Commercial |
$25,047.35
|
| Rate for Payer: Humana ChoiceCare |
$23,514.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,502.84
|
| Rate for Payer: PHCS All Commercial |
$20,419.03
|
| Rate for Payer: PHP All Commercial |
$20,647.73
|
| Rate for Payer: Sagamore Health Network All Products |
$21,017.99
|
| Rate for Payer: Signature Care EPO |
$22,597.07
|
| Rate for Payer: Signature Care PPO |
$23,958.33
|
| Rate for Payer: United Healthcare Commercial |
$21,453.60
|
|
|
TENECTEPLASE FOR STROKE
|
Facility
|
OP
|
$27,225.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
4080184169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$25,319.60 |
| Rate for Payer: Aetna Commercial |
$22,978.22
|
| Rate for Payer: Aetna Medicare |
$8,712.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$174.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8,439.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15,635.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17,018.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$174.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10,018.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9,583.33
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Centivo All Commercial |
$14,810.61
|
| Rate for Payer: Cigna All Commercial |
$23,495.50
|
| Rate for Payer: CORVEL All Commercial |
$25,319.60
|
| Rate for Payer: Coventry All Commercial |
$23,958.33
|
| Rate for Payer: Encore All Commercial |
$25,060.96
|
| Rate for Payer: Frontpath All Commercial |
$25,047.35
|
| Rate for Payer: Humana ChoiceCare |
$23,514.56
|
| Rate for Payer: Humana Medicare |
$8,712.12
|
| Rate for Payer: Lucent All Commercial |
$14,810.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,502.84
|
| Rate for Payer: Managed Health Services Medicaid |
$174.24
|
| Rate for Payer: MDWise Medicaid |
$174.24
|
| Rate for Payer: PHCS All Commercial |
$20,419.03
|
| Rate for Payer: PHP All Commercial |
$20,647.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10,617.90
|
| Rate for Payer: Sagamore Health Network All Products |
$21,017.99
|
| Rate for Payer: Signature Care EPO |
$22,597.07
|
| Rate for Payer: Signature Care PPO |
$23,958.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23,141.57
|
| Rate for Payer: United Healthcare Commercial |
$21,453.60
|
| Rate for Payer: United Healthcare Medicare |
$8,712.12
|
|
|
TENECTEPLASE FOR STROKE
|
Facility
|
IP
|
$27,225.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
4080184169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20,419.03 |
| Max. Negotiated Rate |
$25,319.60 |
| Rate for Payer: Aetna Commercial |
$23,522.73
|
| Rate for Payer: Cash Price |
$16,335.23
|
| Rate for Payer: Cigna All Commercial |
$23,495.50
|
| Rate for Payer: CORVEL All Commercial |
$25,319.60
|
| Rate for Payer: Coventry All Commercial |
$23,958.33
|
| Rate for Payer: Encore All Commercial |
$25,060.96
|
| Rate for Payer: Frontpath All Commercial |
$25,047.35
|
| Rate for Payer: Humana ChoiceCare |
$23,514.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24,502.84
|
| Rate for Payer: PHCS All Commercial |
$20,419.03
|
| Rate for Payer: PHP All Commercial |
$20,647.73
|
| Rate for Payer: Sagamore Health Network All Products |
$21,017.99
|
| Rate for Payer: Signature Care EPO |
$22,597.07
|
| Rate for Payer: Signature Care PPO |
$23,958.33
|
| Rate for Payer: United Healthcare Commercial |
$21,453.60
|
|
|
TERAZOSIN 1 MG ORAL CAP
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 50268076415
|
| Hospital Charge Code |
14550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: Aetna Medicare |
$1.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.65
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Centivo All Commercial |
$2.55
|
| Rate for Payer: Cigna All Commercial |
$4.05
|
| Rate for Payer: CORVEL All Commercial |
$4.36
|
| Rate for Payer: Coventry All Commercial |
$4.13
|
| Rate for Payer: Encore All Commercial |
$4.32
|
| Rate for Payer: Frontpath All Commercial |
$4.31
|
| Rate for Payer: Humana ChoiceCare |
$4.05
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Lucent All Commercial |
$2.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.22
|
| Rate for Payer: PHCS All Commercial |
$3.52
|
| Rate for Payer: PHP All Commercial |
$3.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.83
|
| Rate for Payer: Sagamore Health Network All Products |
$3.62
|
| Rate for Payer: Signature Care EPO |
$3.89
|
| Rate for Payer: Signature Care PPO |
$4.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.99
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
| Rate for Payer: United Healthcare Medicare |
$1.50
|
|
|
TERAZOSIN 1 MG ORAL CAP
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 50268076415
|
| Hospital Charge Code |
14550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$4.05
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cigna All Commercial |
$4.05
|
| Rate for Payer: CORVEL All Commercial |
$4.36
|
| Rate for Payer: Coventry All Commercial |
$4.13
|
| Rate for Payer: Encore All Commercial |
$4.32
|
| Rate for Payer: Frontpath All Commercial |
$4.31
|
| Rate for Payer: Humana ChoiceCare |
$4.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.22
|
| Rate for Payer: PHCS All Commercial |
$3.52
|
| Rate for Payer: PHP All Commercial |
$3.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.62
|
| Rate for Payer: Signature Care EPO |
$3.89
|
| Rate for Payer: Signature Care PPO |
$4.13
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
|
|
TERBINAFINE HCL 250 MG ORAL TAB
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 65862007930
|
| Hospital Charge Code |
12724
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna All Commercial |
$1.44
|
| Rate for Payer: CORVEL All Commercial |
$1.55
|
| Rate for Payer: Coventry All Commercial |
$1.47
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.50
|
| Rate for Payer: PHCS All Commercial |
$1.25
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1.29
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
|
|
TERBINAFINE HCL 250 MG ORAL TAB
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 65862007930
|
| Hospital Charge Code |
12724
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.41
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Centivo All Commercial |
$0.91
|
| Rate for Payer: Cigna All Commercial |
$1.44
|
| Rate for Payer: CORVEL All Commercial |
$1.55
|
| Rate for Payer: Coventry All Commercial |
$1.47
|
| Rate for Payer: Encore All Commercial |
$1.53
|
| Rate for Payer: Frontpath All Commercial |
$1.53
|
| Rate for Payer: Humana ChoiceCare |
$1.44
|
| Rate for Payer: Humana Medicare |
$0.53
|
| Rate for Payer: Lucent All Commercial |
$0.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.50
|
| Rate for Payer: PHCS All Commercial |
$1.25
|
| Rate for Payer: PHP All Commercial |
$1.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1.29
|
| Rate for Payer: Signature Care EPO |
$1.38
|
| Rate for Payer: Signature Care PPO |
$1.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.42
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
TERBUTALINE 1 MG/ML SUBQ SOLN
|
Facility
|
IP
|
$23.63
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$14.18
|
| Rate for Payer: Cigna All Commercial |
$20.39
|
| Rate for Payer: CORVEL All Commercial |
$21.97
|
| Rate for Payer: Coventry All Commercial |
$20.79
|
| Rate for Payer: Encore All Commercial |
$21.75
|
| Rate for Payer: Frontpath All Commercial |
$21.73
|
| Rate for Payer: Humana ChoiceCare |
$20.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.26
|
| Rate for Payer: PHCS All Commercial |
$17.72
|
| Rate for Payer: PHP All Commercial |
$17.92
|
| Rate for Payer: Sagamore Health Network All Products |
$18.24
|
| Rate for Payer: Signature Care EPO |
$19.61
|
| Rate for Payer: Signature Care PPO |
$20.79
|
| Rate for Payer: United Healthcare Commercial |
$18.62
|
|
|
TERBUTALINE 1 MG/ML SUBQ SOLN
|
Facility
|
OP
|
$23.63
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.32 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: Aetna Commercial |
$19.94
|
| Rate for Payer: Aetna Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$13.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.32
|
| Rate for Payer: Cash Price |
$14.18
|
| Rate for Payer: Centivo All Commercial |
$12.85
|
| Rate for Payer: Cigna All Commercial |
$20.39
|
| Rate for Payer: CORVEL All Commercial |
$21.97
|
| Rate for Payer: Coventry All Commercial |
$20.79
|
| Rate for Payer: Encore All Commercial |
$21.75
|
| Rate for Payer: Frontpath All Commercial |
$21.73
|
| Rate for Payer: Humana ChoiceCare |
$20.40
|
| Rate for Payer: Humana Medicare |
$7.56
|
| Rate for Payer: Lucent All Commercial |
$12.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.26
|
| Rate for Payer: PHCS All Commercial |
$17.72
|
| Rate for Payer: PHP All Commercial |
$17.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.21
|
| Rate for Payer: Sagamore Health Network All Products |
$18.24
|
| Rate for Payer: Signature Care EPO |
$19.61
|
| Rate for Payer: Signature Care PPO |
$20.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.08
|
| Rate for Payer: United Healthcare Commercial |
$18.62
|
| Rate for Payer: United Healthcare Medicare |
$7.56
|
|
|
TERBUTALINE 2.5 MG ORAL TAB
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
NDC 00115261101
|
| Hospital Charge Code |
11508
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$11.44 |
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: Aetna Medicare |
$3.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.33
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Centivo All Commercial |
$6.69
|
| Rate for Payer: Cigna All Commercial |
$10.61
|
| Rate for Payer: CORVEL All Commercial |
$11.44
|
| Rate for Payer: Coventry All Commercial |
$10.82
|
| Rate for Payer: Encore All Commercial |
$11.32
|
| Rate for Payer: Frontpath All Commercial |
$11.32
|
| Rate for Payer: Humana ChoiceCare |
$10.62
|
| Rate for Payer: Humana Medicare |
$3.94
|
| Rate for Payer: Lucent All Commercial |
$6.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.07
|
| Rate for Payer: PHCS All Commercial |
$9.22
|
| Rate for Payer: PHP All Commercial |
$9.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.80
|
| Rate for Payer: Sagamore Health Network All Products |
$9.49
|
| Rate for Payer: Signature Care EPO |
$10.21
|
| Rate for Payer: Signature Care PPO |
$10.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.45
|
| Rate for Payer: United Healthcare Commercial |
$9.69
|
| Rate for Payer: United Healthcare Medicare |
$3.94
|
|
