|
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$8,040.37
|
|
|
Service Code
|
APR-DRG 8433
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$8,040.37 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$4,495.69
|
|
|
Service Code
|
APR-DRG 8432
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$4,495.69 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$3,155.63
|
|
|
Service Code
|
APR-DRG 8431
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$3,155.63 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$11,628.28
|
|
|
Service Code
|
APR-DRG 8434
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$11,628.28 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
EZETIMIBE 10 MG ORAL TAB
|
Facility
|
OP
|
$31.76
|
|
|
Service Code
|
NDC 50268029812
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.85 |
| Max. Negotiated Rate |
$29.54 |
| Rate for Payer: Aetna Commercial |
$26.80
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.18
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Centivo All Commercial |
$17.28
|
| Rate for Payer: Cigna All Commercial |
$27.41
|
| Rate for Payer: CORVEL All Commercial |
$29.54
|
| Rate for Payer: Coventry All Commercial |
$27.95
|
| Rate for Payer: Encore All Commercial |
$29.23
|
| Rate for Payer: Frontpath All Commercial |
$29.22
|
| Rate for Payer: Humana ChoiceCare |
$27.43
|
| Rate for Payer: Humana Medicare |
$10.16
|
| Rate for Payer: Lucent All Commercial |
$17.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.58
|
| Rate for Payer: PHCS All Commercial |
$23.82
|
| Rate for Payer: PHP All Commercial |
$24.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.39
|
| Rate for Payer: Sagamore Health Network All Products |
$24.52
|
| Rate for Payer: Signature Care EPO |
$26.36
|
| Rate for Payer: Signature Care PPO |
$27.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.00
|
| Rate for Payer: United Healthcare Commercial |
$25.03
|
| Rate for Payer: United Healthcare Medicare |
$10.16
|
|
|
EZETIMIBE 10 MG ORAL TAB
|
Facility
|
IP
|
$31.76
|
|
|
Service Code
|
NDC 50268029812
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.82 |
| Max. Negotiated Rate |
$29.54 |
| Rate for Payer: Aetna Commercial |
$27.44
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cigna All Commercial |
$27.41
|
| Rate for Payer: CORVEL All Commercial |
$29.54
|
| Rate for Payer: Coventry All Commercial |
$27.95
|
| Rate for Payer: Encore All Commercial |
$29.23
|
| Rate for Payer: Frontpath All Commercial |
$29.22
|
| Rate for Payer: Humana ChoiceCare |
$27.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.58
|
| Rate for Payer: PHCS All Commercial |
$23.82
|
| Rate for Payer: PHP All Commercial |
$24.09
|
| Rate for Payer: Sagamore Health Network All Products |
$24.52
|
| Rate for Payer: Signature Care EPO |
$26.36
|
| Rate for Payer: Signature Care PPO |
$27.95
|
| Rate for Payer: United Healthcare Commercial |
$25.03
|
|
|
FAMOTIDINE 10 MG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
|
FAMOTIDINE 10 MG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
10009
|
|
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 |
$10.80
|
| 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
|
|
|
FAMOTIDINE 20 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904719361
|
| Hospital Charge Code |
10011
|
|
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 |
$0.60
|
| 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
|
|
|
FAMOTIDINE 20 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904719361
|
| Hospital Charge Code |
10011
|
|
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 |
$0.60
|
| 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
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
119375
|
|
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 |
$10.80
|
| 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
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
119375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| 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 |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| 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 |
$5.76
|
|
|
FAMOTIDINE (PF)-NACL (ISO-OS) 20 MG/50 ML IV PGBK
|
Facility
|
OP
|
$39.20
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
12735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.08
|
| Rate for Payer: Aetna Medicare |
$12.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.80
|
| Rate for Payer: Cash Price |
$23.52
|
| Rate for Payer: Centivo All Commercial |
$21.32
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Humana Medicare |
$12.54
|
| Rate for Payer: Lucent All Commercial |
$21.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.29
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.32
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
|
|
FAMOTIDINE (PF)-NACL (ISO-OS) 20 MG/50 ML IV PGBK
|
Facility
|
IP
|
$39.20
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
12735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.87
|
| Rate for Payer: Cash Price |
$23.52
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
|
|
FAT EMULSION 20 % IV EMUL
|
Facility
|
IP
|
$290.50
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$217.88 |
| Max. Negotiated Rate |
$270.17 |
| Rate for Payer: Aetna Commercial |
$250.99
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: Cigna All Commercial |
$250.70
|
| Rate for Payer: CORVEL All Commercial |
$270.17
|
| Rate for Payer: Coventry All Commercial |
$255.64
|
| Rate for Payer: Encore All Commercial |
$267.41
|
| Rate for Payer: Frontpath All Commercial |
$267.26
|
| Rate for Payer: Humana ChoiceCare |
$250.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$261.45
|
| Rate for Payer: PHCS All Commercial |
$217.88
|
| Rate for Payer: PHP All Commercial |
$220.32
|
| Rate for Payer: Sagamore Health Network All Products |
$224.27
|
| Rate for Payer: Signature Care EPO |
$241.12
|
| Rate for Payer: Signature Care PPO |
$255.64
|
| Rate for Payer: United Healthcare Commercial |
$228.91
|
|
|
FAT EMULSION 20 % IV EMUL
|
Facility
|
OP
|
$290.50
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$270.17 |
| Rate for Payer: Aetna Commercial |
$245.18
|
| Rate for Payer: Aetna Medicare |
$92.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$90.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$166.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$181.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$102.26
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: Centivo All Commercial |
$158.03
|
| Rate for Payer: Cigna All Commercial |
$250.70
|
| Rate for Payer: CORVEL All Commercial |
$270.17
|
| Rate for Payer: Coventry All Commercial |
$255.64
|
| Rate for Payer: Encore All Commercial |
$267.41
|
| Rate for Payer: Frontpath All Commercial |
$267.26
|
| Rate for Payer: Humana ChoiceCare |
$250.90
|
| Rate for Payer: Humana Medicare |
$92.96
|
| Rate for Payer: Lucent All Commercial |
$158.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$261.45
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$217.88
|
| Rate for Payer: PHP All Commercial |
$220.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$113.30
|
| Rate for Payer: Sagamore Health Network All Products |
$224.27
|
| Rate for Payer: Signature Care EPO |
$241.12
|
| Rate for Payer: Signature Care PPO |
$255.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$246.93
|
| Rate for Payer: United Healthcare Commercial |
$228.91
|
| Rate for Payer: United Healthcare Medicare |
$92.96
|
|
|
FEBUXOSTAT 40 MG ORAL TAB
|
Facility
|
OP
|
$14.77
|
|
|
Service Code
|
NDC 60687053821
|
| Hospital Charge Code |
97133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$13.74 |
| Rate for Payer: Aetna Commercial |
$12.47
|
| Rate for Payer: Aetna Medicare |
$4.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: Centivo All Commercial |
$8.03
|
| Rate for Payer: Cigna All Commercial |
$12.75
|
| Rate for Payer: CORVEL All Commercial |
$13.74
|
| Rate for Payer: Coventry All Commercial |
$13.00
|
| Rate for Payer: Encore All Commercial |
$13.60
|
| Rate for Payer: Frontpath All Commercial |
$13.59
|
| Rate for Payer: Humana ChoiceCare |
$12.76
|
| Rate for Payer: Humana Medicare |
$4.73
|
| Rate for Payer: Lucent All Commercial |
$8.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$11.08
|
| Rate for Payer: PHP All Commercial |
$11.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.76
|
| Rate for Payer: Sagamore Health Network All Products |
$11.40
|
| Rate for Payer: Signature Care EPO |
$12.26
|
| Rate for Payer: Signature Care PPO |
$13.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.55
|
| Rate for Payer: United Healthcare Commercial |
$11.64
|
| Rate for Payer: United Healthcare Medicare |
$4.73
|
|
|
FEBUXOSTAT 40 MG ORAL TAB
|
Facility
|
IP
|
$14.77
|
|
|
Service Code
|
NDC 60687053821
|
| Hospital Charge Code |
97133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$13.74 |
| Rate for Payer: Aetna Commercial |
$12.76
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: Cigna All Commercial |
$12.75
|
| Rate for Payer: CORVEL All Commercial |
$13.74
|
| Rate for Payer: Coventry All Commercial |
$13.00
|
| Rate for Payer: Encore All Commercial |
$13.60
|
| Rate for Payer: Frontpath All Commercial |
$13.59
|
| Rate for Payer: Humana ChoiceCare |
$12.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$11.08
|
| Rate for Payer: PHP All Commercial |
$11.20
|
| Rate for Payer: Sagamore Health Network All Products |
$11.40
|
| Rate for Payer: Signature Care EPO |
$12.26
|
| Rate for Payer: Signature Care PPO |
$13.00
|
| Rate for Payer: United Healthcare Commercial |
$11.64
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
|
IP
|
$5.92
|
|
|
Service Code
|
NDC 50268031215
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna Commercial |
$5.11
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.50
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.91
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
|
OP
|
$5.92
|
|
|
Service Code
|
NDC 50268031215
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna Commercial |
$4.99
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Centivo All Commercial |
$3.22
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.50
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Lucent All Commercial |
$3.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.31
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.91
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.03
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
| Rate for Payer: United Healthcare Medicare |
$1.89
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
|
OP
|
$5.92
|
|
|
Service Code
|
NDC 50268031211
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna Commercial |
$4.99
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Centivo All Commercial |
$3.22
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.50
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Lucent All Commercial |
$3.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.31
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.91
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.03
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
| Rate for Payer: United Healthcare Medicare |
$1.89
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
|
IP
|
$5.92
|
|
|
Service Code
|
NDC 50268031211
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna Commercial |
$5.11
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cigna All Commercial |
$5.10
|
| Rate for Payer: CORVEL All Commercial |
$5.50
|
| Rate for Payer: Coventry All Commercial |
$5.21
|
| Rate for Payer: Encore All Commercial |
$5.44
|
| Rate for Payer: Frontpath All Commercial |
$5.44
|
| Rate for Payer: Humana ChoiceCare |
$5.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.32
|
| Rate for Payer: PHCS All Commercial |
$4.44
|
| Rate for Payer: PHP All Commercial |
$4.49
|
| Rate for Payer: Sagamore Health Network All Products |
$4.57
|
| Rate for Payer: Signature Care EPO |
$4.91
|
| Rate for Payer: Signature Care PPO |
$5.21
|
| Rate for Payer: United Healthcare Commercial |
$4.66
|
|
|
FENTANYL 100 MCG/HR TD PT72
|
Facility
|
IP
|
$192.91
|
|
|
Service Code
|
NDC 00406900076
|
| Hospital Charge Code |
27908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.68 |
| Max. Negotiated Rate |
$179.40 |
| Rate for Payer: Aetna Commercial |
$166.67
|
| Rate for Payer: Cash Price |
$115.74
|
| Rate for Payer: Cigna All Commercial |
$166.48
|
| Rate for Payer: CORVEL All Commercial |
$179.40
|
| Rate for Payer: Coventry All Commercial |
$169.76
|
| Rate for Payer: Encore All Commercial |
$177.57
|
| Rate for Payer: Frontpath All Commercial |
$177.47
|
| Rate for Payer: Humana ChoiceCare |
$166.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.62
|
| Rate for Payer: PHCS All Commercial |
$144.68
|
| Rate for Payer: PHP All Commercial |
$146.30
|
| Rate for Payer: Sagamore Health Network All Products |
$148.92
|
| Rate for Payer: Signature Care EPO |
$160.11
|
| Rate for Payer: Signature Care PPO |
$169.76
|
| Rate for Payer: United Healthcare Commercial |
$152.01
|
|
|
FENTANYL 100 MCG/HR TD PT72
|
Facility
|
OP
|
$192.91
|
|
|
Service Code
|
NDC 00406900076
|
| Hospital Charge Code |
27908
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$179.40 |
| Rate for Payer: Aetna Commercial |
$162.81
|
| Rate for Payer: Aetna Medicare |
$61.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$120.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.90
|
| Rate for Payer: Cash Price |
$115.74
|
| Rate for Payer: Centivo All Commercial |
$104.94
|
| Rate for Payer: Cigna All Commercial |
$166.48
|
| Rate for Payer: CORVEL All Commercial |
$179.40
|
| Rate for Payer: Coventry All Commercial |
$169.76
|
| Rate for Payer: Encore All Commercial |
$177.57
|
| Rate for Payer: Frontpath All Commercial |
$177.47
|
| Rate for Payer: Humana ChoiceCare |
$166.61
|
| Rate for Payer: Humana Medicare |
$61.73
|
| Rate for Payer: Lucent All Commercial |
$104.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.62
|
| Rate for Payer: PHCS All Commercial |
$144.68
|
| Rate for Payer: PHP All Commercial |
$146.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$75.23
|
| Rate for Payer: Sagamore Health Network All Products |
$148.92
|
| Rate for Payer: Signature Care EPO |
$160.11
|
| Rate for Payer: Signature Care PPO |
$169.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$163.97
|
| Rate for Payer: United Healthcare Commercial |
$152.01
|
| Rate for Payer: United Healthcare Medicare |
$61.73
|
|
|
FENTANYL 12 MCG/HR TD PT72
|
Facility
|
OP
|
$53.07
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$49.36 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$16.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$30.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.68
|
| Rate for Payer: Cash Price |
$31.84
|
| Rate for Payer: Centivo All Commercial |
$28.87
|
| Rate for Payer: Cigna All Commercial |
$45.80
|
| Rate for Payer: CORVEL All Commercial |
$49.36
|
| Rate for Payer: Coventry All Commercial |
$46.71
|
| Rate for Payer: Encore All Commercial |
$48.85
|
| Rate for Payer: Frontpath All Commercial |
$48.83
|
| Rate for Payer: Humana ChoiceCare |
$45.84
|
| Rate for Payer: Humana Medicare |
$16.98
|
| Rate for Payer: Lucent All Commercial |
$28.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.77
|
| Rate for Payer: PHCS All Commercial |
$39.81
|
| Rate for Payer: PHP All Commercial |
$40.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$40.97
|
| Rate for Payer: Signature Care EPO |
$44.05
|
| Rate for Payer: Signature Care PPO |
$46.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$45.11
|
| Rate for Payer: United Healthcare Commercial |
$41.82
|
| Rate for Payer: United Healthcare Medicare |
$16.98
|
|
