|
TECHNETIUM TC 99M DISOFENIN
|
Facility
|
OP
|
$237.44
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
40840071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.61 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna Commercial |
$200.40
|
| Rate for Payer: Aetna Medicare |
$75.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$136.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$148.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$87.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.58
|
| Rate for Payer: Cash Price |
$147.21
|
| Rate for Payer: Centivo All Commercial |
$129.17
|
| Rate for Payer: Cigna All Commercial |
$204.91
|
| Rate for Payer: CORVEL All Commercial |
$220.82
|
| Rate for Payer: Coventry All Commercial |
$208.95
|
| Rate for Payer: Encore All Commercial |
$218.56
|
| Rate for Payer: Frontpath All Commercial |
$218.44
|
| Rate for Payer: Humana ChoiceCare |
$205.08
|
| Rate for Payer: Humana Medicare |
$75.98
|
| Rate for Payer: Lucent All Commercial |
$129.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$213.70
|
| Rate for Payer: PHCS All Commercial |
$178.08
|
| Rate for Payer: PHP All Commercial |
$180.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.60
|
| Rate for Payer: Sagamore Health Network All Products |
$183.30
|
| Rate for Payer: Signature Care EPO |
$197.08
|
| Rate for Payer: Signature Care PPO |
$208.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$201.82
|
| Rate for Payer: United Healthcare Commercial |
$187.10
|
| Rate for Payer: United Healthcare Medicare |
$75.98
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$312.17 |
| Max. Negotiated Rate |
$936.51 |
| Rate for Payer: Aetna Commercial |
$849.91
|
| Rate for Payer: Aetna Medicare |
$322.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$312.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$578.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$629.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$370.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$354.46
|
| Rate for Payer: Cash Price |
$624.34
|
| Rate for Payer: Centivo All Commercial |
$547.81
|
| Rate for Payer: Cigna All Commercial |
$869.04
|
| Rate for Payer: CORVEL All Commercial |
$936.51
|
| Rate for Payer: Coventry All Commercial |
$886.16
|
| Rate for Payer: Encore All Commercial |
$926.94
|
| Rate for Payer: Frontpath All Commercial |
$926.44
|
| Rate for Payer: Humana ChoiceCare |
$869.75
|
| Rate for Payer: Humana Medicare |
$322.24
|
| Rate for Payer: Lucent All Commercial |
$547.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.30
|
| Rate for Payer: PHCS All Commercial |
$755.25
|
| Rate for Payer: PHP All Commercial |
$763.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$392.73
|
| Rate for Payer: Sagamore Health Network All Products |
$777.40
|
| Rate for Payer: Signature Care EPO |
$835.81
|
| Rate for Payer: Signature Care PPO |
$886.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$855.95
|
| Rate for Payer: United Healthcare Commercial |
$793.52
|
| Rate for Payer: United Healthcare Medicare |
$322.24
|
|
|
TECHNETIUM TC 99M LABELED RED BLOOD CELLS
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
40840062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$755.25 |
| Max. Negotiated Rate |
$936.51 |
| Rate for Payer: Aetna Commercial |
$870.05
|
| Rate for Payer: Cash Price |
$624.34
|
| Rate for Payer: Cigna All Commercial |
$869.04
|
| Rate for Payer: CORVEL All Commercial |
$936.51
|
| Rate for Payer: Coventry All Commercial |
$886.16
|
| Rate for Payer: Encore All Commercial |
$926.94
|
| Rate for Payer: Frontpath All Commercial |
$926.44
|
| Rate for Payer: Humana ChoiceCare |
$869.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$906.30
|
| Rate for Payer: PHCS All Commercial |
$755.25
|
| Rate for Payer: PHP All Commercial |
$763.71
|
| Rate for Payer: Sagamore Health Network All Products |
$777.40
|
| Rate for Payer: Signature Care EPO |
$835.81
|
| Rate for Payer: Signature Care PPO |
$886.16
|
| Rate for Payer: United Healthcare Commercial |
$793.52
|
|
|
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 |
$1,088.62
|
| 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 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 |
$1,088.62
|
| 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 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 |
$222.98
|
| 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 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 |
$222.98
|
| 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 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 |
$725.65
|
| 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 |
$725.65
|
| 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 |
$1,978.12
|
| 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 |
$1,978.12
|
| 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 |
$622.45
|
| 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 |
$622.45
|
| 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
|
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 |
$2.57
|
| 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
|
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 |
$2.57
|
| 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 |
$2.57
|
| 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
|
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 |
$2.57
|
| 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
|
|
|
TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON
|
Facility
|
OP
|
$488.57
|
|
|
Service Code
|
CPT 25310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.57 |
| Max. Negotiated Rate |
$488.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$488.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$488.57
|
| Rate for Payer: Managed Health Services Medicaid |
$488.57
|
| Rate for Payer: MDWise Medicaid |
$488.57
|
|
|
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 |
$16,879.74
|
| Rate for Payer: Cash Price |
$16,879.74
|
| 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 |
$16,879.74
|
| 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
|
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 |
$16,879.74
|
| 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 |
$16,879.74
|
| Rate for Payer: Cash Price |
$16,879.74
|
| 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
|
|
|
TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON
|
Facility
|
OP
|
$318.54
|
|
|
Service Code
|
CPT 28220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$318.54 |
| Max. Negotiated Rate |
$318.54 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$318.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$318.54
|
| Rate for Payer: Managed Health Services Medicaid |
$318.54
|
| Rate for Payer: MDWise Medicaid |
$318.54
|
|
|
TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON
|
Facility
|
OP
|
$488.57
|
|
|
Service Code
|
CPT 26455
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.57 |
| Max. Negotiated Rate |
$488.57 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$488.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$488.57
|
| Rate for Payer: Managed Health Services Medicaid |
$488.57
|
| Rate for Payer: MDWise Medicaid |
$488.57
|
|
|
TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON
|
Facility
|
OP
|
$329.12
|
|
|
Service Code
|
CPT 28234
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$329.12 |
| Max. Negotiated Rate |
$329.12 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$329.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$329.12
|
| Rate for Payer: Managed Health Services Medicaid |
$329.12
|
| Rate for Payer: MDWise Medicaid |
$329.12
|
|
