|
TRAMADOL 50 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687079511
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
TRAMADOL 50 MG TABLET #4 ED PACK (CAMERON)
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084808
|
| Hospital Charge Code |
1401000800207
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
TRAMADOL 50 MG TABLET #4 ED PACK (CAMERON)
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084808
|
| Hospital Charge Code |
1401000800207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
|
IP
|
$24.50
|
|
|
Service Code
|
NDC 72485051001
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.38 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna Commercial |
$21.17
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$22.79
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
|
OP
|
$24.50
|
|
|
Service Code
|
NDC 72485051010
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna Commercial |
$20.68
|
| Rate for Payer: Aetna Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.62
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Centivo All Commercial |
$13.33
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$22.79
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Humana Medicare |
$7.84
|
| Rate for Payer: Lucent All Commercial |
$13.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.55
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.82
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
| Rate for Payer: United Healthcare Medicare |
$7.84
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
|
OP
|
$24.50
|
|
|
Service Code
|
NDC 72485051001
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna Commercial |
$20.68
|
| Rate for Payer: Aetna Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.62
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Centivo All Commercial |
$13.33
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$22.79
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Humana Medicare |
$7.84
|
| Rate for Payer: Lucent All Commercial |
$13.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.55
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.82
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
| Rate for Payer: United Healthcare Medicare |
$7.84
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN
|
Facility
|
IP
|
$24.50
|
|
|
Service Code
|
NDC 72485051010
|
| Hospital Charge Code |
153558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.38 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna Commercial |
$21.17
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$22.79
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
|
|
TRAZODONE 50 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
TRAZODONE 50 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS
|
Facility
|
OP
|
$582.98
|
|
|
Service Code
|
CPT 24516
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$582.98 |
| Max. Negotiated Rate |
$582.98 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$582.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$582.98
|
| Rate for Payer: Managed Health Services Medicaid |
$582.98
|
| Rate for Payer: MDWise Medicaid |
$582.98
|
|
|
TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE
|
Facility
|
OP
|
$582.98
|
|
|
Service Code
|
CPT 27759
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$582.98 |
| Max. Negotiated Rate |
$582.98 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$582.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$582.98
|
| Rate for Payer: Managed Health Services Medicaid |
$582.98
|
| Rate for Payer: MDWise Medicaid |
$582.98
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREA
|
Facility
|
OP
|
$12.08
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna Commercial |
$10.19
|
| Rate for Payer: Aetna Medicare |
$3.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.25
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Centivo All Commercial |
$6.57
|
| Rate for Payer: Cigna All Commercial |
$10.42
|
| Rate for Payer: CORVEL All Commercial |
$11.23
|
| Rate for Payer: Coventry All Commercial |
$10.63
|
| Rate for Payer: Encore All Commercial |
$11.12
|
| Rate for Payer: Frontpath All Commercial |
$11.11
|
| Rate for Payer: Humana ChoiceCare |
$10.43
|
| Rate for Payer: Humana Medicare |
$3.86
|
| Rate for Payer: Lucent All Commercial |
$6.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.87
|
| Rate for Payer: PHCS All Commercial |
$9.06
|
| Rate for Payer: PHP All Commercial |
$9.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.71
|
| Rate for Payer: Sagamore Health Network All Products |
$9.32
|
| Rate for Payer: Signature Care EPO |
$10.02
|
| Rate for Payer: Signature Care PPO |
$10.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10.26
|
| Rate for Payer: United Healthcare Commercial |
$9.52
|
| Rate for Payer: United Healthcare Medicare |
$3.86
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREA
|
Facility
|
IP
|
$12.08
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna Commercial |
$10.43
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Cigna All Commercial |
$10.42
|
| Rate for Payer: CORVEL All Commercial |
$11.23
|
| Rate for Payer: Coventry All Commercial |
$10.63
|
| Rate for Payer: Encore All Commercial |
$11.12
|
| Rate for Payer: Frontpath All Commercial |
$11.11
|
| Rate for Payer: Humana ChoiceCare |
$10.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.87
|
| Rate for Payer: PHCS All Commercial |
$9.06
|
| Rate for Payer: PHP All Commercial |
$9.16
|
| Rate for Payer: Sagamore Health Network All Products |
$9.32
|
| Rate for Payer: Signature Care EPO |
$10.02
|
| Rate for Payer: Signature Care PPO |
$10.63
|
| Rate for Payer: United Healthcare Commercial |
$9.52
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT
|
Facility
|
OP
|
$27.93
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$23.57
|
| Rate for Payer: Aetna Medicare |
$8.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.83
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Centivo All Commercial |
$15.19
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Humana Medicare |
$8.94
|
| Rate for Payer: Lucent All Commercial |
$15.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.89
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.74
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
| Rate for Payer: United Healthcare Medicare |
$8.94
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT
|
Facility
|
IP
|
$27.93
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna Commercial |
$24.13
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cigna All Commercial |
$24.10
|
| Rate for Payer: CORVEL All Commercial |
$25.97
|
| Rate for Payer: Coventry All Commercial |
$24.58
|
| Rate for Payer: Encore All Commercial |
$25.71
|
| Rate for Payer: Frontpath All Commercial |
$25.70
|
| Rate for Payer: Humana ChoiceCare |
$24.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.14
|
| Rate for Payer: PHCS All Commercial |
$20.95
|
| Rate for Payer: PHP All Commercial |
$21.18
|
| Rate for Payer: Sagamore Health Network All Products |
$21.56
|
| Rate for Payer: Signature Care EPO |
$23.18
|
| Rate for Payer: Signature Care PPO |
$24.58
|
| Rate for Payer: United Healthcare Commercial |
$22.01
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP
|
Facility
|
IP
|
$79.31
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
11584
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.48 |
| Max. Negotiated Rate |
$73.76 |
| Rate for Payer: Aetna Commercial |
$68.52
|
| Rate for Payer: Cash Price |
$49.17
|
| Rate for Payer: Cigna All Commercial |
$68.44
|
| Rate for Payer: CORVEL All Commercial |
$73.76
|
| Rate for Payer: Coventry All Commercial |
$69.79
|
| Rate for Payer: Encore All Commercial |
$73.00
|
| Rate for Payer: Frontpath All Commercial |
$72.97
|
| Rate for Payer: Humana ChoiceCare |
$68.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.38
|
| Rate for Payer: PHCS All Commercial |
$59.48
|
| Rate for Payer: PHP All Commercial |
$60.15
|
| Rate for Payer: Sagamore Health Network All Products |
$61.23
|
| Rate for Payer: Signature Care EPO |
$65.83
|
| Rate for Payer: Signature Care PPO |
$69.79
|
| Rate for Payer: United Healthcare Commercial |
$62.50
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP
|
Facility
|
OP
|
$79.31
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
11584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.59 |
| Max. Negotiated Rate |
$73.76 |
| Rate for Payer: Aetna Commercial |
$66.94
|
| Rate for Payer: Aetna Medicare |
$25.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.92
|
| Rate for Payer: Cash Price |
$49.17
|
| Rate for Payer: Centivo All Commercial |
$43.14
|
| Rate for Payer: Cigna All Commercial |
$68.44
|
| Rate for Payer: CORVEL All Commercial |
$73.76
|
| Rate for Payer: Coventry All Commercial |
$69.79
|
| Rate for Payer: Encore All Commercial |
$73.00
|
| Rate for Payer: Frontpath All Commercial |
$72.97
|
| Rate for Payer: Humana ChoiceCare |
$68.50
|
| Rate for Payer: Humana Medicare |
$25.38
|
| Rate for Payer: Lucent All Commercial |
$43.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.38
|
| Rate for Payer: PHCS All Commercial |
$59.48
|
| Rate for Payer: PHP All Commercial |
$60.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.93
|
| Rate for Payer: Sagamore Health Network All Products |
$61.23
|
| Rate for Payer: Signature Care EPO |
$65.83
|
| Rate for Payer: Signature Care PPO |
$69.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.41
|
| Rate for Payer: United Healthcare Commercial |
$62.50
|
| Rate for Payer: United Healthcare Medicare |
$25.38
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP
|
Facility
|
IP
|
$50.32
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.74 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna Commercial |
$43.48
|
| Rate for Payer: Aetna Commercial |
$119.51
|
| Rate for Payer: Aetna Commercial |
$43.49
|
| Rate for Payer: Cash Price |
$85.76
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna All Commercial |
$43.43
|
| Rate for Payer: Cigna All Commercial |
$119.37
|
| Rate for Payer: Cigna All Commercial |
$43.43
|
| Rate for Payer: CORVEL All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$128.64
|
| Rate for Payer: CORVEL All Commercial |
$46.80
|
| Rate for Payer: Coventry All Commercial |
$121.72
|
| Rate for Payer: Coventry All Commercial |
$44.29
|
| Rate for Payer: Coventry All Commercial |
$44.28
|
| Rate for Payer: Encore All Commercial |
$46.32
|
| Rate for Payer: Encore All Commercial |
$127.32
|
| Rate for Payer: Encore All Commercial |
$46.33
|
| Rate for Payer: Frontpath All Commercial |
$46.30
|
| Rate for Payer: Frontpath All Commercial |
$127.25
|
| Rate for Payer: Frontpath All Commercial |
$46.30
|
| Rate for Payer: Humana ChoiceCare |
$43.46
|
| Rate for Payer: Humana ChoiceCare |
$119.47
|
| Rate for Payer: Humana ChoiceCare |
$43.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.30
|
| Rate for Payer: PHCS All Commercial |
$37.74
|
| Rate for Payer: PHCS All Commercial |
$103.74
|
| Rate for Payer: PHCS All Commercial |
$37.75
|
| Rate for Payer: PHP All Commercial |
$38.16
|
| Rate for Payer: PHP All Commercial |
$104.90
|
| Rate for Payer: PHP All Commercial |
$38.17
|
| Rate for Payer: Sagamore Health Network All Products |
$38.85
|
| Rate for Payer: Sagamore Health Network All Products |
$38.85
|
| Rate for Payer: Sagamore Health Network All Products |
$106.78
|
| Rate for Payer: Signature Care EPO |
$41.77
|
| Rate for Payer: Signature Care EPO |
$114.81
|
| Rate for Payer: Signature Care EPO |
$41.77
|
| Rate for Payer: Signature Care PPO |
$121.72
|
| Rate for Payer: Signature Care PPO |
$44.29
|
| Rate for Payer: Signature Care PPO |
$44.28
|
| Rate for Payer: United Healthcare Commercial |
$39.65
|
| Rate for Payer: United Healthcare Commercial |
$39.66
|
| Rate for Payer: United Healthcare Commercial |
$109.00
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP
|
Facility
|
OP
|
$138.32
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.88 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$116.74
|
| Rate for Payer: Aetna Commercial |
$42.47
|
| Rate for Payer: Aetna Commercial |
$42.48
|
| Rate for Payer: Aetna Medicare |
$16.10
|
| Rate for Payer: Aetna Medicare |
$44.26
|
| Rate for Payer: Aetna Medicare |
$16.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.72
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$85.76
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Centivo All Commercial |
$75.25
|
| Rate for Payer: Centivo All Commercial |
$27.38
|
| Rate for Payer: Centivo All Commercial |
$27.38
|
| Rate for Payer: Cigna All Commercial |
$119.37
|
| Rate for Payer: Cigna All Commercial |
$43.43
|
| Rate for Payer: Cigna All Commercial |
$43.43
|
| Rate for Payer: CORVEL All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$128.64
|
| Rate for Payer: CORVEL All Commercial |
$46.80
|
| Rate for Payer: Coventry All Commercial |
$121.72
|
| Rate for Payer: Coventry All Commercial |
$44.28
|
| Rate for Payer: Coventry All Commercial |
$44.29
|
| Rate for Payer: Encore All Commercial |
$127.32
|
| Rate for Payer: Encore All Commercial |
$46.33
|
| Rate for Payer: Encore All Commercial |
$46.32
|
| Rate for Payer: Frontpath All Commercial |
$46.30
|
| Rate for Payer: Frontpath All Commercial |
$127.25
|
| Rate for Payer: Frontpath All Commercial |
$46.30
|
| Rate for Payer: Humana ChoiceCare |
$43.46
|
| Rate for Payer: Humana ChoiceCare |
$119.47
|
| Rate for Payer: Humana ChoiceCare |
$43.47
|
| Rate for Payer: Humana Medicare |
$16.10
|
| Rate for Payer: Humana Medicare |
$16.11
|
| Rate for Payer: Humana Medicare |
$44.26
|
| Rate for Payer: Lucent All Commercial |
$27.38
|
| Rate for Payer: Lucent All Commercial |
$75.25
|
| Rate for Payer: Lucent All Commercial |
$27.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.30
|
| Rate for Payer: PHCS All Commercial |
$37.75
|
| Rate for Payer: PHCS All Commercial |
$103.74
|
| Rate for Payer: PHCS All Commercial |
$37.74
|
| Rate for Payer: PHP All Commercial |
$104.90
|
| Rate for Payer: PHP All Commercial |
$38.16
|
| Rate for Payer: PHP All Commercial |
$38.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.63
|
| Rate for Payer: Sagamore Health Network All Products |
$38.85
|
| Rate for Payer: Sagamore Health Network All Products |
$38.85
|
| Rate for Payer: Sagamore Health Network All Products |
$106.78
|
| Rate for Payer: Signature Care EPO |
$41.77
|
| Rate for Payer: Signature Care EPO |
$114.81
|
| Rate for Payer: Signature Care EPO |
$41.77
|
| Rate for Payer: Signature Care PPO |
$121.72
|
| Rate for Payer: Signature Care PPO |
$44.29
|
| Rate for Payer: Signature Care PPO |
$44.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.78
|
| Rate for Payer: United Healthcare Commercial |
$39.65
|
| Rate for Payer: United Healthcare Commercial |
$109.00
|
| Rate for Payer: United Healthcare Commercial |
$39.66
|
| Rate for Payer: United Healthcare Medicare |
$16.11
|
| Rate for Payer: United Healthcare Medicare |
$44.26
|
| Rate for Payer: United Healthcare Medicare |
$16.10
|
|
|
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG ORAL TAB
|
Facility
|
OP
|
$5.41
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Aetna Commercial |
$4.57
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.90
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Centivo All Commercial |
$2.94
|
| Rate for Payer: Cigna All Commercial |
$4.67
|
| Rate for Payer: CORVEL All Commercial |
$5.03
|
| Rate for Payer: Coventry All Commercial |
$4.76
|
| Rate for Payer: Encore All Commercial |
$4.98
|
| Rate for Payer: Frontpath All Commercial |
$4.98
|
| Rate for Payer: Humana ChoiceCare |
$4.67
|
| Rate for Payer: Humana Medicare |
$1.73
|
| Rate for Payer: Lucent All Commercial |
$2.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.87
|
| Rate for Payer: PHCS All Commercial |
$4.06
|
| Rate for Payer: PHP All Commercial |
$4.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.11
|
| Rate for Payer: Sagamore Health Network All Products |
$4.18
|
| Rate for Payer: Signature Care EPO |
$4.49
|
| Rate for Payer: Signature Care PPO |
$4.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.60
|
| Rate for Payer: United Healthcare Commercial |
$4.26
|
| Rate for Payer: United Healthcare Medicare |
$1.73
|
|
|
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5-25 MG ORAL TAB
|
Facility
|
IP
|
$5.41
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cigna All Commercial |
$4.67
|
| Rate for Payer: CORVEL All Commercial |
$5.03
|
| Rate for Payer: Coventry All Commercial |
$4.76
|
| Rate for Payer: Encore All Commercial |
$4.98
|
| Rate for Payer: Frontpath All Commercial |
$4.98
|
| Rate for Payer: Humana ChoiceCare |
$4.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.87
|
| Rate for Payer: PHCS All Commercial |
$4.06
|
| Rate for Payer: PHP All Commercial |
$4.10
|
| Rate for Payer: Sagamore Health Network All Products |
$4.18
|
| Rate for Payer: Signature Care EPO |
$4.49
|
| Rate for Payer: Signature Care PPO |
$4.76
|
| Rate for Payer: United Healthcare Commercial |
$4.26
|
|
|
TRICHLOROACETIC ACID 80 % TOP SOLN
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 10481300801
|
| Hospital Charge Code |
11589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSR
|
Facility
|
IP
|
$8,994.79
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,746.09 |
| Max. Negotiated Rate |
$8,365.15 |
| Rate for Payer: Aetna Commercial |
$7,771.50
|
| Rate for Payer: Cash Price |
$5,576.77
|
| Rate for Payer: Cigna All Commercial |
$7,762.50
|
| Rate for Payer: CORVEL All Commercial |
$8,365.15
|
| Rate for Payer: Coventry All Commercial |
$7,915.42
|
| Rate for Payer: Encore All Commercial |
$8,279.70
|
| Rate for Payer: Frontpath All Commercial |
$8,275.21
|
| Rate for Payer: Humana ChoiceCare |
$7,768.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,095.31
|
| Rate for Payer: PHCS All Commercial |
$6,746.09
|
| Rate for Payer: PHP All Commercial |
$6,821.65
|
| Rate for Payer: Sagamore Health Network All Products |
$6,943.98
|
| Rate for Payer: Signature Care EPO |
$7,465.68
|
| Rate for Payer: Signature Care PPO |
$7,915.42
|
| Rate for Payer: United Healthcare Commercial |
$7,087.89
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSR
|
Facility
|
OP
|
$8,994.79
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$959.44 |
| Max. Negotiated Rate |
$8,365.15 |
| Rate for Payer: Aetna Commercial |
$7,591.60
|
| Rate for Payer: Aetna Medicare |
$2,878.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$959.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,788.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,165.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,622.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$959.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,310.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,166.17
|
| Rate for Payer: Cash Price |
$5,576.77
|
| Rate for Payer: Cash Price |
$5,576.77
|
| Rate for Payer: Centivo All Commercial |
$4,893.17
|
| Rate for Payer: Cigna All Commercial |
$7,762.50
|
| Rate for Payer: CORVEL All Commercial |
$8,365.15
|
| Rate for Payer: Coventry All Commercial |
$7,915.42
|
| Rate for Payer: Encore All Commercial |
$8,279.70
|
| Rate for Payer: Frontpath All Commercial |
$8,275.21
|
| Rate for Payer: Humana ChoiceCare |
$7,768.80
|
| Rate for Payer: Humana Medicare |
$2,878.33
|
| Rate for Payer: Lucent All Commercial |
$4,893.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8,095.31
|
| Rate for Payer: Managed Health Services Medicaid |
$959.44
|
| Rate for Payer: MDWise Medicaid |
$959.44
|
| Rate for Payer: PHCS All Commercial |
$6,746.09
|
| Rate for Payer: PHP All Commercial |
$6,821.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,507.97
|
| Rate for Payer: Sagamore Health Network All Products |
$6,943.98
|
| Rate for Payer: Signature Care EPO |
$7,465.68
|
| Rate for Payer: Signature Care PPO |
$7,915.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,645.57
|
| Rate for Payer: United Healthcare Commercial |
$7,087.89
|
| Rate for Payer: United Healthcare Medicare |
$2,878.33
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSR
|
Facility
|
IP
|
$17,989.58
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
121160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,492.18 |
| Max. Negotiated Rate |
$16,730.31 |
| Rate for Payer: Aetna Commercial |
$15,543.00
|
| Rate for Payer: Cash Price |
$11,153.54
|
| Rate for Payer: Cigna All Commercial |
$15,525.01
|
| Rate for Payer: CORVEL All Commercial |
$16,730.31
|
| Rate for Payer: Coventry All Commercial |
$15,830.83
|
| Rate for Payer: Encore All Commercial |
$16,559.41
|
| Rate for Payer: Frontpath All Commercial |
$16,550.41
|
| Rate for Payer: Humana ChoiceCare |
$15,537.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16,190.62
|
| Rate for Payer: PHCS All Commercial |
$13,492.18
|
| Rate for Payer: PHP All Commercial |
$13,643.30
|
| Rate for Payer: Sagamore Health Network All Products |
$13,887.96
|
| Rate for Payer: Signature Care EPO |
$14,931.35
|
| Rate for Payer: Signature Care PPO |
$15,830.83
|
| Rate for Payer: United Healthcare Commercial |
$14,175.79
|
|
