|
FENTANYL 12 MCG/HR TD PT72
|
Facility
|
IP
|
$53.07
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.81 |
| Max. Negotiated Rate |
$49.36 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Cash Price |
$31.84
|
| 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: 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: 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: United Healthcare Commercial |
$41.82
|
|
|
FENTANYL 25 MCG/HR TD PT72
|
Facility
|
OP
|
$47.42
|
|
|
Service Code
|
NDC 00378912198
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.02
|
| Rate for Payer: Aetna Medicare |
$15.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.69
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Centivo All Commercial |
$25.80
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Humana Medicare |
$15.17
|
| Rate for Payer: Lucent All Commercial |
$25.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.49
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.31
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
| Rate for Payer: United Healthcare Medicare |
$15.17
|
|
|
FENTANYL 25 MCG/HR TD PT72
|
Facility
|
IP
|
$47.42
|
|
|
Service Code
|
NDC 00378912116
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.56 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.97
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
|
|
FENTANYL 25 MCG/HR TD PT72
|
Facility
|
IP
|
$47.42
|
|
|
Service Code
|
NDC 00378912198
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.56 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.97
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
|
|
FENTANYL 25 MCG/HR TD PT72
|
Facility
|
OP
|
$47.42
|
|
|
Service Code
|
NDC 00378912116
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.02
|
| Rate for Payer: Aetna Medicare |
$15.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.69
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Centivo All Commercial |
$25.80
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Humana Medicare |
$15.17
|
| Rate for Payer: Lucent All Commercial |
$25.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.49
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.31
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
| Rate for Payer: United Healthcare Medicare |
$15.17
|
|
|
FENTANYL 4 MCG/0.4 ML SYRINGE - DILUTION (CAMERON)
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00000003635
|
| Hospital Charge Code |
1.401E+12
|
|
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
|
|
|
FENTANYL 4 MCG/0.4 ML SYRINGE - DILUTION (CAMERON)
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00000003635
|
| Hospital Charge Code |
1.401E+12
|
|
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
|
|
|
FENTANYL 50 MCG/HR TD PT72
|
Facility
|
OP
|
$84.22
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
27906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$78.33 |
| Rate for Payer: Aetna Commercial |
$71.09
|
| Rate for Payer: Aetna Medicare |
$26.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$48.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.65
|
| Rate for Payer: Cash Price |
$50.53
|
| Rate for Payer: Centivo All Commercial |
$45.82
|
| Rate for Payer: Cigna All Commercial |
$72.69
|
| Rate for Payer: CORVEL All Commercial |
$78.33
|
| Rate for Payer: Coventry All Commercial |
$74.12
|
| Rate for Payer: Encore All Commercial |
$77.53
|
| Rate for Payer: Frontpath All Commercial |
$77.49
|
| Rate for Payer: Humana ChoiceCare |
$72.74
|
| Rate for Payer: Humana Medicare |
$26.95
|
| Rate for Payer: Lucent All Commercial |
$45.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.80
|
| Rate for Payer: PHCS All Commercial |
$63.17
|
| Rate for Payer: PHP All Commercial |
$63.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.85
|
| Rate for Payer: Sagamore Health Network All Products |
$65.02
|
| Rate for Payer: Signature Care EPO |
$69.91
|
| Rate for Payer: Signature Care PPO |
$74.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.59
|
| Rate for Payer: United Healthcare Commercial |
$66.37
|
| Rate for Payer: United Healthcare Medicare |
$26.95
|
|
|
FENTANYL 50 MCG/HR TD PT72
|
Facility
|
IP
|
$84.22
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
27906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.17 |
| Max. Negotiated Rate |
$78.33 |
| Rate for Payer: Aetna Commercial |
$72.77
|
| Rate for Payer: Cash Price |
$50.53
|
| Rate for Payer: Cigna All Commercial |
$72.69
|
| Rate for Payer: CORVEL All Commercial |
$78.33
|
| Rate for Payer: Coventry All Commercial |
$74.12
|
| Rate for Payer: Encore All Commercial |
$77.53
|
| Rate for Payer: Frontpath All Commercial |
$77.49
|
| Rate for Payer: Humana ChoiceCare |
$72.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.80
|
| Rate for Payer: PHCS All Commercial |
$63.17
|
| Rate for Payer: PHP All Commercial |
$63.88
|
| Rate for Payer: Sagamore Health Network All Products |
$65.02
|
| Rate for Payer: Signature Care EPO |
$69.91
|
| Rate for Payer: Signature Care PPO |
$74.12
|
| Rate for Payer: United Healthcare Commercial |
$66.37
|
|
|
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3037
|
|
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
|
|
|
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3037
|
|
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
|
|
|
FENTANYL (PF)-BUPIVACAINE-NACL 2 MCG/ML- 0.125 % INJ SOLN
|
Facility
|
OP
|
$165.90
|
|
|
Service Code
|
NDC 70092110436
|
| Hospital Charge Code |
30862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.43 |
| Max. Negotiated Rate |
$154.29 |
| Rate for Payer: Aetna Commercial |
$140.02
|
| Rate for Payer: Aetna Medicare |
$53.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$95.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$103.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$61.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$58.40
|
| Rate for Payer: Cash Price |
$99.54
|
| Rate for Payer: Centivo All Commercial |
$90.25
|
| Rate for Payer: Cigna All Commercial |
$143.17
|
| Rate for Payer: CORVEL All Commercial |
$154.29
|
| Rate for Payer: Coventry All Commercial |
$145.99
|
| Rate for Payer: Encore All Commercial |
$152.71
|
| Rate for Payer: Frontpath All Commercial |
$152.63
|
| Rate for Payer: Humana ChoiceCare |
$143.29
|
| Rate for Payer: Humana Medicare |
$53.09
|
| Rate for Payer: Lucent All Commercial |
$90.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$149.31
|
| Rate for Payer: PHCS All Commercial |
$124.42
|
| Rate for Payer: PHP All Commercial |
$125.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$64.70
|
| Rate for Payer: Sagamore Health Network All Products |
$128.07
|
| Rate for Payer: Signature Care EPO |
$137.70
|
| Rate for Payer: Signature Care PPO |
$145.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$141.01
|
| Rate for Payer: United Healthcare Commercial |
$130.73
|
| Rate for Payer: United Healthcare Medicare |
$53.09
|
|
|
FENTANYL (PF)-BUPIVACAINE-NACL 2 MCG/ML- 0.125 % INJ SOLN
|
Facility
|
IP
|
$165.90
|
|
|
Service Code
|
NDC 70092110436
|
| Hospital Charge Code |
30862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.42 |
| Max. Negotiated Rate |
$154.29 |
| Rate for Payer: Aetna Commercial |
$143.34
|
| Rate for Payer: Cash Price |
$99.54
|
| Rate for Payer: Cigna All Commercial |
$143.17
|
| Rate for Payer: CORVEL All Commercial |
$154.29
|
| Rate for Payer: Coventry All Commercial |
$145.99
|
| Rate for Payer: Encore All Commercial |
$152.71
|
| Rate for Payer: Frontpath All Commercial |
$152.63
|
| Rate for Payer: Humana ChoiceCare |
$143.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$149.31
|
| Rate for Payer: PHCS All Commercial |
$124.42
|
| Rate for Payer: PHP All Commercial |
$125.82
|
| Rate for Payer: Sagamore Health Network All Products |
$128.07
|
| Rate for Payer: Signature Care EPO |
$137.70
|
| Rate for Payer: Signature Care PPO |
$145.99
|
| Rate for Payer: United Healthcare Commercial |
$130.73
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML IV SOLN
|
Facility
|
OP
|
$3,576.77
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
165287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$3,326.40 |
| Rate for Payer: Aetna Commercial |
$3,018.80
|
| Rate for Payer: Aetna Medicare |
$1,144.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$2.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,108.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,054.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,235.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$2.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,316.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,259.02
|
| Rate for Payer: Cash Price |
$2,146.06
|
| Rate for Payer: Cash Price |
$2,146.06
|
| Rate for Payer: Centivo All Commercial |
$1,945.76
|
| Rate for Payer: Cigna All Commercial |
$3,086.76
|
| Rate for Payer: CORVEL All Commercial |
$3,326.40
|
| Rate for Payer: Coventry All Commercial |
$3,147.56
|
| Rate for Payer: Encore All Commercial |
$3,292.42
|
| Rate for Payer: Frontpath All Commercial |
$3,290.63
|
| Rate for Payer: Humana ChoiceCare |
$3,089.26
|
| Rate for Payer: Humana Medicare |
$1,144.57
|
| Rate for Payer: Lucent All Commercial |
$1,945.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,219.10
|
| Rate for Payer: Managed Health Services Medicaid |
$2.06
|
| Rate for Payer: MDWise Medicaid |
$2.06
|
| Rate for Payer: PHCS All Commercial |
$2,682.58
|
| Rate for Payer: PHP All Commercial |
$2,712.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,394.94
|
| Rate for Payer: Sagamore Health Network All Products |
$2,761.27
|
| Rate for Payer: Signature Care EPO |
$2,968.72
|
| Rate for Payer: Signature Care PPO |
$3,147.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,040.26
|
| Rate for Payer: United Healthcare Commercial |
$2,818.50
|
| Rate for Payer: United Healthcare Medicare |
$1,144.57
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML IV SOLN
|
Facility
|
IP
|
$3,576.77
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
165287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,682.58 |
| Max. Negotiated Rate |
$3,326.40 |
| Rate for Payer: Aetna Commercial |
$3,090.33
|
| Rate for Payer: Cash Price |
$2,146.06
|
| Rate for Payer: Cigna All Commercial |
$3,086.76
|
| Rate for Payer: CORVEL All Commercial |
$3,326.40
|
| Rate for Payer: Coventry All Commercial |
$3,147.56
|
| Rate for Payer: Encore All Commercial |
$3,292.42
|
| Rate for Payer: Frontpath All Commercial |
$3,290.63
|
| Rate for Payer: Humana ChoiceCare |
$3,089.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,219.10
|
| Rate for Payer: PHCS All Commercial |
$2,682.58
|
| Rate for Payer: PHP All Commercial |
$2,712.62
|
| Rate for Payer: Sagamore Health Network All Products |
$2,761.27
|
| Rate for Payer: Signature Care EPO |
$2,968.72
|
| Rate for Payer: Signature Care PPO |
$3,147.56
|
| Rate for Payer: United Healthcare Commercial |
$2,818.50
|
|
|
FERRIC DERISOMALTOSE 100 MG IRON/ML IV SOLN
|
Facility
|
OP
|
$12,905.55
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
192376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$12,002.16 |
| Rate for Payer: Aetna Commercial |
$10,892.28
|
| Rate for Payer: Aetna Medicare |
$4,129.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,000.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7,411.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8,067.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,749.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,542.75
|
| Rate for Payer: Cash Price |
$7,743.33
|
| Rate for Payer: Cash Price |
$7,743.33
|
| Rate for Payer: Centivo All Commercial |
$7,020.62
|
| Rate for Payer: Cigna All Commercial |
$11,137.49
|
| Rate for Payer: CORVEL All Commercial |
$12,002.16
|
| Rate for Payer: Coventry All Commercial |
$11,356.88
|
| Rate for Payer: Encore All Commercial |
$11,879.56
|
| Rate for Payer: Frontpath All Commercial |
$11,873.11
|
| Rate for Payer: Humana ChoiceCare |
$11,146.52
|
| Rate for Payer: Humana Medicare |
$4,129.78
|
| Rate for Payer: Lucent All Commercial |
$7,020.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,615.00
|
| Rate for Payer: Managed Health Services Medicaid |
$26.65
|
| Rate for Payer: MDWise Medicaid |
$26.65
|
| Rate for Payer: PHCS All Commercial |
$9,679.16
|
| Rate for Payer: PHP All Commercial |
$9,787.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,033.16
|
| Rate for Payer: Sagamore Health Network All Products |
$9,963.08
|
| Rate for Payer: Signature Care EPO |
$10,711.61
|
| Rate for Payer: Signature Care PPO |
$11,356.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,969.72
|
| Rate for Payer: United Healthcare Commercial |
$10,169.57
|
| Rate for Payer: United Healthcare Medicare |
$4,129.78
|
|
|
FERRIC DERISOMALTOSE 100 MG IRON/ML IV SOLN
|
Facility
|
IP
|
$12,905.55
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
192376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,679.16 |
| Max. Negotiated Rate |
$12,002.16 |
| Rate for Payer: Aetna Commercial |
$11,150.40
|
| Rate for Payer: Cash Price |
$7,743.33
|
| Rate for Payer: Cigna All Commercial |
$11,137.49
|
| Rate for Payer: CORVEL All Commercial |
$12,002.16
|
| Rate for Payer: Coventry All Commercial |
$11,356.88
|
| Rate for Payer: Encore All Commercial |
$11,879.56
|
| Rate for Payer: Frontpath All Commercial |
$11,873.11
|
| Rate for Payer: Humana ChoiceCare |
$11,146.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,615.00
|
| Rate for Payer: PHCS All Commercial |
$9,679.16
|
| Rate for Payer: PHP All Commercial |
$9,787.57
|
| Rate for Payer: Sagamore Health Network All Products |
$9,963.08
|
| Rate for Payer: Signature Care EPO |
$10,711.61
|
| Rate for Payer: Signature Care PPO |
$11,356.88
|
| Rate for Payer: United Healthcare Commercial |
$10,169.57
|
|
|
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML TOP SOLA
|
Facility
|
OP
|
$136.58
|
|
|
Service Code
|
NDC 48783011208
|
| Hospital Charge Code |
165668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$127.02 |
| Rate for Payer: Aetna Commercial |
$115.28
|
| Rate for Payer: Aetna Medicare |
$43.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.08
|
| Rate for Payer: Cash Price |
$81.95
|
| Rate for Payer: Cash Price |
$81.95
|
| Rate for Payer: Centivo All Commercial |
$74.30
|
| Rate for Payer: Cigna All Commercial |
$117.87
|
| Rate for Payer: CORVEL All Commercial |
$127.02
|
| Rate for Payer: Coventry All Commercial |
$120.19
|
| Rate for Payer: Encore All Commercial |
$125.73
|
| Rate for Payer: Frontpath All Commercial |
$125.66
|
| Rate for Payer: Humana ChoiceCare |
$117.97
|
| Rate for Payer: Humana Medicare |
$43.71
|
| Rate for Payer: Lucent All Commercial |
$74.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$122.93
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$102.44
|
| Rate for Payer: PHP All Commercial |
$103.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.27
|
| Rate for Payer: Sagamore Health Network All Products |
$105.44
|
| Rate for Payer: Signature Care EPO |
$113.36
|
| Rate for Payer: Signature Care PPO |
$120.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.10
|
| Rate for Payer: United Healthcare Commercial |
$107.63
|
| Rate for Payer: United Healthcare Medicare |
$43.71
|
|
|
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML TOP SOLA
|
Facility
|
IP
|
$136.58
|
|
|
Service Code
|
NDC 48783011208
|
| Hospital Charge Code |
165668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.44 |
| Max. Negotiated Rate |
$127.02 |
| Rate for Payer: Aetna Commercial |
$118.01
|
| Rate for Payer: Cash Price |
$81.95
|
| Rate for Payer: Cigna All Commercial |
$117.87
|
| Rate for Payer: CORVEL All Commercial |
$127.02
|
| Rate for Payer: Coventry All Commercial |
$120.19
|
| Rate for Payer: Encore All Commercial |
$125.73
|
| Rate for Payer: Frontpath All Commercial |
$125.66
|
| Rate for Payer: Humana ChoiceCare |
$117.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$122.93
|
| Rate for Payer: PHCS All Commercial |
$102.44
|
| Rate for Payer: PHP All Commercial |
$103.59
|
| Rate for Payer: Sagamore Health Network All Products |
$105.44
|
| Rate for Payer: Signature Care EPO |
$113.36
|
| Rate for Payer: Signature Care PPO |
$120.19
|
| Rate for Payer: United Healthcare Commercial |
$107.63
|
|
|
FERROUS SULFATE 325 MG ORAL TAB
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 00904759161
|
| Hospital Charge Code |
3074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna All Commercial |
$0.19
|
| Rate for Payer: CORVEL All Commercial |
$0.21
|
| Rate for Payer: Coventry All Commercial |
$0.20
|
| Rate for Payer: Encore All Commercial |
$0.21
|
| Rate for Payer: Frontpath All Commercial |
$0.21
|
| Rate for Payer: Humana ChoiceCare |
$0.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.20
|
| Rate for Payer: PHCS All Commercial |
$0.17
|
| Rate for Payer: PHP All Commercial |
$0.17
|
| Rate for Payer: Sagamore Health Network All Products |
$0.17
|
| Rate for Payer: Signature Care EPO |
$0.19
|
| Rate for Payer: Signature Care PPO |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.18
|
|
|
FERROUS SULFATE 325 MG ORAL TAB
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 00904759161
|
| Hospital Charge Code |
3074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.19
|
| Rate for Payer: Aetna Medicare |
$0.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Centivo All Commercial |
$0.12
|
| Rate for Payer: Cigna All Commercial |
$0.19
|
| Rate for Payer: CORVEL All Commercial |
$0.21
|
| Rate for Payer: Coventry All Commercial |
$0.20
|
| Rate for Payer: Encore All Commercial |
$0.21
|
| Rate for Payer: Frontpath All Commercial |
$0.21
|
| Rate for Payer: Humana ChoiceCare |
$0.19
|
| Rate for Payer: Humana Medicare |
$0.07
|
| Rate for Payer: Lucent All Commercial |
$0.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.20
|
| Rate for Payer: PHCS All Commercial |
$0.17
|
| Rate for Payer: PHP All Commercial |
$0.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.09
|
| Rate for Payer: Sagamore Health Network All Products |
$0.17
|
| Rate for Payer: Signature Care EPO |
$0.19
|
| Rate for Payer: Signature Care PPO |
$0.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN
|
Facility
|
IP
|
$1,556.25
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
98312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,167.19 |
| Max. Negotiated Rate |
$1,447.31 |
| Rate for Payer: Aetna Commercial |
$1,344.60
|
| Rate for Payer: Cash Price |
$933.75
|
| Rate for Payer: Cigna All Commercial |
$1,343.04
|
| Rate for Payer: CORVEL All Commercial |
$1,447.31
|
| Rate for Payer: Coventry All Commercial |
$1,369.50
|
| Rate for Payer: Encore All Commercial |
$1,432.53
|
| Rate for Payer: Frontpath All Commercial |
$1,431.75
|
| Rate for Payer: Humana ChoiceCare |
$1,344.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,400.62
|
| Rate for Payer: PHCS All Commercial |
$1,167.19
|
| Rate for Payer: PHP All Commercial |
$1,180.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1,201.42
|
| Rate for Payer: Signature Care EPO |
$1,291.69
|
| Rate for Payer: Signature Care PPO |
$1,369.50
|
| Rate for Payer: United Healthcare Commercial |
$1,226.32
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN
|
Facility
|
OP
|
$1,556.25
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
98312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1,447.31 |
| Rate for Payer: Aetna Commercial |
$1,313.47
|
| Rate for Payer: Aetna Medicare |
$498.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$482.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$893.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$972.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$572.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$547.80
|
| Rate for Payer: Cash Price |
$933.75
|
| Rate for Payer: Cash Price |
$933.75
|
| Rate for Payer: Centivo All Commercial |
$846.60
|
| Rate for Payer: Cigna All Commercial |
$1,343.04
|
| Rate for Payer: CORVEL All Commercial |
$1,447.31
|
| Rate for Payer: Coventry All Commercial |
$1,369.50
|
| Rate for Payer: Encore All Commercial |
$1,432.53
|
| Rate for Payer: Frontpath All Commercial |
$1,431.75
|
| Rate for Payer: Humana ChoiceCare |
$1,344.13
|
| Rate for Payer: Humana Medicare |
$498.00
|
| Rate for Payer: Lucent All Commercial |
$846.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,400.62
|
| Rate for Payer: Managed Health Services Medicaid |
$1.52
|
| Rate for Payer: MDWise Medicaid |
$1.52
|
| Rate for Payer: PHCS All Commercial |
$1,167.19
|
| Rate for Payer: PHP All Commercial |
$1,180.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$606.94
|
| Rate for Payer: Sagamore Health Network All Products |
$1,201.42
|
| Rate for Payer: Signature Care EPO |
$1,291.69
|
| Rate for Payer: Signature Care PPO |
$1,369.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,322.81
|
| Rate for Payer: United Healthcare Commercial |
$1,226.32
|
| Rate for Payer: United Healthcare Medicare |
$498.00
|
|
|
FILGRASTIM 300 MCG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$1,300.16
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
108075
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$975.12 |
| Max. Negotiated Rate |
$1,209.15 |
| Rate for Payer: Aetna Commercial |
$1,123.34
|
| Rate for Payer: Cash Price |
$780.10
|
| Rate for Payer: Cigna All Commercial |
$1,122.04
|
| Rate for Payer: CORVEL All Commercial |
$1,209.15
|
| Rate for Payer: Coventry All Commercial |
$1,144.14
|
| Rate for Payer: Encore All Commercial |
$1,196.80
|
| Rate for Payer: Frontpath All Commercial |
$1,196.15
|
| Rate for Payer: Humana ChoiceCare |
$1,122.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,170.14
|
| Rate for Payer: PHCS All Commercial |
$975.12
|
| Rate for Payer: PHP All Commercial |
$986.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1,003.72
|
| Rate for Payer: Signature Care EPO |
$1,079.13
|
| Rate for Payer: Signature Care PPO |
$1,144.14
|
| Rate for Payer: United Healthcare Commercial |
$1,024.53
|
|
|
FILGRASTIM 300 MCG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$1,300.16
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
108075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1,209.15 |
| Rate for Payer: Aetna Commercial |
$1,097.34
|
| Rate for Payer: Aetna Medicare |
$416.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$403.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$746.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$812.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$478.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$457.66
|
| Rate for Payer: Cash Price |
$780.10
|
| Rate for Payer: Cash Price |
$780.10
|
| Rate for Payer: Centivo All Commercial |
$707.29
|
| Rate for Payer: Cigna All Commercial |
$1,122.04
|
| Rate for Payer: CORVEL All Commercial |
$1,209.15
|
| Rate for Payer: Coventry All Commercial |
$1,144.14
|
| Rate for Payer: Encore All Commercial |
$1,196.80
|
| Rate for Payer: Frontpath All Commercial |
$1,196.15
|
| Rate for Payer: Humana ChoiceCare |
$1,122.95
|
| Rate for Payer: Humana Medicare |
$416.05
|
| Rate for Payer: Lucent All Commercial |
$707.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,170.14
|
| Rate for Payer: Managed Health Services Medicaid |
$1.10
|
| Rate for Payer: MDWise Medicaid |
$1.10
|
| Rate for Payer: PHCS All Commercial |
$975.12
|
| Rate for Payer: PHP All Commercial |
$986.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$507.06
|
| Rate for Payer: Sagamore Health Network All Products |
$1,003.72
|
| Rate for Payer: Signature Care EPO |
$1,079.13
|
| Rate for Payer: Signature Care PPO |
$1,144.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,105.14
|
| Rate for Payer: United Healthcare Commercial |
$1,024.53
|
| Rate for Payer: United Healthcare Medicare |
$416.05
|
|
