|
KETOCONAZOLE 2 % TOP SHAM
|
Facility
IP
|
$71.40
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
14132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$66.40 |
| Rate for Payer: Aetna Commercial |
$61.69
|
| Rate for Payer: Cash Price |
$44.27
|
| Rate for Payer: Cigna All Commercial |
$61.62
|
| Rate for Payer: CORVEL All Commercial |
$66.40
|
| Rate for Payer: Coventry All Commercial |
$62.83
|
| Rate for Payer: Encore All Commercial |
$65.72
|
| Rate for Payer: Frontpath All Commercial |
$65.69
|
| Rate for Payer: Humana ChoiceCare |
$61.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.26
|
| Rate for Payer: PHCS All Commercial |
$53.55
|
| Rate for Payer: PHP All Commercial |
$54.15
|
| Rate for Payer: Sagamore Health Network All Products |
$55.12
|
| Rate for Payer: Signature Care EPO |
$59.26
|
| Rate for Payer: Signature Care PPO |
$62.83
|
| Rate for Payer: United Healthcare Commercial |
$56.26
|
|
|
KETOCONAZOLE 2 % TOP SHAM
|
Facility
OP
|
$71.40
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
14132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.56 |
| Max. Negotiated Rate |
$66.40 |
| Rate for Payer: Aetna Commercial |
$60.26
|
| Rate for Payer: Aetna Medicare |
$23.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$41.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$44.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$27.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.92
|
| Rate for Payer: Cash Price |
$44.27
|
| Rate for Payer: Cash Price |
$44.27
|
| Rate for Payer: Centivo All Commercial |
$36.41
|
| Rate for Payer: Cigna All Commercial |
$61.62
|
| Rate for Payer: CORVEL All Commercial |
$66.40
|
| Rate for Payer: Coventry All Commercial |
$62.83
|
| Rate for Payer: Encore All Commercial |
$65.72
|
| Rate for Payer: Frontpath All Commercial |
$65.69
|
| Rate for Payer: Humana ChoiceCare |
$61.67
|
| Rate for Payer: Humana Medicare |
$36.41
|
| Rate for Payer: Lucent All Commercial |
$36.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.26
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$53.55
|
| Rate for Payer: PHP All Commercial |
$54.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.85
|
| Rate for Payer: Sagamore Health Network All Products |
$55.12
|
| Rate for Payer: Signature Care EPO |
$59.26
|
| Rate for Payer: Signature Care PPO |
$62.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$60.69
|
| Rate for Payer: United Healthcare Commercial |
$56.26
|
| Rate for Payer: United Healthcare Medicare |
$23.56
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
IP
|
$38.01
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
19733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$35.35 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: Cash Price |
$23.57
|
| Rate for Payer: Cigna All Commercial |
$32.80
|
| Rate for Payer: CORVEL All Commercial |
$35.35
|
| Rate for Payer: Coventry All Commercial |
$33.45
|
| Rate for Payer: Encore All Commercial |
$34.99
|
| Rate for Payer: Frontpath All Commercial |
$34.97
|
| Rate for Payer: Humana ChoiceCare |
$32.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.21
|
| Rate for Payer: PHCS All Commercial |
$28.51
|
| Rate for Payer: PHP All Commercial |
$28.83
|
| Rate for Payer: Sagamore Health Network All Products |
$29.34
|
| Rate for Payer: Signature Care EPO |
$31.55
|
| Rate for Payer: Signature Care PPO |
$33.45
|
| Rate for Payer: United Healthcare Commercial |
$29.95
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
OP
|
$38.01
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
19733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$32.08
|
| Rate for Payer: Aetna Medicare |
$12.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.80
|
| Rate for Payer: Cash Price |
$23.57
|
| Rate for Payer: Cash Price |
$23.57
|
| Rate for Payer: Centivo All Commercial |
$19.39
|
| Rate for Payer: Cigna All Commercial |
$32.80
|
| Rate for Payer: CORVEL All Commercial |
$35.35
|
| Rate for Payer: Coventry All Commercial |
$33.45
|
| Rate for Payer: Encore All Commercial |
$34.99
|
| Rate for Payer: Frontpath All Commercial |
$34.97
|
| Rate for Payer: Humana ChoiceCare |
$32.83
|
| Rate for Payer: Humana Medicare |
$19.39
|
| Rate for Payer: Lucent All Commercial |
$19.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.21
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$28.51
|
| Rate for Payer: PHP All Commercial |
$28.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.82
|
| Rate for Payer: Sagamore Health Network All Products |
$29.34
|
| Rate for Payer: Signature Care EPO |
$31.55
|
| Rate for Payer: Signature Care PPO |
$33.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.31
|
| Rate for Payer: United Healthcare Commercial |
$29.95
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
|
|
KETOROLAC 10 MG ORAL TAB
|
Facility
IP
|
$10.63
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
10371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.18
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
|
|
KETOROLAC 10 MG ORAL TAB
|
Facility
OP
|
$10.63
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
10371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$8.97
|
| Rate for Payer: Aetna Medicare |
$3.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.86
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Centivo All Commercial |
$5.42
|
| Rate for Payer: Cigna All Commercial |
$9.17
|
| Rate for Payer: CORVEL All Commercial |
$9.88
|
| Rate for Payer: Coventry All Commercial |
$9.35
|
| Rate for Payer: Encore All Commercial |
$9.78
|
| Rate for Payer: Frontpath All Commercial |
$9.78
|
| Rate for Payer: Humana ChoiceCare |
$9.18
|
| Rate for Payer: Humana Medicare |
$5.42
|
| Rate for Payer: Lucent All Commercial |
$5.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$7.97
|
| Rate for Payer: PHP All Commercial |
$8.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.14
|
| Rate for Payer: Sagamore Health Network All Products |
$8.20
|
| Rate for Payer: Signature Care EPO |
$8.82
|
| Rate for Payer: Signature Care PPO |
$9.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.03
|
| Rate for Payer: United Healthcare Commercial |
$8.37
|
| Rate for Payer: United Healthcare Medicare |
$3.51
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
KETOROLAC 60 MG/2 ML IM SOLN
|
Facility
IP
|
$36.51
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
91349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.38 |
| Max. Negotiated Rate |
$33.96 |
| Rate for Payer: Aetna Commercial |
$31.55
|
| Rate for Payer: Cash Price |
$22.64
|
| Rate for Payer: Cigna All Commercial |
$31.51
|
| Rate for Payer: CORVEL All Commercial |
$33.96
|
| Rate for Payer: Coventry All Commercial |
$32.13
|
| Rate for Payer: Encore All Commercial |
$33.61
|
| Rate for Payer: Frontpath All Commercial |
$33.59
|
| Rate for Payer: Humana ChoiceCare |
$31.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.86
|
| Rate for Payer: PHCS All Commercial |
$27.38
|
| Rate for Payer: PHP All Commercial |
$27.69
|
| Rate for Payer: Sagamore Health Network All Products |
$28.19
|
| Rate for Payer: Signature Care EPO |
$30.30
|
| Rate for Payer: Signature Care PPO |
$32.13
|
| Rate for Payer: United Healthcare Commercial |
$28.77
|
|
|
KETOROLAC 60 MG/2 ML IM SOLN
|
Facility
OP
|
$36.51
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
91349
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$33.96 |
| Rate for Payer: Aetna Commercial |
$30.82
|
| Rate for Payer: Aetna Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.25
|
| Rate for Payer: Cash Price |
$22.64
|
| Rate for Payer: Centivo All Commercial |
$18.62
|
| Rate for Payer: Cigna All Commercial |
$31.51
|
| Rate for Payer: CORVEL All Commercial |
$33.96
|
| Rate for Payer: Coventry All Commercial |
$32.13
|
| Rate for Payer: Encore All Commercial |
$33.61
|
| Rate for Payer: Frontpath All Commercial |
$33.59
|
| Rate for Payer: Humana ChoiceCare |
$31.54
|
| Rate for Payer: Humana Medicare |
$18.62
|
| Rate for Payer: Lucent All Commercial |
$18.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.86
|
| Rate for Payer: PHCS All Commercial |
$27.38
|
| Rate for Payer: PHP All Commercial |
$27.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.24
|
| Rate for Payer: Sagamore Health Network All Products |
$28.19
|
| Rate for Payer: Signature Care EPO |
$30.30
|
| Rate for Payer: Signature Care PPO |
$32.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.04
|
| Rate for Payer: United Healthcare Commercial |
$28.77
|
| Rate for Payer: United Healthcare Medicare |
$12.05
|
|
|
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR
|
Facility
IP
|
$10,500.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
178918
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7,875.00 |
| Max. Negotiated Rate |
$9,765.00 |
| Rate for Payer: Aetna Commercial |
$9,072.00
|
| Rate for Payer: Cash Price |
$6,510.00
|
| Rate for Payer: Cigna All Commercial |
$9,061.50
|
| Rate for Payer: CORVEL All Commercial |
$9,765.00
|
| Rate for Payer: Coventry All Commercial |
$9,240.00
|
| Rate for Payer: Encore All Commercial |
$9,665.25
|
| Rate for Payer: Frontpath All Commercial |
$9,660.00
|
| Rate for Payer: Humana ChoiceCare |
$9,068.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,450.00
|
| Rate for Payer: PHCS All Commercial |
$7,875.00
|
| Rate for Payer: PHP All Commercial |
$7,963.20
|
| Rate for Payer: Sagamore Health Network All Products |
$8,106.00
|
| Rate for Payer: Signature Care EPO |
$8,715.00
|
| Rate for Payer: Signature Care PPO |
$9,240.00
|
| Rate for Payer: United Healthcare Commercial |
$8,274.00
|
|
|
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR
|
Facility
OP
|
$10,500.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
178918
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,465.00 |
| Max. Negotiated Rate |
$9,765.00 |
| Rate for Payer: Aetna Commercial |
$8,862.00
|
| Rate for Payer: Aetna Medicare |
$3,465.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,465.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,030.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,563.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,984.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,811.50
|
| Rate for Payer: Cash Price |
$6,510.00
|
| Rate for Payer: Centivo All Commercial |
$5,355.00
|
| Rate for Payer: Cigna All Commercial |
$9,061.50
|
| Rate for Payer: CORVEL All Commercial |
$9,765.00
|
| Rate for Payer: Coventry All Commercial |
$9,240.00
|
| Rate for Payer: Encore All Commercial |
$9,665.25
|
| Rate for Payer: Frontpath All Commercial |
$9,660.00
|
| Rate for Payer: Humana ChoiceCare |
$9,068.85
|
| Rate for Payer: Humana Medicare |
$5,355.00
|
| Rate for Payer: Lucent All Commercial |
$5,355.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,450.00
|
| Rate for Payer: PHCS All Commercial |
$7,875.00
|
| Rate for Payer: PHP All Commercial |
$7,963.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,095.00
|
| Rate for Payer: Sagamore Health Network All Products |
$8,106.00
|
| Rate for Payer: Signature Care EPO |
$8,715.00
|
| Rate for Payer: Signature Care PPO |
$9,240.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,925.00
|
| Rate for Payer: United Healthcare Commercial |
$8,274.00
|
| Rate for Payer: United Healthcare Medicare |
$3,465.00
|
|
|
KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR
|
Facility
IP
|
$57.72
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
121547
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$43.29 |
| Max. Negotiated Rate |
$53.68 |
| Rate for Payer: Aetna Commercial |
$49.87
|
| Rate for Payer: Cash Price |
$35.79
|
| Rate for Payer: Cigna All Commercial |
$49.81
|
| Rate for Payer: CORVEL All Commercial |
$53.68
|
| Rate for Payer: Coventry All Commercial |
$50.80
|
| Rate for Payer: Encore All Commercial |
$53.13
|
| Rate for Payer: Frontpath All Commercial |
$53.10
|
| Rate for Payer: Humana ChoiceCare |
$49.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.95
|
| Rate for Payer: PHCS All Commercial |
$43.29
|
| Rate for Payer: PHP All Commercial |
$43.78
|
| Rate for Payer: Sagamore Health Network All Products |
$44.56
|
| Rate for Payer: Signature Care EPO |
$47.91
|
| Rate for Payer: Signature Care PPO |
$50.80
|
| Rate for Payer: United Healthcare Commercial |
$45.48
|
|
|
KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR
|
Facility
OP
|
$57.72
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
121547
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$19.05 |
| Max. Negotiated Rate |
$53.68 |
| Rate for Payer: Aetna Commercial |
$48.72
|
| Rate for Payer: Aetna Medicare |
$19.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$33.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.95
|
| Rate for Payer: Cash Price |
$35.79
|
| Rate for Payer: Centivo All Commercial |
$29.44
|
| Rate for Payer: Cigna All Commercial |
$49.81
|
| Rate for Payer: CORVEL All Commercial |
$53.68
|
| Rate for Payer: Coventry All Commercial |
$50.80
|
| Rate for Payer: Encore All Commercial |
$53.13
|
| Rate for Payer: Frontpath All Commercial |
$53.10
|
| Rate for Payer: Humana ChoiceCare |
$49.85
|
| Rate for Payer: Humana Medicare |
$29.44
|
| Rate for Payer: Lucent All Commercial |
$29.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.95
|
| Rate for Payer: PHCS All Commercial |
$43.29
|
| Rate for Payer: PHP All Commercial |
$43.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.51
|
| Rate for Payer: Sagamore Health Network All Products |
$44.56
|
| Rate for Payer: Signature Care EPO |
$47.91
|
| Rate for Payer: Signature Care PPO |
$50.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$49.06
|
| Rate for Payer: United Healthcare Commercial |
$45.48
|
| Rate for Payer: United Healthcare Medicare |
$19.05
|
|
|
KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR
|
Facility
IP
|
$1,734.56
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
121541
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,300.92 |
| Max. Negotiated Rate |
$1,613.14 |
| Rate for Payer: Aetna Commercial |
$1,498.66
|
| Rate for Payer: Cash Price |
$1,075.43
|
| Rate for Payer: Cigna All Commercial |
$1,496.93
|
| Rate for Payer: CORVEL All Commercial |
$1,613.14
|
| Rate for Payer: Coventry All Commercial |
$1,526.41
|
| Rate for Payer: Encore All Commercial |
$1,596.66
|
| Rate for Payer: Frontpath All Commercial |
$1,595.80
|
| Rate for Payer: Humana ChoiceCare |
$1,498.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,561.10
|
| Rate for Payer: PHCS All Commercial |
$1,300.92
|
| Rate for Payer: PHP All Commercial |
$1,315.49
|
| Rate for Payer: Sagamore Health Network All Products |
$1,339.08
|
| Rate for Payer: Signature Care EPO |
$1,439.68
|
| Rate for Payer: Signature Care PPO |
$1,526.41
|
| Rate for Payer: United Healthcare Commercial |
$1,366.83
|
|
|
KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR
|
Facility
OP
|
$1,734.56
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
121541
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$572.40 |
| Max. Negotiated Rate |
$1,613.14 |
| Rate for Payer: Aetna Commercial |
$1,463.97
|
| Rate for Payer: Aetna Medicare |
$572.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$572.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$996.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,084.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$658.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$629.65
|
| Rate for Payer: Cash Price |
$1,075.43
|
| Rate for Payer: Centivo All Commercial |
$884.63
|
| Rate for Payer: Cigna All Commercial |
$1,496.93
|
| Rate for Payer: CORVEL All Commercial |
$1,613.14
|
| Rate for Payer: Coventry All Commercial |
$1,526.41
|
| Rate for Payer: Encore All Commercial |
$1,596.66
|
| Rate for Payer: Frontpath All Commercial |
$1,595.80
|
| Rate for Payer: Humana ChoiceCare |
$1,498.14
|
| Rate for Payer: Humana Medicare |
$884.63
|
| Rate for Payer: Lucent All Commercial |
$884.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,561.10
|
| Rate for Payer: PHCS All Commercial |
$1,300.92
|
| Rate for Payer: PHP All Commercial |
$1,315.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$676.48
|
| Rate for Payer: Sagamore Health Network All Products |
$1,339.08
|
| Rate for Payer: Signature Care EPO |
$1,439.68
|
| Rate for Payer: Signature Care PPO |
$1,526.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,474.38
|
| Rate for Payer: United Healthcare Commercial |
$1,366.83
|
| Rate for Payer: United Healthcare Medicare |
$572.40
|
|
|
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR
|
Facility
IP
|
$82,250.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
197065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$61,687.50 |
| Max. Negotiated Rate |
$76,492.50 |
| Rate for Payer: Aetna Commercial |
$71,064.00
|
| Rate for Payer: Cash Price |
$50,995.00
|
| Rate for Payer: Cigna All Commercial |
$70,981.75
|
| Rate for Payer: CORVEL All Commercial |
$76,492.50
|
| Rate for Payer: Coventry All Commercial |
$72,380.00
|
| Rate for Payer: Encore All Commercial |
$75,711.12
|
| Rate for Payer: Frontpath All Commercial |
$75,670.00
|
| Rate for Payer: Humana ChoiceCare |
$71,039.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74,025.00
|
| Rate for Payer: PHCS All Commercial |
$61,687.50
|
| Rate for Payer: PHP All Commercial |
$62,378.40
|
| Rate for Payer: Sagamore Health Network All Products |
$63,497.00
|
| Rate for Payer: Signature Care EPO |
$68,267.50
|
| Rate for Payer: Signature Care PPO |
$72,380.00
|
| Rate for Payer: United Healthcare Commercial |
$64,813.00
|
|
|
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR
|
Facility
OP
|
$82,250.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
197065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$987.00 |
| Max. Negotiated Rate |
$76,492.50 |
| Rate for Payer: Aetna Commercial |
$69,419.00
|
| Rate for Payer: Aetna Medicare |
$27,142.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27,142.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$47,236.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51,414.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$987.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31,213.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29,856.75
|
| Rate for Payer: Cash Price |
$50,995.00
|
| Rate for Payer: Cash Price |
$50,995.00
|
| Rate for Payer: Centivo All Commercial |
$41,947.50
|
| Rate for Payer: Cigna All Commercial |
$70,981.75
|
| Rate for Payer: CORVEL All Commercial |
$76,492.50
|
| Rate for Payer: Coventry All Commercial |
$72,380.00
|
| Rate for Payer: Encore All Commercial |
$75,711.12
|
| Rate for Payer: Frontpath All Commercial |
$75,670.00
|
| Rate for Payer: Humana ChoiceCare |
$71,039.32
|
| Rate for Payer: Humana Medicare |
$41,947.50
|
| Rate for Payer: Lucent All Commercial |
$41,947.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74,025.00
|
| Rate for Payer: Managed Health Services Medicaid |
$987.00
|
| Rate for Payer: MDWise Medicaid |
$987.00
|
| Rate for Payer: PHCS All Commercial |
$61,687.50
|
| Rate for Payer: PHP All Commercial |
$62,378.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32,077.50
|
| Rate for Payer: Sagamore Health Network All Products |
$63,497.00
|
| Rate for Payer: Signature Care EPO |
$68,267.50
|
| Rate for Payer: Signature Care PPO |
$72,380.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$69,912.50
|
| Rate for Payer: United Healthcare Commercial |
$64,813.00
|
| Rate for Payer: United Healthcare Medicare |
$27,142.50
|
|
|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR
|
Facility
OP
|
$317.52
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$104.78 |
| Max. Negotiated Rate |
$295.29 |
| Rate for Payer: Aetna Commercial |
$267.99
|
| Rate for Payer: Aetna Medicare |
$104.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$104.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$182.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$198.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$120.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.26
|
| Rate for Payer: Cash Price |
$196.86
|
| Rate for Payer: Centivo All Commercial |
$161.94
|
| Rate for Payer: Cigna All Commercial |
$274.02
|
| Rate for Payer: CORVEL All Commercial |
$295.29
|
| Rate for Payer: Coventry All Commercial |
$279.42
|
| Rate for Payer: Encore All Commercial |
$292.28
|
| Rate for Payer: Frontpath All Commercial |
$292.12
|
| Rate for Payer: Humana ChoiceCare |
$274.24
|
| Rate for Payer: Humana Medicare |
$161.94
|
| Rate for Payer: Lucent All Commercial |
$161.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$285.77
|
| Rate for Payer: PHCS All Commercial |
$238.14
|
| Rate for Payer: PHP All Commercial |
$240.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.83
|
| Rate for Payer: Sagamore Health Network All Products |
$245.13
|
| Rate for Payer: Signature Care EPO |
$263.54
|
| Rate for Payer: Signature Care PPO |
$279.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$269.89
|
| Rate for Payer: United Healthcare Commercial |
$250.21
|
| Rate for Payer: United Healthcare Medicare |
$104.78
|
|
|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR
|
Facility
IP
|
$317.52
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$238.14 |
| Max. Negotiated Rate |
$295.29 |
| Rate for Payer: Aetna Commercial |
$274.34
|
| Rate for Payer: Cash Price |
$196.86
|
| Rate for Payer: Cigna All Commercial |
$274.02
|
| Rate for Payer: CORVEL All Commercial |
$295.29
|
| Rate for Payer: Coventry All Commercial |
$279.42
|
| Rate for Payer: Encore All Commercial |
$292.28
|
| Rate for Payer: Frontpath All Commercial |
$292.12
|
| Rate for Payer: Humana ChoiceCare |
$274.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$285.77
|
| Rate for Payer: PHCS All Commercial |
$238.14
|
| Rate for Payer: PHP All Commercial |
$240.81
|
| Rate for Payer: Sagamore Health Network All Products |
$245.13
|
| Rate for Payer: Signature Care EPO |
$263.54
|
| Rate for Payer: Signature Care PPO |
$279.42
|
| Rate for Payer: United Healthcare Commercial |
$250.21
|
|
|
KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT
|
Facility
IP
|
$10,489.05
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
153749
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7,866.78 |
| Max. Negotiated Rate |
$9,754.81 |
| Rate for Payer: Aetna Commercial |
$9,062.53
|
| Rate for Payer: Cash Price |
$6,503.21
|
| Rate for Payer: Cigna All Commercial |
$9,052.05
|
| Rate for Payer: CORVEL All Commercial |
$9,754.81
|
| Rate for Payer: Coventry All Commercial |
$9,230.36
|
| Rate for Payer: Encore All Commercial |
$9,655.17
|
| Rate for Payer: Frontpath All Commercial |
$9,649.92
|
| Rate for Payer: Humana ChoiceCare |
$9,059.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,440.14
|
| Rate for Payer: PHCS All Commercial |
$7,866.78
|
| Rate for Payer: PHP All Commercial |
$7,954.89
|
| Rate for Payer: Sagamore Health Network All Products |
$8,097.54
|
| Rate for Payer: Signature Care EPO |
$8,705.91
|
| Rate for Payer: Signature Care PPO |
$9,230.36
|
| Rate for Payer: United Healthcare Commercial |
$8,265.37
|
|
|
KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT
|
Facility
OP
|
$10,489.05
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
153749
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,461.38 |
| Max. Negotiated Rate |
$9,754.81 |
| Rate for Payer: Aetna Commercial |
$8,852.75
|
| Rate for Payer: Aetna Medicare |
$3,461.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,461.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,023.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,556.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,980.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,807.52
|
| Rate for Payer: Cash Price |
$6,503.21
|
| Rate for Payer: Centivo All Commercial |
$5,349.41
|
| Rate for Payer: Cigna All Commercial |
$9,052.05
|
| Rate for Payer: CORVEL All Commercial |
$9,754.81
|
| Rate for Payer: Coventry All Commercial |
$9,230.36
|
| Rate for Payer: Encore All Commercial |
$9,655.17
|
| Rate for Payer: Frontpath All Commercial |
$9,649.92
|
| Rate for Payer: Humana ChoiceCare |
$9,059.39
|
| Rate for Payer: Humana Medicare |
$5,349.41
|
| Rate for Payer: Lucent All Commercial |
$5,349.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,440.14
|
| Rate for Payer: PHCS All Commercial |
$7,866.78
|
| Rate for Payer: PHP All Commercial |
$7,954.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,090.73
|
| Rate for Payer: Sagamore Health Network All Products |
$8,097.54
|
| Rate for Payer: Signature Care EPO |
$8,705.91
|
| Rate for Payer: Signature Care PPO |
$9,230.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,915.69
|
| Rate for Payer: United Healthcare Commercial |
$8,265.37
|
| Rate for Payer: United Healthcare Medicare |
$3,461.38
|
|
|
KIT PREP TC-99M-MEDRONATE SOD 20 MG IV SOLR
|
Facility
OP
|
$319.86
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
121124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$105.55 |
| Max. Negotiated Rate |
$297.47 |
| Rate for Payer: Aetna Commercial |
$269.96
|
| Rate for Payer: Aetna Medicare |
$105.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$183.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$199.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.11
|
| Rate for Payer: Cash Price |
$198.31
|
| Rate for Payer: Centivo All Commercial |
$163.13
|
| Rate for Payer: Cigna All Commercial |
$276.04
|
| Rate for Payer: CORVEL All Commercial |
$297.47
|
| Rate for Payer: Coventry All Commercial |
$281.48
|
| Rate for Payer: Encore All Commercial |
$294.43
|
| Rate for Payer: Frontpath All Commercial |
$294.27
|
| Rate for Payer: Humana ChoiceCare |
$276.26
|
| Rate for Payer: Humana Medicare |
$163.13
|
| Rate for Payer: Lucent All Commercial |
$163.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.87
|
| Rate for Payer: PHCS All Commercial |
$239.90
|
| Rate for Payer: PHP All Commercial |
$242.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.75
|
| Rate for Payer: Sagamore Health Network All Products |
$246.93
|
| Rate for Payer: Signature Care EPO |
$265.48
|
| Rate for Payer: Signature Care PPO |
$281.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$271.88
|
| Rate for Payer: United Healthcare Commercial |
$252.05
|
| Rate for Payer: United Healthcare Medicare |
$105.55
|
|
|
KIT PREP TC-99M-MEDRONATE SOD 20 MG IV SOLR
|
Facility
IP
|
$319.86
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
121124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$239.90 |
| Max. Negotiated Rate |
$297.47 |
| Rate for Payer: Aetna Commercial |
$276.36
|
| Rate for Payer: Cash Price |
$198.31
|
| Rate for Payer: Cigna All Commercial |
$276.04
|
| Rate for Payer: CORVEL All Commercial |
$297.47
|
| Rate for Payer: Coventry All Commercial |
$281.48
|
| Rate for Payer: Encore All Commercial |
$294.43
|
| Rate for Payer: Frontpath All Commercial |
$294.27
|
| Rate for Payer: Humana ChoiceCare |
$276.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.87
|
| Rate for Payer: PHCS All Commercial |
$239.90
|
| Rate for Payer: PHP All Commercial |
$242.58
|
| Rate for Payer: Sagamore Health Network All Products |
$246.93
|
| Rate for Payer: Signature Care EPO |
$265.48
|
| Rate for Payer: Signature Care PPO |
$281.48
|
| Rate for Payer: United Healthcare Commercial |
$252.05
|
|
|
KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR
|
Facility
IP
|
$387.42
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
152912
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$290.56 |
| Max. Negotiated Rate |
$360.30 |
| Rate for Payer: Aetna Commercial |
$334.73
|
| Rate for Payer: Cash Price |
$240.20
|
| Rate for Payer: Cigna All Commercial |
$334.34
|
| Rate for Payer: CORVEL All Commercial |
$360.30
|
| Rate for Payer: Coventry All Commercial |
$340.93
|
| Rate for Payer: Encore All Commercial |
$356.62
|
| Rate for Payer: Frontpath All Commercial |
$356.43
|
| Rate for Payer: Humana ChoiceCare |
$334.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$348.68
|
| Rate for Payer: PHCS All Commercial |
$290.56
|
| Rate for Payer: PHP All Commercial |
$293.82
|
| Rate for Payer: Sagamore Health Network All Products |
$299.09
|
| Rate for Payer: Signature Care EPO |
$321.56
|
| Rate for Payer: Signature Care PPO |
$340.93
|
| Rate for Payer: United Healthcare Commercial |
$305.29
|
|
